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Hypertension: Detection, Evaluation and Non-Pharmacologic Intervention
Hypertension: Detection, Evaluation and Non-Pharmacologic Intervention
Detection, Evaluation
and Non-pharmacologic Intervention
Misbah Keen, MD, FAAFP
Act. Asst. Professor Family Medicine
University of Washington School of Medicine
Seattle WA
Problem Magnitude
Definition
A systolic blood pressure ( SBP) >139
mmHg and/or
A diastolic (DBP) >89 mmHg.
Based on the average of two or more
properly
measured, seated BP
readings.
On each of two or more office visits.
BP Measurement
At least two measurements should be
made and the average recorded.
Clinicians should provide to patients
their specific BP numbers and the BP
goal of their treatment.
www.nhlbi.nih.gov
Classification
www.nhlbi.nih
.gov
Prehypertension
Pre-HTN
Systolic Diastolic
HTN
Isolated
Diastolic
HTN
Hypertensive Crises
Hypertensive Urgencies
Severe elevated BP in the upper range of
stage II hypertension.
Without progressive end-organ
dysfunction.
Examples: Highly elevated BP without
severe headache, shortness of breath or
chest pain.
Usually due to under-controlled HTN.
Hypertensive Emergencies
Types of Hypertension
Primary HTN:
also known as
essential HTN.
accounts for 95%
cases of HTN.
no universally
established cause
known.
Secondary HTN:
less common cause
of HTN ( 5%).
secondary to other
potentially rectifiable
causes.
Common
Uncommon
Pheochromocytoma
Glucocorticoid excess
Coarctation of Aorta
Hyper/hypothyroidism
Secondary HTN-Screening
Tests
www.nhlbi.nih.gov
Renovascular HTN
Aortic/renal dissection
Takayasus arteritis
Thrombotic/cholesterol emboli
CVD
Post transplantation stenosis
Post radiation
Complications of Prolonged
Uncontrolled HTN
Changes in the vessel wall leading to
vessel trauma and arteriosclerosis
throughout the vasculature
Complications arise due to the target
organ dysfunction and ultimately failure.
Damage to the blood vessels can be seen
on fundoscopy.
Target Organs
CVS (Heart and Blood Vessels)
The kidneys
Nervous system
The Eyes
Effects On CVS
Ventricular hypertrophy, dysfunction and
failure.
Arrhithymias
Coronary artery disease, Acute MI
Arterial aneurysm, dissection, and
rupture.
Nervous System
Stroke, intracerebral and subaracnoid
hemorrhage.
Cerebral atrophy and dementia
The Eyes
Retinopathy, retinal hemorrhages and
impaired vision.
Vitreous hemorrhage, retinal detachment
Neuropathy of the nerves leading to
extraoccular muscle paralysis and
dysfunction
Normal Retina
Hypertensive
Retinopathy
A: Hemorrhages
B: Exudates (Fatty
Deposits)
C: Cotton Wool Spots
(Micro Strokes)
AV Nicking
Hypertension
Cigarette smoking
Obesity (body mass index 30 kg/m2)
Physical inactivity
Dyslipidemia
Diabetes mellitus
Microalbuminuria or estimated GFR <60 mL/min
Age (older than 55 for men, 65 for women)
Family history of premature cardiovascular disease (men
under age 55 or women under age 65)
Sleep apnea
Drug-induced or related causes
Chronic kidney disease
Primary aldosteronism
Renovascular disease
Chronic steroid therapy and Cushings syndrome
Pheochromocytoma
Coarctation of the aorta
Thyroid or parathyroid disease
Heart
Left ventricular hypertrophy
Angina or prior myocardial infarction
Prior coronary revascularization
Heart failure
Brain
Stroke or transient ischemic attack
Chronic kidney disease
Peripheral arterial disease
Retinopathy
History
History-contd.
History-contd.
Family history of DM : Patient may also
be Diabetic
Cigarette smoker: Aggravate HTN,
independently a risk factor for CAD and
stroke
High alcohol: A cause of HTN
High salt intake: Advice low salt intake
Examination
Examination-contd.
Thorough examination of the heart and
lungs
Abdomen for enlarged kidneys, masses,
and abnormal aortic pulsation
Lower extremities for edema and pulses
Neurological assessment
Routine Labs
EKG.
Urinalysis.
Blood glucose and hematocrit; serum potassium,
creatinine ( or estimated GFR), and calcium.
HDL cholesterol, LDL cholesterol, and
triglycerides.
Optional tests
urinary albumin excretion.
albumin/creatinine ratio.
Goals of Treatment
Benefits of Treatment
Reductions in stroke incidence,
averaging 3540 percent
Reductions in MI, averaging 2025
percent
Reductions in HF, averaging >50 percent.
Lifestyle modifications
www.nhlbi.nih.gov
DASH Diet
Dietary approaches to Stop Hypertension
As effective as one medication
JNC 7 Summary
Joint National Commission 7th Report
PDF File on website
50 page document
Other Resources
Hyperlipedemia Information
www.nhlbi.nih.gov/guidelines/cholesterol/index.htm
Questions
mkeen@fammed.washington.edu