HPT Training Module Oct 2010

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Ministry of Health, Malaysia 2010 First published 2010 Disease Control Division Ministry of Health, Malaysia Level 6, Block E10, Parcel E Federal Government Administration Centre 62590 PUTRAJAYA Tel: 03-8883 4145 Fax: 03-8888 6277
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MANAGEMENT OF HYPERTENSION (3rd Edition)
TRAINING MODULE FOR HEALTH CARE PROVIDERS
HYPERTENSION GUIDELINE WORKING GROUP

CHAIRPERSON Dr. Abdul Rashid A. Rahman Professor of Medicine & Clinical Pharmacology and Senior Consultant Physician, Cyberjaya University College of Medical Sciences and An Nur Specialist Hospital, Selangor SECRETARY Dr. Sunita Bavanandan Consultant Nephrologist, Kuala Lumpur Hospital, Kuala Lumpur Dr. Anis Salwa Kamaruddin Principal Assistant Director, Desease Control Division, Ministry of Health, Putrajaya Dr. Chia Yook Chin Professor of Primary Care Medicine and Senior Consultant Primary Care Physician, University Malaya Medical Centre, Kuala Lumpur Dr. Fan Kin Sing Consultant Nephrologist, Gleanagles Intan Medical Centre, Kuala Lumpur Dr. Ghazali Ahmad Consultant Nephrologist and Head of Department, Department of Nephrology, Kuala Lumpur Hospital, Kuala Lumpur Dr. Khoo Ee Ming Professor of Primary Care Medicine and Senior Consultant Primary Care Physician, University Malaya Medical Centre, Kuala Lumpur Dr. Khalid Yusoff Professor of Medicine and Senior Consultant Cardiologist University Technology MARA, Selangor Dr. Robaayah Zambahari Senior Consultant Cardiologist, National Heart Institute, Kuala Lumpur Dr. Zaleha Abdullah Mahdy Professor and Senior Consultant Obstetrician & Gynaecologist, Hospital Universiti Kebangsaan Malaysia, Kuala Lumpur Dr. Hj. Azhari Rosman Consultant Cardiologist & Electrophysiologist, National Heart Institute, Kuala Lumpur Dr. Chua Chin Teong Consultant Nephrologist, Selangor Dr. Faridah Aryani Md. Yusof Clinical Trial Pharmacist and Pharmacoeconomist, Clinical Research Centre, Kuala Lumpur Hospital, Kuala Lumpur Dr. Guna Segaran Consultant Obstetrician and Gynaecologist, Damansara Specialist Hospital, Selangor Dr. Khoo Kah Lim Consultant Cardiologist, Pantai Medical Centre, Kuala Lumpur Dr. Lim Yam Ngo Consultant Paediatric Nephorologist, Kuala Lumpur Hospital, Kuala Lumpur Dr. Yap Piang Kian Consultant Physician & Endocrinologist, Subang Jaya Medical Centre, Selangor
HYPERTENSION GUIDELINE WORKING GROUP
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EDITORS
Associate Professor Dr. Anis Safura Ramli Consultant Family Medicine Specialist, Head of Primary Care Medicine Discipline, Faculty of Medicine, Universiti Teknologi MARA (UiTM), Sungai Buloh Campus Dr. Ng. Kien Keat Senior Lecturer & Family Medicine Specialist, Primary Care Medicine Discipline, Faculty of Medicine, Universiti Teknologi MARA (UiTM), Sungai Buloh Campus Dr. Mastura Ismail Consultant Family Medicine Specialist, Klinik Kesihatan Seremban 2, Negeri Sembilan Dr. Feisul Idzwan Mustapha Public Heath Specialist and Senior Principal Assistant Director, Disease Control Division, Ministry of Health, Malaysia Dr. Norhayati Ab. Shatar Medical Officer, Principal Assistant Director, Disease Control Division, Ministry of Health, Malaysia
CONTRIBUTORS
Professor Dr. Teng Cheong Lieng Senior Consultant Family Medicine Specialist, International Medical University (IMU), Bukit Jalil Associate Professor Dr. Tong Seng Fah Consultant Family Medicine Specialist, Universiti Kebangsaan Malaysia (UKM), Bangi Associate Professor Dr. Anis Safura Ramli Consultant Family Medicine Specialist, Universiti Teknologi Mara (UiTM), Sungai Buloh Dr. Mastura Ismail Consultant Family Medicine Specialist, Klinik Kesihatan Seremban 2, Negeri Sembilan Dr. Suhazeli Abdullah Consultant Family Medicine Specialist, Klinik Kesihatan Marang, Terengganu Dr. Verna Lee Kar Mun Senior Lecturer & Family Medicine Specialist, International Medical University (IMU), Bukit Jalil Dr. Chew Boon How Senior Lecturer & Family Medicine Specialist, Universiti Putra Malaysia (UPM), Serdang Dr. Ambigga Devi S. Krishnapillai Senior Lecturer & Family Medicine Specialist, Universiti Teknologi Mara (UiTM), Sungai Buloh Dr. Maizatullifah Miskan Senior Lecturer & Family Medicine Specialist, Universiti Teknologi Mara (UiTM), Sungai Buloh Dr. Ng Kien Keat Senior Lecturer & Family Medicine Specialist, Universiti Teknologi Mara (UiTM), Sungai Buloh Dr. Mazapuspavina Md. Yasin Senior Lecturer & Family Medicine Specialist, Universiti Teknologi Mara (UiTM), Sungai Buloh Dr. Farnaza Ariffin Senior Lecturer & Family Medicine Specialist, Universiti Teknologi Mara (UiTM), Sungai Buloh Dr. Nafiza Mat Nasir Senior Lecturer & Family Medicine Specialist, Universiti Teknologi Mara (UiTM), Sungai Buloh
EDITORS & CONTRIBUTORS
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TABLE OF CONTENTS
Hypertension Guideline Working Group Editors & Contributors Introduction
Topic 1 Topic 2 Topic 3 Topic 4 Introduction & Overview of Hypertension Burden in Malaysia Diagnosis and Management of Pre-hypertension Diagnosis and Management of Stage 1 Hypertension Diagnosis and Management of Stage 2 Hypertension & Resistant Hypertension Diagnosis and Management of Stage 3 Hypertension Hypertension and Diabetes Hypertension and Metabolic Syndrome Hypertension and Cardiovascular Disease Hypertension and Stroke Hypertension in the Elderly Hypertension in Pregnancy Hypertension and Oral Contraceptive Pills Hypertension and Hormone Replacement Therapy Workshop on Blood Pressure Measurement (Techniques & Skills) Pre-test and Post-test questionnaires (MCQs)
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1 21 31 43
TABLE OF CONTENTS
Topic 5 Topic 6 Topic 7 Topic 8 Topic 9 Topic 10 Topic 11 Topic 12 Topic 13 Topic 14
53 63 73 79 87 101 107 117 121 129
Appendix
135
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INTRODUCTION
The Clinical Practice Guidelines (CPG) on the Management of Hypertension (3rd Edition) was published in February 2008 and the Quick Reference (QR) for Health Care Providers was published in January 2010.
OBJECTIVE
This Training Module is developed to assist the trainers to:
1. 2. 3. Deliver the key content and messages of the CPG systematically. Demonstrate the applicability of CPG recommendations in clinical practice via interactive case discussions. Offer implementation strategies for effective hypertension management based on key elements of the Wagner Chronic Care Model.
This document contains the following:

1. 2. 3. 4. 5. CD-ROM containing the powerpoint presentations. Introduction and summary of training module content. Interactive case discussions in the beginning of each topic. Pre-test and post-test questionnaire (MCQs). Evaluation feedback of the training session.
Target Audience:
All levels of health care providers involved with the care of hypertensive patients in both primary care and secondary care settings.
Clinical Questions
In tandem with the main CPG, the clinical questions to be addressed in this training module include: 1. What are the current best practices in the management of a patient with hypertension? 2. How can hypertension management be done in tandem with the overall strategy to manage global vascular risk of a patient? 3. How can we improve the outcome of care for hypertensive patients?
Key Recommendations for Successful Implementation of this Training Module:

1. 2. 3. 4. 5. 6. 7. 8. Use interactive group discussion methods, rather than didactic way of teaching. Gauge the learning and language used (English/Malay/Others) to the level of target audience (suited to various levels of health care providers). Use problem-based facilitating methods. Encourage participants to familiarize themselves with the CPG and the QR prior to the training session (prerequisite). Emphasize teamwork. Allow participants to express their ideas, concerns and expectations openly. Address issues constructively. Obtain systematic feedback from participants.
INTRODUCTION
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Key implementation strategies to improve outcome for patients with chronic conditions in primary care (Adapted from the Wagner Chronic Care Model and WHO Innovative Care for Chronic Conditions Framework):
Key Elements
Delivery system redesign
Implementation Strategies
Level of actions
Redesign the delivery system using MESO LEVEL* multidisciplinary care teams, supported by District Health Office mutually understood care plan and Primary Health Care pathways.* Team Define roles and tasks among team members.* Stratify patients by risks and provide case management for those who are most at risk.* Involve secondary care specialists and create mutually agreed shared care plans for patients with severe complications and end-stage disease.* Develop national# and local chronic disease MACRO LEVEL# registries.* Policy makers Use electronic medical record and appointment system.* MESO LEVEL* Use electronic prescribing, reminder and Primary Health Care alerts on potential drug interaction and test Team results.* Create paper-based registries and MICRO LEVEL* comprehensive medical records in resource- Individual doctors and limited setting.* allied health care providers Embed evidence-based clinical guidelines recommendations into the structure of day-to-day decision-making process e.g. electronic reminders, academic detailing, etc.* Make patients aware of the evidencebased guidelines recommendations e.g. treatment targets, choice of therapy, etc.* Empower patients and their families with knowledge, skills and confidence to take effective control over their chronic Provide self-management tools, and routinely assess problems and accomplishments.* Establish ongoing collaborative effort between care team and patients for long term benefit.* MESO LEVEL* Primary Health Care Team MICRO LEVEL* Individual doctors and allied health care providers MESO LEVEL* Primary Health Care Team MICRO LEVEL* Individual doctors and allied health care providers Patients and families
INTRODUCTION
Clinical information systems
Decision support
Patient selfmanagement support
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Key Elements
Healthcare organization involvement
Implementation Strategies
Become the agent of change to transform chronic disease care.@ Restructure health care system and policy with a clear focus to improve chronic disease care.# Create universal funding mechanism to improve access and equity.# Provide incentives for achieving clinical targets, enhancing preventive care, or other quality improvement activities.# Perform ongoing clinical audit as part of quality assurance programme to improve chronic care quality.* Develop link with community resources which provide self-management support e.g. self-help groups, non-governmental organizations, etc.*
Level of actions
ALL LEVELS@ MACRO LEVEL# Policy makers MESO LEVEL* Primary Health Care Team
Community resources
MESO LEVEL* Primary Health Care Team MICRO LEVEL* Individual doctors and allied health care providers Patients and families
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INTRODUCTION
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Summary of Training Module Content

Teaching Learning Method
Lecture
No
1.
Topic
Introduction & Overview of CPG on Hypertension Management
Objective
To provide an overview of HPT burden in Malaysia To provide the knowledge based regarding definition, diagnosis, assessment, CV risk stratification and management of HPT To offer implementation strategies for effective hypertension management based on key elements of the Wagner Chronic Care Mode
Content
Epidemiology of Hypertension Definition and classification of hypertension Measurement of blood pressure Diagnosis and assessment Cardiovascular risk stratification Algorithm for the management of hypertension Lifestyle modification advice Pharmacological Agents The Wagner Chronic Care Model Roles and responsibilities of multidisciplinary care team in managing hypertension Roles and responsibilities of patients in self-managing hypertension Key messages Case scenario 1 Management based on CPG recommendation Summary of evidence for the recommendation Key messages
Duration (minutes)
60 (45 minutes introductory lecture + 15 minutes Q&A)
INTRODUCTION
2.
Diagnosis and To highlight the importance management of opportunistic screening for Pre-hypertension of Prehypertension To highlight the importance of therapeutic lifestyle modification in the management of Pre-hypertension Diagnosis and To highlight the importance management of opportunistic screening of Stage 1 of blood pressure Hypertension To highlight the importance of performing CV risk in guiding treatment
Interactive case discussion
60 (45 minutes interactive discussion + 15 minutes Q&A)
3.
Case scenario 2 Management based on CPG recommendation Summary of evidence for the recommendation Key messages Case scenario 3 Management based on CPG recommendation Summary of evidence for the recommendation Key messages
60 (45 minutes interactive discussion + 15 minutes Q&A) 60 (45 minutes interactive discussion + 15 minutes Q&A)
4. Diagnosis and To highlight the importance management of combination treatment of Stage 2 in the management of Hypertension Stage 2 Hypertension and Resistant To highlight the importance of identifying resistant Hypertension hypertension 5. Diagnosis and To highlight the importance management of hypertensive urgencies and emergencies of Stage 3 Hypertension To highlight the importance of assessing for target organ damages/complications
Case scenario 4 Management based on CPG recommendation Summary of evidence for the recommendation Key messages
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No
6.
Topic
Hypertension and Diabetes Mellitus
Objective
To highlight the importance of aggressive BP control in Diabetes To highlight the appropriate choice of pharmacological treatment according to current evidence
Content

Duration (minutes)
7.
Hypertension To highlight the importance Case scenario 6 and Metabolic of diagnosing MetS Management based on CPG Syndrome To highlight the importance recommendation (MetS) of treating HPT in MetS Summary of evidence for the recommendation Key messages Hypertension To appreciate HPT as a major risk factor to many and Cardiovascular cardiovascular diseases To make an appropriate Disease choice of anti-hypertensive medication in patients with concomitant cardiovascular disease To be aware of the targets for treatment Hypertension and Stroke To highlight the danger of rapid reduction of BP in patients with acute stroke To highlight the appropriate choice of pharmacological treatment according to current evidence Case scenario 7 Management based on CPG recommendation Summary of evidence for the recommendation Key messages
60 (45 minutes interactive discussion + 15 minutes Q&A) 60 (45 minutes interactive discussion + 15 minutes Q&A)
8.
11. Hypertension in Pregnancy
To highlight the classifications of Hypertension in Pregnancy To highlight the importance of identifying those at risks of developing Hypertension in Pregnancy
Case scenario 10 Summary of evidence for the recommendation Summary of evidence for the recommendation Key messages
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10. Hypertension in the Elderly
To highlight the importance Case scenario 9 of treating systolic Management based on CPG HPT in elderly recommendation Summary of evidence for the To address the issues of recommendation polypharmacy in elderly Key messages
INTRODUCTION
9.
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Topic
12. Hypertension and Oral Contraceptive Pills
Objective
To highlight the important interaction between BP and OCP
Content
Case scenario 11 Management based on CPG recommendation Summary of evidence for the recommendation Key messages Case scenario 12 Management based on CPG recommendation Summary of evidence for the recommendation Key messages Hands-on skills training

Duration (minutes)
60 (45 minutes interactive discussion + 15 minutes Q&A) 60 (45 minutes interactive discussion + 15 minutes Q&A) 60 Lecture: 20 minutes Hands-on: 40 minutes
13. Hypertension and Hormone Replacement Therapy
To highlight the important interaction between BP and HRT
INTRODUCTION
14. Workshop on BP measurement (technique and skills)
To demonstrate accurate techniques of BP measurements
Workshop 5 Lecture followed by hands-on training
15. Assessment of knowledge
To test the knowledge of participants pre and post training
15 T/F MCQs 15 Single Best Answer (SBA) Questions
Pre-test and post test questionnaire
60
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Slide 1
PRESENTATION OUTLINE
Epidemiology of Hypertension Definition Measurement of Blood Pressure Diagnosis & Classification Evaluation & Assessment Management Algorithm Cardiovascular Risks Stratification Therapeutic Lifestyle Modification Pharmacological Agents The Wagner Chronic Care Model Key messages
INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA
Slide 2
GLOBAL BURDEN FOR HYPERTENSION
An Estimated 972 million individuals worldwide suffer from hypertension in the year 2000. Kearney et al. Global burden of hypertension: analysis of worldwide data. Lancet 2005; 365 (9455):217-23
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THE RISING EPIDEMIC OF HYPERTENSION
National Health Morbidity Surveys I, II & III (1986-2006)
Slide 4
NHMS III : AWARENESS RATE
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NHMS III : TREATMENT RATES
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NHMS III : CONTROLLED RATE
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DEFINITION
Hypertension is defined as persistent elevation of systolic BP of 140 mmHg or greater and/or diastolic BP of 90 mmHg or greater.
Slide 8
INITIAL ASSESSMENT
Initial BP (mmHg) Systolic Diastolic Follow-up recommended to confirm diagnosis and/or review response to treatment. Recheck in one year
< 130 and < 85 130-139 and 85-89 140-159 and/or 90-99 160-179 and/or 100-109 180-209 and/or 110-119 210 and/or 120
Recheck within 3-6 months Confirm within two months and treat if medium, high or very high risks Evaluate within one month and treat when confirmed Look for symptoms and sign of hypertensive urgency or emergency, if asymptomatic, evaluate within one week and treat whan confirmed Initiate drug treatment immediately
Slide 9
DIAGNOSIS & CLASSIFICATION
Category
Optimal Prehypertension Stage 1 HPT Stage 2 HPT Stage 3 HPT
Systolic (mmHg)
< 120 120-139 140-159 160-179 180 and
Diastolic (mmHg)
< 80 80-89 90-99 100-109 110
Diagnosis of hypertension is made based on the average of two or more readings, taken at two or more visits to the health care providers
and/or and/or and/or and/or
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Slide 10
EVALUATION
EVALUATION OF NEWLY DIAGNOSED HYPERTENSIVE PATIENTS Evaluation should include through history, physical examination and relevant investigations. Three main objectives: 1. To exclude secondary causes of hypertension 2. To ascertain the presence of target organ damage (TOD) 3. To assess lifestyle and identity other cardiovascular risk factors and/or concomitant disorders that may affect treatment and prognosis.
Slide 11
MEDICAL HISTORY
duration and level of elevated BP if known symptoms of secondary causes of hypertension symptoms of target organ damage, e.g. coronary heart disease (CHD) and cerebrovascular disease symptoms of concomitant disease that will affect prognosis or treatment, e.g. diabetes mellitus, renal disease and gout family history of hypertension, CHD, stroke, diabetes, renal disease or dyslipidaemia dietary history including salt, fat, caffeine and alcohol intake drug history of either prescribed or over-the-counter medication (NSAIDS, nasal decongestants) and herbal treatment lifestyle and environmental factors that will affect treatment and outcome, e.g. smoking, physical activity, work stress and excessive weight gain since childhood
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PHYSICAL EXAMINATIONS
general examination: height, weight and waist circumference two or more BP measurements separated by two minutes with the patient either supine or seated; and after standing for at least one minute measure BP on both arms fundoscopy look for carotid bruit, abdominal bruit, presence of peripheral pulses and radio-femoral delay cardiac examination chest examination for evidence of cardiac failure abdominal examination for renal masses, aortic aneurysm and abdominal obesity neurological examination to look for evidence of stroke signs of endocrine disorders, e.g. Cushing syndrome, acromegaly and thyroid disease
BASELINE INVESTIGATIONS
Full blood count Urinalysis Urine albumin excretion or albumin/creatinine ratio Renal profile and serum uric acid Fasting blood sugar Fasting lipid profile Electrocardiogram (ECG) Chest X-ray (if clinically indicated)
Note : Should be repeated 6-12 monthly thereafter (except for Chest X-Ray)
Slide 14
CARDIOVASCULAR RISK FACTORS
Hypertension Cigarette smoking Central obesity (waist circumference > 90 cm for men, > 80 cm for women) Physical inactivity Dyslipidaemia Diabetes mellitus Microalbuminuria Estimated GFR < 60 mL/min Age (> 55 years for men, > 65 years for women) Family history of premature cardiovascular disease (men < 55 years or women < 65 years)
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Slide 15
SECONDARY CAUSES
Sleep apnoea Drug-induced or drug-related Chronic kidney disease Primary aldosteronism Renovascular disease Chronic steroid therapy and Cushing syndrome Phaeochromocytoma Acromegaly Thyroid or parathyroid disease Coarctation of the aorta Takayasu Arteritis
Slide 16
TARGET ORGAN DAMAGE & COMPLICATIONS
MANIFESTATIONS OF TOD/TARGET ORGAN COMPLICATION (TOC) Organ System Manifestations
Cardiac
Left ventricular hypertrophy (LVH), coronary heart disease (CHD), heart failure
Cerebrovascular
Transient ischaemic attack (TIA), stroke
Peripheral vasculature
Absence of one or more major pulses in extremities (except dorsalis pedis) with or without intermittent claudication
Renal
GFR < 60ml/min/1.73m2, proteinuria (1+), microalbuminuria (2 out of 3 positive tests over a period of 4-6 months)
Retinopathy
Haemorrhages or exudates, with or without papilloedema
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ALGORITHM FOR THE MANAGEMENT OF HYPERTENSION
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CARDIOVASCULAR RISK STRATIFICATION
Co-existing Condition BP Levels (mmHg) SBP 120-139 and/or DBP 80-89 SBP 140-159 and/or DBP 90-99 SBP 160-179 and/or DBP 100-109 SBP 180-209 and/or DBP 100-119 SBP 210 and/or DBP 120 Risk Level Low Medium High Very High No RF No TOD No TOC TOD or RF (1-2), No TOC TOD or RF ( 3) or Clinical atherosclerosis Previous MI or Previous Stroke or Diabetes Mellitus (DM)
Low
Medium
High
Very High
Low
Medium
High
Very High
Medium
High
Very High
Very High
High
High
Very High
Very High
Very High
Very High
Very High
Very High
Risk of major CV event in 10 years < 10% 10-20% 20-30% > 30%
Management Lifestyle changes Drug treatment and lifestyle changes Drug treatment and lifestyle changes Drug treatment and lifestyle changes
TOD : LVH, Retinopathy, Proteinuria / TOC : Heart Failure, Renal Failure) Risk Factors (RF): additional RF (smoking, TC > 6.5 mmol/L, family history of premature vascular disease) Clinical atherosclerosis (CHD, carotid stenosis, peripheral vascular disease, TIA, stroke) MI: Mycardial Infarction Legend: Green Yellow Orange Red
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BLOOD PRESSURE TREATMENT TARGETS
Category Uncomplicated hypertension Hypertension in high risk groups: DM, History of CVD Diabetics with proteinuria of > 1g/24 hours
Once target BP is achieved, follow-up at 3-6 month interval is appropriate.
Target blood pressure (mmHg) < 140/90 < 130/80 < 125/75
Slide 20
THERAPEUTIC LIFESTYLE MODIFICATION
Therapeutic lifestyle modification is the first line treatment in all patients with hypertension.
Weight reduction As far as possible aim for an ideal Body Mass Index [Weight (kg)/Height2 (m)] for Asians, the normal range has been proposed to be 18.5 to 23.5 kg/m2. However a weight loss as little as 4.5 kg significantly reduces BP
Salt intake
An intake of < 100 mmol of sodium or 6g of sodium chloride a day is recommended (equivalent to < 1 1/4 teaspoonfuls of salt or 3 teaspoonfuls of monosodium glutamate)
Alcohol intake
Physical activity
General advice on cardiovascular health would be for milder exercise, such as brisk walking for 30 60 minutes at least 3 times a week
Diet
A diet rich in fruits, vegetables and dairy products with reduced saturated and total fat can substantially lower BP (11/6 mmHg in hypertensive patients and 4/2 mmHg in patients with high normal BP)
Smoking cessation
Cessation of smoking is important in the overall management of the patients with hypertension in reducing cardiovascular risk
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Standard advice is to restrict intake to no more than 21 units for men and 14 units for women per week (1 unit equivalent to 1/2 a pint of beer or 100 ml of wine or 20 ml of proof whisky)
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ANTIHYPERTENSIVE AGENTS
Formulation Minimum dose Maximum dose Remarks
Diuretics
Chlorothiazide Hydrochlorothiazide Amiloride/hydrochlorothiazide 5mg/50mg Indapamide SR Indapamide Triamterene/hydrochlorothiazide 50mg/25mg 250 mg OD 25 mg OD 1 tablet OD 1.5 mg OD 2.5 mg OD 1 tablet BD 500 mg OD 200 mg OD 4 tablet OD 1.5 mg OD 2.5 mg OD 2 tablet BD Potassium should be closely monitored. Used with care in patient with gout. Potassium sparing diuretics may cause hyperkalemia if given with ACEIs/ARBs/renal insufficiency.
-blockers
Atenolol Bisoprolol Metoprolol Propranolol
50 mg OD 5 mg OD 50 mg BD 40 mg BD
100 mg OD 10 mg OD 200 mg BD 320 mg BD
Contraindicated in patient with COAD, severe Peripheral Vascular Disease and heart block.
Calcium Channel Blockers (CCBs)

Amlodipine Diltiazem Diltiazem SR Felodipine Lercanidipine Nifedipine Nifedine SR Verapamil Verapamil CR 5 mg OD 30 mg TDS 90 mg BD 2.5 mg OD 10 mg OD 10 mg TDS 30 mg OD 80 mg BD 200 mg OD 10 mg OD 60 mg TDS 90 mg BD 10 mg OD 20 mg OD 30 mg TDS 120 mg OD 240 mg TDS 200 mg BD Verapamil may reduce heart rate and use with care with -blockers
ACE Inhibitors (ACEIs)

Captopril Enalapril Lisinopril Perindopril Ramipril Quinapril 25 mg BD 2.5 mg OD 5 mg OD 2 mg OD 2.5 mg OD 2.5 mg OD 50 mg TDS 20 mg BD 80 mg OD 8 mg OD 10 mg OD 40 mg BD Contraindicated in pregnancy and bilateral renal artery stenosis Check serum creatinine before initiation and repeat 2 weeks after initiation ACEIs should be stopped if rise in creatinine > 30% from baseline
Angiotensin Receptor Blockers (ARBs)

Candesartan Irbesartan Losartan Telmisartan Valsartan Olmesartan 8 mg OD 150 mg OD 50 mg OD 20 mg OD 80 mg OD 20 mg OD 16 mg OD 300 mg OD 100 mg OD 80 mg OD 160 mg OD 40 mg OD Contraindicated in pregnancy and bilateral renal artery stenosis
Miscellaneous
Prazosin (-blocker) Doxazosin Labetalol Carvedilol Methyldopa 0.5 mg BD 1 mg OD 100 mg BD 12.5 mg OD 125 mg BD 10 mg BD 16 mg OD 800 mg TDS 50 mg OD 1 gm BD Doxazosin is useful in patient with benign prostatic hypertrophy In elderly, start Labetolol with 50mg BD
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Slide 22
PHARMACOLOGICAL MANAGEMENT OF STAGE 1 HYPERTENSION
Slide 23
CHOICE OF FIRST LINE MONOTHERAPY
In patients with newly diagnosed uncomplicated hypertension who have no compelling indications, choice of first line monotherapy includes ACEIs, ARBs, CCBs and Diuretics. -blockers are no longer recommended for first line monotherapy in this group of patients. However, it may be considered in younger people, particularly those who are intolerant or contraindicated to ACEI or ARB, women of child bearing potential and patients with evidence of increased sympathetic drive.
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PHARMACOLOGICAL MANAGEMENT OF STAGE 2 HYPERTENSION Initiating therapy with the right combination of at least 2 drugs is recommended. EFFECTIVE ANTIHYPERTENSIVE COMBINATION
Effective combination -blockers + diuretics Comments Benefits proven in the elderly, cost-effective. However, may increase the risk of new onset diabetes Relatively cheap, appropriate for concurrent CHD Appropriate for concurrent dysliplidaemias and diabetes mellitus Appropriate for concurrent heart failure, diabetes mellitus and stroke Appropriate for concurrent heart failure and diabetes mellitus
-blockers + CCBs CCBs + ACEls/ARBs
ACEls + diuretics
ARBs + diuretics
Slide 25
CHOICE OF HYPERTENSIVE AGENTS IN PATIENTS WITH CONCOMITANT CONDITIONS
Concomitant disease Diabetes mellitus (without nephropathy) Diabetes mellitus (with nephropathy) Gout Dyslipidaemia Coronary heart disease Heart failure Asthma Peripheral vascular disease Non-diabetic renal impairment Renal artery stenosis Elderly with no co-morbid conditions Very elderly (> 80 years old) with no co-morbid conditions Diuretics + ++ +/+/+ +++ + + ++ + +++ +++ -blockers +/+/+ +/+++ +++# +/+ + + + ACEIs +++ +++ + + +++ +++ + + +++ ++$ + ++ CCBs + ++* + + ++ +@ + + +* + +++ + Peripheral -blockers +/+/+ + + + + + + + +/+/ARBs ++ +++ + + ++ +++ + + ++ ++$ + +
The grading of recommendation from (+) to (+++) is based on increasing levels of evidence and/or current widely accepted practice +/- Use with care Contraindicated * Only non-dihydropyridine CCB # Metoprolol, bisoprolol, carvedilol dose needs to be gradually titrated Current evidence available for amlodipine and felodipine only @ $ Contraindicated in bilateral renal artery stenosis
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RESISTANT HYPERTENSION
If BP is still > 140/90 mmHg with combination of 3 drugs (including a diuretic at near maximal doses) - check on the possible causes of resistant HPT: Non-compliance Secondary hypertension White coat hypertension Excessive salt or liquorice intake Drug interaction Complications of long standing hypertension e.g nephrosclerosis, loss of aortic distensibility and atherosclerotic renal artery stenosis
Slide 27
SEVERE HYPERTENSION
Severe hypertension is defined as BP > 180/110mm Hg (persistent elevation after 30 minutes bed rest) Possible clinical scenarios Asymptomatic severe HPT Incidental findings Non-specific symptoms like headache, dizziness, lethargy Management Most can be managed as outpatient Review existing drug regime and compliance For newly-diagnosed, consider admission for evaluation For established HPT, admit if compliance remains a problem Hypertensive urgencies Presents with grade III or IV retinal changes, or proteinuria 2+, but no overt organ failure Management Initial treatment should aim for 25% reduction in BP over 24 hours but not lower than 160/90mm Hg Combination therapy is often necessary (see table below) Admit patient if BP remain > 180/110 mmHg Hypertensive emergencies Presents with symptoms and signs of TOC e.g. acute heart failure, subarachnoid haemorrhage, acute coronary syndromes Management All patient should be admitted Aim to reduce BP by 25% over 3-12 hours but not lower than 160/90 mmHg Best achieved with parenteral drugs
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Slide 28
THE CHRONIC CARE MODEL
Slide 29
6 ELEMENT OF CHRONIC CARE MODEL
No. 1. Elements Health care organization & policies Community resources Self management support Delivery system redesign Decision support Explanation Create policies with a clear focus to improve chronic disease care. Goals, values & incentives to care providers must be aligned with payers & MOH Patients & care providers need linkages with community resources such as home care, exercise program and support groups Empower patients with knowledge and skills to enhance confidence to self-care. Build quality relationship through effective communication Multi-disciplinary practice team with clear division of labour; planned management and visits Translate evidence based clinical practice guideline recommendations into daily clinical practice and improve access to specialist expertise Computerized system to remind & prompt actions; support shared care among multiple professionals, provide feedback to health care personel and track progress
2.
3.
4. 5.
6.
Clinical information system
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Slide 30
Multi Disciplinary Team Members Doctors Roles and Responsibilities Lead the multidisciplinary team Negotiate and create care pathways to work with other members of the team Perform a complete history and physical examination Review investigation results Ascertain the presence or absence of TOD/TOC Identify other CV risk factors and/or concomitant disorders that affect treatment and prognosis Assess global CV risks for individual patient Exclude secondary causes of HPT in suspected cases Explain to patient regarding achievement of control targets Make therapeutic decisions Emphasize the advice given by other allied team members Assess and address patients ideas, concerns and expectations Offer psychosocial support where appropriate
Slide 31
Multi Disciplinary Team Members Nurses Roles and Responsibilities Conduct anthropometric measurements Coordinate baseline/ relevant investigations Assess lifestyle diet, exercise and smoking status Educate patient regarding hypertension, cardiovascular risks and potential complications Educate patient regarding control targets Counsel patient regarding therapeutic lifestyle modification Arrange follow-up as per care pathway Track and remind defaulters Assess and address patients ideas, concerns and expectations Offer psychosocial support where appropriate
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Multi Disciplinary Team Members MA Roles and Responsibilities Conduct anthropometric measurements Coordinate baseline/ relevant investigations as agreed in the care pathway Assess lifestyle diet, exercise and smoking status Continue drug treatment if BP controlled Discuss with doctor if BP not controlled Educate patient regarding hypertension, cardiovascular risks and potential complications Educate patient regarding control targets Counsel patient regarding therapeutic lifestyle modification Arrange follow-up as per care pathway Track and remind defaulters Assess and address patients ideas, concerns and expectations Offer psychosocial support where appropriate
Slide 33
Multi Disciplinary Team Members Pharmacists Roles and Responsibilities Educate patient regarding antihypertensive medication, its potential benefits and side effects Monitor side-effects Assess adherence to medication Assess and address patients ideas, concerns and expectations of the medications Perform detail dietary assessment Educate patient regarding calorie intake Counsel regarding healthy dietary habit Counsel regarding weight management where appropriate Assess and address patients ideas, concerns and expectations
Dieticians
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Slide 34
KEY LEARNING POINTS
Hypertension (HPT) is defined as persistant elevations of SBP of 140mmHg and/or DBP 90 mmHg In 2006, prevalence of HPT in Malaysia was 42.6% among those aged 30 years HPT is a silent disease; 64% of cases remain undiagnosed. Therefore, BP should be measured at every chance encounter Untreated or sub-optimally controlled HPT leads to increased cardiovascular, cerebrovascular and renal morbidity and mortality A SBP of 120-139 and/or DBP of 80-90mm Hg is defined as pre-HPT and should be treated in certain high risk groups Therapeutics lifestyle changes should be recommended for all individuals with HPT and pre-HPT Decision to commence pharmacological treatment should be based on global cardiovascular risks and not on the level of blood pressure (BP) per se In patients with newly diagnosed uncomplicated HPT who have no compelling indications, choice of first line monotherapy includes ACEIs, ARBs, CCBs and Diuretics. -blockers are no longer recommended as first line monotherapy Only 26% of treated patients achieve target BP Combination therapy is often required ti achieve target and may be instituted early
Slide 35
KEY PRACTICE POINTS
Produce a prepared, proactive health care team to manage chronic conditions Create effective clinical information systems e.g. disease registry, comprehensive medical records Translate CPG recommendations into daily clinical practice Empower patients to self-manage their conditions Perform continuous quality improvement activities e.g. Clinical Audit
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Slide 1
Mr. A 38 years old Male Divorced with 3 children Delivery Man
VISIT 1
Present to the clinic with acute URTI symptoms BP 138/88 mmHg Smoking 20 cig x 20 years Beer 1-2/day Sedentary lifestyle Father hypertensive, hyperlipidaemic, AMI and CABG (age 68). Wt 91kg, Ht 170cm, BMI 31.5, WC 97cm
Case 1
INTERACTIVE CASE DISCUSSION 1 DIAGNOSIS AND MANAGEMENT OF PRE-HYPERTENSION
Slide 2
DISCUSSION POINT
How do you confirm the diagnosis? What would you do next?
Slide 3
HPT is a silent disease; 64% of cases remain undiagnosed. Therefore, BP should be measured at every chance encounter.
RECOMMENDATIONS FOR FOLLOW-UP BASED ON INITIAL BLOOD PRESSURE MEASUREMENTS FOR ADULTS
Initial BP (mmHg) Systolic Diastolic Follow-up recommended to confirm diagnosis and/or review response to treatment. Recheck in one year Recheck within 3-6 months Confirm within two months and treat if medium, high or very high risks Evaluate within one month and treat when confirmed Look for symptoms and sign of hypertensive urgency or emergency, if asymptomatic, evaluate within one week and treat whan confirmed Initiate drug treatment immediately
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Slide 4
VISIT 1: FURTHER ACTIONS
Explain to him that his BP is slightly high (best is < 120/80 mmHg). Explain the significance of the reading and the importance of confirming the diagnosis Assess cardiovascular risk factors: - Smoking - Obesity - Sedentary lifestyle - FH of hypertension and CVD Order further tests: - UFEME - Fasting lipids - Renal profile - ECG Arrange follow-up visit in 3 month
VISIT 2: BP REVIEW
Mr. A came back to the clinic after 3 months BP checked again in this visit 138/88 mmHg (no change) Renal profile and serum uric acid normal Fasting glucose normal Fasting lipid profile normal Urinalysis and UACR - normal ECG normal
DIAGNOSIS AND CLASSIFICATION OF HYPERTENSION

Mr. As average BP taken at the 2 visits = 138/88 mmHg
Category
Systolic (mmHg)
< 120 120-139 140-159 160-179 180 and
Diastolic (mmHg)
< 80 80-89 90-99 100-109 110
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Slide 6
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DEFINITION OF PREHYPERTENSION
Prehypertension is a defined as systolic BP (SBP) 120 to 139 or dictolic BP (SBP) 80 to 89 mmHg, based on 2 or more properly measured seated BP readings on each of 2 or more office visits.11
Slide 8
DISCUSSION POINT 2
How do you manage Mr. A?
Slide 9
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Co-existing Condition BP Levels (mmHg) SBP 120-139 and/or DBP 80-89 SBP 140-159 and/or DBP 90-99 SBP 160-179 and/or DBP 100-109 SBP 180-209 and/or DBP 100-119 SBP 210 and/or DBP 120
Legend: Green Yellow
No RF No TOD No TOC
TOD or RF (1-2), No TOC
TOD or RF ( 3) or Clinical atherosclerosis
Previous MI or Previous Stroke or Diabetes Mellitus (DM)
Low
Medium
High
Very High
Low
Medium
High
Very High
Medium
High
Very High
Very High
High
High
Very High
Very High
Very High
Very High
Very High
Very High
Orange
Red
Slide 11
Therapeutic lifestyle intervention should recommended for all patients with preHPT. There is presently inadequate evidence for pharmacological intervention in preHPT patients at low or moderate total CV risks.
Slide 12
VISIT 2: SUMMARY OF MANAGEMENT PLAN FOR MR. A
Educate regarding the diagnosis of Prehypertension and his CV risk stratification medium risk Empower patient to self-manage through therapeutic lifestyle modification using motivational interviewing techniques - MR. A is motivated to stop smoking, reduce his alcohol intake and reduce his weight Refer to the smoking cessation clinic Provide information and leaflet on DASH eating plan Review after 3 months and assess CV risks annually
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Slide 13
DISCUSSION POINT 3
How do you deliver therapeutic lifestyle modification advice? How can you influence him to change his unhealthy lifestyle?
Slide 14
Weight reduction Aim for an ideal BMI (<23 kg/m2) or ideal wt (<66.5 kg). However a weight loss as little as 4.5 kg significantly reduces BP An intake of < 100 mmol of sodium or 6g of sodium chloride a day is recommended (equivalent to < 1 1/4 teaspoonfuls of salt or 3 teaspoonfuls of monosodium glutamate) Standard advice is to restrict intake to no more than 21 units for men and 14 units for women per week (1 unit equivalent to 1/2 a pint of beer or 100ml of wine or 20ml of proof whisky) General advice on cardiovascular health would be for milder exercise, such as brisk walking 30 mins daily A diet rich in fruits, vegetables and dairy products with reduced saturated and total fat can substantially lower BP (11/6 mmHg in hypertensive patients and 4/2 mmHg in patients with high normal BP) Cessation of smoking is important in the overall management of the patients with hypertension in reducing cardiovascular risk
Salt intake
Alcohol intake
Physical activity
Diet
Smoking cessation
Slide 15
MOTIVATIONAL INTERVIEWING
A collaborative person centred guidance strategy to elicit and strengthen motivation to change. The goal is to increase intrinsic motivation, rather than to impose it externally. The spirit of Motivational Interviewing: Collaborative: partnership between patients and health care providers Evocative: evocating patients own motivation for change Honouring autonomy: acceptance that patient make his/her own choice
Rollnick S, Miller WR, Butler CC. Motivational interviewing in health care: Helping patients change behaviour. New York: Guilford Press, 2008
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MOTIVATIONAL INTERVIEWING USING CHANGE STRUCTURED CONSULTATION
CHECK HEAR AVOID NOTE GIVE END : : : : : : checking patient perspectives hearing what the patient says avoiding unsolicited advice noting the patients intentions and goals giving feedback to the patient when requested ending the interview with a summary of the patients plan
Slide 17
http:/www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf.
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Slide 18
BEWARE OF HIDDEN SALTS
Most salts/sodium are added during food processing, cooking and eating Very little are naturally occuring in diet
Slide 19
http:/www.moh.gov.my/v/diet
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Slide 21
SUMMARY OF EVIDENCE
37% of Malaysian population has Pre-HPT (NHMS II, 1996) 2/3 of patients with pre-HPT progressed to stage 1 Hypertension over 4 year period (TROPHY Study) Pre-HPT tends to cluster with other CVD risk factors Obesity and weight gain contributes to the progression All pre-HPT should be managed with therapeutic lifestyle modification Decisions regarding pharmacological treatment should be based on individuals global CVD risk
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Slide 22
KEY LEARNING POINTS
HPT is a silent disease; 64% of cases remain undiagnosed. Therefore, BP should be measured at every chance encounter PreHPT is defined as SBP 120-139 and/or DBP 80-89 mmHg, based on 2 BP readings at 2 clinic visits Therapeutics lifestyle changes should be recommended for all individuals with HPT and pre-HPT Decision to commence pharmacological treatment should be based on global cardiovascular risks and not on the level of blood pressure (BP) per se There is presently inadequate evidence for pharmacological intervention in preHPT patients at low or moderate total CV risks
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Slide 1
Mr. MN 40 years old Male
Married with 3 children Clerk
VISIT 1
Came to the clinic c/o of sore throat Otherwise well no other symptom Smoker 20 cigarettes a day Temperature 36.5 C, BP 150/90 mmHg
Case 2
Throat and chest examinations unremarkable Diagnosis of viral URTI was made and symptomatic treatment was given
INTERACTIVE CASE DISCUSSION 2 DIAGNOSIS AND MANAGEMENT OF STAGE 1 HYPERTENSION
Slide 2
DISCUSSION POINT 1
What would you do now? How do you explain your plan to the patient?
Slide 3
HPT is a silent disease; 64% of cases remain undiagnosed. Therefore, BP should be measured at every chance encounter.
RECOMMENDATIONS OF FOLLOW-UP BASED ON INITIAL BLOOD PRESSURE MEASUREMENTS FOR ADULTS

Initial BP (mmHg) Systolic Diastolic Follow-up recommended to confirm diagnosis and/or review response to treatment. Recheck in one year Recheck within 3-6 months Confirm within two months and treat if medium, high or very high risks Evaluate within one month and treat when confirmed Look for symptoms and sign of hypertensive urgency or emergency, if asymptomatic, evaluate within one week and treat whan confirmed Initiate drug treatment immediately
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Slide 4
VISIT 1: FURTHER ACTIONS
Explain to him that he has a raised BP (150/90 mmHg) Explain the significance of the reading and the importance of confirming the diagnosis Advise to stop smoking Negotiate the management plan: 1. Arrange to see the nurse/AMO for BP check within 1 month 2. Arrange baseline investigations 3. Arrange follow-up visit within 2 months
Slide 5
VISIT 2: BP REVIEW
Mr. MN came back to the clinic after 2 months Feeling very well generally BP checked by nurse a month ago 148/90 mmHg BP checked again in this visit 150/92 mmHg
Slide 6
DISCUSSION POINT 2
What is the diagnosis? What is your next step of action?
Slide 7
DIAGNOSIS AND CLASSIFICATION OF HYPERTENSION
Mr. MNs average BP taken at the 3 visits = 149/90 mmHg
Category
Systolic (mmHg)
< 120 120-139 140-159 160-179 180 and
Diastolic (mmHg)
< 80 80-89 90-99 100-109 110
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Slide 8
EVALUATION
EVALUATION OF NEWLY DIAGNOSED HYPERTENSIVE PATIENTS Evaluation should include through history, physical examination and relevant investigations. Three main objectives: 1. To exclude secondary causes of hypertension. 2. To ascertain the presence of target organ damage (TOD). 3. To assess lifestyle and identity other cardiovascular risk factors and/or concomitant disoders that may affect treatment and prognosis.
Slide 9
VISIT 2: FURTHER HISTORY

Still smoking 20 cigarettes a day and not ready to stop Eat out regularly with family and friends No time to do any exercise No significant past medical history Not on any regular medication Mother (aged 70) has hypertension No family history of heart attacks or strokes No symptoms to suggest target organ damage, e.g. chest pain, blurred vision No symptoms to suggest secondary causes of hypertension
Slide 10
VISIT 2: PHYSICAL EXAMINATION FINDINGS
BMI 26 kg/m2 Waist circumference (WC) 88 cm Fundoscopy normal Cardiovascular examinations normal Chest examinations normal Abdominal examinations normal Neurological examinations normal
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Slide 11
Full blood count Urinalysis Urine albumin excretion or albumin/creatinine ratio Renal profile and serum uric acid Fasting blood sugar Fasting lipid profile Electrocardiogram (ECG) Chest X-ray (if clinically indicated)
Note : Should be repeated 6-12 monthly thereafter (except for Chest X-Ray)
Slide 12
VISIT 2: BASELINE INVESTIGATION RESULTS
Renal Profile and serum uric acid - normal Full Blood Count - normal Fasting Blood Sugar 5.4 mmol/l Fasting Lipid Profile: - Total cholesterol 6.7 mmol/l - Triglycerides 2.0 mmol/l - HDL 0.9 mmol/l - LDL 3.4 mmol/l Urinalysis and UACR - normal ECG - normal
DISCUSSION POINT 3
How do you manage Mr. MN? What is your next step of action
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Low
Medium
High
Very High
Low
Medium
High
Very High
Medium
High
Very High
Very High
Very High
Very High
Very High
Very High
Legend:
Green
Yellow
Orange
Red
Slide 16
DISCUSSION POINT 4
How do you deliver therapeutic lifestyle modification advice? How do you commence pharmacotherapy? Which antihypertensive agent would you choose as first line? What is the target blood pressure? When would you see him again?
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TOD : LVH, Retinopathy, Proteinuria / TOC : Heart Failure, Renal Failure) Risk Factors (RF): additional RF (smoking, TC > 6.5 mmol/L, family history of premature vascular disease) Clinical atherosclerosis (CHD, carotid stenosis, peripheral vascular disease, TIA, stroke) MI: Mycardial Infarction
High
High
Very High
Very High
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Slide 17
Therapeutic lifestyle modification is the first line treatment in all patients with Hypertension Weight reduction Aim for an ideal BMI (<23 kg/m2) or ideal wt (<66.5 kg). However a weight loss as little as 4.5 kg significantly reduces BP An intake of < 100 mmol of sodium or 6g of sodium chloride a day is recommended (equivalent to < 1 1/4 teaspoonfuls of salt or 3 teaspoonfuls of monosodium glutamate) Standard advice is to restrict intake to no more than 21 units for men and 14 units for women per week (1 unit equivalent to 1/2 a pint of beer or 100ml of wine or 20ml of proof whisky) General advice on cardiovascular health would be for milder exercise, such as brisk walking 30 mins daily A diet rich in fruits, vegetables and dairy products with reduced saturated and total fat can substantially lower BP (11/6 mmHg in hypertensive patients and 4/2 mmHg in patients with high normal BP) Cessation of smoking is important in the overall management of the patients with hypertension in reducing cardiovascular risk
Salt intake
Alcohol intake
Physical activity
Diet
Smoking cessation
Slide 18
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Slide 19
CHOICE OF FIRST LINE MONOTHERAPY
In patients with newly diagnosed uncomplicated hypertension who have no compelling indications, choice of first line monotherapy includes ACEIs, ARBs, CCBs and Diuretics -blockers are no longer recommended for first line monotherapy in this group of patients However, it may be considered in younger people, particularly those who are intolerant or contraindicated to ACEI or ARB, women of child bearing potential and patients with evidence of increased sympathetic drive
Slide 20
Category Uncomplicated hypertension Hypertension in high risk groups: DM, History of CVD Diabetics with proteinuria of > 1 g/24 hours
Slide 21
VISIT 2: SUMMARY OF MANAGEMENT PLAN FOR MR. MN
Educate regarding the diagnosis of Stage 1 Hypertension, its associated CV risk factors and potential complications Educate regarding BP treatment target < 140/90 mmHg, choice of medication potential benefits vs side effects Empower patient to self-manage through therapeutic lifestyle modification. Commence a single antihypertensive agent at low dose e.g. ACE Inhibitor Commence statin therapy for mixed dyslipidaemia Arrange Renal Profile to be done within 2 weeks (post ACEi) Review after 1 month
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Slide 22
VISIT 3: FOLLOW UP
Mr. MN came for review after 1 month His Renal Profile was normal Feeling very well generally No side effect of ACE Inhibitor or statin Still smoking Dietary habit no change Started to do some gardening and walk around his neighborhood BP checked again in this visit 146/86 mmHg BMI and WC no change
Slide 23
DISCUSSION POINT 5
What is the state of his BP control? How would you manage Mr. MN at this stage? What is your next step of action?
Slide 24
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VISIT 3: SUMMARY OF MANAGEMENT PLAN FOR MR. MN
Educate regarding the state of his BP control - treatment target < 140/90 mmHg is still not achieved Re-emphasize therapeutic lifestyle modification: - Smoking cessation, healthy eating, exercise Increase the dose of ACE Inhibitor Recheck Renal Profile within 2 weeks Review after 1 month - If well-controlled continue treatment, review 3-6 monthly - If uncontrolled see algorithm for management of Stage 1 HPT Continue long-term follow up Assess CV risks annually
SUMMARY OF EVIDENCE
Monotherapy can lower BP to < 140/90 mmHg in 40%- 60% of patients with mild to moderate HPT -blockers no longer recommended for 1 line monotherapy in newly diagnosed uncomplicated HPT Meta-analysis has shown that -blockers is not as effective in lowering BP and in prevention of stroke compared to other agents Incidence of new-onset diabetes with -blockers is also higher compared to other drugs
KEY LEARNING POINTS

HPT is a silent disease; 64% of cases remain undiagnosed. Therefore, BP should be measured at every chance encounter Stage 1 HPT is defined as SBP 140-159 and/or DBP 90-99 mmHg, based on 2 BP readings at 2 clinic visits Therapeutic lifestyle changes should be recommended for all individuals with HPT and pre-HPT Decision to commence pharmacologica treatment should be based on global cardiovascular risks and not on the level of blood pressure (BP) per se In patients with newly diagnosed uncomplicated HPT who have no compelling indicatons, choice of first line monotherapy includes ACEIs ARBs, CCBs and Diuretics. -blockers are no longer recommended as first line monotherapy
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Slide 26
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Slide 1
Mr. NKH 45 years old Male Teacher Non-smoker
VISIT 1
Came to the clinic with referral letter Found to have high BP in a health screening campaign (160/100 mmHg) Remained well & asymptomatic BP checked again in this visit 164/100 mmHg
Case 3
INTERACTIVE CASE DISCUSSION 3 DIAGNOSIS AND MANAGEMENT OF STAGE 2 HYPERTENSION & RESISTANT HYPERTENSION
Slide 2
DISCUSSION POINT 1
What is your diagnosis? How would you evaluate his problem?
Slide 3
DIAGNOSIS
CLASSIFICATION OF BLOOD PRESSURE (adults 18 years)
Category
Systolic (mmHg)
< 120 120-139 140-159 160-179 180 and
Diastolic (mmHg)
< 80 80-89 90-99 100-109 110
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Slide 4
EVALUATION
EVALUATION OF NEWLY DIAGNOSED HYPERTENSIVE PATIENTS Evaluation should include through history, physical examination and relevant investigations. Three main objectives: 1. To exclude secondary causes of hypertension. 2. To ascertain the presence of target organ damage (TOD). 3. To assess lifestyle and identity other cardiovascular risk factors and/or concomitant disoders that may affect treatment and prognosis.
Slide 5
VISIT 1: FURTHER INFORMATION
Exercised 3x/week Not known to have any medical problem No family history of premature CVD BMI= 22.8 kg/m2 Other physical examinations: unremarkable Normal ECG & urine analysis Normal diabetic & dyslipidaemia screening
Slide 6
DISCUSSION POINT 2
How would you risk-stratify him? Can you estimate his 10-year CV risk? How would you manage this patient?
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No RF No TOD No TOC
Low
Medium
High
Very High
Low
Medium
High
Very High
Medium
High
Very High
Very High
High
High
Very High
Very High
Very High
Very High
Very High
Very High
Orange
Red
Slide 8
10 YEAR CV RISK ESTIMATION
Risk Level Low Medium High Very High
Legend: Green Yellow Orange Red
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Slide 9
DISCUSSION POINT 3
How do you commence pharmacotherapy? What drugs would you consider? What is his BP treatment target? When would you see him again?
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Slide 11
CHOICE OF PHARMACOTHERAPY
Pharmalogical management of stage 2 hypertension Initiating therapy with the right combination of at least 2 drugs is recommended Effective Combination -blockers + diuretics -blockers + CCBs ACEIs + diuretics ARBs + diuretics CCBs + ACEIs/ARBs
Slide 12
CHOICE OF ANTIHYPERTENSIVE AGENTS IN PATIENTS WITH CONCOMITANT CONDITIONS
Concomitant disease Diabetes mellitus (without nephropathy) Diabetes mellitus (with nephropathy) Gout Dyslipidaemia Coronary heart disease Heart failure Asthma Peripheral vascular disease Non-diabetic renal impairment Renal artery stenosis Elderly with no co-morbid conditions Very elderly (> 80 years old) with no co-morbid conditions Diuretics + ++ +/+/+ +++ + + ++ + +++ +++ -blockers +/+/+ +/+++ +++# +/+ + + + ACEIs +++ +++ + + +++ +++ + + +++ ++$ + ++ CCBs + ++* + + ++ +@ + + +* + +++ + Peripheral -blockers +/+/+ + + + + + + + +/+/ARBs ++ +++ + + ++ +++ + + ++ ++$ + +
The grading of recommendation from (+) to (+++) is based on increasing levels of evidence and/or current widely accepted practice +/- Use with care Contraindicated Only non-dihydropyridine CCB * # Metoprolol, bisoprolol, carvedilol dose needs to be gradually titrated @ Current evidence available for amlodipine and felodipine only Contraindicated in bilateral renal artery stenosis $
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Slide 13
Category Uncomplicated HPT Hypertension in high risk groups Diabetics with proteinuria of (> 1 g/24 hours)
Slide 14
VISIT 1: SUMMARY OF MANAGEMENT PLAN FOR MR. NKH
Explain to him that he has Stage 2 HPT and he has medium CV risk Deliver therapeutic lifestyle modification advice Educate regarding potential complications, the need to start medication and his treatment target Initiate therapy with 2 drugs e.g. CCB + ACEi Review monthly until target BP is achieved Review 3-monthly once target BP is achieved Re-assess CV risks annually
Slide 15
VISIT 2
Mr. NKH continued his follow-up at a GP Treated with 3 anti-HPTs (Felodipine 10 mg od + FORTZAAR 100-50) for 6 months Reason for re-visit: request to continue treatment BP remained uncontrolled (150/90 mmHg) Asymptomatic Normal physical examination
Slide 16
DISCUSSION POINT 4
What is your diagnosis? What are the possible causes would you consider? How would you evaluate this patient?
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Slide 17
RESISTANT HYPERTENSION
BP remains > 140/90 mmHg *with 3 anti-HPTs (including if possible a diuretic) * > 130/80 mmHg in patients with diabetes or chronic kidney disease Possible causes: - Non-compliance Pseudoresistance - White coat HPT - Poor diet control* - Complications of long standing HPT - Secondary HPT
*excessive sodium intake, excessive liquorice intake and drug interactions
Slide 18
EVALUATION OF RESISTANT HYPERTENSION
Exclude pseudoresistant: - Is patient adherent with prescribed regimen? - Obtain home/ ambulatory BP to exclude white coat effect Identify contributing lifestyle factors & drug interaction: - Obesity, physical inactivity, excessive alcohol/ salt intake, low-fiber diet, NSAIDs & stimulants etc Look for secondary causes of HPT Exclude complications of long-standing HPT
Slide 19
Mr. NKH is compliant with the treatment regime No sleeping problem identified No White Coat effect detected Like to enjoy taking high salt diet Normal renal profile Normal U/S ABD & KUB No secondary causes/complications of HPT detected
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Slide 20
DISCUSSION POINT 5
How would you manage this patient? How would you maximize his concordance to the treatment plan? When would you consider to refer this patient?
Slide 21
VISIT 2: SUMMARY OF MANAGEMENT PLAN FOR MR. NKH
Explain to him that he has resistant hypertension Strengthen therapeutic lifestyle modification advice Reverse contributing factors (reduce salt intake) Re-educate regarding his potential complications & treatment target Continue & optimize his current treatment regime (CCB + ARB + Diuretic) Review monthly until target BP is achieved Review 3-monthly once target BP is achieved Re-assess CV risks annually
Slide 22
WAYS TO ACHIEVE TREATMENT CONCORDANCE
Develop rapport with patients Regard patients as partners in managing their conditions Educate patient regarding their conditions Influence behaviour change through motivational interviewing skills Check on drug adverse effects regularly Adhere to CPG recommendations
Slide 23
RESISTANT HPT : WHEN TO REFER?
Refer to specialist for known or suspected secondary cause(s) of hypertension Refer to specialist if BP remains uncontrolled after 6 months of treatment Refer if you are not sure
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Slide 24
KEY LEARNING POINTS
Stage 2 HPT is defined as SBP 160-179 and/or DBP 100-109 mmHg, based on 2 BP readings at 2 clinic visits Therapeutics lifestyle changes should be recommended for all individuals with HPT and pre-HPT Combination of at least 2 drugs is recommended once diagnosis is confirmed Once BP is controlled, most patients will require lifelong treatment If BP is still > 140/90 mmHg with 3 drugs (including diuretics at optimal doses), patients by definition have resistant HPT
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Slide 1
Mdm. ZBL 48 years old Smoker Married with 5 children Housewife
VISIT 1
Came to the clinic c/o mild, intermittent throbbing headaches No alarm symptom Diagnosed to have HPT 10 years ago Defaulted on her follow up since the last 5 years as she felt well BMI 25 kg/m2, Waist Circumference (WC) 80cm BP 194/110 mmHg
Case 4
Slide 2
DISCUSSION POINT 1
What further history would you elicit from this patient? Comment on the physical examination findings? Give other relevant physical examinations needed to be performed? What investigations would you arrange for this patient?
Slide 3
Smokes 10 cigs a day for the past 20 years Loves to cook and family loves her food No time to do any exercise - busy with family routines Has been buying her antihypertensive tablets from the pharmacy on and off Currently not on any medication Mother (aged 75) has hypertension No family history of heart attack or stroke No symptoms to suggest target organ damage (e.g. chest pain, blurred vision) No symptoms to suggest secondary causes of HPT
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Slide 4
VISIT 1: FURTHER EXAMINATION FINDINGS
Cardiovascular examination S1 S2 heard, Grade 2 systolic murmur best heard at left sternal edge Respiratory examination-normal Other systems revealed no significant abnormality
Slide 5
FUNDOSCOPY
Grade III hypertensive retinopathy - note the flame hemorrhage (ruptured microaneurysm) directly superior to the optic disc (pale area at 5 o'clock). The white lesions (arrow) are well demarcated and represent hard exudates (increased vessel permeability). There is no papilledema.
Slide 6
VISIT 1: FURTHER EXAMINATION FINDINGS
BP checked again after 30 minutes bed rest: 190/108 mmHg
Slide 7
URGENT INVESTIGATIONS
Electrocardiogram (ECG) Urinalysis (UFEME) Random blood glucose
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Slide 8
VISIT 1: INVESTIGATION RESULTS
Urinalysis proteinuria 2+
Slide 9
ECG RESULTS
ECG showed the presence of LVH tall R wave in V6 with T wave inversions in V4-V6 (strain patterns)
Slide 10
DISCUSSION POINT 2
What is the diagnosis? How many target organ damages/ complications has she got? Could you estimate her global CV risk? How would you manage this patient?
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Slide 11
SEVERE HYPERTENSION
Severe hypertension is defined as BP > 180/110 mmHg (persistent elevation after 30 minutes bed rest) Possible clinical scenarios Asymptomatic severe HPT Incidental findings Non-specific symptoms like headache, dizziness, lethargy Management Most can be managed as outpatient Review existing drug regime and compliance For newly-diagnosed, consider admission for evaluation For established HPT, admit if compliance remains a problem Hypertensive urgencies Presents with grade III or IV retinal changes, or proteinuria 2+, but no overt organ failure Management Initial treatment should aim for 25% reduction in BP over 24 hours but not lower than 160/90mm Hg Combination therapy is often necessary (see table below) Admit patient if BP remain > 180/110mm Hg Hypertensive emergencies Presents with symptoms and signs of TOC e.g. acute heart failure, subarachnoid haemorrhage, acute coronary syndromes
Management All patient should be admitted Aim to reduce BP by 25% over 3-12 hours but not lower than 160/90 mmHg Best achieved with parenteral drugs
Slide 12
MANIFESTATIONS OF TOD/TARGET ORGAN COMPLICATION (TOC)
Organ System Manifestations Left ventricular hypertrophy (LVH), coronary heart disease (CHD), heart failure. Transient ischaemic attack (TIA), stroke. Absence of one or more major pulses in extremities (except dorsalis pedis) with or without intermittent claudication. GFR < 60ml/min/1.73m2, proteinuria (1+), microalbuminuria (2 out of 3 positive tests over a period of 4-6 months). Haemorrhages or exudates, with or without papilloedema.
Cardiac
Cerebrovascular Peripheral vasculature
Renal
Retinopathy
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No RF No TOD No TOC
Low
Medium
High
Very High
Low
Medium
High
Very High
Medium
High
Very High
Very High
High
High
Very High
Very High
Very High
Very High
Very High
Very High
Orange
Red
Slide 14
TREATMENT OPTIONS FOR HYPERTENSIVE URGENSIES (ORAL)
Drug Dose Onset of action (hr) 0.5 0.5 2.0 Duration (hr) 3-5 6 6 Frequency (hr) 1-2 hrs 1-2 hrs 4 hrs
Nifedipine Labetalol
Captopril
200-400 mg
10-20 mg
25 mg
Slide 15
Rapid reduction of BP (within minutes to hours) in asymptomatic severe HPT or hypertensive urgencies is best avoided as it may precipitate ischaemic events.
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Slide 16
VISIT 1: SUMMARY OF MANAGEMENT PLAN FOR MRS. ZBL
Explain to her that she has Stage 3 HPT (Hypertensive Urgencies) with very high CV risk Explain the significance of the diagnosis and the importance to stabilize her blood pressure Give nifedipine 10mg tablet orally as a stat dose (BP measured again after 30 minutes bed rest : 186/100 mmHg) Explain to her that she needs to be admitted to the nearest hospital as her BP remains high
Slide 17
VISIT 2: BP REVIEW
Mdm. ZBL came back to the clinic 1 week after being discharged from the hospital. Feeling well generally She brought along a discharge summary from the hospital which contains the following informations: Medications: - Amlodipine 10 mg daily - Perindopril 8 mg daily - Simvastatin 40 mg nocte Investigations: - FBS 5.8 mmol/l, Renal Profile normal. - TC 6.7, TG 2.6, HDL 1.3, LDL 3.4 (all in mmol/litres). - Liver Function Test normal - Urine Microalbumin positive - Awaiting ECHO appointment BP examination done in the clinic 156/90 mmHg
DISCUSSION POINT 3
Summarise her current problems. How would you manage this lady now? What is her target blood pressure?
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Slide 18
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Slide 19
Therapeutic lifestyle modification is the first line treatment in all patients with Hypertension Weight reduction Aim for an ideal BMI (<23 kg/m2) or ideal wt (<66.5 kg). However a weight loss as little as 4.5 kg significantly reduces BP An intake of < 100 mmol of sodium or 6g of sodium chloride a day is recommended (equivalent to < 1 1/4 teaspoonfuls of salt or 3 teaspoonfuls of monosodium glutamate) Standard advice is to restrict intake to no more than 21 units for men and 14 units for women per week (1 unit equivalent to 1/2 a pint of beer or 100ml of wine or 20ml of proof whisky) General advice on cardiovascular health would be for milder exercise, such as brisk walking 30 mins daily A diet rich in fruits, vegetables and dairy products with reduced saturated and total fat can substantially lower BP (11/6 mmHg in hypertensive patients and 4/2 mmHg in patients with high normal BP) Cessation of smoking is important in the overall management of the patients with hypertension in reducing cardiovascular risk
Salt intake
Alcohol intake
Physical activity
Diet
Smoking cessation
Slide 20
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Slide 21
SUMMARY OF MDM. ZBLS PROBLEMS:
1. 2. 3. 4. 5. 6. Uncontrolled hypertension (Target BP < 130/80) Very high CV risk with multiple TODs (LVH, proteinuria and Grade III Hypertensive Retinopathy Overweight Sedentary lifestyle Smoker Unhealthy dietary habit
Slide 22
VISIT 2: SUMMARY OF MANAGEMENT PLAN FOR MDM. ZBL
Educate regarding the state of her BP control - treatment target < 130/80 mmHg Re-emphasize therapeutic lifestyle modification Influence behaviour change through motivational interviewing techniques Add another type of antihypertensive agent e.g. thiazide diuretics Review monthly until target BP is achieved Review 3-monthly once target BP is achieved Consider resistant HPT if BP remains uncontrolled with 3 agents (including diuretics at maximum dose) Assess CV risks annually
Slide 23
DISCUSSION POINT 4
What is the commonest cause of severe HPT? How would you maximize her concordance to the treatment plan?
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Slide 24
COMMON CAUSES OF SEVERE HYPERTENSION
The most common cause of severe hypertension is still long standing poorly controlled essential hypertension
Cause
Renal parenchymal disease Systematic disorders with renal involvement Renovascular Endocrine Drug Coarctation of Aorta Pre-eclampsia/eclampsia
Example
Chronic pyelonephritis Tubulointerstitial nephritis Systemic lupus erythematosus Atherosclerotic disease Fibromuscular dysplasia Pheochromocytoma Cushing syndrome Cocaine Amphetamines Primary glomerulonephritis Systemic sclerosis Vasculitides Polyarteritis nodosa Conn Syndrome (primary hyperaldosteronism) Cyclosporin Clodine withdrawal
Slide 25
WAYS TO ACHIEVE TREATMENT CONCORDANCE
Develop rapport with patients Regard patients as partners in managing their conditions Educate patient regarding their conditions Influence behaviour change through motivational interviewing techniques Check on drug adverse effects regularly Adhere to CPG recommendations
Slide 26
KEY LEARNING POINTS
Stage 3 HPT is defined as SBP > 180 and/or DBP 110 mmHg, based on > 2 BP readings at > 2 clinic visits Rapid reduction of BP (within minutes to hours) in asymptomatic severe hypertension or hypertensive urgencies is best avoided as it may precipitate ischaemic events Emphasis on the therapeutic lifestyle intervention must be done at every clinic visit Combination therapy is recommended in patients presenting with stage 2 hypertension or beyond If BP is still > 140/90 mmHg with 3 drugs (including diuretics at maximum doses), patients by definition have resistant HPT
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Slide 1
Mr. LM 51-year-old Married with 4 girls Lorry driver for a paint factory
VISIT 1
Referred by a GP to the health clinic for insulin initiation c/o tiredness & blurring of vision for 2 weeks Diabetes since 2005, on Metformin 1 g BD, Gliclazide 80mg BD & Simvastatin 40 mg ON Poor adherence to low sugar diet & exercise Non-smoker & non-alcoholic
Case 5
INTERACTIVE CASE DISCUSSION 5 HYPERTENSION AND DIABETES
Slide 2
VISIT 1: PHYSICAL EXAMINATIONS
Blood pressure 140/90 mmHg (average of 2 readings) Weight 74 kg & Height 170 cm, BMI 25.6kg/m2 Bilateral cataracts Peripheral neuropathy of both lower limbs
Slide 3
VISIT 1: INVESTIGATION RESULTS FROM THE GP
HbA1c FBS 11.5% 10.8 mmol/L
LDL-C 3.6 mmol/L TG 1.75 mmol/L Urine albumin 2+, repeat in the clinic 1+ Renal function normal Liver function normal ECG stat in the clinic normal
Slide 4
DISCUSSION POINT 1
What are his problems? How would you tell him?
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Slide 5
SUMMARY OF MR. LMS CLINICAL PROBLEMS
Uncontrolled diabetes with - Nephropathy - Cataract? retinopathy - Peripheral neuropathy Unhealthy diet and low physical activity Dyslipidemia Hypertension
Slide 6
HOW COMMON IS HYPERTENSION IN PATIENTS WITH DIABETES MELLITUS?
The Hypertension in Diabetes Study Group reported a 39% prevalence of hypertension among newly diagnosed diabetic patients In half of the diabetes patients, the elevated BP presents before the onset of microalbuminuria Strongly associated with obesity Hypertension is frequently present as a component of the metabolic syndrome
Slide 7
DIAGNOSIS
Hypertension should be detected and treated early in the course of diabetes mellitus to prevent cardiovascular disease and delay the progression of renal disease and delay diabetic retinopathy
Slide 8
Eat at the factory cafeteria 4 times per day (breakfast, morning snack, lunch & afternoon snack) with teh tarik 3 times per day Unable to drive company lorry due to vision problem (loss of income) No time to do exercise Compliant to his medication No home sugar or BP monitoring Wife has recently been diagnosed to have breast cancer Mother had hypertension & diabetes, died of stroke (aged 60)
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Slide 9
DISCUSSION POINT 2
How do you manage Mr. LM? What is your next step of action?
Slide 10
Low
Medium
High
Very High
Low
Medium
High
Very High
Medium
High
Very High
Very High
High
High
Very High
Very High
Very High
Very High
Very High
Very High
TOD : LVH, Retinopathy, Proteinuria / TOC : Heart Failure, Renal Failure Risk Factors (RF): additional RF (smoking, TC > 6.5 mmol/L, family history of premature vascular disease) Clinical atherosclerosis (CHD, carotid stenosis, peripheral vascular disease, TIA, stroke) MI: Mycardial Infarction Legend: Green Yellow Orange Red
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Slide 11
THERAPEUTICS LIFESTYLE MODIFICATION-DIETARY COUNSELING
Dietary counseling should be targeted to: - Achieve an optimal body weight - Achieve an agreed glycaemic control - Manage concomitant dyslipidaemia Moderate dietary sodium restriction to enhance the effects of BP lowering drugs especially ACEIs and ARBs Further sodium restriction, with or without a diuretic, may be necessary in the presence of nephropathy or when the BP is difficult to control
Slide 12
THERAPEUTICS LIFESTYLE MODIFICATION-REGULAR PHYSICAL EXERCISE
General advice on cardiovascular health would be for milder exercise, such as brisk walking for 30 60 minutes at least 3 times a week
Slide 13
DISCUSSION POINT 3
Would you commence antihypertensive agent? Which antihypertensive agent would you choose and why? What is his target blood pressure? How soon would you see him again?
Slide 14
PHARMACOLOGICAL MANAGEMENT
Pharmacological treatment should be initiated when: 1. The BP is persistently > 130/80 mmHg or 2. There is a presence of microalbuminuria or overt proteinuria even if the BP is not elevated
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Slide 15
CHOICE OF ANTIHYPERTENSIVES
Certain classes of antihypertensive drugs may compromise diabetic control & aggravate its complications Drugs Diuretics Adverse 1. High doses will decrease insulin responsiveness 2. Dyslipidaemia 1. 2. 3. 4. Masking of early symptoms of hypoglycaemia Slowing of recovery from hypoglycaemia Aggravation of symptoms of peripheral vascular disease Dyslipidaemia
-blockers
Peripheral -blockers / Centrally acting drugs
1. Worsening of orthostatic hypertension
Slide 16
ANGIOTENSIN CONVERTING ENZYME INHIBITORS (ACEIs)
1. Drugs of choice based on extensive data attesting to their cardiovascular and renal protective effects in diabetic patients 2. In addition they do not have adverse effects on lipid and carbohydrate metabolism 3. If an ACEI is not tolerated, an ARB should be considered
Slide 17
ANGIOTENSION RECEPTOR BLOCKERS (ARBs)
1. Reported to be superior to conventional non-ACEI antihypertensive drugs in slowing the progress of diabetic nephropathy at both the i. microalbuminuric stage and ii. overt nephropathy stage 2. They have been shown to be of similar efficacy as ACEIs but better tolerated 3. There have been no reports of adverse effects on carbohydrate and lipid metabolism
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Slide 18
DIURETICS
1. Can be added on when monotherapy is inadequate 2. The lowest possible dose should be used to minimise adverse metabolic effects 3. Adverse metabolic effects from higher doses have been reportedly reduced when used in combination with an ACEI or an ARB
Slide 19
CALCIUM CHANNEL BLOCKERS (CCBs)
1. Can be added on when monotherapy is inadequate 2. Do not have significant adverse metabolic effects or compromise diabetic control 3. Nondihydropyridine CCBs may be more superior to dihydropyridine CCBs in reducing proteinuria in diabetic nephropathy
Slide 20
-BLOCKERS & PERIPHERAL -BLOCKERS
1. -blockers may be used when ACEIs, ARBs or CCBs cannot be used or when there are concomitant compelling indications 2. Peripheral -blockers do not have adverse effects on carbohydrate or lipid metabolism but orthostatic hypotension due to autonomic neuropathy may be aggravated
TARGET BLOOD PRESSURE

Tight BP control should take precedence over the class of antihypertensive drug used The BP should be targeted to < 130/80 mmHg There are suggestions that a lower target BP may be necessary to maximally protect against the development and progression of cardiovascular and renal disease The BP should be lowered even further to < 125/75 mmHg in the presence of proteinuria of > 1 g/24 hours
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Slide 22
RECOMMENDATIONS
1. ACEIs are the agents of choice for patients with diabetes without proteinuria 2. ACEIs or ARBs are the agents of choice for patients with diabetes and proteinuria 3. -blockers, diuretics or CCBs may be considered if either of the above cannot be used
Slide 23
Category Target blood pressure (mmHg) < 140/90 < 130/80 < 125/75
Uncomplicated HPT Hypertension in high risk groups Diabetics with proteinuria of (> 1 g/24 hours)
Slide 24
VISIT 1: SUMMARY OF MANAGEMENT PLAN FOR MR. LMS HYPERTENSION
1. Explain regarding the diagnosis of hypertension, its contribution of risk to diabetic complications 2. Educate regarding the need of BP treatment, target of < 130/80 mmHg, choice of medication, potential heart & kidneys protection vs. side effects 3. Empower patient to self-manage through diet and exercise, home monitoring of sugar & BP 4. Commence ACEI as single antihypertensive agent 5. Arrange renal profile to be done within 2 weeks 6. Review after 1 month
Slide 25
VISIT 2: FOLLOW UP AT 1 MONTH LATER
Feeling very well generally, no new complaint No side effect of ACEI or insulin Had visited the ophthalmologist, reply letter stated he has immature cataract and moderate to severe non-proliferative diabetic retinopathy in both eyes, laser therapy done, and follow-up in 3 months Still taking 4 meals in the factory cafetaria but able to keep ONE teh tarik a day, and reduced some oily & salty food as he claimed he cannot control the menu Started to walk 20 to 30 minutes around his neighborhood every weekend
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Slide 26
Home glucose monitoring 5 8 mmol/L Home BP monitoring 120 - 130/80 - 90 mmHg BMI and WC no change BP in the clinic 130/80 mmHg Renal profile was normal Fasting blood sugar 6 mmol/L Urine protein 1+
Slide 27
DISCUSSION POINT 4
What is the state of his BP control? How would you manage Mr. LM at this stage? What is your next step of action?
Slide 28
VISIT 2: FURTHER MANAGEMENT FOR MR. LM
Inform him that his treatment target < 130/80 mmHg is still not achieved Set personalized treatment goals with him Increase walking to 30 min three times a week Reduce outside food to 2 times per day to control oil & salt intake BP monitoring at least twice per week targeting < 130/80 Emphasize on low salt diet & praise him for walking every weekend Increase the dose of ACEI or add a low dose diuretics
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Slide 29
VISIT 2: FURTHER MANAGEMENT FOR MR. LM
Plan to review after 1 month If well-controlled continue treatment, review 3-6 monthly If uncontrolled check adherence, change/adjust medications 2 to 4 weekly till target achieved Inform & emphasize needs for long-term follow up Educate importance of CV risks assessment annually Complication assessment 6-monthly
Slide 30
KEY LEARNING POINTS
About 2 in 5 people with recently diagnosed diabetes will have hypertension About 1 in 2 patients will have hypertension before the diagnosis of microalbuminuria Antihypertensive should be initiated when the BP is persistently > 130/80 mmHg or there is microalbuminuria / proteinuria ACEIs / ARBs are the agents of choice for patients with diabetes The BP should be targeted to < 130/80 mmHg or to < 125/75 mmHg if the proteinuria > 1 g/24 hours
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Slide 1
Mr. AH 50 years old Male Married with 4 children Food hawker
REVIEW VISIT 1
Came to the clinic for routine review of blood pressure On -blocker and thiazide diuretic Smoker 20 cigarettes a day Otherwise well, no significant past medical history BMI 30 kg/m2, Waist Circumference (WC) 98 cm BP 152/90 mmHg, other examinations normal FBS 5.8 mmol/l, Renal Profile normal TC 6.7, TG 2.6, HDL 1.3, LDL 3.4 (all in mmol/litres)
Case 6
INTERACTIVE CASE DISCUSSION 6 HYPERTENSION AND METABOLIC SYNDROME
Slide 2
DISCUSSION POINT 1
What is the diagnosis? What is the target blood pressure? Comment on his current medication. How do you manage this patient? How do you explain your plan to the patient?
Slide 3
METABOLIC SYNDROME DIAGNOSIS
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Slide 4
Slide 5
-blockers and thiazide diuretics have the potential to increase the incidence of new onset diabetes, and this should be taken into consideration when choosing drugs for patients diagnosed with Metabolic Syndrome.
Slide 6
REVIEW VISIT 1: SUMMARY OF MANAGEMENT PLAN
Explain to him that he has Metabolic syndrome and the significance of the diagnosis in relation to CV risks. Explain that his BP is still not controlled (target < 130/80 mmHg) Discuss lifestyle modifications e.g. exercise, diet and weight reduction Discuss about his medication and explain that it is unsuitable for his condition. Discuss changing his medication to ACE Inhibitor or CCB Commence him on statin Arrange for Renal Profile (RP), FSL, LFT, ECG and urinalysis Arrange for a follow up in 3 months
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Slide 7
REVIEW VISIT 2
Mr. AH came for follow up after 3 months Tried to do more walking Still smoking not ready to stop Tried to cut down on salt and fried food but finding it difficult because he works as a food hawker Mother aged 75 has Hypertension and Diabetes Mellitus. Father died at 65 with MI Has been taking Perindopril 8mg once daily and Simvastatin 40 mg once daily as prescribed in the last visit there is no side effect BP 142/86 mmHg, BMI 30 kg/m2, WC 97cm TC 5.2, TG 1.6, HDL 1.3, LDL 2.4 (all in mmol/litres) RP, LFT, ECG and urinalysis normal
Slide 8
DISCUSSION POINT 2
How do you manage this patient at this stage?
Slide 9
Re-emphasize the significance of having Metabolic Syndrome in relation to his CV and DM risk factors Educate regarding BP control target still not achieved Educate regarding FSL reading target now achieved Re-emphasize self-management through lifestyle modification (no change in BMI or WC after 3 months) Consider adding Calcium Channel Blocker (CCB) Continue statin Discuss referral to a dietician Arrange follow up in 3 months
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Slide 10
As far as possible aim for an ideal Body Mass Index [Weight (kg)/Height2 (m)] for Asians, the normal range has been proposed to be 18.5 to 23.5 kg/m2. However a weight loss as little as 4.5 kg significantly reduces BP An intake of < 100 mmol of sodium or 6g of sodium chloride a day is recommended (equivalent to < 1 1/4 teaspoonfuls of salt or 3 teaspoonfuls of monosodium glutamate) Standard advice is to restrict intake to no more than 21 units for men and 14 units for women per week (1 unit equivalent to 1/2 a pint of beer or 100 ml of wine or 20 ml of proof whisky) General advice on cardiovascular health would be for milder exercise, such as brisk walking for 30 60 minutes at least 3 times a week A diet rich in fruits, vegetables and dairy products with reduced saturated and total fat can substantially lower BP (11/6 mmHg in hypertensive patients and 4/2 mmHg in patients with high normal BP) Cessation of smoking is important in the overall management of the patients with hypertension in reducing cardiovascular risk
Weight reduction
Salt intake
Alcohol intake
Physical activity
Diet
Smoking cessation
Slide 11
DISCUSSION POINT 3
Discuss the factors which may prevent this patient from achieving targets (weight/ BP) Discuss the factors which may motivate the patient to change What else can we do to help the patient?
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Slide 12
REVIEW VISIT 3
Mr. AH brings along his wife who wants to help him. She is afraid of losing him Has been doing more exercise at home by walking to the local shops to get the newspaper His wife is trying to cook healthier meals Now smokes 15/day No side effect with ACE Inhibitor, CCB or Statin BP checked 130/80 mmHg Lost 2 kg since last appointment Hes happy with his progress Still waiting for his appointment with dietician
Slide 13

Continue to give encouragement and motivation for his positive lifestyle changes Get his wife involved in giving him encouragement and support Chase up his dietician appointment If BP remain controlled, continue with 3-6 monthly follow up Review his CV and DM risks annually
Slide 14
SUMMARY OF EVIDENCE
Metabolic Syndrome is a cluster of risk factors predisposing to CV disease and Diabetes. A person with Metabolic syndrome is twice likely to develop heart disease and five times more likely to develop DM. Various components of Metabolic Syndrome should be treated separately.
Slide 15
KEY LEARNING POINTS
Metabolic syndrome is a cluster of risk factors predisposing to CV disease and DM Hypertension in Metabolic Syndrome must be treated aggressively to lower the risk. Target BP < 130/80 mmHg Thiazide diuretics and -blockers are found to increase incidence of developing DM in Metabolic Syndrome Therapeutic lifestyle changes is key to patient management and achieving targets It is important to treat all of the variables in Metabolic Syndrome independently
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Slide 1
Mr. M 53-year-old Male
VISIT 1
Was referred back to you from hospital with the following diagnoses: - Hypertensive heart disease - Left ventricular hypertrophy - Hypercholesterolaemia
Case 7
Slide 2
INTERACTIVE CASE DISCUSSION 7 HYPERTENSION AND CARDIOVASCULAR DISEASE
VISIT 1
These were the list of medications he was discharged with: - Losartan 50 mg OM - Simvastatin 40 mg ON - HCT 12.5 mg OM - Atenolol 50 mg OM The letter stated that: kindly follow up and do the needful The patient expected you to prescribe the medication for him.
Slide 3
DISCUSSION POINT 1
What would be your aims in this consultation in relation to hypertension management? How would you tell him?
Slide 4
TIPS FOR DISCUSSION POINT 1
Try to have an outline for your points and be clear of the reasons for your points Write down your answer, you dont have to write down your name. Discuss you answer with the person you are comfortable with. Tell us your answer once you are ready (10 minutes)
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Slide 5
WHAT WOULD BE YOUR AIMS IN THIS CONSULTATION IN RELATION TO HYPERTENSION MANAGEMENT?
1. Assess any other target organ damage The referral letter stated that he has hypertensive heart disease. Hence it is likely that he may suffer from various vascular related diseases like: Ischaemic heart disease Left ventricular hypertrophy Heart failure
Hypertensive vascular disease is a multi-organ disease. Many systems could be affected by HPT.
Stroke Peripheral vascular disease Renal disease, secondary renal artery stenosis
Slide 6

2. Check for target control: BP < 130/80 mmHg, and other CVD risk factors Risk factors Smoking Wt Waist circumference Diet Exercise Cholesterol/DM Targets Abstinence BMI chart ideally < 23 kg/m2 Male < 90 cm, Female < 80 cm Low salt and possibly low cholesterol diet 30 minutes 3-5 times/day See relevant CPG
Slide 7
3. Assess for suitability/adherence of medications Essentially covers: i. Side-effects ii. Co-morbidities iii. Psycho-social issues related to treatment of HPT
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Slide 8
1. 2. 3. 4. Assess any other target organ damage Check for target control Assess for suitability/adherence of medications Self-management plan and holistic care (will not be discussed in details)
Slide 9
DISCUSSION POINT 2
For each of these aims below (or your own aims), what are your actions? 1. Target organ damage assessment 2. Target BP control assessment 3. Assessment of optimal medication/adherence What is your next step of action?
Slide 10
HISTORY TAKING: ASK FOR
1. Symptoms of IHD, heart failure: NYHA class, claudication, history of stroke and admission 2. Any consultation with specialist care and what care has he been receiving? 3. How has he been with the control of HPT, is he aware of his blood pressure and any form of home blood pressure monitoring? 4. Any side effects from the medication, any problems (including personal preferences, disruption of daily routine) in taking the medication?
Slide 11
PHYSICAL EXAMINATIONS
1. Observe: gait (remember the neurological complication) 2. Body mass index, waist circumference 3. BP, pulse (including peripheral pulses: remember to check this to detect underlying PVD; -blocker effect) 4. Signs of end-organ damage: e.g. heart failure etc
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Slide 12
INVESTIGATIONS
1. 2. 3. 4. 5. ECG: to look for features of LVH, IHD Urine protein, KIV quantification of urine protein Blood: renal profile, cholesterol, fasting blood sugar level CXR (if it is not done) Further referral to cardiologist for assessment
Slide 13
Mr. M had been having HPT for 15 years He had not been regular with his medication apparently because of frequent traveling as a businessman He ended up in the hospital because of minor cuts he sustained while doing some carpentry work at home and was subsequently noted to have uncontrolled blood pressure His effort tolerance had been good Quick dietary assessment did not reveal any significant issue. He exercised regularly
Slide 14
VISIT 1: PHYSICAL EXAMINATIONS
BMI = 26 kg/m2 WC = 105 cm BP 142/94 mmHg PR 56 bpm Right dorsalis pedis pulse was difficult to palpate No sign of heart failure/cardiomegaly You had a good look at the ankle (Do you know the reason for examining the ankle?)
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Slide 15
VISIT 1: INVESTIGATIONS
The levels of blood urea and serum creatinine were normal, K+ = 4.8 mmol/L Fasting blood sugar = 5.3 mmol/L Urine dipstix: normal reading for protein, no cell/cast was noted Cholesterol profile: TC 5.7 mmol/L HDL-C 0.9 mmol/L TG 1.8 mmol/L LDL-C 3.6 mmol/L ECG (next slide)
Slide 16
Slide 17
HE WAS OBVIOUSLY NOT TREATED TO TARGET
What are his target? Parameters BP LDL-C (as the primary target) BMI WC Targets < 130/80 mmHg 3.4 mmol/L < 23.0 kg/m2 < 90 cm
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Slide 18
DISCUSSION POINT 3
What is your diagnosis for him now? Would you alter his medication or continue the same regime? Give reason.
Slide 19
WHAT IS YOUR DIAGNOSIS FOR HIM NOW?
HPT: suboptimal control Left ventricular hypertrophy Hypercholesterolaemia Possibility of peripheral vascular disease Problems with adherence
Slide 20
WOULD YOU ALTER HIS MEDICATION OR CONTINUE THE SAME REGIME? GIVE REASON
He was given these medications from the hospital: 1. Losartan 50 mg OM 2. Simvastatin 40 mg ON 3. Hydrochlorothiazide (HCT) 12.5 mg OM 4. Atenolol 50 mg OM You were stuck and not sure which is the best. Suddenly, you thought of referring to the CPG on HPT.
Slide 21
RECOMMENDATIONS
Hypertensive patients with LVH should receive an ARB as the first line treatment In CHD, -blockers, ACEIs and long acting CCBs are the drugs of choice -blockers, ACEIs, and aldosterone antagonists should be considered in patients with CHD especially in post myocardial infarction and when associated with LV dysfunction -blockers need to be cautiously used in patients with peripheral vascular disease. They are contraindicated in patients with severe PVD Diuretics, ACEIs, -blockers, ARBs, and aldosterone antagonists are drugs of choice for heart failure. ARB is indeed the correct choice -blockers may not be a suitable choice for him!
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Slide 22
PHARMACOLOGICAL MANAGEMENT
Choice of Hypertensive drugs in patients with concomitants conditions
Concomitant disease Coronary heart disease Heart failure Asthma Peripheral vascular disease Diuretics + +++ + + -blockers +++ +++# +/ACEIs +++ +++ + + CCBs ++ +@ + + Peripheral -blockers + + + + ARBs ++ +++ + +
Diuretic is also the correct choice
Slide 23
DISCUSSION POINT 4
What will be the best choice then?
Slide 24
WHAT WILL BE THE BEST CHOICE THEN?
Perindopril (ACE-I) 2 mg (has to re-start the regime as he has not been taking Losartan) HCT 12.5 mg OM Simvastatin 80 mg ON Felodipine 5 mg OM (explore the option of fixed dose combinatio therapy)
Slide 25
KEY LEARNING POINTS
The cardiovascular complications of HPT signify a long standing hypertension and possibly have other target organ damage There are a wide range of choices for anti-hypertensives Appropriate choice of anti-hypertensive medication depends in co-morbidities and complications, taking into consideration patients perspective Cost and side-effect can be a significant determinants
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Mr. AK 58 years old Male Married with 5 grand children Retired teacher
Case 8
VISIT 1
Brought to the clinic by his son on a wheel chair Developed right sided weakness and slurred speech since 5 am today
Slide 2
INTERACTIVE CASE DISCUSSION 8 HYPERTENSION AND STROKE

No vomiting, headache, fever, blurred vision, fits, incontinence No history of injury Known to have hypertension for 10 years Defaulted treatment since the last 5 years and is currently not on any medication Smokes 20 cigarettes a day BP 210/100 mmHg, slurred speech, orientated to time, place and person Right side UL/LL: Power 3+/5, tone normal, reflexes normal Plantar equivocal Cardiovascular and chest examinations unremarkable
Slide 3
DISCUSSION POINT 1
What is the diagnosis?
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Slide 4
SEVERE HYPERTENSION
Severe hypertension is defined as BP > 180/110mm Hg (persistent elevation after 30 minutes bed rest) Possible clinical scenarios Asymptomatic severe HPT Incidental findings Non-specific symptoms like headache, dizziness, lethargy Management Most can be managed as outpatient Review existing drug regime and compliance For newly-diagnosed, consider admission for evaluation For established HPT, admit if compliance remains a problem Hypertensive urgencies Presents with grade III or IV retinal changes, or proteinuria 2+, but no overt organ failure Management Initial treatment should aim for 25% reduction in BP over 24 hours but not lower than 160/90mm Hg Combination therapy is often necessary (see table below) Admit patient if BP remain > 180/110mm Hg Hypertensive emergencies Presents with symptoms and signs of TOC e.g. acute heart failure, subarachnoid haemorrhage, acute coronary syndromes Management All patient should be admitted Aim to reduce BP by 25% over 3-12 hours but not lower than 160/90 mmHg Best achieved with parenteral drugs
Slide 5
MANIFESTATIONS OF TOD/TARGET ORGAN COMPLICATION (TOC)
Organ System Manifestations Left ventricular hypertrophy (LVH), coronary heart disease (CHD), heart failure Transient ischaemic attack (TIA), stroke Absence of one or more major pulses in extremities (except dorsalis pedis) with or without intermittent claudication GFR < 60ml/min/1.73m2, proteinuria (1+), microalbuminuria (2 out of 3 positive tests over a period of 4-6 months) Haemorrhages or exudates, with or without papilloedema
Cardiac
Cerebrovascular Peripheral vasculature
Renal
Retinopathy
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Slide 6
COMMON CAUSES OF SEVERE HYPERTENSION*
Slide 7
HYPERTENSION AND STROKE
Blood pressure is the most consistent and powerful predictor of stroke and high blood pressure is the most important modifiable cause of stroke. BP levels are continously associated with the risk for stroke. Although both SBP and DBP are associated with stroke, SBP is more predictive. In the Asia Pacific region, up to 66% of stroke can be attributed to hypertension.
Slide 8
DISCUSSION POINT 2
How would you manage the patient? How would you explain your plan to him and his son?
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Slide 9
SEVERE HYPERTENSION
Severe hypertension is defined as BP > 180/110 mmHg (persistent elevation after 30 minutes bed rest) Possible clinical scenarios Asymptomatic severe HPT Incidental findings Non-specific symptoms like headache, dizziness, lethargy Management Most can be managed as outpatient Review existing drug regime and compliance For newly-diagnosed, consider admission for evaluation For established HPT, admit if compliance remains a problem Hypertensive urgencies Presents with grade III or IV retinal changes, or proteinuria 2+, but no overt organ failure Management Initial treatment should aim for 25% reduction in BP over 24 hours but not lower than 160/90mm Hg Combination therapy is often necessary (see table below) Admit patient if BP remain > 180/110 mmHg Hypertensive emergencies Presents with symptoms and signs of TOC e.g. acute heart failure, subarachnoid haemorrhage, acute coronary syndromes Management All patient should be admitted Aim to reduce BP by 25% over 3-12 hours but not lower than 160/90 mmHg Best achieved with parenteral drugs
Slide 10
TREATMENT OF HYPERTENSION IN ACUTE STROKE
Recommendations Lowering blood pressure is the key to both primary and secondary prevention of stroke In acute stroke, lowering BP is best avoided in the first few days unless hypertensive emergencies co-exist In primary prevention, the benefits of BP lowering is seen in both normotensive and hypertensive patients ACEI- or ARB- based treatment is preferred in secondary prevention
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Slide 11
TREATMENT OF HYPERTENSION IN ACUTE STROKE
Treatment of elevated BP in acute stroke is still controversial. In general, it is best to avoid lowering BP in the first few days after a stroke unless there is evidence of accelerated hypertension or patients presenting concurrently with hypertensive emergencies. Recommendations Lowering blood pressure is the key to both primary and secondary prevention of stroke In acute stroke, lowering BP is best avoided in the first few days unless hypertensive emergencies co-exist In primary prevention, the benefits of BP lowering is seen in both normotensive and hypertensive patients ACEI- or ARB- based treatment is preferred in secondary prevention
Slide 12
TREATMENT OPTIONS FOR HYPERTENSIVE EMERGENCIES (PARENTERAL)
Slide 13
VISIT 1: SUMMARY OF MANAGEMENT PLAN FOR MR. AK
Explain the diagnosis to the patient and his son Hypertensive Emergency presenting with Stroke (Right Hemiparesis) Explain the importance of hospital admission and the importance of confirming the type of stroke (haemorrhagic/Infarct) Arrange and prepare for hospital admission: 1. Secure intravenous line 2. Inform the receiving hospital Send by ambulance, accompanied by paramedics 3.
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Slide 14
VISIT 2: BP REVIEW
Mr. AK came back to the clinic 1 month after being discharged from the hospital Stable but no improvement of symptoms Still has residual weakness of right side of body and slurred speech Tolerating oral fluids and soft diet Using diapers due to mobility problems but no incontinence Appointment with physiotherapist: twice per week Appointment with neurologist: in 4 months
Slide 15
VISIT 2: BP REVIEW
He brought along a discharged letter from the hospital which contains the following informations: Diagnosis: Left Cerebral Infarct CT scan of brain: Left temporo-parietal hypodense lesion. No midline shift. Findings consistent with Left Cerebral Infarct. Medications: - Hydrochlorothiazide 25 mg daily - Perindopril 4 mg daily - Simvastatin 40 mg nocte - Aspirin 150 mg daily Investigations: - FBS 5.5 mmol/l, Renal Profile normal. - TC 6.5, TG 2.3, HDL 0.9, LDL 4.6 (all in mmol/litres). - Liver Function Test normal - Urine Microalbumin positive - ECG: LVH - awaiting ECHO appointment BP upon discharge 150/90 mmHg Please review his blood pressure
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Slide 16
Taken care at home by his wife and youngest daughter Stopped smoking since incidence Eat home-cook meal Has been to Physiotherapy twice for mobilization exercise Adhering to the medication given by hospital Understand that Stroke is the complication of Hypertension No symptoms to suggest secondary causes of hypertension
Slide 17
BMI: 26 kg/m2 Waist circumference (WC): 88 cm BP: 140/90 mmHg Fundoscopy : normal Cardiovascular examinations - normal Chest examinations normal Abdominal examinations normal Neurological examinations Right side UL/LL: Power 3+/5, hypertonia, reflexes brisk, sensation: normal Plantar: up going
Slide 18
DISCUSSION POINT 3
What is the level of his global CV risk stratification? How would you manage the patient? How do you educate the patient to prevent him from getting another stroke? What is his target BP and cholesterol level?
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Slide 10
Low
Medium
High
Very High
Low
Medium
High
Very High
Medium
High
Very High
Very High
High
High
Very High
Very High
Very High
Very High
Very High
Very High
CV Risk level is calculated based on his untreated BP

Legend: Green Yellow Orange Red
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TOD : LVH, Retinopathy, Proteinuria / TOC : Heart Failure, Renal Failure Risk Factors (RF): additional RF (smoking, TC > 6.5 mmol/L, family history of premature vascular disease) Clinical atherosclerosis (CHD, carotid stenosis, peripheral vascular disease, TIA, stroke) MI: Mycardial Infarction
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Slide 20
TABLE 3. CARDIOVASCULAR RISK FACTORS
Major risk factors Hypertension Cigarette Smoking Central obesity (waist circumference > 90 cm for men, > 80 cm for women) Physical inactivity Dyslipidaemia Diabetes mellitus Microalbuminuria Estimated GFR* < 60 mL/min Age (> 55 years for men, > 65 years for women) Family history of premature cardiovascular disease (men < 55 years or women < 65 years) Target Organ Damage Heart Left ventricular hypertrophy Angina or prior myocardial infarction Prior coronary revascularisation Heart failure
*GFR, glomerular filtration rate
Brain Stroke or transient ischemic attack Chronic kidney disease Peripheral arterial disease Retinopathy
Slide 21
Therapeutic lifestyle modification is the first line treatment in all patients with Hypertension Weight reduction Aim for an ideal BMI (<23 kg/m2) or ideal wt (<66.5 kg). However a weight loss as little as 4.5 kg significantly reduces BP An intake of < 100 mmol of sodium or 6 g of sodium chloride a day is recommended (equivalent to < 1 1/4 teaspoonfuls of salt or 3 teaspoonfuls of monosodium glutamate) Standard advice is to restrict intake to no more than 21 units for men and 14 units for women per week (1 unit equivalent to 1/2 a pint of beer or 100 ml of wine or 20 ml of proof whisky) General advice on cardiovascular health would be for milder exercise, such as brisk walking 30 mins daily A diet rich in fruits, vegetables and dairy products with reduced saturated and total fat can substantially lower BP (11/6 mmHg in hypertensive patients and 4/2 mmHg in patients with high normal BP) Cessation of smoking is important in the overall management of the patients with hypertension in reducing cardiovascular risk
Salt intake
Alcohol intake
Physical activity
Diet
Smoking cessation
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Slide 22
SECONDARY PREVENTION OF STROKE
BP lowering has been shown to reduce the risk of subsequent strokes ACEI + diuretic has been shown to reduce stroke recurrence ARBs lower the morbidity and mortality from further strokes
Slide 23
Category Uncomplicated HPT HPT in high risk groups: DM, History of CVD Diabetics with proteinuria of (> 1 g/24 hours)
Slide 24
TARGET LDL- C LEVELS
* **
Almost all individuals with 0-1 risk factor have a 10 year risk < 10%, thus 10 year risk assessment in there individials with 0-1 risk factor is not necessary. These include individuals with multiple risk factors but a 10 year risk of CHD of < 20%
*** After 8-12 weeks of TLC
Stroke Stroke is the 3rd leading cause of mortality in Malaysia. Evidence for the role of elevated serum cholesterol in the pathogenesis of stroke is lacking. Fibrates and statins are safe and should be considered in all patients presenting with strokes or transient ischaemic attacks.
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Slide 25
VISIT 2: SUMMARY OF MANAGEMENT PLAN FOR MR. AK
Educate him regarding the risk of recurrent stroke and the need to modify his very high CV risk Educate regarding BP treatment target < 130/80 mmHg, choice of medication potential benefits vs side effects Empower patient to self-manage through therapeutic lifestyle modification and self home BP monitoring. Continue ACE Inhibitor and Diuretic Add another agent e.g. CCB as his BP is still uncontrolled Continue statin and aspirin Monitor Renal Profile, Fasting Serum Lipid and LFT Review monthly until target BP is achieved Review 3 monthly once target BP is achieved Continue long-term follow up Assess CV risks annually
Slide 26
PRIMARY PREVENTION OF STROKE
Trials have shown that a 10 mmHg reduction in SBP or a 5 mmHg reduction in DBP in hypertensive patient can lead to a 34% reduction in the risk of stroke. -blockers, diuretics, CCBs, ACEIs and ARBs have been shown to reduce risk and mortality of stroke.
Slide 27
SUMMARY OF EVIDENCE - HYPERTENSION AND STROKE
Blood pressure is the most consistent and powerful predictor of stroke and high blood pressure is the most important modifiable cause of stroke -blockers, diuretics, CCBs, ACEIs, and ARBs have been shown to reduce the risk and mortality of stroke Calcium channel blockers in particular, provided significantly better protection against stroke compared with diuretics and/or -blockers in Asian and Caucasian populations. Combination of an ACEI and diuretics has been shown to reduce stroke recurrence in both normotensive and hypertensive patients when treatment was started at least two weeks after the stroke The morbidity and mortality from further strokes were also shown to be significantly lower in patients receiveing ARBs compared to CCBs for the same level of BP control In haemorrhagic stroke, in general, it is best to avoid lowering BP in the first few days after a stroke unless there is evidence of accelerated hypertension or patients presenting concurrently with hypertensive emergencies
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Slide 28
KEY LEARNING POINTS
Therapeutics lifestyle changes should be recommended for all individuals with HPT and pre-HPT Blood pressure is the most consistent and powerful predictor of stroke and high blood pressure is the most important modifiable cause of stroke Lowering blood pressure is the key to both primary and secondary prevention of stroke Rapid reduction of BP (within minutes to hours) in asymptomatic severe hypertension or hypertensive urgencies is best avoided as it may precipitate ischaemic events In primary prevention, a CCB-based therapy is preferred in secondary prevention, the benefits of BP lowering is seen in both normotensive and hypertensive patients ACEI- or ARB- based treatment is preferred in secondary prevention
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Slide 1
Mr. MR 70 years old Male Married with 5 children Retired teacher
REVIEW VISIT 1
Known hypertensive since 2 years, came to the Case 9 clinic for follow-up Previous BP ranged from SBP 160-172 mmHg and DBP 74-80 mmHg Also has osteoarthritis of knees and constipation occasionally Current medication Nifedipine 10 mg tds, Diclofenac sodium 50 mg tds(prn), Ranitidine 150 mg od (prn), Lactulose syrup 15 ml ON (prn) On examination: alert, conscious and oriented PR 70/min, BP 170/76 mmHg on standing and sitting BMI 26 kg/m2 Respiratory, Cardiovascular, GIT and CNS examinationsunremarkable
INTERACTIVE CASE DISCUSSION 9 HYPERTENSION IN THE ELDERLY
Slide 2
DISCUSSION POINT 1
Describe the type of hypertension in this man Comment on his BP control status Comment on his medications How do you explain your management plan to the patient?
Slide 3
DEFINITION OF HYPERTENSION IN THE ELDERY IS THE SAME AS IN THE GENERAL POPULATION
Category
Systolic (mmHg)
< 120 120-139 140-159 160-179 180 and
Diastolic (mmHg)
< 80 80-89 90-99 100-109 110
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Slide 4
Slide 5
Five major classes of antihypertensive drugs (diuretics, -blockers, CCBs, ACEIs and ARBs) have been shown to reduce CV events in the elderly In older patients with isolated systolic hypertension, diuretics are preferred because they significantly reduce multiple endpoints
Slide 6
Educate Mr. MR regarding his uncontrolled systolic BP (170/76 mmHg) and its impact Negotiate the management plan: 1. Advice on therapeutic lifestyle change to lose weight by exercise and modest salt reduction. 2. Change his medication - stop the nifedipine, change to hydrochlorothiazide 12.5 mg once daily. 3. Arrange annual investigations to assess CV risks. 4. Arrange follow-up visit within 1 month.
Slide 7
REVIEW VISIT 2
Mr. MR came back to the clinic after 1 month Feeling very well generally BP checked again in this visit 160/72 mmHg on standing and sitting His FBS, FSL, Renal Profile, Urine Analysis and ECG were normal
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Slide 8
DISCUSSION POINT 2
Describe the blood pressure control status Discuss the underlying reasons for his BP control status What is your next step of action?
Slide 9
Educate Mr. MR that his systolic BP is still uncontrolled Assess his adherence to treatment Add a long-acting CCB at the lowest dose e.g. Amlodipine 5 mg od Arrange follow up review in 1 month
Slide 10
REVIEW VISIT 3
Mr. MR came back to the clinic after 1 month Feeling very well generally BP checked again in this visit 140/68 mmHg
Slide 11
DISCUSSION POINT 3
What is your next step of action?
Slide 12
Inform Mr. MR that his BP has achieved the control target Re-emphasize lifestyle intervention Emphasize the importance of adherence to treatment and long term follow-up Arrange follow up every 3 months Assess CV risks annually
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Slide 13
SUMMARY OF EVIDENCE (1)
HPT magnifies risk for CVD in the elderly compared with younger populations SBP is a better predictor of CV events than DBP especially in the elderly SBP increases linearly with age leading to an increase of isolated systolic hypertension in the elderly In patients with marked SBP and not tolerating treatment well, reducing SBP to below 160 mmHg initially is acceptable. Subsequently attempts should be made to reduce BP to target level
Slide 14
Several RCT have shown that treatment of hypertension in the elderly up to the age of 84 years reduces CV morbidity and mortality, particularly stroke For those > 85 years, benefit of treating hypertension prevents the fatal and debilitating consequences of hypertension such as stroke, heart failure and dementia. (HYVET TRIAL 2008)
Slide 15
Salt restriction is especially effective in the elderly due to greater sensitivity to sodium Five major classes of antihypertensive drugs (diuretics, -blockers, CCBs, ACEIs and ARBs) have been shown to reduce CV events in the elderly In older patients with isolated systolic hypertension, diuretics are preferred because they significantly reduce multiple endpoints
Slide 16
Several trials using CCBs have shown benefits particularly in stroke reduction ACEi are the drugs of choice for those with concomitant left ventricular systolic dysfunction, post MI or DM ARBs have also been shown to reduce fatal and non-fatal strokes in hypertensive patients aged 65 years or older
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Slide 17
The starting dose of HPT medications in older patients should be at the lowest available In order to maximise adherence, the drug regime should be as simple as possible The elderly tend to be on polypharmacy drug interactions should be taken into account when considering antihypertensive treatment
Slide 18
KEY LEARNING POINTS
The goals of treatment of hypertension in older patients should be the same as in younger patients In those patients with marked SBP and not tolerating treatment well, reducing SBP to below 160 mmHg initially is acceptable. Subsequently, attempts should be made to reduce BP to target levels Weight loss and modest salt reduction are effective in the elderly because of their greater sensitivity to sodium Five major classes of drugs have been shown to reduce CV events in the elderly (diuretics, -blockers, CCBs, ACEi and ARBs) ACEi are the drugs of choice for those with concomitant left ventricular systolic dysfunction, post MI and DM
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Slide 1
Mdm NH 35 years old G1P0 Housewife
VISIT 1
Came for antenatal booking. POA 21 weeks UPT positive done by private GP 3 months ago Booking BP 130/80 mmHg Otherwise well no other symptoms Strong family history of hypertension BP 140/90 mmHg Normal physical examination
Case 10
INTERACTIVE CASE DISCUSSION 10 HYPERTENSION IN PREGNANCY
Slide 2
DISCUSSION POINT 1
How would you manage the patient?
Slide 3
VISIT 1: SUMMARY OF MANAGEMENT PLAN FOR MDM. NH
Explain to her that she has a raised BP (140/90 mmHg) Explain the significance of the reading and the importance of confirming the diagnosis Negotiate the management plan: 1. Arrange to see the nurse for E.O.D BP check for 1 week 2. Arrange baseline investigations 3. Advise on sign and symptoms of pre-eclampsia 4. Arrange follow-up visit within 1 week
Slide 4
VISIT 2: BP REVIEW
Mdm. NH came back to the clinic after 1 week Feeling very well generally BP checked by nurse over a week 140/90, 145/95, 140/90 mmHg BP checked again in this visit 140/90 mmHg Urine albumin - nil
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Slide 5
DISCUSSION POINT 2
What is the diagnosis? What is your next step of action?
Slide 6
HYPERTENSION IN PREGNANCY
Group of diseases in which hypertension is the chief clinical manifestation in pregnancy two distinct groups: Normotensive women who develop pre-eclampsia syndrome Women with chronic hypertension who are at the higher risk of developing superimposed pre-eclampsia
Slide 7
Mdm. NHs BP taken 2 visits were 140/90 mmHg Hypertension in Pregnancy is defined as a systolic blood pressure (BP) 140 mmHg and/or a diastolic BP 90 mmHg. An increase of 15 mmHg and 30 mmHg diastolic and systolic BP levels above baseline BP is no longer recognized as hypertension if absolute values are below 140/90 mmHg. Korotkoff V should now be used as the cut-off point for diastolic BP, and Korotkoff IV utilized only when Korotkoff V is absent.
DIAGNOSIS
Slide 8
Biochemical investigations: Platelet count, hematocrit Serum uric acid and creatinine Liver function test UFEME OGTT 24 hour urine protein Other relevant investigation TRO secondary causes
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Slide 9
No significant past medical history Not on any regular medication Both parents hypertensive Father had heart attacks at aged 60 years No pre-eclamptic symptoms No symptoms to suggest secondary causes of hypertension Sedentary lifestyle Normal diet
Slide 10
BP 140/90 mmHg Normal weight gain Fundoscopy normal Cardiac & respiratory examinations normal Symphysis fundal height 21 cm Neurological examinations normal
Slide 11
VISIT 2: BASELINE INVESTIGATION RESULTS
Renal Profile: Urea 3.2 , Sodium 132, Potassium 3.5, Chloride 101 (all in mmol/L), Creatinine 65 mol/L Serum uric acid: 200 mol/L Full Blood Count: Hb 11.5 g/dL, wbc 4500/mL, platelet 211,000/mL OGTT: 5.3/7.0 mmol/L Urinalysis - albumin negative
Slide 12
DISCUSSION POINT 3
How do you classify hypertension in pregnancy? What do you think Madam NH has?
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Slide 13
CLASSIFICATION OF HDP HDP
Preeclamsiaeclampsia
Gestational HPT
Chronic HPT
Preeclampsia superimposed on chronic HPT
Slide 14
CLASSIFICATION OF HDP
1. Preeclampsia-eclampsia: clinically diagnosed in the presence of de novo hypertension after gestational week 20, and one or more of the following: i. Significant proteinuria. ii. Renal insufficiency: serum creatinine 90 mol/l or oliguria. iii. Liver disease: raised transaminases and/or severe right upper quadrant or epigastric pain. iv. Neurological problems: convulsions (eclampsia), hyperreflexia with clonus or severe headaches, persistent visual disturbances (scotoma). v. Haematological disturbances: thrombocytopenia, coagulopathy, haemolysis. vi. Fetal growth restriction. This is followed by normalisation of the BP by three months postpartum. Oedema is no longer part of the definition of preeclampsia. Either excessive weight gain or failure to gain weight in pregnancy may herald the onset of preeclampsia.
Slide 15
CLASSIFICATION OF HDP
2. Gestational hypertension: hypertension alone, detected for the first time after 20 weeks pregnancy. The definition is changed to transient when pressure normalizes postpartum. 3. Chronic hypertension: hypertension diagnosed prior to gestational week 20; or presence of hypertension preconception, or de novo hypertension. 4. Preeclampsia superimposed on chronic hypertension: This can be diagnosed by the appearance of any of the following in a woman with chronic hypertension: i) De novo proteinuria after gestational week 20. ii) A sudden increase in the severity of hypertension. iii) Appearance of features of preeclampsia-eclampsia. iv) A sudden increase in proteinuria in women who have preexisting proteinuria early in gestation.
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Slide 16
DISCUSSION POINT 4
How do you manage Mdm NH? What is your next step of action?
Slide 17
MANAGEMENT
Early diagnosis of Hypertension in Pregnancy is vital Recognition of Severity - mild - severe Colour Coding Red Code - Mild pre eclampsia and more than 36 weeks gestation - Severe pre eclampsia - Eclampsia Yellow Code - Mild pre eclampsia and less than 36 weeks gestation
Slide 18
Educate regarding the diagnosis of Hypertension in pregnancy, and potential complications Educate regarding BP treatment target < 140/90 mmHg, choice of medication potential benefits vs side effects Regular fetal and maternal surveillance Monitor sign and symptom of impending pre-eclampsia Empower patient to self-manage through therapeutic lifestyle modification Address transportation problems if any Address adverse traditional beliefs and taboos Refer early to Obstetrician in nearest hospital for combine care
Slide 19
VISIT 3: FOLLOW UP
Mdm. NH came for review after 2 weeks (POA 23 weeks) Her Renal Profile was normal Has headache and mild epigastric pain BP checked again in this visit 150/100 mmHg Weight increasing Repeat urine protein 2+
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Slide 20
DISCUSSION POINT 5
How do you manage this lady at this stage?
Slide 21
Educate on her BP level BP is high and she is symptomatic (severe pre-eclampsia) She needs to be admitted to the hospital for BP stabilization Perform appropriate resuscitation in the clinic before transfer
Slide 22
ANTIHYPERTENSIVE DRUGS COMMONLY USED IN PREGNANCY
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Slide 23
SEVERE PREECLAMPSIA
Must be promptly identified so that the patient can be urgently admitted to hospital for close observation and timely delivery. The Royal College of Obstetrician and Gynecology (RCOG) defines severe pre eclampsia as follows: 1. Systolic BP 170 mmHg or diastolic BP 110 mmHg (acute hypertensive crisis in pregnancy) on two occasions, with proteinuria of 1 g/day. 2. Diastolic BP 100 mmHg on two occasions, with significant proteinuria (1+ on dipstick), with two or more signs or symptoms of imminent eclampsia: h. abnormal liver enzymes (elevated ALT a. severe headache or AST) b. visual disturbance i. HELLP syndrome (haemolysis, c. epigastric pain and/or vomiting elevated liver enzymes, low platelets) d. clonus j. intrauterine growth restriction (IUGR) e. Papilloedema k. pulmonary oedema and/or congestive f. liver tenderness cardiac failure g. platelet count below 100,000/cmm
Slide 24
ANTICONVULSANTS IN PREECLAMPSIA-ECLAMPSIA
Parenteral magnesium sulphate is currently the drug of choice for the prevention of eclampsia and to abort an eclamptic fit. The alternative is intravenous diazepam (intravenous bolus 10 mg slowly over 10-15 minutes followed by infusion), bearing in mind that it is inferior in efficacy compared to magnesium sulphate.
Slide 25
POSTPARTUM CARE
Advised to have BP checked regularly at local clinics if there is a significant delay in their scheduled hospital follow-up In these patients, the dose of antihypertensive should be tailed down gradually and not stopped suddenly De novo onset of hypertension or aggravation of BP levels during the postpartum period, can occur These patients should be promptly referred to hospital especially if there is significant proteinuria. Eclampsia may occur in the postpartum period Chronic hypertension is diagnosed when the hypertension and/or proteinuria fails to disappear within three months postpartum
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Slide 26
KEY LEARNING POINTS
1. Preconception counseling and adjustment of treatment in women with chronic hypertension. 2. Recognition of women at high risk of preeclampsia and referral in early pregnancy for screening and prophylaxis. 3. Nutritional supplementation for prevention of preeclampsia and/or its complications. 4. Prevention of eclampsia and other complications of preeclampsia 5. Primary care providers play an important role in preventing, detecting, monitoring and managing preeclampsia and its complications
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Slide 1
Puan Rahmah 35 years old Para 4 Last child birth 6/12 ago Accountant
VISIT 1
Referred to you for BP 150/90 mmHg after 1/12 on Combine Oral Contraceptive (COC) Currently not breast-feeding her child Generally well- asymptomatic Strong family history of hypertension
Case 11
Slide 2
INTERACTIVE CASE DISCUSSION 11 HYPERTENSION AND OCP
DISCUSSION POINT 1
What further history would you like to elicit? What physical examinations would you perform? List the investigation you would do?
Slide 3
VISIT 1- FURTHER HISTORY
Blood pressure before starting COC 130/80 mmHg History of pregnancy induce hypertension No symptoms of secondary causes of HPT & TOD Unhealthy diet & sedentary lifestyle Non smoker but husband is a chronic smoker Not on any other medication except COC Stressful at work and at home taking care of 4 children
Slide 4
VISIT 1- PHYSICAL EXAMINATIONS
Repeat BP 152/90 mmHg BMI 23 kg/m2 Urine albumin negative, RBS 5.5 mmol/L, ECG normal
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Slide 5
DISCUSSION POINT 2
Discuss the patients problems
Slide 6
VISIT 1
Problem List Stage 1 hypertension on COC Passive smoker, poor diet control, sedentary lifestyle Stressful at work and home
Slide 7
DISCUSSION POINT 3
What would you do now? How do you explain your plan to the patient? Discuss alternative methods of contraception for this patient
Slide 8
VISIT 1- FURTHER ACTIONS
Explain that she needs to stop the COC in order to control her BP Advice and reinforce on therapeutic life-style change diet, exercise, stress management Closer monitoring of BP and CVD risk factors Counsel on other methods of contraception e.g. IUCD, POP, injectable depots, implants & barrier methods
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Slide 9
HYPERTENSION AND ORAL CONTRACEPTIVES
The incidence of hypertension is reported to be higher in women taking combined oral contraceptives (COC), especially in obese and older women. The mechanism by which the BP rises is unknown. A women who develops hypertension while using COC should be advised to stop taking them and should be offered alternative forms of contraceptions. Progesterone Only Pills and low dose COC are not known to raise BP nor increase the risks of myocardial infarction. They are recommended alternatives for patients with hypertension or those who develop hypertension and yet wish to continue oral contraception. A prudent approach to the use of oral contraception would be to measure baseline BP before initiating treatment. Blood pressure should be reviewed regularly, at least every six month.
Slide 10
SUMMARY OF EVIDENCE
A woman who develops hypertension while using COC should be advised to stop taking them and should be offered alternative forms of contraception Blood pressure should be reviewed regularly, at least every six months
Slide 11
KEY LEARNING POINTS
The incidence of hypertension is reported to be higher in women taking COC, especially in obese and older women Before started all woman on OCP the blood pressure must be check then monitored regularly while she is on OCP Woman who develops hypertension while using COC should be advised to stop taking them and should be offered alternative forms of contraception Progesterone Only Pills191 and low dose COC, recommended alternatives for patients with hypertension or develop hypertension and wish to continue with OCP
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Slide 1
Madam OKL 52 years old Married with 4 children Teacher
VISIT 1
Came to the clinic for review Was commenced on hormone replacement Case 12 therapy (HRT) - Progyluton 2 months ago when she presented with worsening hot flushes and vaginal dryness Last menstruation was about a year ago Last blood tests were done 6 months ago (confirmed her postmenopausal status) BP readings were between 140/90-150/94 mmHg for the past 6 months before she was commenced on HRT
INTERACTIVE CASE DISCUSSION 12 HYPERTENSION AND HORMONE REPLACEMENT THERAPY
Slide 2
No symptoms of CVD and TOD Practice a prudent diet Does regular walk every morning Non-smoker Taking mefenamic acid for her painful knee occasionally Children are healthy Parents died of old age at 70+ years old Living with husband
Slide 3
VISIT 1: PHYSICAL EXAMINATIONS AND BASELINE INVESTIGATIONS Result
BMI 22 kg/m2, WC= 75 cm Neck - no goitre, no carotid bruit Heart and lung - normal Abdomen and pelvic - normal Legs - normal Other systems normal FBG 5.5 mmol/L, Fasting serum lipid normal Urine microalbumin negative ECG normal
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Slide 4
DISCUSSION POINT 1
What is the diagnosis? What is her global CV risk stratification level?
Slide 5
DIAGNOSIS & CLASSIFICATION OF HYPERTENSION
Category
Systolic (mmHg)
< 120 120-139 140-159 160-179 180 and
Diastolic (mmHg)
< 80 80-89 90-99 100-109 110
Slide 6
Low
Medium
High
Very High
Low
Medium
High
Very High
Medium
High
Very High
Very High
High
High
Very High
Very High
Very High
Very High
Very High
Very High
Orange
Red
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No RF No TOD No TOC
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Slide 7
Her BP was checked again twice (15 minutes apart) on this visit: 160/100 mmHg
Slide 8
DISCUSSION POINT 2
Summarise Mdm. OKLs problems. How do you manage this lady?
Slide 9
VISIT 1: SUMMARY OF PROBLEMS
Post-menopause with persistent vasomotor symptoms Underlying Stage 1 hypertension worsening to Stage 2 (160/100 mmHg) since commencing HRT No significant co-existing CV risk factor apart from HPT
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Slide 10
Slide 11
HYPERTENSION AND HOME REPLACEMENT THERAPY
The presence of hypertension is not a contraindication to oestrogen-based hormonal replacement therapy (HRT). It is recommended that all women treated with HRT should have their BP monitored every six months. The decision to continue or discontinue HRT in these patients should be individualised. The Womens Health Initiative (WHI) trial involving 98, 705 women aged 50-79 years, concluded that the use of HRT increased cardiovascular events. Conjugated equine estrogen (CEE), alone or in combination with medroxyprogesterone acetate, was used in the study. In view of this, greater caution and closer monitoring is required for hypertensive patients on CEE.
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Slide 12
Pharmalogical management of stage 2 hypertension Initiating therapy with the right combination of at least 2 drugs is recommended Effective Combination -blockers + diuretics -blockers + CCBs ACEIs + diuretics ARBs + diuretics CCBs + ACEIs/ARBs
Slide 13
Slide 14
VISIT 1: SUMMARY OF MANAGEMENT PLAN FOR MDM. OKL
Explain to her that she has an underlying Stage 1 HPT which is now worsening. Initiate therapy with 2 drugs e.g. CCB + ACEi Discuss the option of continuing HRT and advise to have regular Pap smear and mammogram Re-emphasize on therapeutic lifestyle modification Educate regarding potential complications, the need to start medication and her treatment target Review monthly until target BP is achieved Review 3-monthly once target BP is achieved Re-assess CV risks annually
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Slide 15
A NOTE ON HORMONE REPLACEMENT THERAPY-PROGYLUTON
11 white tab each containing Calendar pack of Oestradiol valerate 2 mg, 10 brown tab each containing Norgestrel 500 mcg, Oestradiol Valerate 2 mg Before starting treatment, a thorough general medical (including blood pressure measurement, urine test for sugar and, if necessary, special liver tests), and gynaecological examination (including the breasts and a cytological smear) should be carried out to detect any diseases requiring treatment or any risks and, above all, to rule out pregnancy. Control examinations are recommended at about 6-monthly intervals Progyluton is not a contraceptive. Where applicable contraception should be practised with non-hormonal methods
Slide 16
The presence of hypertension is not a contraindication to oestrogen based hormonal replacement therapy (HRT) It is recommended that all women treated with HRT should have their BP monitored every six months The decision to continue or discontinue HRT in these patients should be individualized The Women's Health Initiative (WHI) trial involving 98, 705 women aged 50-79 years, concluded that the use of HRT increased cardiovascular events. In view of this, greater caution and closer monitoring is required for hypertensive patients on CEE
SUMMARY OF EVIDENCE
Slide 17
KEY LEARNING POINTS
Stage 1 HPT is defined as SBP 140 and/or DBP 90 mmHg or greater, based on > 2 BP readings at > 2 clinic visits HRT is safe in hypertensive women. The presence of hypertension is not a contraindication to oestrogen based hormonal replacement therapy (HRT) Untreated or sub-optimally controlled hypertension leads to increased cardiovascular, cerebrovascular and renal morbidity and mortality Decision to commence pharmacological treatment should be based om global cardiovascular risks and not on the level of blood pressure (BP) per se All women treated with HRT should have their BP monitored every six months including regular gynaecological examination, mammogram and cervical smear
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Slide 1
GOLD STANDARD BP MEASUREMENT
Invasive Measurement
WORKSHOP ON BP (BP MEASUREMENT TECHNIQUE & SKILLS)
Slide 2
MERCURY COLUMN SPHYGMOMANOMETER-GOLD STANDARD NON INVASIVE METHOD
Slide 3
STEPS TO BP MEASUREMENT
Check the machine 1. The mercury meniscus make sure it is at zero. If not, minus the baseline reading 2. Inflation deflation device a) after 3-5 seconds of rapid inflation the mercury column should touch 200 mmHg or 40 mmHg above estimated SBP b) ability to deflate at a rate of 2-3 mmHg per second 3. Cuff both length and width of the bladder must be correct. The length of the bladder must at least be 80% of the circumference of the arm and the width at least 40% the circumference of the arm
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Slide 4
BLADDER LENGTHS
Slide 5
Rest the patient, back rested on the chair and arm supported at heart level, no coffee or smoking 30 minutes before Wrap the cuff properly Palpate the brachial or radial artery Inflate the bladder until the pulse disappear and inflate another 30 mmHg Deflate the cuff slowly until the pulse is felt again (estimated SBP) Bladder inflated to 30 mmHg above the estimated SBP
First repetitive appearance of clear tapping sound (Korotkoff 1) is SBP. Disappearance of sound (Korotkoff V) is DBP. If Korotkof sound does not disappear, use Korotkof 1V (muffling) Measure on both arm at first visit. If > 20/10 mmHg is abnormal Measure lying and standing (after 1 minute) BP for the elderly and the diabetics
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Slide 6
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Slide 7
CLINICAL HYPERTENSION
Slide 8
THE SPHYGMOMANOMETER
Beware of defective machine
Slide 9
AUTOMATED SPHYGMOMANOMETER
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Slide 10
OTHER METHODS OF MEASUREMENT
Aneroid sphygmomanometer Automated ambulatory BP devices Validated by either BHS or AAMI methods
Slide 11
AMBULATORY BP
Indicated in: suspected white coat hypertension borderline hypertension labile hypertension resistant hypertension (not controlled on 3 drugs including a diuretics) hypotensive symptoms
Slide 12
Slide 13
DETECTING POSTURAL HYPERTENSION
BP taken both lying and at least 1 minute standing Significant drop: SBP 20 mmHg
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Slide 14
MEASURING BILATERAL BP DIFFERENCES
Difference of BP Consider: 20/10 mmHg Atherosclerosis Congenital co-arctation of aorta Vasculitis: big vessels disease: Takayasu disease
Slide 15
AUSCULTATORY GAPS
It is a normal phenomenon seen in elderly
Slide 16
CHANGE IN BP WITH DAILY ACTIVITIES
Activities Meetings Work Transportation Walking Dressing Chores Telephone SBP +20 +16 +14 +12 +12 +11 +10 DBP +15 +13 +9 +6 +10 +7 +7 Activities Eating Talking Desk work Reading Television Relaxing Sleeping SBP +9 +7 +6 +2 +0.3 0 -10 DBP +10 +7 +5 +2 +3.2 0 -8
Slide 17
KEY LEARNING POINTS
Proper steps in blood pressure measurement is important to avoid inaccurate readings. Optimal blood pressure measurement determines management strategies
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PRE & POST TEST QUESTIONNAIRE MULTIPLE CHOICES QUESTIONS (MCQs) (TRUE/FALSE)
TOPIC 2: DIAGNOSIS AND MANAGEMENT OF PRE-HYPERTENSION
1. The following statement(s) is/are true regarding pre-hypertension: A. If left untreated, almost two thirds will progress to develop stage 1 hypertension B. Younger individuals are associated with a higher rate of progression C. It tends to cluster with other cardiovascular risk factors D. Almost a third of BP-related deaths from coronary heart disease occur in pre-hypertensive individuals E. Pre-hypertensive level of blood pressure itself is an independent cardiovascular risk factor 2. With regards to the management of pre-hypertension, the following statement(s) is/are true: A. All patients should be managed with therapeutic lifestyle modification B. Patients should be followed up at least once every 2 years C. Decisions regarding pharmacological treatment should be based on the individuals global cardiovascular risk D. Pharmacological treatment is indicated in pre-hypertensive patients at low cardiovascular risk E. In patients with diabetes mellitus and pre-hypertension, pharmacological treatment is required if BP is > 130/80 mmHg
PRE-TEST AND POST-TEST QUESTIONNAIRE (MCQs)
TOPIC 3: DIAGNOSIS AND MANAGEMENT OF STAGE 1 HYPERTENSION

1. Madam Y has recently been diagnosed with stage 1 hypertension. She is a heavy smoker and her total cholesterol is 6.8 mmol/L. The following statement(s) is/are true regarding her condition and management: A. She has a medium cardiovascular risk B. Her target blood pressure is < 140/90 mmHg C. Pharmacological treatment should commence with combination of 2 drugs at low dose D. -blocker is recommended for first line therapy for this patient E. Thiazide diuretic is contraindicated in her case 2. The following statement(s) is/are true with regards to the management of stage 1 hypertension: A. In patients without target organ damage, an observational period of 3-6 months on lifestyle modification is recommended B. Monotherapy can lower the blood pressure to < 140/90 mmHg in 40-60% of cases C. Increasing the dose of the initial drug is an option if patient shows response but target BP is not achieved D. Monotherapy should be continued for at least 6 months before a second drug can be added E. Substituting the drug with another class is recommended when the drug is not tolerated
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TOPIC 4: DIAGNOSIS AND MANAGEMENT OF STAGE 2 HYPERTENSION & RESISTANT HYPERTENSION

1. For patients with stage 2 hypertension, the target blood pressure of < 140/90 mmHg is recommended if they have: A. History of tobacco smoking B. Diabetes mellitus C. Chronic kidney disease D. Central obesity E. Cardiovascular disease 2. Below is/are the recommended antihypertensive combination(s) for patients with stage 2 hypertension and heart failure: A. -blocker + ACEi B. -blocker + CCB C. CCB + ACEi D. ACEI + diuretic E. ARB + diuretic 3. The following statement(s) is/are true with regards to resistant hypertension: A. It is defined when a patients BP is > 140/90 mmHg on 3 antihypertensive agents including a diuretic at near maximal dose B. Non-compliance to medication must be excluded C. The commonest cause is secondary hypertension D. Excessive salt intake is a contributing factor E. Specialist referral is required in suspected cases of renal artery stenosis
TOPIC 5: DIAGNOSIS AND MANAGEMENT OF STAGE 3 HYPERTENSION

1. A 48-year-old woman is evaluated for hypertension. Physical examination showed BP: 182/86 mmHg. She does not give history of headaches. Fundoscopy showed that she has Grade 3 Hypertensive retinopathy. Her home blood pressure measurements remain the same results as above. Which of the following statement(s) is/are true : A. She is having Hypertensive Urgencies B. Patient can be reassured of her blood pressure readings C. She needs to be referred to the nearest hospital for initiating antihypertensive agent D. She can be managed as outpatient with just home blood pressure monitoring E. She may need hospital admission if her blood pressure remains elevated after 30 minutes of rest 2. A 56-year-old man was diagnosed with essential hypertension 6 months ago. His blood pressure remained elevated at average 174/110 mmHg. He was taking Tablet Amlodipine 5 mg daily. His blood pressure today in the clinic is 172/112 mmHg. He denied of having any headache or blurring of vision. There were no hypertensive retinopathy changes in his eyes. Which of the following statement(s) is/are most appropriate for the patient at the current situation? A. He must be referred to the hospital today for further evaluation of his blood pressure readings B. Advice him to continue to comply with his current medicine C. He has Stage 3 Hypertension D. We should ask for symptoms of limb weakness. E. We would order Urine microalbumin test 3. The following statement(s) is/are correct regarding the management of Stage 3 Hypertension: A. Patients blood pressure target is < 140/90 mmHg if there is no target organ complication B. Non-adherence to therapy is an important cause of uncontrolled blood pressure C. Monotherapy is sufficient to get the blood pressure to target D. Fundoscopy and an ECG evaluation are needed for assessments of their target organ damage or complication E. There is no role of therapeutic lifestyle changes for these patients
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TOPIC 6: HYPERTENSION AND DIABETES

1. A 54-year-old man with type 2 diabetes has had intermittent mild headaches for the past one month. He is now euglycemic with oral hypoglycemic agents and lifestyle modifications. His older sister has had hypertension and has been taking antihypertensive medications for several years. Physical exam reveals an afebrile medium size man with a BP of 158/96 mm Hg (average of 2 readings), normal and regular peripheral pulses, hard exudates and narrowing of the arterioles on fundoscopic exam, and no carotid bruits. Lungs are clear and neurologic exam is also normal. His recent test result show the following: fasting plasma glucose, 5.8 mmol/L; HbA1c, 6.9%; normal urinalysis; and normal electrocardiogram (ECG). Which of the following(s) would you consider for treatment of this patient? A. A thiazide-type diuretic B. A combination of a -blocker and thiazide-type diuretic C. A combination of a -blocker and an ACE inhibitor D. A combination of a calcium channel blocker and an ACE inhibitor E. A combination of a thiazide-type diuretic and a ARB 2. In the drug management of hypertension in diabetic patients, A. amlodipine worsens peripheral neuropathy B. atenolol causes hypoglycemia C. hydrochlorothiazide is contraindicated in the presence of proteinuria D. perindopril prevents cardiovascular events E. prazocin reduces glucose metabolism 3. Which of the following statements regarding management of hypertensive patient with type 2 diabetes mellitus is/are TRUE? A. When the systolic blood pressure is > 20 mmHg above goal or diastolic blood pressure is > 10 mmHg above goal, monotherapy is recommended B. Many patients require 3 or more antihypertensive medications to achieve blood pressure goal C. All patients with diabetes and hypertension should be treated with calcium channel blocker D. They need less stringent blood pressure goal E. Pharmacotherapy is indicated in patients with microalbuminuria
TOPIC 7: HYPERTENSION AND METABOLIC SYNDROME

1. Which of the criterion/criteria below is/are TRUE for Metabolic Syndrome A. Waist circumference of > 90 in men and > 80 in women B. Raised Blood pressure > 130/85 mmHg C. Fasting blood sugar of > 6.1 mmol/L D. Raised Triglyceride and Low HDL E. Raised Triglyceride and Raised LDL 2. In the drug management for patients with Hypertension and Metabolic Syndrome. A. Thiazide Diuretics is recommended as first line agent B. -blockers should be avoided C. ACE Inhibitor is a recommended drug of choice D. Calcium Channel Blocker should be avoided E. Combination therapy is considered safe 3. Which of the statement(s) below regarding Metabolic Syndrome is/are TRUE A. It is associated with increased risk of developing cardiovascular disease B. It is associated with increased risk of developing diabetes insipidus C. Lifestyle modification is not as important as drug management D. It requires education for patients to achieve target BP of < 130/80 mmHg E. Weight loss management is crucial in reversing risk of Metabolic Syndrome
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TOPIC 8: HYPERTENSION AND CARDIOVASCULAR DISEASE

1. A 56-year-old man presented with intermittent left pain calf pain worsen on prolong walking. He has no significant past medical history. His blood pressure was 140/90 mmHg. The left dorsalis pedis pulse was weaker than the right side. Which of the following statement(s) is/are correct? A. His risk of stroke is high B. Electrocardiography is an optional investigation C. He should be called back within a week to confirm his status of hypertension D. Atenolol is an appropriate anti-hypertensive E. His target blood pressure is < 140/90 mmHg 2. Which of the following scenario(s) is/are correctly paired with the optimal choice of antihypertensives given? A. A 60-year-old woman with congestive cardiac failure secondary to prolong uncontrolled hypertensive: Atenolol B. A 50-year-old man with primary stage II hypertension and left ventricular hypertrophy: Losartan C. A 70-year-old man with primary hypertension and significant Q wave in his electrocardiogram at the anterior chest leads: Amlodipine D. A 45-year-old man with primary hypertension and recent myocardial infarct: Perindopril E. A 66-year-old woman with uncontrolled hypertension and congestive heart failure NYHA classII who are already on T. Perindopril 4 mg daily: Metoprolol 3. The following(s) is/are necessary in the assessment of patient presented with symptoms of heart failure and prolong hypertension: A. Urine protein B. Heamoglobin level C. Chest X-ray D. Doppler ultrasound of peripheral arteries in the lower limb E. Serum potassium and sodium
TOPIC 9: HYPERTENSION AND STROKE

1. Ahmad, a 45-year-old businessman presented to the health clinic with left sided body weakness of 1 day duration. His vital signs are as below: BP : 190/110 mmHg PR : 90 beats/min Temp : 36.5C RR : 14 breaths/min The following statement(s) is/are correct regarding Ahmads condition: A. Ahmad is categorized under Hypertensive Urgencies B. Oral Captopril can be given to lower Ahmads blood pressure C. Aspirin is recommended D. He can be treated as an out-patient E. He needs oxygen supplementation for cerebral protection 2. The following statement(s) is/are correct regarding hypertension and stroke: A. Dyslipidaemia is a better predictor of stroke compared to blood pressure B. Drug treatment is recommended in previous history of Transient Ischaemic Attack (TIA) C. In haemorrhagic stroke presented with BP > 180/110 mmHg, immediate reduction of BP is best avoided D. Diastolic blood pressure (DBP) is more predictive for stroke E. -blockers have been shown to reduce risk and mortality of stroke
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3. Mr. Tan a 58-year-old pensioner had history of ischaemic stroke 5 years ago. His current medications are Aspirin 150 mg OD and Hydrochlorothiazide 25mg OD. The following statement(s) is/are correct: A. CCB provides better protection than Thiazide Diuretic regarding secondary prevention B. It is recommended to withhold his Hydrochlorothiazide if his blood pressure ranges from 110-120/70-80 mmHg C. Perindopril is the preferred choice D. His target LDL level is < 3.4 mmol/L E. His target blood pressure control is < 140/90 mmHg 4. The following statement(s) is/are correct regarding Stroke: A. In Asia Pacific region, about 2/3 of strokes attributed to hypertension B. Combination of an ACE-Inhibitor and diuretic has been shown to reduce recurrent stroke. C. Treatment with aspirin alone is sufficient D. In primary prevention, the risk of stroke is significantly reduced with 10 mmHg reduction of systolic blood pressure E. In severe hypertensive with acute stroke, blood pressure lowering to < 160/90 mmHg is mandatory
TOPIC 10: HYPERTENSION IN THE ELDERLY

1. Based on current evidence, the following class(es) of drugs has / have been shown to reduce cardiovascular events in the elderly: A. Calcium channel blockers B. Ace inhibitors C. -blockers D. Diuretics E. -blockers 2. When prescribing antihypertensive agents in the elderly, the following rule(s) is/are important: A. Start with low dose B. Go slow on increasing the dose C. Combination preparation is encouraged D. The target BP is below 130/80 mm Hg E. In patients with marked systolic hypertension, reducing SBP below 160 mmHg is initially acceptable 3. In patients with postural hypertension, the following BP should be used as a guide to treatment decisions: A. Standing BP B. Sitting BP C. Lying BP D. Supine BP E. Ambulatory BP
TOPIC 11: HYPERTENSION IN PREGNANCY

1. Which of the following(s) is/are the risk factor(s) for developing high blood pressure in pregnancy? A. First pregnancy B. Previous history of hypertension during pregnancy C. Twin pregnancy D. Diabetes Mellitus E. Poor weight gain
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2. What is/are the complication(s) of hypertension in pregnancy? A. Fits B. Stroke C. Placenta accreta D. Stillborn E. Disseminated intravascular coagulopathy 3. Which of the following(s) is/are the sign(s) of pre-eclampsia? A. Sudden increase in weight (> 1 kg per week) B. Polyuria C. Epigastric pain D. Visual disturbance such as blurred vision E. Nausea and vomiting
TOPIC 12: HYPERTENSION AND ORAL CONTRACEPTIVE PILLS

1. The following statement(s) is/are true regarding hypertension and oral contraceptives: A. Baseline blood pressure is essential before initiating combined oral contraceptive (COC) B. Progestrogene only pills (POP) are known to raise blood pressure C. Incidence of hypertension is reported to be higher in woman taking COC D. Women who develop hypertension while using COC are advisable to continue using COC provided their blood pressure is monitored regularly E. Low dose COC is a recommended alternative for patients with hypertension who wish to continue oral contraception 2. The following contraceptive method(s) is/are known to raise blood pressure: A. Combined oral contraceptive (COC) B. Intrauterine Devices (IUDs) C. Progesterone only pills (POP) D. Mirena E. Low dose COC
TOPIC 13: HYPERTENSION AND HORMONE REPLACEMENT THERAPY

1. In the management of a hypertensive post-menopausal women on hormone replacement therapy: A. The decision to continue or discontinue HRT in these patients should be individualised B. Physician should be aware that the use of HRT increased the risk of recurrent cardiovascular events C. Monitoring of every three months is recommended if BP is uncontrolled D. Cardiovascular risk stratification should be done annually E. Pap smear should be done bi-annually up to 65 years of age 2. A hypertensive woman on hormone replacement therapy is at risk for: A. Breast cancer B. Colorectal cancer C. Venous thromboembolism D. Osteoporosis E. Gall-bladder disease
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PRE & POST TEST QUESTIONNAIRE MULTIPLE CHOICES QUESTIONS (MCQs) (TRUE/FALSE) ANSWER
TOPIC 2: DIAGNOSIS AND MANAGEMENT OF PRE-HYPERTENSION 1. A. B. C. D. E. 2. A. B. C. D. E. T F T T T T F T F T 2. A. B. C. D. E. F F T T T 3. A. B. C. D. E. T T T F T 2. A. B. C. D. E. 3. A. B. C. D. E. T T F T T T F T T T
TOPIC 6: HYPERTENSION AND DIABETES 1. A. B. C. D. E. 2. A. B. C. D. E. 3. A. B. C. D. E. F F F T T F F F T F F T F F T
TOPIC 9: HYPERTENSION AND STROKE 1. A. B. C. D. E. 2. A. B. C. D. E. 3. A. B. C. D. E. 4. A. B. C. D. E. F T F F T F T T F T T F T F F T T F T F
TOPIC 12: HYPERTENSION AND OCP 1. A. B. C. D. E. 2. A. B. C. D. E. T F T F T T F F F F
TOPIC 3: DIAGNOSIS AND MANAGEMENT OF STAGE 1 HYPERTENSION 1. A. B. C. D. E. 2. A. B. C. D. E. T T F F F T T T F T
TOPIC 7: HYPERTENSION AND METABOLIC SYNDROME 1. A. B. C. D. E. 2. A. B. C. D. E. 3. A. B. C. D. E. T T T T F F T F T T T F F T T
TOPIC 4: DIAGNOSIS AND MANAGEMENT OF STAGE 2 HYPERTENSION & RESISTANT HYPERTENSION 1. A. B. C. D. E. 2. A. B. C. D. E. 3. A. B. C. D. E. T F T T T T F F T T T T F T T
TOPIC 13: HYPERTENSION AND HORMONE REPLACEMENT THERAPY 1. A. B. C. D. E. 2. A. B. C. D. E. T T F T F T F T F F
TOPIC 10: HYPERTENSION IN THE ELDERLY 1. A. B. C. D. E. 2. A. B. C. D. E. 3. A. B. C. D. E. T T T T F T T F F T T F F T F
TOPIC 8: HYPERTENSION AND CARDIOVASCULAR DISEASE 1. A. B. C. D. E. 2. A. B. C. D. E. T F F F F F T F T F
TOPIC 5: DIAGNOSIS AND MANAGEMENT OF STAGE 3 HYPERTENSION 1. A. B. C. D. E. T F F F T
TOPIC 11: HYPERTENSION IN PREGNANCY 1. A. B. C. D. E. T T T T F

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02.

HYPERTENSION GUIDELINE WORKING GROUP

HYPERTENSION GUIDELINE WORKING GROUP

TRAINING MODULE FOR HEALTH CARE PROVIDERS

MANAGEMENT OF HYPERTENSION (3rd Edition)

53 63 73 79 87 101 107 117 121 129

This document contains the following:

Key Recommendations for Successful Implementation of this Training Module:

TRAINING MODULE FOR HEALTH CARE PROVIDERS

MANAGEMENT OF HYPERTENSION (3rd Edition)

Clinical information systems

Patient selfmanagement support

TRAINING MODULE FOR HEALTH CARE PROVIDERS

MANAGEMENT OF HYPERTENSION (3rd Edition)

Summary of Training Module Content

Interactive case discussion

60 (45 minutes interactive discussion + 15 minutes Q&A)

Interactive case discussion

Interactive case discussion

Interactive case discussion

60 (45 minutes interactive discussion + 15 minutes Q&A)

Teaching Learning Method

Interactive case discussion

Interactive case discussion

11. Hypertension in Pregnancy

Interactive case discussion

60 (45 minutes interactive discussion + 15 minutes Q&A)

TRAINING MODULE FOR HEALTH CARE PROVIDERS

MANAGEMENT OF HYPERTENSION (3rd Edition)

10. Hypertension in the Elderly

Interactive case discussion

60 (45 minutes interactive discussion + 15 minutes Q&A)

Interactive case discussion

60 (45 minutes interactive discussion + 15 minutes Q&A)

Teaching Learning Method

13. Hypertension and Hormone Replacement Therapy

To highlight the important interaction between BP and HRT

Interactive case discussion

14. Workshop on BP measurement (technique and skills)

To demonstrate accurate techniques of BP measurements

Workshop 5 Lecture followed by hands-on training

15. Assessment of knowledge

To test the knowledge of participants pre and post training

15 T/F MCQs 15 Single Best Answer (SBA) Questions

Pre-test and post test questionnaire

INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA

National Health Morbidity Surveys I, II & III (1986-2006)

TRAINING MODULE FOR HEALTH CARE PROVIDERS

MANAGEMENT OF HYPERTENSION (3rd Edition)

INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA

INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA

MANAGEMENT OF HYPERTENSION (3rd Edition)

TRAINING MODULE FOR HEALTH CARE PROVIDERS

NHMS III : CONTROLLED RATE

and/or and/or and/or and/or

TRAINING MODULE FOR HEALTH CARE PROVIDERS

MANAGEMENT OF HYPERTENSION (3rd Edition)

INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA

TRAINING MODULE FOR HEALTH CARE PROVIDERS

MANAGEMENT OF HYPERTENSION (3rd Edition)

INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA

INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA

Transient ischaemic attack (TIA), stroke