© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
* For Best Viewing:
Open in Slide Show Mode Click on icon or
From the View menu, select the Slide Show option
* To help you as you prepare a talk, we have included the relevant text from ITC in the notes pages of each slide
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
Terms of Use
The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets constitutes copyright infringement.
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
in the clinic
Hypertension
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
Cardiovascular disease
Retinopathy
Cerebrovascular disease
Ischemic heart disease
Left ventricular hypertrophy
Atrial fibrillation
Heart failure
Chronic kidney disease
Peripheral vascular disease
What long-term health risks are associated with hypertension?
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
Should clinicians screen for hypertension?
USPS Task Force
Screen the general adult population
No specific screening interval recommended
JNC 7 Guidelines
Screen every 2 years if <120/80 mm Hg
Annually if >139/89 mm Hg
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
What is prehypertension, and what is its proper management?
Blood pressure 120/80 to 139/89 mm Hg
“Prehypertension” is not in 2014 evidence-based guideline for management of adult high blood pressure
Drug therapy is not recommended for prehypertension
Evidence lacking on whether it decreases or prevents cardiovascular events
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
CLINICAL BOTTOM LINE: Screening and Prevention... Cardiovascular risk increases as blood pressure increases
Screen all adults for hypertension at 1- to 2-yr intervals
Lifestyle modification can delay hypertension + CVD onset
No evidence for adding pharmacotherapy for prevention
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
How should clinicians diagnose and stage hypertension?
When to diagnose hypertension:
≥2 readings obtained at 3 visits 2-4 wk apart
Average ≥140mmHg (systolic) or ≥90mmHg (diastolic)
Hypertension stages (JNC 7)
Normal blood pressure: ≤120/80 mm Hg
Prehypertensive: 120/80 to 139/89 mm Hg
Stage 1: 140/90 to 159/99 mm Hg
Stage 2: ≥160/100 mm Hg
If >50y, systolic blood pressure >140 mmHg more important CVD risk factor than diastolic hypertension
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
Instructions for Taking Blood Pressure
Have patient relax, sitting for >5 min
Support patient’s arm
Use stethoscope bell, not diaphragm, for auscultation
Check blood pressure first in both arms: Use arm with higher reading for all other + future readings
Measure blood pressure in sitting, standing, and lying positions (separate measurements by 2 min)
Use correct cuff size and note if special cuff size needed
Record systolic and diastolic pressures
Record exact results to nearest even number
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
Common errors that lead to falsely increased readings
Failure to have patient sit quietly for 5 min before reading
Failure to support limb
Using a cuff that is too small or deflating cuff too rapidly
To detect pseudohypertension, use Osler’s maneuver
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
What is white coat hypertension?
Elevated blood pressure at the office
Lower blood pressure at home or with 24-h ambulatory blood pressure monitor
Prevalence: 10% to 20%
Poses elevated risk for overt hypertension and CVD
Lifestyle modifications and regular follow-up recommended
Pharmacologic treatment not recommended
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
What is masked hypertension?
Normotensive in the office but elevated blood pressure out of the office
Prevalence: 10% to 40%
Increases sustained hypertension and CV death risk
Screen for suspected masked hypertension
Home readings
Ambulatory blood pressure monitoring
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
When is ambulatory blood pressure monitoring indicated?
Possible white coat hypertension
Unusual variability of blood pressure
Evaluation of nocturnal hypertension
Evaluation of drug-resistant hypertension
Determining the efficacy of drug treatment over 24h
Diagnosis and treatment of hypertension in pregnancy
Evaluation of symptomatic hypotension on various medications
Evaluation of episodic hypertension or autonomic dysfunction
Possible masked hypertension
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
What are the key elements of the history?
Assess duration, rapidity of onset, hypertension severity
Ask about cardiovascular risk factors, concomitant medical conditions, symptoms of target organ damage
Ask about past treatment and its effects
Ask about lifestyle
Ask about increased stress, physical inactivity, salt
Note any family history of hypertension, renal disease, cardiovascular problems, stroke, and diabetes
Review current medications (including OTC)
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
What are the essential elements of the physical examination?
Height, weight, BMI, waist circumference, skin lesions
Fundoscopy
Examination of neck
Cardiopulmonary examination
Abdominal examination
Neurologic examination
Peripheral pulses
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
Which laboratory tests should be done in newly diagnosed cases?
Newly diagnosed hypertension
Measure hemoglobin or hematocrit, serum electrolytes, serum creatinine, serum glucose, and fasting lipid levels
Urinalysis with microscopic examination
12-lead electrocardiography
Tests indicated by clinical factors or anticipated treatment
Echocardiography (more sensitive than EKG for LVH)
Serum uric acid levels (if patient has gout)
Microalbuminuria (if patient has diabetes)
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
Which patients should be evaluated for secondary hypertension, and how should they be evaluated?
Symptoms and Signs that Suggest Secondary Hypertension
New-onset hypertension at age <25 or >55 years
Drug-resistant hypertension
Spontaneous hypokalemia
Palpitations, headaches, and sweating
Severe vascular disease
Epigastric bruit
Radial-femoral pulse delay
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
Work-up for Possible Secondary Hypertension
Coarctation of aorta
The Cushing syndrome
Primary aldosteronism
Pheochromocytoma
Renal vascular disease
Renal parenchymal disease
Parathyroid disorders
Thyroid disease
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
CLINICAL BOTTOM LINE: Diagnosis...
≥140mmHg systolic or ≥90mmHg diastolic Measure blood pressure on several occasions, then average
Goals of the diagnostic evaluation Search for a secondary cause Detect other CVD risk factors Detect damage to target organs
History: past treatment, current meds, lifestyle factors Physical: eyegrounds, cardiovascular and nervous system Routine labs: hemoglobin, serum creatinine, glucose, lipid,
and electrolyte levels; urinalysis; EKG
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
What are treatment goals for patients with hypertension?
Goal: <140/90mmHg in patients with hypertension
Guidelines for Blood Pressure Goals from JNC 7
<140/90mmHg if <60 years old
<150/90mmHg if ≥60 years old
Kidney Disease Improving Global Outcomes (KDGO)
130/80mmHg for patients with CKD
<130/80mmHg if excreting >30 mg urine albumin/d
AHA/ACC
<140/90mmHg
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
What are the recommended lifestyle modifications for treating hypertension?
Salt restriction
Weight loss (to <20% above ideal weight for height)
Exercise (≥30 minutes aerobic exercise most days)
Smoking cessation
Alcohol intake limited to no more than 2 drinks daily
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
When is antihypertensive drug therapy indicated, and which drugs should clinicians prescribe as initial therapy?
Diuretics (thiazide)
ACE-inhibitors
Angiotensin-receptor blocker
Potassium-sparing diuretics
β-blockers
Calcium-channel blockers
Reserpine
Central β-agonists
Guanethidine
α-blockers
Hydralazine
Direct renin inhibitor
Drug treatments for hypertension
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
How should clinicians modify treatment on the basis of patient characteristics and comorbid conditions?
Compelling Indications for Individual Drug Classes
Heart failure: Diuretic, ß-blocker, ACE inhibitor, ARB, aldosterone antagonist
Postmyocardial infarction: ß-blocker, ACE inhibitor, aldosterone antagonist
High coronary disease risk: Diuretic, ß-blocker, ACE inhibitor, ARB + CCB
Diabetes: Diuretic, ß-blocker, ACE inhibitor, ARB, CCB
Chronic kidney disease: ACE inhibitor, ARB
Recurrent stroke prevention: Diuretic, ACE inhibitor
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
What is the role of combination therapies?
Advantages
Better adherence
May cost less for patients than individual prescriptions
ACE inhibitors or ARBs + hydrochlorothiazide
Good initial therapy if blood pressure >160/100mmHg
ACE inhibitors and ARBs + nonhydropyridine CCBs
Adding ACE inhibitor or ARB avoids edema of amlodipine monotherapy
ACE inhibitor-ARB combination therapy
ACE inhibitor-ARB combinations don’t seem to have clinical advantages
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
When blood pressure is poorly controlled, how should clinicians decide among increasing dose, adding an additional agent, or switching to another drug class?
Consider ambulatory blood pressure monitoring
Ask about co-medication with blood pressure-increasing drugs
Ask about excessive alcohol or salt intake
Reconsider secondary causes of hypertension
Evaluate medication adherence
Treat uncontrolled hypertension: use several drugs, each targeting different disease mechanism
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
Drug therapy for specific disease mechanisms of hypertension
Volume overload
Thiazide; loop diuretic; aldosterone antagonist
Sympathetic overactivity
ß-blocker (use to counteract reflex tachycardia from vasodilators or in heart failure)
Increased vascular resistance
ACE inhibitor or ARB (use in heart failure)
Smooth-muscle contraction
Dihydropyridine CCBs; ß-blocker; hydralazine
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
How often should patients with hypertension be seen?
Stable, well-controlled hypertension
Recheck at 6- to 12-month intervals
Blood pressure 140/90 to 159/99mmHg
Recheck at 2 months intervals
Blood pressure ≥160100mmHg
Recheck at ≤1 month intervals
After adjusting medications: allow 2-4 weeks for blood pressure to stabilize
Lab testing: intervals depend on number and type of medications and medical comorbidity
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
What is the value of home blood pressure monitoring?
Inexpensive way to monitor blood pressure
Especially before and after changing therapy
More accurate than in-office measurement
Instruct on correct technique
Have patient chart blood pressure once or twice per day
Brachial artery blood pressure cuff measurements more accurate than wrist cuff measurements
Helps confirm diagnosis in untreated patient
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
When should clinicians consider hospitalization?
Situations in which severe hypertension constitutes crisis
Cardiovascular
Left-ventricular failure; myocardial infarction
Unstable angina; aortic dissection
After vascular surgery or coronary artery bypass grafting
Neurologic
Hypertensive encephalopathy; thrombotic stroke
Subarachnoid or intracranial hemorrhage
Other
Severe catecholamine excess
Eclampsia in pregnancy
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
Drug-resistant hypertension uncontrolled with ≥3 drugs
Uncertainty about how to evaluate or manage suspected secondary hypertension
Need for assistance assessing target organ damage
When should clinicians consider referral to a hypertension specialist?
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
How should clinicians distinguish between a hypertensive emergency and a pseudocrisis?
Hypertensive urgency
Blood pressure >180/110mmHg w/o target organ damage
Patients can usually be managed with oral medications
Usually sent home after a few hours of observation
Hypertensive emergency
Elevated blood pressure with impending or acute progressive target organ damage
Usually requires admission to ICU and IV medication
Several drugs available to decrease blood pressure quickly
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (6): ITC6-1.
CLINICAL BOTTOM LINE: Treatment...
Blood pressure goal if patient <60y: <140/90 mmHg
Blood pressure goal if patient >60y: <150/90 mmHg
Lifestyle modifications can decrease blood pressure
Most patients also need at least 1 drug to reach goal
Severe hypertension requires urgent treatment if:
Acute cardiovascular or neurologic events are present
Patient is pregnant
Severe catecholamine excess is present