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Definition of Hypertension:Matter of controversy

Old guidelines (2010) :

HTN was as having BP>140/90 X 3 separate occasions :

Also the cutoff point for HTN in patient with diabetes and chronic kidney disease patients was 130/85 and the optimal goal of treatment regardless of patient age was to lower and keep BP to 139/89

New guidelinesproposed by ACC/AHA & adopted since 2017 :

�Under the new guidelines nearly 47% of American population of fall under having elevated BP.

�The new guidelines don't apply if the patient has been already diagnosed with HTN and is under treatment .

�The guidelines also redefined the various categories of hypertension. It eliminated the category of prehypertension.

�f patient had previously been diagnosed with high blood pressure, the new guidelines don't affect them too much.

�-Elevated Blood pressure is defined 120 to 129 systolic and less than 80 diastolic

�-Stage 1 hypertension is 130 to 139 systolic or 80 to 89 diastolic.

�-A BP reading of 140/90 mm Hg or higher is considered Stage 2 hypertension,

�-and anything higher than 180 mmHg systole and/or 120 mm Hg diastole is Hypertensive crisis.

New guidelines still emphasis on the way the BP is taken and how to eliminate a false elevated reading

Use a standard Monitor for the arm

�Avoid:

�Eliminate the chances of a high reading by:

•Patient should avoid taking caffeinated or alcoholic beverages 30 minutesbeforehand.

•Ask the patient to sit quietly for five minutes with his /her back supported andthe legs uncrossed.

•Patient arm should be supported on the table so the elbow should be at theheart level.

•Wrap the cuff over bare skin not on the cloth.

•Patient should not talk during the measurement.

•Leave the deflated cuff in place, wait a minute, then take a second reading. Ifthe readings are close, average them.

�If it is the first time the BP reading is high and the patient does not recall any history of having High Blood pressure inquire about any recent medication usewhether prescription or OTC.

�taking any allergy or cold medications drugs such as Clarinase, Cirrus, Zyrtec-D ,Panadol Cold sinus ,Advil Cold sinus , Flutab which have high concentration of αAdrenergic agonists (such as Pseudoephedrine or phenylephrine ) will show a high BP reading.

�Some examples of agents that induce hypertension include nonsteroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) inhibitors; illicit drugs; sympathomimetic agents; oral contraceptive or adrenal steroid hormones; cyclosporine and tacrolimus; licorice; erythropoietin

�Chronic Steroid use

History and Physical Exam:�The history of known renal disease, abdominal masses, anemia.

�A history of sweating, labile hypertension, and palpitations suggeststhe diagnosis of pheochromocytoma.

�A history of cold or heat tolerance, sweating, lack of energy, andbradycardia or tachycardia may indicate hypothyroidism orhyperthyroidism.

�A history of obstructive sleep apnea may be noted.

�A history of weakness suggests hyperaldosteronism.

�Kidney stones raise the possibility of hyperparathyroidism.

�If it is the first time the BP reading is high at this point the diagnosis is stillnot HTN but we are dealing with Elevated blood-pressure reading, withoutdiagnosis of hypertension.

�First time BP reading should be confirmed again with one more High readingto name be diagnosed as HTN.

�Diagnosis of Hypertension is made now are we dealing with the essential orsecondary Hypertension?

Essential Hypertension Vs Secondary HTN

�Primary (essential) hypertension�For most adults, there's no identifiable cause of high blood pressure. This type of high blood pressure,

called primary (essential) hypertension, tends to develop gradually over many years.

�Secondary hypertension�Hypertension due to an underlying disease. tends to appear suddenly and cause higher blood pressure

than does primary hypertension.

�Obstructive sleep apnea

�Kidney problems( Chronic Kidney disease , Glomerulonephritis , Acute kidney Injury)

�Adrenal gland tumors (including Pheochromocytoma, Conn syndrome or Primary Hyperaldosteronism )

�Thyroid problems (hyperthyroidism)

�Certain defects congenital such as Coarctation of Aorta, Fibromuscular dysplasia of renal artery

�Certain illegal drugs, such as cocaine and amphetamines

Hypertension is diagnosed now work up should be done looking for the presence of any end organ damage:

�12-lead electrocardiogram looking for any LVH or LBBB

�Complete blood count (CBC), for possible micrangipathic hemolytic anemia

�Chest radiograph, evidence of cardiomegaly

�Urinalaysis or Dipstick urinalysis can be used to detect hematuria or proteinuria(renal impairment),

�Microscopic urinalysis can be used to detect red blood cells (RBCs) or RBC casts(renal impairment)

�Electrolytes

�Blood urea nitrogen (BUN), and creatinine levels (used to identify renal impairment.

urine Microalbuminuria particularly if diabetic)

�fasting blood glucose or HBA1c

�calcium;

�and lipid profile following a 9- to 12-hour fast (total cholesterol, high-density lipoprotein [HDL] cholesterol, low-density lipoprotein [LDL]cholesterol, and triglycerides).

�An increase in cardiovascular risk is associated with a decreased GFR leveland with albuminuria.

Optional studies include a toxicology screen, pregnancy test, and endocrinetesting.

Treatment approach :

�A life style modification (regardless of HTN stage )

�Drug therapy: reserved only for

A- Stage I with stigmata of atherosclerosis( et. PVD, CAD ,TIA- Stroke / hypercholesterolemia ) or without prior CAD or Stroke with 10-year risk of heart disease or stroke using the ASCVD algorithm greater than10 %

B- stage 2 HTN

Stage I HTN without stigmata of atherosclerosis (et. PVD, CAD ,TIA- Stroke) with ASCVD 10 y risk of heart disease or stroke <10% by using the ASCVD algorithm

10-year risk of heart disease or stroke using the ASCVD algorithm published in 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk

https://www.cvriskcalculator.com/This calculator assumes that you have not had a prior heart attack or stroke.

ICD 10 Coding classification for insurance billing :

�Elevated blood-pressure reading, without diagnosis of hypertension. (ICD 10 :R03.0 )

�essential HTN (ICD 10 : I 10 )

�Secondary hypertension, unspecified. (ICD 10 : I 15.9 )

�Hypertensive Urgency ( ICD 10 :I 16.0)

�Emergency(presence of the above symptoms ) ( ICD 10: I 16.1)

Medication Therapy:

�for stage 1 start 1 first line medication and if 20/10 above the treatment target afterfollow up then add another first line agent, for the stage 2 we should use 2 first lines andfor better patient compliance the single dose of combined drugs is recommended

�All first-line antihypertensive agents may be considered for patients with diabetes,although ACE inhibitors/ARBs are preferred in the presence of albuminuria. Patients withdiabetes also have a target BP of less than 130/80 mm Hg.

�if black start with HCTZ or CCB since B blockers ACEI/ARBs are less effective in thisethnicity

�There is no compelling evidence to promote different treatment of hypertension basedon sex.

�Beta blockers may be continued through elective surgical procedures, but they shouldnot be initiated on the day of surgery. Patients with chronic conditions such as chronickidney disease or heart failure should be treated to a goal BP of less than 130/80 mm Hgwith appropriate medications.

�CCB (dihydropridine short acting or long acting (Arteriolar dilator rebound tachycardialong acting better for CAD)

�β Blockers: β1 metoprolol, β1 ,α1 effect Carvedilol

NICE guideline

Hypertensive crisis ( I 16.9)

�Any reading higher than 180/120 or Diastole>120 mm Hg is Hypertensive crisis

�Urgency ( I 16.0)�No end organ damage (lack of symptoms of CHF, ACS,AD, Hypertensive

Encephalopathy, TIA- Stroke ,Acute renal Failure)Rx oral prescription

�Emergency(presence of the above symptoms ) ( I 16.1)Transfer to ER �25% reduction of MAP (Diastolic+(systolic-diastolic)/3) within the first h then admit to ICU lower

below 160/110 with the next 6 h then bring it to normal within the next 48 if no complication then discharge

References:

�https://www.acc.org/latest-in-cardiology/articles/2017/11/08/11/47/mon-5pm-bp-guideline-aha-2017

�https://bjcardio.co.uk/2011/10/changes-to-hypertension-guidelines/

�https://emedicine.medscape.com/article/1952052-questions-and-answers

�https://www.nice.org.uk/guidance/cg127

�https://emedicine.medscape.com/article/1952052-overview

�https://www.health.harvard.edu/heart-health/reading-the-new-blood-pressure-guidelines

�https://www.cvriskcalculator.com/

�http://www.onlinejacc.org/guidelines/highbloodpressure

�http://www.cardiobrief.org/2017/11/13/new-blood-pressure-guideline-sets-lower-13080-threshold/

�https://www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure/blood-pressure-vs-heart-rate-pulse

�https://emedicine.medscape.com/article/241381-guidelines

�https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/symptoms-causes/syc-20373410