Chronic hypertension resident survival guide: Difference between revisions
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===Stage 1 Hypertension=== | ===Stage 1 Hypertension=== | ||
{{familytree/start}} | |||
{{familytree | | | | | | | | A01 | A01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Determine who to treat:'''<br> | |||
---- | |||
❑ BP ≥ 150/90 mmHg in patients ≥ 60 years <br> | |||
❑ BP ≥ 140/90 mmHg in patients < 60 years<br> | |||
❑ BP ≥ 140/90 mmHg in patients ≥ 18 years with <br>CKD or DM <br> | |||
</div>}} | |||
{{familytree | | | | | | | | |!| | |}} | |||
{{familytree | | | | | | | | B01 | |B01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Review BP goals:'''<br> | |||
---- | |||
'''General population'''<br> | |||
❑ BP < 150/90 mmHg in patients ≥ 60 years <br> | |||
❑ BP < 140/90 mmHg in patients < 60 years<br> | |||
'''Patients with DM or CKD'''<br> | |||
❑ BP < 140/90 mmHg in patients<br> | |||
</div>}} | |||
{{familytree | | | | | | | | |!| | | |}} | |||
{{familytree | | | | | | | | C01 | | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initiate lifestyle modification:'''<br> | |||
---- | |||
❑ Weight reduction<br> | |||
:❑ Maintain a waist circumference of <br> | |||
:* <40 inches (102cm) for men<br> | |||
:* <35 inches (88cm) for women <br> | |||
:* BMI of ≤25 kg/m2<br> | |||
❑ Adopt healthy diet<br> | |||
:❑ DASH diet (rich in fruits, vegetables, whole grains, low sodium, low-fat proteins)<br> | |||
:❑ Dietary sodium intake of ≤ 100 mmol/day (2.4g Na or 6g NaCl)<br> | |||
❑ Limit alcohol consumption<br> | |||
:❑ ≤ 2 drinks/day for men (24oz beer or 10oz wine or 3oz 40% whisky<br> | |||
:❑ ≤ 1 drink/day for women<br> | |||
❑ Regular aerobic physical activity (brisk walking, jogging, cycling, swimming) for at least 30 mins per day <br> | |||
❑ Patient education<br> | |||
</div>}} | |||
{{familytree | | | | | | | | |!| | | |}} | |||
{{familytree | | | | | | | | D01 | | D01=Does the patient have DM or CKD?}} | |||
{{familytree | | | | | | |,|-|^|-|.| |}} | |||
{{familytree | | | | | | E01 | | E02 | | |E01=Yes|E02=No}} | |||
{{familytree | | | |,|-|-|^|.| | |!| | |}} | |||
{{familytree | | | F01 | | F02 | |!| | |F01=CKD ± DM|F02=DM only}} | |||
{{familytree | | | |!| | | |`|-|v|'| | |}} | |||
{{familytree | | | |!| | | | | G02 | | G02=Consider the race of the patient}} | |||
{{familytree | | | |!| | | |,|-|^|-|.| | |}} | |||
{{familytree | | | |!| | | H01 | | H02 | | H01=Black population|H02=Non-black population}} | |||
{{familytree | | | |!| | | |!| | | |!| |}} | |||
{{familytree | | | I03 | | | I01 | | I02 | | I01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Initiate:'''<br> | |||
❑ Thiazide-type diuretic alone, '''OR'''<br> | |||
❑ CCB alone, '''OR'''<br> | |||
❑ Combination of the two classes <br> | |||
</div>|I02=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initiate:'''<br> | |||
❑ Thiazide-type diuretic alone, '''OR'''<br> | |||
❑ ACEI alone, '''OR'''<br> | |||
❑ ARBs alone, '''OR'''<br> | |||
❑ CCB alone, '''OR'''<br> | |||
❑ Combination of all the classes <br><br> | |||
'''Avoid the use of ACEIs and ARBs in combination'''<br> | |||
</div>|I03=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Initiate:'''<br> | |||
❑ ACE inhibitors alone, '''OR'''<br> | |||
❑ ARBs alone, '''OR'''<br> | |||
❑ ACEI or ARBs in combination with other drug class e.g., <br> | |||
'''Avoid the combine use of ACEIs and ARBs in a patient'''</div>}} | |||
{{familytree | | | |`|-|-|-|+|-|-|-|'| | |}} | |||
{{familytree | | | | | | | J01 | | | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Has the target BP been reached?'''</div>}} | |||
{{familytree | | | | | |,|-|^|-|.| | |}} | |||
{{familytree | | | | | K01 | | K02 | | |K01=Yes|K02=No}} | |||
{{familytree | | | | | |!| | | |!| | |}} | |||
{{familytree | | | | | |!| | | L01 | |L01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Consider the following:'''<br> | |||
❑ <br> | |||
❑ <br> | |||
❑ <br> | |||
❑ <br> | |||
❑ <br></div>}} | |||
{{familytree | | | | | |`|-|v|-|'| |}} | |||
{{familytree | | | | | | | M01 | | |M01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Monitoring and follow-up:'''<br> | |||
❑ <br> | |||
❑ <br> | |||
❑ <br> | |||
❑ <br> | |||
❑ <br></div>}} | |||
{{familytree/end}} | |||
==Diagnosis== | ==Diagnosis== | ||
{{familytree/start}} | {{familytree/start}} |
Revision as of 17:58, 22 April 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayokunle Olubaniyi, M.B,B.S [2]
Hypertension Resident Survival Guide Microchapters |
---|
Overview |
Classification |
Causes |
Diagnosis |
Treatment |
Medications |
Do's |
Don'ts |
Overview
Classification
Classification | Blood pressure (mmHg) |
---|---|
Normal | < 120/80 |
Prehypertension | 120-139/80-89 |
Stage 1 hypertension | 140-159/90-99 |
Stage 2 hypertension | ≥ 160/110 |
Isolated systolic hypertension | |
Isolated diastolic hypertension |
Causes
Life Threatening Causes
Common Causes
Diagnosis
Shown below is an algorithm summarizing the diagnosis of
General Approach to Suspected Hypertension
Suspected hypertension BP > 140/90 mmHg | |||||||||||||||||||||||||||||||||||||||||
Blood pressure measurement Before taking the BP
❑ Take 2 readings and find the average Click here for more information regarding blood pressure measurement | |||||||||||||||||||||||||||||||||||||||||
Office BP >140/90 mmHg on 2-3 visits | |||||||||||||||||||||||||||||||||||||||||
Does the patient have any evidence of target organ damage, DM, or CKD? | |||||||||||||||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||||||||||||||
Proceed to hypertensive crisis resident survival guide | Perform home BP/out-of-office monitoring | ||||||||||||||||||||||||||||||||||||||||
Is the average home BP measurement <140/90? | |||||||||||||||||||||||||||||||||||||||||
Yes | Inconclusive | No | |||||||||||||||||||||||||||||||||||||||
Perform 24-hour ABPM | |||||||||||||||||||||||||||||||||||||||||
Is the 24-hour ABPM ≤135/85? | |||||||||||||||||||||||||||||||||||||||||
White-coat hypertension confirmed | Yes | No | Hypertension confirmed | ||||||||||||||||||||||||||||||||||||||
❑ Continue BP monitoring ❑ Follow-up appointment in .... | Classify the patient based on the BP reading | ||||||||||||||||||||||||||||||||||||||||
SBP 120-139 mmHg DBP - 80-89 mmHg | SBP 149-159 mmHg DBP 90-99 mmHg | SBP >160 mmHg DBP >110 mmHg | |||||||||||||||||||||||||||||||||||||||
Prehypertension | Stage 1 hypertension Proceed to complete diagnostic approach | Stage 2 hypertension
Proceed to hypertensive crisis resident survival guide | |||||||||||||||||||||||||||||||||||||||
Determine who to treat based on the following: | |||||||||||||||||||||||||||||||||||||||||
Complete Diagnostic Approach
Obtain a detailed history: History of present hypertension
❑ Excessive sodium intake >2.4g per day ❑ Eyes:
❑ Cardiovascular:
❑ Kidneys:
| |||||||||||||||||||
Examine the patient: General examination: Neck
Respiratory examination Abdominal examination
| |||||||||||||||||||
Order tests: Routine
❑ Serum calcium
Additional tests based on results of the routine tests above:
❑ 24-hour free urinary cortisol (elevated in Cushing's syndrome)
❑ Chest CT angiography (To evaluate aortic coarctation) | |||||||||||||||||||
Does this patient have an identifiable secondary etiology? | |||||||||||||||||||
Yes | No | ||||||||||||||||||
Primary hypertension | Secondary hypertension | ||||||||||||||||||
Proceed to treatment | |||||||||||||||||||
Treatment
Shown below is an algorithm summarizing the treatment of
Prehypertension
Stage 1 Hypertension
Determine who to treat: ❑ BP ≥ 150/90 mmHg in patients ≥ 60 years | |||||||||||||||||||||||||||||
Review BP goals: General population | |||||||||||||||||||||||||||||
Initiate lifestyle modification: ❑ Weight reduction
❑ Adopt healthy diet
❑ Limit alcohol consumption
❑ Regular aerobic physical activity (brisk walking, jogging, cycling, swimming) for at least 30 mins per day | |||||||||||||||||||||||||||||
Does the patient have DM or CKD? | |||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||
CKD ± DM | DM only | ||||||||||||||||||||||||||||
Consider the race of the patient | |||||||||||||||||||||||||||||
Black population | Non-black population | ||||||||||||||||||||||||||||
Initiate: ❑ ACE inhibitors alone, OR | Initiate: ❑ Thiazide-type diuretic alone, OR | Initiate: ❑ Thiazide-type diuretic alone, OR | |||||||||||||||||||||||||||
Has the target BP been reached? | |||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||
Consider the following: ❑ | |||||||||||||||||||||||||||||
Monitoring and follow-up: ❑ | |||||||||||||||||||||||||||||
Diagnosis
Determine who to treat: ❑ BP ≥ 150/90 mmHg in patients ≥ 60 years | |||||||||||||||||||||||||||||
Review BP goals: General population | |||||||||||||||||||||||||||||
Initiate lifestyle modification: ❑ Weight reduction
❑ Adopt healthy diet
❑ Limit alcohol consumption
❑ Regular aerobic physical activity (brisk walking, jogging, cycling, swimming) for at least 30 mins per day | |||||||||||||||||||||||||||||
Does the patient have DM or CKD? | |||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||
CKD ± DM | DM only | ||||||||||||||||||||||||||||
Consider the race of the patient | |||||||||||||||||||||||||||||
Black population | Non-black population | ||||||||||||||||||||||||||||
Initiate: ❑ ACE inhibitors alone, OR | Initiate: ❑ Thiazide-type diuretic alone, OR | Initiate: ❑ Thiazide-type diuretic alone, OR | |||||||||||||||||||||||||||
Has the target BP been reached? | |||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||
Consider the following: ❑ | |||||||||||||||||||||||||||||
Monitoring and follow-up: ❑ | |||||||||||||||||||||||||||||