HYPERTENSION

OPD Case Management

Reporter: Karlo Gil A. Pagkaliwangan, MD
Moderator: Marpe Z.Viray, MD
Resource Persons: Khristian F. Ojeda, MD, FPCP, CSPSH
Israel M. Madlangsakay, MD, DPCP
January 15, 2020
 REFERENCES
• Kasper D.L. etal (2018) Harrison’s Principles of Internal Medicine. 20th
Edition. New York. McGraw-Hill Education.
• American Heart Association, 2019 Understanding Blood Pressure Readings
• American Heart Association, 2019 BP Raisers: Learn What Could Raise
Your Blood Pressure
• Bakris G etal, 2019, ACC/AHA Versus ESC/ESH on Hypertension Guidelines
• Hypertension Clinical Practice Guideline, 2017
• James P.A, etal (2014) 2014 Evidence-Based Guidelines for the
Management of High Blood Pressure in Adults. JAMA.
• Maas, A etal (2009) Women’s Health in Menopause with a Focus on
Hypertension
• Coylewright, M etal (2007) Menopause and Hypertension An Age-Old
Debate
 General Objective
• At the end of this conference, the audience
should be able to properly diagnose and
manage a case of hypertension in the out
patient department
 Specific Objectives
• To create an individualized concept map
correlating the patient’s risk factors with the
pathophysiology and symptoms of
hypertension
• To compare the hypertension guideline
recommendations of Harrison’s Principles of
Internal Medicine 20th Edition, American Heart
Association and European Society of
Hypertension
• MJ
• 56/F
• Widow
• Roman Catholic
• Marikina city
• OPD consult: 12/11/19
• Informant: Patient good reliability
HEADACHE
 History of Present Illness
• Patient is apparently well until 2 days prior to
consult (PTC),
+ Occipital headache, radiating to the nape area with
pain scale of 5/10, described as squeezing, relieved by
rest and aggravated by tedious activity, lasting for 2 to
3 minutes
 No nausea/vomiting, body weakness, chest pain and
difficulty of breathing.
 Patient’s relative took her BP which was
140/100mmHg.
No medications taken. No consult done.
 History of Present Illness
• Few hours PTC, recurrence of symptoms
prompted consult in our OPD.
 History of Present Illness
• Past Medical History
(-) Hypertension
Usual Blood Pressure:
Highest Blood Pressure:
(-) DM
(-) Thyroid Disease
(-) PTB
(-) Bronchial Asthma
(-) Allergy
(-) Previous surgery
(-) Malignancy
 Family History
(+) DM – Maternal
(-) Malignancy
(+) Hypertension – Both
(-) Thyroid disease
(-) Bronchial Asthma
 Personal and Social History
– Seamstress
– Widow
– Non-smoker
– Non-alcoholic beverage drinker
– Denies illicit drug use and abuse
– Usual food intake: fried foods, salty and
preservative foods
– G2P2 (2002)
– Menopause: 51 years old
 REVIEW OF SYSTEMS
• Constitutional – (-) weight loss, (-)fever, (-)chills, (-)malaise
• Ear, nose, throat and mouth – (-) hearing loss, (-) sinusitis, (-)sore throat, (-) oral
cavities
• Gastrointestinal – (-)nausea, (-)vomiting, (-) diarrhea, (-) constipation
• Integumentary – (-)skin rashes, (-)moles, (-)dryness, (-)lumps, (-)pigmentation
• Endocrine – (-)polyuria, (-)polydipsia, (-)cold-heat intolerance
• Genitourinary – (-)hematuria, (-) nocturia, (-)incontinence
• Hematologic – (-)anemia, (-)bruising, (-)bleeding, (-)lymph node enlargement
• Eyes – (-)diplopia, (-)blurred vision, (+)glasses
• Cardiovascular – (-)chest pain or pressure, (-) palpitations, (-)murmur
• Musculoskeletal – (-)arthritis, (-)joint stiffness, (-) swelling, (-) myalgias, (-)gout
• Neurologic – (-) paresthesia (-) hemiparesis/plegia (+) headache (-)dizziness, (-
)syncope, (-)seizures, (-) vertigo, (-)weakness, (-) tremor
• Respiratory – (-)cough, (-)wheezing, (-) asthma
• Psychiatry – (-)depression, (-)agitation, (-)panic-anxiety, (-)memory disturbance
 PHYSICAL EXAMINATION
• BP= 160/100 HR=89 RR=21 T=36.8
• Weight=70kg Height= 152cm BMI=30.30 (Asian C)
• Awake, alert, not in cardiorespiratory arrest
• Anicteric sclera, pink palpebral conjunctivae, no
nasoaural discharge, no post nasal drip, no cervico-
lymphadenopathy, no neck vein distention
• Symmetrical chest expansion, no deformities, no
retractions, clear breath sounds
• Adynamic precordium, normal rate, regular rhythm,
apex beat at 5th LICS MCL, (-) murmur
 PHYSICAL EXAMINATION
• Flabby, no deformities, normoactive bowel
sounds, tympanitic upon percussion on all
quadrants, liver span 6cm, no tenderness
upon light and deep palpation
• No gross deformities, full and equal pulse, no
bipedal edema, no cyanosis, CRT </= 2 sec
 SALIENT FEATURES
SUBJECTIVE OBJECTIVE
56/female BP = 140/100
(+)headache radiating to nape area, pain BMI=30.30 obese
scale 5/10 aggravated by tedious activity,
relieved by rest
(+) Family history (-) neck vein distention
Menopause 51/F (-) murmur
Fond of eating fatty foods, salty food and (-) bipedal edema
preservatives
(-) chest pain
(-) body weakness
(-) nausea/vomiting (-) full and equal pulses
(-) difficulty of breathing
(-) palpitations
 WORKING IMPRESSION
• Hypertension Stage 2
• Obese I (Asian Cut off)
 CONCEPT MAP MJ

MODIFIABLE NON MODIFIABLE

(+) Family History

56 years old
Increase Sedentary Lifestyle Menopause
Female
salty/fatty intake Graded association
(Increase Risk if (30 minutes of moderately with hypertension,
Dietary Salt Intake intense physical activity, 6-7
as the prevalence
is >6g NaCl/day) days a week)
increased with the Arteriosclerosis
number of structural
generations with a alterations and
family calcifications
BMI – 30.30 Obese
(Increase hypertension
consequence of
obesity, 60% of Large Artery Stiffness
Hypertension are Peripheral Vascular
>20% obese) Resistance

Centrally located
body fat
Central obesity was
classified WC >90cm
males; WC>80cm for
female
 Estrogen/androgen ratio

Increase
BMI
Endothelial
dysfunction
Sympathetic
activation
Decrease
in NO
Increase renin
release

Increase Increase in
Increase
oxidative
angiotensin II endothelin
stress

Renal vasoconstriciton

HYPERTENSION HEADACHE
 DIFFERENTIAL DIAGNOSIS
RULE IN RULE OUT
ACUTE MIGRAINE (+) headache radiating to Sensitivity to light and
nape area touch - photophobia
With aura
CVA INFARCT and BLEED 56yo Paresthesia/hemiparesis
140/100 mmHg dysarthria
(+) headache radiating to
nape area
Family history of
hypertension
HYPERTENSION BP – 140/100
BMI - 30
56yo
(+) headache radiating to
nape area
Family history
hypertension
 LABORATORIES
TEST NV units RESULT
FBS 3.8-5.8 5.4 – (97mg/dL)
BUN 2.5-7.5 6.37
Creatinine 53.0 – 97.2 90.3
BUA 149-405 324.48
Cholesterol 3.5-5.2 5.09
Triglycerides 0.39 – 1.49 0.91 – (80.6mg/dl)
HDL 1.17 – 1.56 1.57 – (60.71mg/dl)
LDL 1.69 – 4.55 4.50
SGOT <40 16.07
SGPT <32 14.22
Na 135-148 136.6
K 3.5-5.5 4.54
 LABORATORIES
TEST NV NV
WBC 7.80 5-10
RBC 5.11 4.2-5.2
Hemoglobin 12.8 12-16
Hematocrit 41.8 35-47
MCV 81.8 80-100
MCH 25.2 27.0-32.0
MCHC 30.7 32-36
Platelet Count 363 150-450
Segmenters 51.7 40-60
Lymphocytes 38.2 20-40
Monotcytes 3.7 2.0-8.0
Eosinophils 6.1 1.0-6.0
Basophils 0.3 0.1-1.0
 MANAGEMENT
• Low salt low fat diet
• Losartan 50mg/tab once a day
• Ff up after a month, bring daily BP monitoring
 HYPERTENSION
• Level of blood pressure at which the
institution of therapy reduces blood pressure-
related morbidity and mortality

Kasper D.L. etal (2018) Harrison’s Principles of Internal Medicine. 20th Edition. New York.
McGraw-Hill Education.
 EPIDEMIOLOGY
• Average systolic BP higher for men than
women during early adulthood
• >/= 60 years old, systolic BP of women are
higher than men
• >/= 60 years old, likelihood of hypertension is
65.4%
• Increase hypertension consequence of
obesity, 60% of Hypertension are >20% obese
Kasper D.L. etal (2018) Harrison’s Principles of Internal Medicine. 20th Edition. New York.
McGraw-Hill Education.
 EPIDEMIOLOGY
• High dietary intake of NaCl
• Low intake of calcium and potassium
• Alcohol consumption, psychosocial stress and
low level of physical activity
• Heritability of hypertension 30-40%

Kasper D.L. etal (2018) Harrison’s Principles of Internal Medicine. 20th Edition. New York.
McGraw-Hill Education.
MECHANISM OF HYPERTENSION
STROKE
VOLUME

CO

HEART RATE
ARTERIAL
PRESSURE
VASCULAR STRUCTURE

PERIPHERAL
RESISTANCE

VASCULAR FUNCTION

Kasper D.L. etal (2018) Harrison’s Principles of Internal Medicine. 20th Edition. New York.
McGraw-Hill Education.
 MECHANISM OF HYPERTENSION
• INTRAVASCULAR VOLUME
• Sodium predominantly extracellular ion, primary
determinant extracelllular fluid vol

Pressure across the vascular bed

BLOOD FLOW=
Vascular Resistance

Kasper D.L. etal (2018) Harrison’s Principles of Internal Medicine. 20th Edition. New York.
McGraw-Hill Education.
 MECHANISM OF HYPERTENSION
• AUTONOMIC NERVOUS SYSTEM
– A1 – post synaptic smooth muscles
vasoconstriction
– A2 – presynaptic, negative feedback
– B1 – stimulates rate and strength cardiac
contraction and increase cardiac output
– B2 – vasodilatation and relax smooth muscle

Kasper D.L. etal (2018) Harrison’s Principles of Internal Medicine. 20th Edition. New York.
McGraw-Hill Education.
 MECHANISM OF HYPERTENSION
• RENIN-ANGIOTENSIN ALDOSTERONE
ANGIOTENSINOGEN
RENIN
Bradykinin
ANGIOTENSIN I

ACE-kininase II
ANGIOTENSIN II Inactive
Peptide

AT1 Receptor AT2 Receptor

Aldosterone Kasper D.L. etal (2018) Harrison’s Principles of Internal Medicine. 20th Edition. New York.
McGraw-Hill Education.
 MECHANISM OF HYPERTENSION
• VASCULAR MECHANISM

Kasper D.L. etal (2018) Harrison’s Principles of Internal Medicine. 20th Edition. New York.
McGraw-Hill Education.
 DIAGNOSIS
• Key Steps for Proper Blood Pressure
Measurements
– Properly placed the patient
• Back supported, feet flat on ground
– Wait 5 mins, check BP 3x, 1 min apart
– Eliminate first, then average the 2
– Provide the reading to patient

Bakris G etal, 2019, ACC/AHA Versus ESC/ESH on Hypertension Guidelines

 DIAGNOSIS
• Selection of proper cuff size as a function of
arm circumference

ARM CIRCUMFERENCE (cm) USUAL CUFF SIZE

22-26 Small adult
27-34 Adult
35-44 Large adult
45-52 Adult thigh

Bakris G etal, 2019, ACC/AHA Versus ESC/ESH on Hypertension Guidelines

DIAGNOSIS

Bakris G etal, 2019, ACC/AHA Versus ESC/ESH on Hypertension Guidelines

 Harrison’s American College European JNC 8
COMPARISON
of Society of
Cardiology/Americ Cardiology/
an Heart European
Association Society of
(ACC/AHA) Hypertension
(ESC/ESH)
How to Average of two or > 140/90
more seated blood S D
diagnose?/How pressure readings
S D mmHg
to define if its during each of two Office/c >/=130 >/=80 Office/ >/=1 >/= 90
linic BP clinic 40
hypertension or more outpatient
visit Daytim >/=130 >/=80 Daytim >/= >/= 85
e mean e mean 135
Nightti >/= >/= 70
Nightti >/= >/=65 me 120
N <120 <80 me 110 mean
24 hr >/= >/= 80
Pre 120- 80- 24 hr >/= >/= 75 mean 130
H 139 89 mean 125
Home >/= >/= 85
St 1 140- 90- Home >/=130 >/= 80 mean 135
159 99 BP

St 2 >/=1 >/=
60 100
ISH >/=1 <90
40
 Harrison’s ACC/AHA ESC/ESH JNC 8
When to treat >/=140/90 >130/80 >/=140/90 >/= 60 years: >/=150/90
<60 years: >/= 140
hypertension? >/= 18 yrs with CKD:
>/=140/90
>/= 18 yrs with DM: >/=
140/90
Treatments Single or mixed Initial single Initial single Strategy A – start 1 drug,
titrate to max, then add
pills pill pill second
combination combination Strategy B – start 1 drug
therapy in therapy in and then add second
patients patients >/= before achieving max of
1st drug
>20/10 140/90 Strategy C – 2 drugs at
mmHg above the same time, either 2
BP goal separate pills or as a
single pill combination
BP Goals SBP - < 135-140 <130/80 Systolic >/= 60 years: <150/90
<60 years: <140/90
DBP - <80-85 targets < 140 All ages DM, no CKD:
And close to <140/90
130 All ages CKD with or
without DM: <140/90
PHARMACOLOGICAL THERAPY
Beta blocker
Alpha
adrenergic
blocker
Beta blocker – decrease cardiac output owing to reduction
of heart rate and contractility

Cardioselective – Atenolol

Non selective – metoprolol, propanolol

Combined alpha/beta – labetalol, carvedilol

Alpha Adrenergic Blocker - post synaptic
selective a-adrenoreceptor anatagonist lower BP
by decreasing vascular resistance
Prazosin
Doxazosin
Sympatholytic Agents – centrally actin a2
sympathetic agonist decrease peripheral resistance
by inhibiting sympathetic outflow
DIURETICS (stroke volume-
preload)
Thiazides – inhibit Na/Cl
pump in distal convoluted
tubule -> increase Na
excretion
(Hydrochloothiazides,
Cholrathidone)

Potassium Sparing – act by

inhibition of ENaC in distal
nephron
(Amiloride, Triamterene)

Loop Diuretics -Na-K-2Cl

cotransporter in thick
ascending loop of henle
- Reserved for low GFR
- (Furosemide)
Aldosterone Antagonist –
non selective aldosterone
blocker (Spirinolactone)
ACE INHIBITOR – decrease the production of angiotensin II, increase bradykinin and
reduce sympathetic activity
ANGIOTEBSIN RECEPTOR BLOCKER– provide selective blocker of AT1 receptors
 NON DIHYPRYRIDINES – reduce vascular resistance through L-channel
blockade , which reduces intracellular calcium and blunts vasoconstriction
VERAPAMIL, DILTIAZEM
 NON PHARMACOLOGICAL INTERVENTIONS FOR
PREVENTION AND TREATMENT OF HYPERTENSION

• PHYSICAL ACTIVITY
DOSE Approx Impact on SBP

Hypertension Normotension

Aerobic 90-150 min/week 5/8 mm Hg 2/4 mmHg

65-75% HR reserve
Dynamic 90-150 min/week 4mmHg -2mmHg
Resistance 50-80% 1 rep max
6 exer, 3set/exer,
10rep/set
Isometric 4x2min, 1 min rest 5 mmHg 4mmHg
between exer, 30% -
40% max voluntary
contractions, 3
sessions/week
8-10 weeks
Bakris G etal, 2019, ACC/AHA Versus ESC/ESH on Hypertension Guidelines
 NON PHARMACOLOGICAL INTERVENTIONS FOR
PREVENTION AND TREATMENT OF HYPERTENSION
Approx Impact on SBP
Hypertension Normotension
DASH DIET Fruits, vegetables, whole grain 11mmHg 3 mmHg
and low-fat dairy products
Weight loss Ideal body weight is best goal, 5 mmHg 2/3mmHg
>/= 1 kg reduction in body
weight for most adults who are
overweight
Dietary Na <1500 mg/day optimal goal 5/6mmHg 2/3mmHg
>/= 1000 mg/day for most adults
Dietary K 3500-5000 mg/day 4/5 mmHg 2 mmHg
Alcohol Men: < 2 drinks/day 4 mmHg 3 mmHg
consumption Female: <1 drink/day

Bakris G etal, 2019, ACC/AHA Versus ESC/ESH on Hypertension Guidelines

Kasper D.L. etal (2018) Harrison’s Principles of Internal Medicine. 20th Edition. New York.
McGraw-Hill Education.
 Guidelines Approach
• BP measurement according to guidelines – 7-8
mins
• BP meds review and updates – 3-4mins
• Lifestyle review and discussion – 7-10mins
• CV risk assessment via ASCVD app 1min
• All information presented to physician at visit
start: TOTAL – 23-28 mins

Bakris G etal, 2019, ACC/AHA Versus ESC/ESH on Hypertension Guidelines

THANK YOU