Upload
cynthia-warth
View
228
Download
0
Embed Size (px)
Citation preview
B2B - Hypertension
Dr Jen Leppard, MD, CCFP-EMMarch 28, 2014
LMCC Objectives – HTN
1. Diagnose HTN and determine its severity2. Investigate target organ damage and 2o causes3. List medical management4. Recognition and management of HTN urgencies
and emergencies
1a. Diagnosis• 2014 Canadian
Guidelines:
o >160/>100 X 3
o OR
o >140/>90 X 5
o can use office, ambulatory, or home BP cuffs to measure
BP: 140-179 / 90-109
ABPM (If available)
Office BPM
Office BPM
Home BPM (If available)
Yes
Hypertension Visit 2
Target Organ Damageor Diabetes
or BP ≥ 180/110?
Hypertension Visit 1
BP Measurement,History and Physical
examination
Hypertensive
Urgency / Emergency
Diagnosisof HTN
No
Diagnostic algorithm for hypertension
2014
Criteria for Diagnosis of HTN and Criteria for F/UBP: 140-179 / 90-109
ABPM (If available)
Diagnosisof HTN
Awake BP>135 SBP or>85 DBP or
24-hour>130 SBP or
>80 DBP
Awake BP<135/85
and24-hour<130/80
Continue to follow-up
Office BP
Diagnosisof HTN
Hypertension visit 3 >160 SBP or >100 DBP
>140 SBP or>90 DBP
< 140 / 90
Diagnosisof HTN
Continue to follow-up
<160 / 100
Hypertension visit 4-5
ABPM or HBPMor
Home BPMHome BPM
>135/85>135/85 < 135/85 < 135/85
Diagnosisof HTN
Continue to follow-up
Patients with high normal blood pressure (office SBP
130-139 and/or DBP 85-89) should be followed annually.
Repeat Home BPM
Repeat Home BPM
If<
135/85
If<
135/85
or
2014
1b. Severity• End organ damage
o Acute vs Chronic
• Acute - discussed with hypertensive emergencies• Chronic Target Organ Damage
2a. Investigations of Target Organ
Damage
MCQ 10: What test is not needed in ambulatory testing for HTN?
A. Urine, urine albumin (DM)B. Lytes + creatinineC. Fasting glucose + cholesterolD. CBC + diff E. ECG
Routine Laboratory TestsPreliminary Investigations of patients with hypertension
1. Urinalysis2. Blood chemistry (potassium, sodium and creatinine)3. Fasting glucose and/or glycated hemoglobin (A1c) 4. Fasting total cholesterol and high density lipoprotein cholesterol
(HDL), low density lipoprotein cholesterol (LDL), triglycerides5. Standard 12-leads ECG
Currently there is insufficient evidence to recommend routine testing of microalbuminuria in people with hypertension who do not have diabetes
2014
Types of HTN• Secondary HTN• 5-10%• Identifiable Cause• ABCDE
• Essential HTN• Most common (90%)• Cause unknown
2b. Secondary HTN• A – Apnea, Aldosterone
o Obstructive Sleep Apneao Hyperaldosteronism
• B – Bruits, Bad kidneyso Renovascular disease (atherosclerosis, fibromuscular dysplasia)o Renal parenchymal disease
• C – Catecholamines, Coarct, Cushing’so Pheochromocytomao Coarctation of the Aortao Cushing’s Disease
• D – Drugs, Diet
• E – Erythropoietin, Endocrine Disorderso Increased EPO from endogenous or exogenous sourceso Hypo or Hyperthyroid, Hyperparathyroid,
CDMQ: What are the clinical
clues and investigations
for 2o causes?
Secondary HTNObstructive Sleep Apnea
Body habitusBed partner complaintsDaytime somnolence
Sleep study
Hyperaldosteronism May look cushingoid Low K+, high Na+24 hour urinary aldosterone level
Renovascular Disease
Abdominal bruitOnset before 30 or after 55 years old
Doppler US, MRA
Renal Parenchymal Disease
Peripheral Edema, ascites, pulm edemaPoor urine output
Elevated BUN, CreatUrinalysis, incl. ACRUltrasound, CXR
Secondary HTN
Pheochromocytoma
Headache, labile or paroxysmal HTNPalpitations, pallor, diaphoresis
24 hour urine metanephrines
Aortic Coarctation
Decreased BP in lower extremitiesDelayed femoral pulse
ECHOCT Angio
Cushing’s Disease
Cushingoid Dexamethasone suppression test
Stimulant Drugs
Sympathomimetic toxidrome
Urine toxECG
Secondary HTN
Hypothyroid Weight gain, constipation, hair loss, fatigue
Serum TSH
Hyperthyroid Weight loss, temperature intolerance, tachycardia, tremors
Serum TSH
Hyperparathyroid Signs of hypercalcemia
Serum PTHCalcium
Drugs NSAIDS, steroids, estrogens decongestants, EPO, MAOIs, SNRIs, SSRIs, stimulants, excessive EtOH, licorice root, immunosuppresants
Diet ObesityHigh salt intake
Ambulatory Management
Non-Pharmacologic• Physical Exercise – 30-60min 4-7X/day• Weight Reduction• Alcohol Consumption - < 2 drinks/day• DASH Diet – (Dietary Approach to Stop HTN)• Sodium Intake - < 2000mg Sodium/day (5g salt)• Stress Management
Ambulatory Management
Pharmacotherapy
AACEi (Ramipril)
ARBs (Candsartan)
BBeta-Blockers(Metoprolol)
CCCB
(Amlodipine)
DDiuretic(HCTZ)
Specific Pharmacotherapy
CAD• ACEI /ARB • Angina/recent MI: Beta-blocker
DM• + Renal: ACEI/ARB• CCB• Thiazide
Specific Pharmacotherapy
Asthma• Avoid Beta-Blocker
CKD (no DM)• ACEI/ARB• Thiazide
Improving Compliance
• Tailor pill-taking to fit patients’ daily habits• Once Daily Dosing• Combination pills• Dosettes/Blister Packs
4. HTN Emergencies
HTN Emergency=
ACUTE Target Organ Damage
What are the target organs?
MCQ 9: Which is not an HTN
emergency?
A. 35 M 220/140, dizzy, normal neuro examB. 50 M 200/120, chest pain, CXR wide mediastinumC. 25 F 28 wks pregnant, 150/80, seizureD. 80 F 220/120, left arm weaknessE. 45 F 200/120, crackles to apex, JVP 6cm
ACS
Pulmonary edema
Aortic Dissectio
n
HTN emergencies are…
Bleeds, seizures Encephalopathy (not just headache,
dizzy)
Acute Kidney Injury
Investigations for HTN emergency
ACS
Pulmonary edema
Aortic Dissection
Bleeds, seizure,
encephalopathy
AKI
Treat HTN emergency: General Management
• BP: Reduce MAP by 25%
• Iv medications:• Labetolol• Nitroprusside• Hydralazine
CDMQ: 45 F 220/120, bilateral crackles,
JVP 6cm, Sat 80%. List specific treatment
(3)?
Specific Treatment: Pulmonary Edema
• BiPAP• Nitro Drip IV• Furosemide iv
Specific Treatment: ACS
• Nitro*• (Beta Blocker)• ASA• Anti-platelet
Specific TreatmentAortic Dissection
Type A – Ascending – Surgical Mgt
Type B – Descending – Medical
Nitroprusside + beta blocker (esmolol)OR
Labetalol
Specific Treatment: Seizure+ preg (Eclampsia)