Chronic hypertension resident survival guide: Difference between revisions
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===Stage 1 Hypertension=== | ===Stage 1 Hypertension=== | ||
Shown below is an algorithm summarizing the treatment of hypertension based on the 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8) and the 2013 ESH/ESC guidelines for the management of arterial hypertension.<ref name="James-2014">{{Cite journal | last1 = James | first1 = PA. | last2 = Oparil | first2 = S. | last3 = Carter | first3 = BL. | last4 = Cushman | first4 = WC. | last5 = Dennison-Himmelfarb | first5 = C. | last6 = Handler | first6 = J. | last7 = Lackland | first7 = DT. | last8 = LeFevre | first8 = ML. | last9 = MacKenzie | first9 = TD. | title = 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). | journal = JAMA | volume = 311 | issue = 5 | pages = 507-20 | month = Feb | year = 2014 | doi = 10.1001/jama.2013.284427 | PMID = 24352797 }}</ref><ref name="Mancia-2013">{{Cite journal | last1 = Mancia | first1 = G. | last2 = Fagard | first2 = R. | last3 = Narkiewicz | first3 = K. | last4 = Redán | first4 = J. | last5 = Zanchetti | first5 = A. | last6 = Böhm | first6 = M. | last7 = Christiaens | first7 = T. | last8 = Cifkova | first8 = R. | last9 = De Backer | first9 = G. | title = 2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension. | journal = J Hypertens | volume = 31 | issue = 10 | pages = 1925-38 | month = Oct | year = 2013 | doi = 10.1097/HJH.0b013e328364ca4c | PMID = 24107724 }}</ref> | |||
<span style="font-size:85%">'''Abbreviations:''' | |||
'''ACEI:''' [[ACE inhibitors]]; | |||
'''ARBs:''' [[Angiotensin II receptor antagonist|Angiotensin II receptor blockers]]; | |||
'''BMI:''' [[Body mass index]]; | |||
'''BP:''' [[Blood pressure]]; | |||
'''CCBs:''' [[Calcium channel blockers]]; | |||
'''CKD:''' [[Chronic kidney disease]]; | |||
'''DASH:''' [[Dietary Approaches to Stop Hypertension]]; | |||
'''DM:''' [[Diabetes mellitus]] | |||
</span> | |||
<br> | |||
{{familytree/start}} | {{familytree/start}} | ||
{{familytree | | | | | | | | A01 | A01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Determine who to treat:'''<br> | {{familytree | | | | | | | | A01 | A01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Determine who to treat:'''<br> | ||
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{{familytree | | | | | | | | C01 | | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initiate lifestyle modification:'''<br> | {{familytree | | | | | | | | C01 | | |C01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initiate lifestyle modification:'''<br> | ||
---- | ---- | ||
❑ Weight reduction<br> | ❑ [[Weight reduction]]<br> | ||
:❑ Maintain a waist circumference of <br> | :❑ Maintain a waist circumference of <br> | ||
:* <40 inches (102cm) for men<br> | :* <40 inches (102cm) for men<br> | ||
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:* BMI of ≤25 kg/m2<br> | :* BMI of ≤25 kg/m2<br> | ||
❑ Adopt healthy diet<br> | ❑ Adopt healthy diet<br> | ||
:❑ DASH diet (rich in fruits, vegetables, whole grains, low sodium, low-fat proteins)<br> | :❑ [[Dietary Approaches to Stop Hypertension|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> | :❑ Dietary [[sodium]] intake of ≤ 100 mmol/day (2.4g Na or 6g NaCl)<br> | ||
❑ Limit alcohol consumption<br> | ❑ Limit [[alcohol]] consumption<br> | ||
:❑ ≤ 2 drinks/day for men (24oz beer or 10oz wine or 3oz 40% whisky<br> | :❑ ≤ 2 drinks/day for men (24oz beer or 10oz wine or 3oz 40% whisky<br> | ||
:❑ ≤ 1 drink/day for women<br> | :❑ ≤ 1 drink/day for women<br> | ||
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{{familytree | | | |!| | | |!| | | |!| |}} | {{familytree | | | |!| | | |!| | | |!| |}} | ||
{{familytree | | | I03 | | | I01 | | I02 | | I01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Initiate:'''<br> | {{familytree | | | I03 | | | I01 | | I02 | | I01=<div style="float: left; text-align: left; width: 15em; padding:1em;">'''Initiate:'''<br> | ||
❑ Thiazide | ❑ [[Thiazide diuretic]] alone, '''OR'''<br> | ||
❑ CCB alone, '''OR'''<br> | ❑ [[CCB]] alone, '''OR'''<br> | ||
❑ Combination of the two classes <br> | ❑ Combination of the two classes <br> | ||
</div>|I02=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initiate:'''<br> | </div>|I02=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Initiate:'''<br> | ||
❑ Thiazide | ❑ [[Thiazide diuretic]] alone, '''OR'''<br> | ||
❑ ACEI alone, '''OR'''<br> | ❑ [[ACEI]] alone, '''OR'''<br> | ||
❑ ARBs alone, '''OR'''<br> | ❑ [[ARBs]] alone, '''OR'''<br> | ||
❑ CCB alone, '''OR'''<br> | ❑ [[CCB]] alone, '''OR'''<br> | ||
❑ Combination of all the classes <br><br> | ❑ Combination of all the classes <br><br> | ||
'''Avoid the use of | '''Avoid the use of [[ACEI]]s and [[ARBs]] in combination'''<br> | ||
</div>|I03=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Initiate:'''<br> | </div>|I03=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Initiate:'''<br> | ||
❑ ACE inhibitors alone, '''OR'''<br> | ❑ [[ACE inhibitors]] alone, '''OR'''<br> | ||
❑ ARBs alone, '''OR'''<br> | ❑ [[ARBs]] alone, '''OR'''<br> | ||
❑ ACEI or ARBs in combination with other drug class e.g., <br> | ❑ [[ACEI]] or [[ARBs]] in combination with other drug class e.g., <br> | ||
'''Avoid the | '''Avoid the combined use of ACEIs and ARBs in a patient'''</div>}} | ||
{{familytree | | | |`|-|-|-|+|-|-|-|'| | |}} | {{familytree | | | |`|-|-|-|+|-|-|-|'| | |}} | ||
{{familytree | | | | | | | J01 | | | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Has the target BP been reached?'''</div>}} | {{familytree | | | | | | | J01 | | | |J01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Has the target BP been reached?'''</div>}} | ||
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{{familytree | | | | | K01 | | K02 | | |K01=Yes|K02=No}} | {{familytree | | | | | K01 | | K02 | | |K01=Yes|K02=No}} | ||
{{familytree | | | | | |!| | | |!| | |}} | {{familytree | | | | | |!| | | |!| | |}} | ||
{{familytree | | | | | |!| | | L01 | |L01=Click here for <br>further therapeutic options<br> | {{familytree | | | | | |!| | | L01 | |L01=Click [[Hypertension resident survival guide#Choice of Regimen|'''here for <br>further therapeutic options''']]<br> | ||
}} | }} | ||
{{familytree | | | | | |`|-|v|-|'| |}} | {{familytree | | | | | |`|-|v|-|'| |}} | ||
{{familytree | | | | | | | M01 | | |M01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Monitoring and follow-up:'''<br> | {{familytree | | | | | | | M01 | | |M01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Monitoring and follow-up:'''<br> | ||
'''Monitor:'''<br> | '''Monitor:'''<br> | ||
❑ Serum potassium and creatinine at least 1-2 times per year<br> | ❑ Serum [[potassium]] and [[creatinine]] at least 1-2 times per year<br> | ||
'''Follow-up visits'''<br> | '''Follow-up visits'''<br> | ||
❑ Schedule 2-4 weekly visits to assess:<br> | ❑ Schedule 2-4 weekly visits to assess:<br> | ||
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❑ 3-6 monthly visits when BP goal is achieved<br> | ❑ 3-6 monthly visits when BP goal is achieved<br> | ||
❑ Reinforce strategies to improve compliance to medication usage<br> | ❑ Reinforce strategies to improve compliance to medication usage<br> | ||
:❑ Self-monitoring of blood pressure<br> | :❑ Self-monitoring of [[blood pressure]]<br> | ||
:❑ Simplification of drug regimen<br> | :❑ Simplification of drug regimen<br> | ||
:❑ Telephone follow-up, reminders, home visits<br> | :❑ Telephone follow-up, reminders, home visits<br> |
Revision as of 21:41, 25 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 |
Medical Therapy |
Do's |
Don'ts |
Overview
Hypertension (HTN) is defined as a systolic blood pressure (SBP) ≥ 140 mmHg and diastolic blood pressure (DBP) ≥ 90 mmHg.[1] It is usually detected during the screening of an asymptomatic individual, but the diagnosis is based on persistent elevation of blood pressure after the average of 2 or more blood pressure measurements taken on each of 2 or more hospital visits. Hypertension can either be primary or essential, whenever the etiology cannot be identified; or secondary, whenever the etiology (e.g., hyperthyroidism, pheochromocytoma, renal artery stenosis) is known. The presence of diabetes mellitus, cigarette smoking, excessive sodium intake, obesity, and sedentary lifestyle increases the risk of developing essential hypertension. Lifestyle modifications such as weight reduction, reduction in alcohol consumption, exercise are recommended to all patients in addition to pharmacological therapy, when required.
Classification
Classification | Blood pressure (mmHg) |
---|---|
Normal | < 120/80 |
Prehypertension | SBP 120-139 DBP 80-89 |
Stage 1 hypertension | SBP 149-159 DBP 90-99 |
Stage 2 hypertension | SBP >160 DBP >110 |
Isolated systolic hypertension | SBP ≥ 140 DBP < 90 |
Isolated diastolic hypertension | SBP <140 DBP ≥90 |
Causes
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
- Aortic coarctation
- Cocaine or amphetamine overdose
- Pheochromocytoma
- Preeclampsia
Common Causes
Primary or Essential Hypertension
- No underlying cause is identified. Risk factors include: high sodium intake, obesity, sedentary lifestyle, and excessive alcohol intake.
Secondary Hypertension
- Aortic coarctation
- Chronic kidney disease
- Cocaine or amphetamine overdose
- Cushing's syndrome
- Hyperthyroidism
- Hypothyroidism
- Medications (e.g., oral contraceptive pills, NSAIDs)
- Nephrotic syndrome
- Pheochromocytoma
- Polycystic kidney disease
- Preeclampsia
- Renal artery stenosis
- Sleep apnea
Pseudohypertension
Click here for the complete list of causes.
Diagnosis
Shown below is an algorithm summarizing the diagnosis of hypertension based on the seventh report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and 2013 ESH/ESC guidelines for the management of arterial hypertension.[2][3]
Abbreviations:
ABPM: Ambulatory blood pressure monitoring;
BP: Blood pressure;
CKD: Chronic kidney disease;
DBP: Diastolic blood pressure;
DM: Diabetes mellitus;
SBP: Systolic blood pressure
General Approach
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 | |||||||||||||||||||||||||||||||||||||||
Stage 1 hypertension Proceed to the complete diagnostic approach | Stage 2 hypertension
Proceed to hypertensive crisis resident survival guide | ||||||||||||||||||||||||||||||||||||||||
Complete Diagnostic Approach
Shown below is an algorithm summarizing the diagnosis of hypertension based on the seventh report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and 2013 ESH/ESC guidelines for the management of arterial hypertension.[2][3]
Abbreviations:
BMI: Body mass index;
BP: Blood pressure;
CNS: Central nervous system;
CT: Computed tomography;
CVD: Cardiovascular disease;
eGFR: Estimated glomerular filtration rate;
EKG: Electrocardiogram;
HTN: Hypertension;
LVH: Left ventricular hypertrophy;
MI: Myocardial infarction;
NSAIDs: Non steroidal anti-inflammatory drugs;
TSH: Thyroid stimulating hormone;
UTI: Urinary tract infection
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
| |||||||||||||||||||
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 the 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 hypertension based on the 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8), ESH/ESC guidelines for the management of arterial hypertension, and the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.[4][2][3]
Prehypertension
Does the patient have chronic kidney disease or diabetes mellitus? | |||||||||||||||||||
Yes | No | ||||||||||||||||||
❑ Commence lifestyle modification, THEN | ❑ Commence lifestyle modification | ||||||||||||||||||
Stage 1 Hypertension
Shown below is an algorithm summarizing the treatment of hypertension based on the 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8) and the 2013 ESH/ESC guidelines for the management of arterial hypertension.[5][2]
Abbreviations:
ACEI: ACE inhibitors;
ARBs: Angiotensin II receptor blockers;
BMI: Body mass index;
BP: Blood pressure;
CCBs: Calcium channel blockers;
CKD: Chronic kidney disease;
DASH: Dietary Approaches to Stop Hypertension;
DM: Diabetes mellitus
Determine who to treat: ❑ BP ≥ 150/90 mmHg in patients ≥ 60 years | |||||||||||||||||||||||||||||
Review BP goals: General population | |||||||||||||||||||||||||||||
Initiate lifestyle modification:
❑ 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 diuretic alone, OR | ||||||||||||||||||||||||||||
Has the target BP been reached? | |||||||||||||||||||||||||||||
Yes | No | ||||||||||||||||||||||||||||
Click here for further therapeutic options | |||||||||||||||||||||||||||||
Monitoring and follow-up: Monitor:
❑ 3-6 monthly visits when BP goal is achieved
| |||||||||||||||||||||||||||||
Medical Therapy
Choice of Regimen
Assess BP and cardiovascular risk | |||||||||||||||||||||||||||||||||||||||||||||||||
Mild elevation of BP Low CV risk | Severe elevation of BP High CV risk | ||||||||||||||||||||||||||||||||||||||||||||||||
Consider starting with a single agent | Consider 2-drug combination | ||||||||||||||||||||||||||||||||||||||||||||||||
Target BP achieved? | Target BP achieved? | ||||||||||||||||||||||||||||||||||||||||||||||||
Continue with current regimen | Yes | No | No | Yes | Continue with current regimen | ||||||||||||||||||||||||||||||||||||||||||||
Switch to a different drug Titrate until maximum dose is reached, if necessary | Increase dose of present drug and titrate accordingly | Increase dose of present combination | Add a third drug and titrate to maximum dose, if necessary | ||||||||||||||||||||||||||||||||||||||||||||||
If BP goal is not achieved Add a second drug | |||||||||||||||||||||||||||||||||||||||||||||||||
Maximum dose of 2-drug combination reached | |||||||||||||||||||||||||||||||||||||||||||||||||
If BP goal is not achieved Switch to a different 2-drug combination and titrate to the maximum dose, if necessary OR Add a third drug and titrate to the maximum dose, if necessary | |||||||||||||||||||||||||||||||||||||||||||||||||
Drug List
Do's
Don'ts
- The combination of ACE inhibitors and ARBs in a patient is not recommended.
References
- ↑ Cuddy ML (2005). "Treatment of hypertension: guidelines from JNC 7 (the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure 1)". J Pract Nurs. 55 (4): 17–21, quiz 22-3. PMID 16512265.
- ↑ 2.0 2.1 2.2 2.3 Mancia, G.; Fagard, R.; Narkiewicz, K.; Redán, J.; Zanchetti, A.; Böhm, M.; Christiaens, T.; Cifkova, R.; De Backer, G. (2013). "2013 Practice guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC): ESH/ESC Task Force for the Management of Arterial Hypertension". J Hypertens. 31 (10): 1925–38. doi:10.1097/HJH.0b013e328364ca4c. PMID 24107724. Unknown parameter
|month=
ignored (help) - ↑ 3.0 3.1 3.2 Chobanian, AV.; Bakris, GL.; Black, HR.; Cushman, WC.; Green, LA.; Izzo, JL.; Jones, DW.; Materson, BJ.; Oparil, S. (2003). "Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure". Hypertension. 42 (6): 1206–52. doi:10.1161/01.HYP.0000107251.49515.c2. PMID 14656957. Unknown parameter
|month=
ignored (help) - ↑ Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL; et al. (2003). "Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure". Hypertension. 42 (6): 1206–52. doi:10.1161/01.HYP.0000107251.49515.c2. PMID 14656957.
- ↑ James, PA.; Oparil, S.; Carter, BL.; Cushman, WC.; Dennison-Himmelfarb, C.; Handler, J.; Lackland, DT.; LeFevre, ML.; MacKenzie, TD. (2014). "2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8)". JAMA. 311 (5): 507–20. doi:10.1001/jama.2013.284427. PMID 24352797. Unknown parameter
|month=
ignored (help)