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B2B - Hypertension. Dr Jen Leppard, MD, CCFP-EM March 28, 2014. LMCC Objectives – HTN. Diagnose HTN and determine its severity Investigate target organ damage and 2 o causes List medical management Recognition and management of HTN urgencies and emergencies. 1a. Diagnosis.

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b2b hypertension

B2B - Hypertension

Dr Jen Leppard, MD, CCFP-EM

March 28, 2014

lmcc objectives htn
LMCC Objectives – HTN
  • Diagnose HTN and determine its severity
  • Investigate target organ damage and 2o causes
  • List medical management
  • Recognition and management of HTN urgencies and emergencies
1a diagnosis
1a. Diagnosis
  • 2014 Canadian Guidelines:
    • >160/>100 X 3
    • OR
    • >140/>90 X 5
    • can use office, ambulatory, or home BP cuffs to measure
diagnostic algorithm for hypertension
Diagnostic algorithm for hypertension

HypertensionVisit1

BP Measurement,

History and Physical examination

Hypertensive

Urgency / Emergency

Hypertension Visit 2

Target Organ Damage

or Diabetes

or BP ≥ 180/110?

Diagnosis

of HTN

Yes

No

BP: 140-179 / 90-109

Office

BPM

ABPM

(If available)

Home BPM

(If available)

2014

criteria for diagnosis of htn and criteria for f u
Criteria for Diagnosis of HTN and Criteria for F/U

Office BP

ABPM (If available)

Home BPM

Hypertension visit 3

>160 SBP or >100 DBP

Diagnosis

of HTN

Awake BP

<135/85

and

24-hour

<130/80

Awake BP

>135 SBP or

>85 DBP or

24-hour

>130 SBP or

>80 DBP

< 135/85

>135/85

<160 / 100

ABPM or HBPM

or

Hypertension visit 4-5

>140 SBP or

>90 DBP

Diagnosis

of HTN

Diagnosis

of HTN

Continue to follow-up

Continue to follow-up

Diagnosis

of HTN

Continue to follow-up

< 140 / 90

BP: 140-179 / 90-109

or

Repeat Home BPM

If

< 135/85

Patients with high normal blood pressure (office SBP 130-139 and/or DBP 85-89) should be followed annually.

2014

1b severity
1b. Severity
  • End organ damage
    • Acute vs Chronic
  • Acute - discussed with hypertensive emergencies
  • Chronic Target Organ Damage
2a investigations of target organ damage
2a. Investigations of Target Organ Damage

MCQ 10: What test is not needed in ambulatory testing for HTN?

  • Urine, urine albumin (DM)
  • Lytes + creatinine
  • Fasting glucose + cholesterol
  • CBC + diff
  • ECG
routine laboratory tests
Routine Laboratory Tests

Preliminary Investigations of patients with hypertension

  • Urinalysis
  • Blood chemistry (potassium, sodium and creatinine)
  • Fasting glucose and/or glycated hemoglobin (A1c)
  • Fasting total cholesterol and high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), triglycerides
  • 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
Types of HTN
  • Essential HTN
  • Most common (90%)
  • Cause unknown
  • Secondary HTN
  • 5-10%
  • Identifiable Cause
  • ABCDE
2b secondary htn
2b. Secondary HTN
  • A – Apnea, Aldosterone
    • Obstructive Sleep Apnea
    • Hyperaldosteronism
  • B – Bruits, Bad kidneys
    • Renovascular disease (atherosclerosis, fibromuscular dysplasia)
    • Renal parenchymal disease
  • C – Catecholamines, Coarct, Cushing’s
    • Pheochromocytoma
    • Coarctation of the Aorta
    • Cushing’s Disease
  • D – Drugs, Diet
  • E – Erythropoietin, Endocrine Disorders
    • Increased EPO from endogenous or exogenous sources
    • Hypo or Hyperthyroid, Hyperparathyroid,
ambulatory management non pharmacologic
Ambulatory ManagementNon-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
Ambulatory ManagementPharmacotherapy

A

ACEi (Ramipril)

ARBs (Candsartan)

B

Beta-Blockers

(Metoprolol)

C

CCB

(Amlodipine)

D

Diuretic

(HCTZ)

specific pharmacotherapy
Specific Pharmacotherapy

CAD

  • ACEI /ARB
  • Angina/recent MI: Beta-blocker

DM

  • + Renal: ACEI/ARB
  • CCB
  • Thiazide
specific pharmacotherapy1
Specific Pharmacotherapy

Asthma

  • Avoid Beta-Blocker

CKD (no DM)

  • ACEI/ARB
  • Thiazide
improving compliance
Improving Compliance
  • Tailor pill-taking to fit patients’ daily habits
  • Once Daily Dosing
  • Combination pills
  • Dosettes/Blister Packs
4 htn emergencies
4. HTN Emergencies

HTN Emergency

=

ACUTE Target Organ Damage

mcq 9 which is not an htn emergency
MCQ 9: Which is not an HTN emergency?
  • 35 M 220/140, dizzy, normal neuro exam
  • 50 M 200/120, chest pain, CXR wide mediastinum
  • 25 F 28 wks pregnant, 150/80, seizure
  • 80 F 220/120, left arm weakness
  • 45 F 200/120, crackles to apex, JVP 6cm
htn emergencies are
HTN emergencies are…

Aortic Dissection

Pulmonary edema

ACS

slide24

Bleeds, seizures Encephalopathy

(not just headache, dizzy)

Acute Kidney Injury

i nvestigations for htn emergency
Investigations for HTN emergency

Aortic Dissection

AKI

Pulmonary edema

ACS

Bleeds, seizure, encephalopathy

treat htn emergency general management
Treat HTN emergency: General Management
  • BP: Reduce MAP by 25%
  • Iv medications:
  • Labetolol
  • Nitroprusside
  • Hydralazine
specific treatment pulmonary edema
Specific Treatment: Pulmonary Edema
  • BiPAP
  • Nitro Drip IV
  • Furosemide iv
specific treatment acs
Specific Treatment: ACS
  • Nitro*
  • (Beta Blocker)
  • ASA
  • Anti-platelet
specific treatment aortic dissection
Specific TreatmentAortic Dissection

Type A – Ascending – Surgical Mgt

Type B – Descending – Medical

Nitroprusside + beta blocker (esmolol)

OR

Labetalol