HT 4 2555

Team Base :

Hypertension Sarunyu Suwanaugsorn

Padiporn Limaumpornpet

Suwikran Wongpraphairot

Department of Internal Medicine , PSU

1.

2.

3. Secondary Hypertension

4.

5.

6.

7.

Objectives

A. 40 BP 140/90 mmHg heart LV 2+

B. 60 BP 150/90 mmHg

C. 70 BP 160/100 mmHg

D. 35 BP, 145/90 mmHg, prolonged expiratory phase with faint sound

Objective 1:

Classification of Hypertension (JNC VII)

Category Systolic Diastolic

Optimal

ESC Hypertension Guidelines 2007

categories Systolic

(mmHg)

Diastolic

(mmHg)

optimal

Blood Pressure Thresholds (mmHg) for Definition of Hypertension

with Different Types of Measurement

SBP DBP

Office or Clinic 140 90

24-hour 125-130 80

Day 85

Night 120 70

Home 130-135 85

Diagnostic algorithm for high Blood Pressure including Office,

ABPM and Home Blood Pressure Measurement

BP: 140-179 / 90-109

ABPM (If available) Clinic BPM HBPM

Yes

Hypertension Visit 2 Target Organ Damage

or Diabetes

or Chronic Kidney Disease

or BP 180/110?

Hypertension Visit 1 BP Measurement,

History and Physical examination

Hypertensive

Urgency / Emergency

Diagnosis

of HTN

No

Diagnostic algorithm for high Blood Pressure including

Office, ABPM and Home Blood Pressure Measurement

BP: 140-179 / 90-109

ABPM (If available) Clinic BP HBPM

Diagnosis

of HTN

Awake BP

135 SBP or 85 DBP

Or 24-hour

130 SBP or 80 DBP

Awake BP

< 135/85 and

24-hour

< 130/80

Continue to follow-

up

Diagnosis

of HTN

Hypertension visit 3

160 SBP or 100 DBP

140 SBP or 90 DBP

< 140 / 90

Diagnosis

of HTN

Continue to

follow-up

< 160 / 100

Hypertension visit 4-5

ABPM or HBPM

or

135 SBP or DBP 85

< 135/85

Diagnosis

of HTN

Continue to

follow-up

or

50 gout 102/72 . blood pressure 130-142/80-92 .

A.

B.

C. cuff

D. arm support

Objective 2

Blood Pressure Assessment:

Patient preparation and posture Standardized Preparation:

Patient

1. No acute anxiety, stress or pain.

2. No caffeine, smoking or nicotine in the preceding 30

minutes.

3. No use of substances containing adrenergic

stimulants such as phenylephrine or

pseudoephedrine (may be present in nasal

decongestants or ophthalmic drops).

4. Bladder and bowel comfortable.

5. No tight clothing on arm or forearm.

6. Quiet room with comfortable temperature

7. Rest for at least 5 minutes before measurement

8. Patient should stay silent prior and during the

procedure.

Blood Pressure Assessment:

Patient preparation and posture

Standardized technique:

Posture

The patient should be calmly

seated with his or her back well

supported and arm supported at

the level of the heart.

His or her feet should touch the

floor and legs should not be

crossed.

Recommended Equipment for

Measuring Blood Pressure

Automated oscillometric devices:

Use a validated automated device according to BHS, AAMI or IP clinical protocols.

For home blood pressure measurement devices, a logo on the packaging ensures that this type of device and model meets the international standards for accurate blood pressure measurement.

AAMI=Association for the Advancement of Medical Instrumentation;

BHS=British Hypertension Society; IP: International Protocol.

Recommended Technique

for Measuring Blood Pressure (cont.)

Select a device with an appropriate size cuff

Use an appropriate size cuff

Arm circumference (cm) Size of Cuff (cm)

From 18 to 26 9 x 18 (child)

From 26 to 33 12 x 23 (standard adult model)

From 33 to 41 15 x 33 (large)

More than 41 18 x 36 (extra large, obese)

For automated devices, follow the manufacturers directions.

For manual readings using a stethoscope and sphygmomanometer, use the table as a guide.



Locate the brachial pulse and centre the

cuff bladder over it

Position cuff at the heart level

Arm should be supported


for Measuring Blood Pressure* (cont.)

To exclude possibility of auscultatory gap, increase cuff pressure rapidly to 30 mmHg above level of disappearance of radial pulse

Place stethoscope over the brachial artery

*with manual or semi automated devices

2011 Canadian Hypertension Education Program Recommendations


for Measuring Blood Pressure* (cont.)

Drop pressure by 2 mmHg / beat Appearance of sound (phase I

Korotkoff) = systolic pressure

Drop pressure by 2 mmHg / beat Disappearance of sound (phase V

Korotkoff) = diastolic pressure

Record measurement

Take at least 2 blood pressure measurements, 1 minute apart

Korotkoff sounds and auscultatory gaps

Systolic BP

Diastolic BP

200

180

160

140

120

100

80

60

40

20

0

No sound

Clear sound

Clear sound

Muffled sound

No sound

Phase 1

Phase 3

Phase 4

Phase 5

Muffling Phase 2

Auscultatory gap No sound

mmHg

Korotkoff sounds

Phase 4

Phase 3



The seated BP measurement is the standard position to determine diagnostic and therapeutic treatment decisions

The standing blood pressure is used to test for postural hypotension, if present, which may modify the treatment.

Recommended Technique for

Measuring BP: Standing BP

Perform in patients

over age 65

with diabetes

if there are symptoms of postural hypotension

Check after 1 to 5 minutes in the standing position and

under circumstances when the patients complains of

symptoms suggestive of hypotension.

40 2 T 36.5oC, BP 170/110 mmHg, P 92/min, R 20/min, , puffy face and eyelids, JVP 3 cm (upright position) urinalysis: sp.gr. 1.015, protein 2+, RBC numerous, WBC 3-5/HPF, red cell

cast 2-3/HPF

A. Hypothyroidism

B. Chronic renal failure

C. Acute glomerulonephritis

D. Congestive heart failure

Objective 3 secondary Hypertension

30 2 BP BP (mmHg)

Right arm 180/90

Left arm 140/80

Right leg 150/80

Left leg 178/90

P 80/min regular, low amplitude at left brachial a., right dorsalis

pedis, right poplitial and left carotid a., heart : LV1+, normal

S1S2, no murmur, abdominal bruit at RUQ area


A.Elevation of ESR

B.High thyroid hormone

C.Cathecholamine excess

D.High aldosterone, low renin


30 : Height 135 cm, BW 35 kg, BP 170/100 mmHg (upper extremities) 130/80 mmHg (lower extremities), web neck, low hairline, no secondary sex

characteristics, delayed lower extremities pulses

A.Coarctation of aorta

B.Aortic dissection

C.Takayasu arteritis

D.Premature atherosclerosis


50 5 BP 160/90 mmHg, spider nevi on anterior chest wall, lung increased AP diameter, generalized diminished breath sound, heart LV2+, loud P2, no murmur, abdomen shifting dullness +ve, spleen 3 cm BLCM, decreased DTR both upper and lower extremities

A. Polyneuropathy

B. Portal hypertension

C. Left ventricular hypertrophy

D. Pulmonary hypertension

Objective 4

Autoregulation

In the uninjured, normotensive brain, autoregulation is effective over MAP ranging

from about 50 150

In the chronic hypertensive, this range is increased (e.g. 80 180)

Autoregulation

Varon J, Marik PE. Chest. 2000;118:214-227

60 1 1 : BP 220/120 mmHg, P 100 bpm, drowsy, +ve papilledema, no stiff neck, heart- S4+ve, no localized neurological deficit BUN 70 mg/dL, Cr 3.5 mg/dL, urinalysis: protein 2+, blood 1+, RBC 5-10/HPF, WBC 0-1/HPF, no cast

A. Uremia

B. Hypertensive encephalopathy

C. Viral encephalitis

D. Intracerebral hemorrhage

Objective 5:

A.Urine metanephrines

B.Serum cardiac troponin-T CK-MB

C.Plasma aldosterone and renin activity

D.Urine analysis

Objective 5:

Diseases Attributable to Hypertension

Hypertension

Heart failure

Stroke Coronary heart disease

Myocardial infarction

Left ventricular

hypertrophy

Aortic aneurysm

Retinopathy

Peripheral vascular disease

Hypertensive

encephalopathy

Chronic kidney failure

Cerebral hemorrhage

Adapted from: Arch Intern Med 1996; 156:1926-1935.

All

Vascular

Complications of Hypertension:

End-Organ Damage

Chobanian AV, et al. JAMA. 2003;289:2560-2572.

Peripheral Vascular Disease Renal Failure,

Proteinuria

LVH, CHD, CHF Stroke

Retinopathy

CHD = coronary heart disease CHF = congestive heart failure LVH = left ventricular hypertrophy

Hypertension

50 3 6 1 : BW 90 kg, height 160 cm, BP 160/100 mmHg, P 64/min, R 24/min, acanthosis nigricans at back of neck, heart - loud P2

A. Sleep lab

B. Echocardiography

C. Thyroid function test

D. Fasting plasma glucose

Objective 6:

40 2 : BP 190/120 mmHg (supine) and 160/90 mmHg (upright), PR

120/min, BMI 18 kg/m2, moist skin, heart - LV1+, normal S1S2, no murmur,

A. Thyrotoxicosis

B. Cushing syndrome

C. Primary hyperaldosteronism

D. Pheochromocytoma

Objective 6:

55 3 3 BP 150/90 mmHg, P 72/min, R 16/min, T 37oC : BUN 16 mg/dL, Cr 1.2 mg/dL, Na 145 mEq/L, K 3.2 mEq/L, Cl 110 mEq/L, HCO3 30 mEq/L, urine

microalbumin +ve, TTKG 8 (normal

Hx/PE Cr K FBS CXR/ECG lipid urine

/

/

/

+++

+++

+++

+

+

++

+

-

+

-

+

+

-

+

+

+

+/-

-

-

+

-

A. () 10

B. () 10

C. hemorrhagic stroke hemorrhagic stroke ischemic stroke

D. 2 systolic BP stroke 10

Objective 7:

www.nheso.or.th 2551-2552

Prevalence of HT in Thailand; 4th NHES

0

5

10

15

20

0 100 200 300

5 Y

ea

r R

isk

(%

)

Stroke

Myocardial

Infarction

Systolic Blood Pressure (mmHg)

Differing influence of hypertension on

absolute and relative risk of stroke and MI

Brown, M.J. Lancet 2000; 355: 659 - 660

20 40 60 80 120 140 160 180 220 240 260 280

Normotensives Hypertensives

BP Reductions as Small as 2 mmHg Reduce the

Risk of CV Events by Up to 10%

Meta-analysis of 61 prospective, observational studies

1 million adults

12.7 million person-years

Prospective Studies Collaboration. Lancet. 2002;360:1903-1913.

2 mmHg

decrease in

mean SBP 10% reduction in

risk of stroke

mortality

7% reduction in

risk of IHD

mortality

Mechanisms Controlling CO and TPR

Artery Vein

2. Hormonal

Renal

Ang II

Adrenal

Catecholamines

Aldosterone

3. Local Factors

1. Neural

SymNS

PSNS

CRITICAL POINTS!

1. These organ systems and mechanisms control physical factors of CO and TPR

2. Therefore, they are the targets of antihypertensive therapy.

Determinants of Arterial Pressure

Mean Arterial

Pressure = X Arteriolar

Diameter

Blood

Volume

Stroke

Volume

Heart

Rate

Filling Pressure Contractility

Blood Volume Venous Tone

CRITICAL POINT!

Change any physical factors

controlling CO and/or TPR

and MAP can be altered.

Regulation of Blood Pressure

Adrenoceptors

Brain Stem

Sympathetic Stimulation

Peripheral

Resistance

BP

Cardiac

Output Renin

Renal blood

flow

Angiotensinogen

Angiotensin I

Aldosterone

Sodium Retension

Angiotensin II

BP= CO x PVR

Documents

HT 4 2555