Hypertension Elizabeth Evans DNP Renal Medicine Associates 2/29/2020
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Hypertension Elizabeth Evans DNP Renal Medicine Associates 2/29/2020
Define normal blood pressure, elevated blood pressure and stages
of hypertension
Identify risk factors for hypertension
Objectives Describe the treatment approaches for elevated hypertension,
including lifestyle modifications and medication therapy
I have no conflicts of interest to disclose
Hypertension is the most common chronic disease among adults
in the world.
Identified as the leading risk factor for premature death, disability
and overall disease burden worldwide.
Each increase of 20mm Hg in the systolic BP or 10 mm Hg in the
Prevalence diastolic BP doubles the risk of death from stroke or heart disease.
Most patients with hypertension could lower their BP through
lifestyle changes.
To diagnose hypertension, BP readings should use the average of
2 or more careful BP measurements taken on > 2 occasions using
careful BP measurement technique.
Step 1 – Properly prepare the patient (sit in chair, feet on floor and
back supported for > 5 minutes; avoid caffeine, exercise &
smoking for at least 30 minutes; ensure patient has voided; no
talking; ensure BP cuff will go on skin (not clothing); do not take
while patient on exam table).
Step 2 – Use proper BP measurement technique (calibrated BP
Key Steps for cuff; support patient’s arm; apply BP cuff on upper arm at the
level of the right atrium (sternum mid-point).
Proper BP Step 3 – Proper measurement (1st visit – measure both arms – use
Measurement the arm with the higher reading; separate repeat measurements
by 1-2 minutes; for auscultation – listen for Korotkoff sounds).
Checklist Step 4 – Proper documentation – note time of BP Rx.
Step 5 – Average the readings – use an average of > 2 readings
obtained on > 2 occasions to estimate the patient’s BP.
Step 6 – Provide the patient the BP readings both in writing and
verbally.
Arm Size/Circumference (measure arm at bicep Appropriate Cuff Size
level or half-way between elbow and shoulder)
22-26 cm (8.6 to 10.2 inches) Small adult
27 – 34 cm (10.3 to 13.4 inches) Adult
Proper BP cuff
34 – 44 cm (13.5 to 17.3 inches) Large Adult
size based on
arm size 45 – 52 cm ( 17.4 to 20.4 inches) Adult Thigh
https://www.youtube.com/watch?v=-BCDM4i3Cho
Primary Hypertension Secondary Hypertension
Gradual increase in BP with slow BP lability, episodic pallor and dizziness
rate of rise in BP. (pheochromocytoma)
Lifestyle factors that favor higher Muscle cramps, weakness (hypokalemia
BP (weight gain, high-sodium diet, from primary aldosteronism or secondary
Primary versus decreased activity, job change aldosteronism due to renovascular disease)
with increased travel, excessive
Secondary alcohol intake).
Hypertension- Family history of hypertension Snoring, hypersomnolence (OSA)
Prostatism (CKD due to post-renal urinary
How to obstruction)
recognize the Edema, fatigue, anemia (kidney disease)
History of coarctation repair (residual HTN
differences associated with coarctation)
Absence of family history of HTN
Medication or substance abuse (alcohol,
NSAIDs, cocaine, amphetamines)
Central obesity, easy bruising, facial
rounding (Cushings syndrome)ACC/AHA Systolic BP in mm Diastolic BP in Treatment Plan
2017 Hg mm Hg
guideline
definition
Normal 100 Lifestyle changes
Hypertension and 2 or more
antihypertensive
medications
Whelton et al, 2017 American College of Cardiology/American Heart Association High Blood Pressure Clinical Practice Guidelines. Office BP measurements are often not accurate; recommend to
diagnose and follow-up using home BP measurements (HBPM) or
ambulatory BP measurements (ABPM).
Examples of inaccurate readings: white coat HTN and masked
HTN and see the difference:
BP Classification Office BP Daytime ABPM or HBPM
Office versus Normal BP 130/80 mm Hg
White Coat HTN > 130/80 mm Hg < 130/80 mm Hg
Masked HTN 130/80 mm Hg > 130/80 mm HgHealthy Diet – Dietary approaches to Diet rich in fruits, vegetables, whole
Stop HTN (DASH diet). grains low fat dairy products with total
reduced fat intake.
Weight loss – focus on losing weight. Ideal body weight – 1 mm Hg BP
decrease for every 1kg body weight loss.
Lifestyle Sodium – reduce dietary sodium intake Attempt to lower sodium intake by 1000
toStop Nicotine
• cigarettes and e-cigarettes
• dipping and chewing tobacco
• remember to provide stop smoking resources
• avoid 2nd hand smoke
• ask if they are willing to stop smoking every visit
Other Lifestyle Restrict medications that increase BP:
• Non-steroidal anti-inflammatories (NSAIDs),
changes • caffeine
• decongestants
• some herbal supplements
• oral contraceptives
• recreational drugs
• angiogenesis or tyrosine kinase inhibitors
• amphetamines
• some antidepressants
Adapted from Whelton et al, 2017 ACC/AHA High Blood Pressure
Clinical Practice GuidelinesFood Group Number of Servings Daily
Grains and grain products 7 or 8
Vegetables 4 or 5
DASH diet –
Dietary Fruits 4 or 5
Approaches to Low-fat or fat-free dairy foods 2 or 3
Stop
Lean meat, fish and poultryPrimary Agent/Class Drug
Thiazide or Thiazide-like drugs Chlorthalidone,
Hydrochlorothiazide, Indapamide
ACE Inhibitors (Angiotensin Benazapril, Captropril, Enalapril,
Converting Enzyme Inhibitors) Fosinopril, Lisinopril, Moexipril,
Oral Anti- Perindopril, Quinapril, Ramipril,
hypertensive Trandolaprils (the prils)
Medications- ARBS (Angiotensin Receptor Azilsartan, Candesartan, Eprosartan,
Blockers) Losartan, Irbesartan, Olmesartan,
Primary Telmisartan, Varsartan (the sartans)
Agents CCBs (Calcium Channel Blockers) Amlodipine, Felodipine, Isradipine,
dihydropyrdines -- CCB-D Nisoldipine, Nicardipine SR,
Nifedipine LA
CCBs (Calcium Channel Blockers) Diltiazem ER, Verapamil ER, Verapil
nondihydropyridines – CCB-ND SR, Verapamil – delayed onsetSecondary Agents Drugs
Loop Diuretics Bumetanide, Furosemide, Torsemide
Potassium Sparing Diuretics Amiloride, Triamterene
Aldosterone Antagonists Diuretics (MRAs) Eplerenone, Spironolactone
Cardioselective Beta Blockers Atenolol, Betaxolol, Bisoprolol,
Oral Anti- Metoprolol tartrate and succinate
hypertensive Cardioselective/vasodilatory Beta Blockers Nebivolol
Noncardioselective Beta Blockers Nadolol, Propranol IR and LA
Agents – Beta Blockers – intrinsic sympathomimetic Acebutolol, Penbutolol, Pindolol
Secondary activity
Agents Alpha & Beta receptor Beta Blockers All Carvedilols, Labetalol
Direct renin inhibitor DRI) Aliskiren
Alpha-1 Blockers Doxazosin, Prazosin, Terazosin
Central Alpha-agonist & other centrally Clonidine (oral/patch), Methyldopa,
acting drugs Guanfacine
Central Vasolidators Hydralazine, MinoxidilCo-morbid Disease First Line Drugs Other Drugs to
add or avoid
Ischemic heart disease MI/Angina - BBs, CCB-D Thiazides, MRAs.
Heart Failure with reduced ACEi, ARBs, MRA; diuretic; AR- CCB-ND are not
First Line ejection fraction neprilysin inhibitor-ARB med; BB
(carvedilol, bisoprolol, metoprol
recommended
Do Not combine
Drugs for ol succinate). ACE and ARBs.
Heart Failure with Diuretics; Chlorthalidone – HTN Avoid CCBs-ND
Hypertension preserved ejection fraction control HTN due to fluid mgmt.
based Chronic Kidney Disease ACEi; use ARB if intolerant to
(CKD) or Kidney Transplant ACEi.
on comorbid Diabetes Diuretics; CCBs, ACEi; ARBs
diseases or Atrial Fibrillation BB (rate and BP control).
special patient Metabolic Syndrome
Pregnancy
Weight loss, exercise. ?drug
Methylodopa, Nifedipine,
Caution thiazides
BB or CCBs appear
groups Labetalol. Stop ACEi/ARB/DRI to prevent pre-
due to fetal abnormalities. eclampsia.
Black adults without heart Thiazides, CCBs; >2 meds are Lifestyle changes
failure or CKD recommended to achieve Some of these drugs may decrease your body's supply of the mineral
potassium. Symptoms such as weakness, leg cramps or being tired
may result. Eating foods containing potassium may help prevent
significant potassium loss. If your doctor recommends it, you could
prevent potassium loss by taking a liquid or tablet that has potassium
along with the diuretic. Diuretics such as amiloride (Midamar)*,
spironolactone (Aldactone)* or triamterene (Dyrenium)* are called
Diuretic "potassium sparing" agents. They don't cause the body to lose
potassium. They might be prescribed alone, but are usually used with
another diuretic. Some of these combinations are Aldactazide*,
possible side Dyazide*, Maxzide* or Moduretic*.
effects: Some people suffer from attacks of gout after prolonged treatment
with diuretics. This side effect isn't common and can be managed by
other treatment.
People with diabetes may find that diuretic drugs increase their blood
sugar level. A change in medication, diet, insulin or oral anti-diabetic
dosage corrects this in most cases.
Impotence may occur. Insomnia
Cold hands and feet
Tiredness or depression
Slow heartbeat
Symptoms of asthma
Possible Beta Impotence may also occur
Blocker Side If you have diabetes and you're taking insulin, have your responses
Effects to therapy monitored closely.
If you have been prescribed beta-blockers, consult your healthcare
provider prior to conception if you are considering pregnancy or if
there is a chance you could become pregnant. If you discover that
you are pregnant consult your healthcare provider as soon as
possible to determine the safest medication for you at this time. Skin rash
Loss of taste
Chronic dry, hacking cough
Possible Ace In rare instances, kidney damage
Women who are taking ACE inhibitors or ARBs for high blood pressure
Inhibitors or should not become pregnant while on this class of drugs. If you're
taking an ACE inhibitor or an ARB and think you might be pregnant,
Angiotensin see your doctor immediately. These drugs have been shown to be
dangerous to both mother and baby during pregnancy. They can
Receptor cause low blood pressure, severe kidney failure, excess
potassium (hyperkalemia) and even death of the newborn.
Blocker Side May cause occasional dizziness.
Effects ARBs should not be used during pregnancy.Medications that act
directly on the renin-angiotensin system can cause injury or even
death to a developing fetus. When pregnancy is detected, consult
your healthcare professional as soon as possible. Alpha methyldopa (Aldomet)* may produce a greater drop in blood
pressure when you're in an upright position (standing or walking), and
it may make you feel weak or faint if the pressure has been lowered
too far. This drug may also cause drowsiness or sluggishness, dryness
of the mouth, fever or anemia. Male patients may experience
impotence. If this side effect persists, your doctor may have to change
the drug dosage or use another medication.
Possible Side Clonidine (Catapres)*, guanabenz (Wytensin)* or guanfacine (Tenex)*
Effects of may produce severe dryness of the mouth, constipation or
drowsiness. If you're taking any of these drugs, don't stop suddenly
Central because your blood pressure may rise quickly to dangerously high
levels.
Agonists and Hydralazine (Apresoline)* may cause headaches, swelling around the
eyes, heart palpitations or aches and pains in the joints. Usually none
Vasodilators of these symptoms are severe, and most will go away after a few
weeks of treatment. This drug isn't usually used by itself.
Minoxidil (Loniten)* is a potent drug that's usually used only in
resistant cases of severe high blood pressure. It may cause fluid
retention (marked weight gain) or excessive hair growth. Palpitations
Possible Swollen ankles
Calcium
Constipation
Channel
Headache
Blocker Side
Effects DizzinessNormal BP Elevated BP Stage 1 HTN Stage 2 HTN
140/90 mmHg
Hg mmHg
Promote Initiate Is estimated 10 year CVD Initiate lifestyle
optimal lifestyle < 10%? If no, initiate changes and BP
lifestyle changes lifestyle changes and re- lowering medication.
habits eval in 3-6 months.
Re-evaluate Re-evaluate in Is estimated 10 year CVD Re-evaluate in one
How to in one year. 3-6 months. > 10 %? If yes, initiate
lifestyle changes and BP
month.
manage HTN lowering medication and
re-evaluate in one month.
Eval in 1 month- is BP goal If BP goal not met,
met? Why not? Increase why not & increase
med & see monthly til BP meds. See monthly
at goal. When BP at goal, til BP at goal. When
evaluate every 3-6 goal met, eval every
months. 3-6 months.How to assess Scores: Low Risk 20%
Aggressive BP treatment in the elderly – does it Treatment put them at too high risk? issues: HTN treatment may slow cognitive decline.
Clinical Frailty
Scale
Athanase Benetos. Circulation Research. Hypertension Management
in Older and Frail Older Patients, Volume: 124, Issue: 7, Pages: 1045-
1060, DOI: (10.1161/CIRCRESAHA.118.313236) © 2019 American Heart Association, Inc.Decisional
Algorithm for the
management of
Hypertension
in patients
aged 80 + years
Athanase Benetos. Circulation Research. Hypertension Management
in Older and Frail Older Patients, Volume: 124, Issue: 7, Pages: 1045-
1060, DOI: (10.1161/CIRCRESAHA.118.313236) © 2019 American Heart Association, Inc. 2004 Kdoqi – HTN pre-dialysis is >140/90 pre-dialysis and HTN
post-dialysis is >130/80
However dialysis BP readings are often taken without looking at
appropriate technique (cuff size, arm placement, clothing, etc).
Do we use the BP readings taken in dialysis are not taken for diagnostic readings
same HTN but to monitor cardiovascular stability before, during and
immediately for evaluating the dialysis treatment.
goals for Potential factors leading to inaccurate dialysis bp readings: white
coat syndrome, limited time for patients to relax, cannulation fear,
dialysis unknown validity of the bp devices attached to the hemodialysis
machine, medication adherence or holding medications pre-
patients? dialysis, fluid volume excess, dialysis suite temperature.
ABPM is the “gold standard” method for diagnosing HTN in esrd.
This predicts all-cause and CV mortality better than peridialytic BP. HTN in dialysis should be defined on the basis of home BP or ABPM
measurements.
Diagnosis of Home BP in HD: an average BP > 135/85 checked am/pm over 6 non-
dialysis days (2 wk period). Measured in quiet room, seated with back
HTN in dialysis and arm supported, after 5 min rest with 2 bp checks per occasion
taken 1-2 min apart.
patients Home BP in PD: average BP > 135/85 over 7 consecutive days with
same technique as above.
( Sarafidis, Persu et al, 2017.
Hypertension in dialysis patients: a ABPM in HD: average BP > 130/80 over 24-h monitoring, during a mid-
consensus document by the weekday free of HD. If possible, extend to 44 hr, covering a whole mid
European Renal and Cardiovascular week dialysis interval. PD is 24-h monitoring same BP.
Medicine (EURECA-m) working For HD: no recommendations can be made on the basis of pre or post
group of the European Renal
Association – European Dialysis and
dialysis BP. If no home or ABPM available, base the reading on office
Transplant Association (ERA-EDTA) BP taken mid weekday free of HD, with average of 3 measurements
and the Hypertension and the with 1-2 min intervals obtained in sitting position with 5 min of quiet
Kidney working group of the rest.
European Society of Hypertension The threshold of office BP > 140/90 can be used as the HTN diagnosis
(ESH).
of HTN in HD/PD patients. Sodium and volume overload
Main
Increase arterial stiffness
mechanisms of Activation of the sympathetic nervous system
HTN in dialysis Activation of the renin-angiotensin-aldosterone system
patients Endothelial dysfunction (i.e imbalance between endothelium-
( Sarafidis, Persu et al, 2017. Hypertension in
dialysis patients: a consensus document by derived vasodilators and vasoconstriction)
the European Renal and Cardiovascular
Medicine (EURECA-m) working group of the High prevalence of sleep apnea
European Renal Association – European
Dialysis and Transplant Association (ERA-
EDTA) and the Hypertension and the Kidney
Use of Erythropoietin-stimulating agents
working group of the European Society of
Hypertension (ESH). >172,000 patients followed for median 25 months. 43% of the patients died
during the followup. Criteria: 4-6 months after HD initiation using FMC data
from 2001-2012.
Identified a general trend: increased mortality with either high pre-HD SBP
and peridialytic SBP increase OR low pre-HD SBP and peridalytic SBP decline.
Association of all-cause Identified 4 distinct pre-HD SBP levels: 110, 130, 160, 180 mmHg
mortality with pre- Patients with pre-HD SBP levels of 110 that had an increase of SBP was
dialysis systolic blood associated with better survival. Decreased SBP associated with increased
mortality.
pressure and it
peridialytic change in Patients with pre-HD SBP 130 (normal) that had SBP decrease was not
associated with increased mortality. SBP increase was associated with
chronic hemodialysis decreased mortality.
patients Patients with 160/180 pre-HD SBP that had SBP increase was associated with
(Zhange, Preciado, Wang et al, 2020. increased mortality. SBP decrease was associated with decreased mortality.
Nephrology Dialysis Transplantation, 1-7.)
Generally, SBP declines by >30mmHg or any SBP increase is associated with
higher mortality.
Patient with high pre-HD SBP and increased SBP may suffer from chronic FVO
and vascular stiffness. These patients might benefit from more intensive fluid
removal. Achievement of individual patients’ dry weight
Minimization of inter- and intradialytic sodium gain
Restriction of sodium intake to Beta Blockers (lol): Carvedilol reduced mortality compared with
placebo in HD patients with dilated cardiomyopathy
Thrice weekly Atenolol reduced CV events c/w thrice weekly
lisinopril in HD pts with HTN and LVH.
ACEi (pril): Fosinopril did not reduce CV events & mortality c/w
Pharmacologic placebo in HD patients with LVH.
ARBS (sartan): Losartan/valsartan/candesartan reduced CV events
HTN & mortality treatment not including ACEi/ARBs in HD patients.
Treatment Olmesartan did not reduce CV events or mortality c/w treatment
not including ACEi/ARBs in HD patient with HTN.
CCBs (pine): Amlodipine reduced CV events c/w placement in HD
patients with HTN.
MRAs: Spironolactone may reduce CV events & mortality c/w no
additional treatment or placebo in HD and PD. ACOG has recommended treating pregnant patients as chronically
hypertensive according to recently changed criteria from the
American College of Cardiology and the American Heart
Association, which call for classifying blood pressure into the
following categories:
Normal. Systolic BP less than 120 mm Hg; diastolic BP less than
HTN in 80 mm Hg.
Pregnancy Elevated. Systolic BP greater than or equal to 120-129 mm Hg;
diastolic BP greater than 80 mm Hg.
ACOG 2019 guidelines for Hypertension
Treatment in Pregnancy
Stage 1 hypertension. Systolic BP, 130-139 mm Hg; diastolic BP,
80-89 mm Hg.
Stage 2 hypertension. Systolic BP greater than or equal to 140
mm Hg; diastolic BP greater than or equal to 90 mm Hg.HTN Pregnant women with chronic hypertension also should receive
low-dose aspirin between 12 weeks and 28 weeks of gestation.
Treatment Antihypertensive therapy should be initiated for women with
Guidelines persistent chronic hypertension at systolic pressure of 160 mm Hg
or higher and/or diastolic pressure of 110 mm Hg or higher.
during Consider treating patients at lower blood pressure (BP) thresholds
Pregnancy depending on comorbidities or underlying impaired renal function.Drug Therapy for Hypertension in Pregnancy
KDIGO Clinical Practice Guidelines on the management of BP in Chronic Kidney Disease January 2020
1. Lose weight: By far the most effective means of reducing elevated blood
pressure is to lose weight. And it doesn't require major weight loss to make a
difference. Even losing as little as 10 pounds can lower your blood pressure.
2. Read labels : Americans eat far too much dietary sodium, up to three times the
recommended total amount, which is 1,500 milligrams (mg) daily for individuals
with high blood pressure. It doesn't take much sodium to reach that 1,500-mg
daily cap — just 3/4 of a teaspoon of salt. There's half of that amount of sodium in
one Egg McMuffin breakfast sandwich. Weed out high-sodium foods by reading
labels carefully. "It is very difficult to lower dietary sodium without reading labels,
unless you prepare all of your own food. Beware of the "salty six," common foods
where high amounts of sodium may be lurking: breads and rolls, cold cuts and
cured meats, pizza, poultry, soup, sandwiches.
3. Get moving: It doesn't take much exercise to make a difference in your health.
Small Changes Aim for a half-hour at least five days a week. "Make sure you're doing something
you love, or it won't stick." "For some that means dancing; for others, biking or
to lower BP taking brisk walks with a friend." Even everyday activities such as gardening can
help.
4. Pump some iron: Add some weight lifting to your exercise regimen to help
lose weight and stay fit. Women lose muscle mass steadily as we age, and weight
lifting is an often-overlooked part of an exercise plan.
5. Limit alcohol to one drink per day: Drinking too much, too often, can increase
your blood pressure, so practice moderation.
6. Relieve stress with daily meditation or deep breathing sessions: Stress
hormones constrict your blood vessels and can lead to temporary spikes in blood
pressure. In addition, over time, stress can trigger unhealthy habits that put your
cardiovascular health at risk. These might include overeating, poor sleep, and
misusing drugs and alcohol. For all these reasons, reducing stress should be a
priority if you're looking to lower your blood pressure. Big Breakfast with Hotcakes (2100 mg sodium): 87% of
recommended sodium
6-Piece Buttermilk Crispy Tenders (2090 mg sodium): 87% of
recommended sodium
20-Piece Chicken McNuggets (1680mg sodium): 70% of the
recommended sodium
MCDonalds Double Quarter Pounder with Cheese (1300mg sodium): 54% of
the recommended sodium
Saltiest Foods The average adult consumes 3,400 mg of sodium per day
from AHA according to the Mayo Clinic. The primary cause of the excessive
daily intake of sodium is processed and preserved foods. These are
the menu offerings in America's fast-food restaurants like
McDonald's. 59 y/o female with Lupus with CKD stage 4, HTN.
April 2018 -- Uncontrolled hypertension (153/96) increased Serum
Creatinine (2.53 mg/dl) and proteinuria (UACR 1289).
Further medication adjustment, added chlorthalidone 12.5 – 25mg
that patient adjusted daily based on blood pressure and
Case Study edema/weight gain to keep SBP around 115-125.
Serum Creatinine 2.37 – 2.32 mg/dl (eGFR 21-22) now all of 2019
with UACR decreased to 681 and SBP maintained in the 115-125
range.Thank you and any questions
You can also read
