Risk Stratification and Treatment Recommendations for hypertension

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Risk Stratification and Treatment Recommendations
for hypertension

• 1- Determine blood pressure stage.
• 2- Determine risk group by major risk factors
• and TOD/CCD.
• 3- Determine treatment recommendations
• (by using the recommended table).
• 4- Determine target blood pressure.
• 5- Refer to specific treatment recommendations

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Major Risk Factors

• Smoking
• Dyslipidemia
• Diabetes mellitus
• Age gt 60 years
• Gender
• - Men
• - Postmenopausal women
• Family history (first degree relative) of
  cardiovascular diseases
• - Women lt age 65
• - Men lt age 55

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TOD/CCD (Target Organ Damage/ Clinical
Cardiovascular Disease)

• Heart diseases
• - LVH (left ventricular hypertrophy)
• - Angina/prior MI
• - Prior Coronary revascularization
• - Heart failure
• Stroke or transient ischaemic attacks (TIA)
• Nephropathy
• Peripheral arterial disease
• Hypertensive retinopathy

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• Risk Group A
• No major risk factors
• No TOD/CCD
• Risk Group B
• At least one major risk factor,
• not including diabetes
• No TOD/CCD
• Risk Group C
• TOD/CCD and/or diabetes, with
• or without other risk factors

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Blood pressure stages (mm Hg)

• High-normal (130-139/85-89)
• Stage 1 (140-159/90-99)
• Stages 2 and 3 (160/100)

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Risk Group C TOD/CCD and/or diabetes, with or without other risk factors Risk Group B At least one major risk factor, not including diabetes No TOD/CCD Risk Group A No major risk factors No TOD/CCD Blood pressure stages (mm Hg)
Drug therapy for those with heart failure, renal insufficiency or diabetes Lifestyle modification Lifestyle modification Lifestyle modification High-normal (130-139/85-89)
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Risk Group C TOD/CCD and/or diabetes, with or without other risk factors Risk Group B At least one major risk factor, not including diabetes No TOD/CCD Risk Group A No major risk factors No TOD/CCD Blood pressure stages (mm Hg)
Drug therapy Lifestyle modification Lifestyle modification (up to 6 months) For patients with multiple risk factors, clinicians should consider drugs as initial therapy plus lifestyle modifications. Lifestyle modification (up to 12 months) Stage 1 (140-159/90-99)
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Risk Group C TOD/CCD and/or diabetes, with or without other risk factors Risk Group B At least one major risk factor, not including diabetes No TOD/CCD Risk Group A No major risk factors No TOD/CCD Blood pressure stages (mm Hg)
Drug therapy Lifestyle modification Drug therapy Lifestyle modification Drug therapy Lifestyle modification Stages 2 and 3 (160/100)
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• Example A patient with diabetes and a blood
  pressure of 142/94 mm Hg plus left ventricular
  hypertrophy should be classified as having stage
  1
• hypertension with target organ disease (left
  ventricular hypertrophy) and with another major
  risk factor (diabetes). This patient would be
  categorized
• as Stage 1, Risk Group C, and recommended for
  immediate initiation of pharmacologic treatment.

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Target blood pressure

• lt140/90 mm Hg Uncomplicated hypertension, Risk
  Group A, Risk Group B, Risk Group C except for
  the following
• lt130/80 mm Hg in Diabetes
• lt130/85 mm Hg Renal failure heart failure
• lt125/75 mm Hg Renal failure with proteinuria
  gt1 gram/24 hours

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Patient 1 A patient diagnosed to have mild
hypertension.
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Patient 2 A young patient with hyperdynamic
circulation
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Patient 3an elderly patient with no particular
chronic diseases other than hypertention.Such a
person is liable to suffer from isolated systolic
hypertension resulting from increased vascular
stiffness .
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Patient 4 A patient with gout
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Patient 5 A patient with ischemic heart disease
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Patient 6 A patient with asthma
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Patient 7 A patient with peripheral vascular
disease
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Patient 8 A patient with type 2 diabetes
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Patient 9 A patient with type I diabetes
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Patient 10 A patient with congestive heart
failure
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Patient 11 A pregnant patient
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Measuring blood pressure

• Conventional (mechanical) sphygmomanometer with
  aneroid manometer and stethoscope, used to
  measure blood pressure

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• Automated arm blood pressure meter showing
  arterial hypertension (shown a systolic blood
  pressure 158 mmHg, diastolic blood pressure
  99 mmHg and heart rate of 80 beats per minute).

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• Diagnosis of hypertension is generally on the
  basis of a persistently high blood pressure.
  Usually this requires three separate measurements
  at least one week apart. Exceptionally, if the
  elevation is extreme, or end-organ damage is
  present then the diagnosis may be applied and
  treatment commenced immediately.

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• Measurements in control of hypertension should
  be
• at least 1 hour after caffeine,
• 30 minutes after smoking or strenuous exercise
  and without any stress.
• Cuff size is also important. The bladder should
  encircle and cover two-thirds of the length of
  the (upper) arm.
• The patient should be sitting upright in a chair
  with both feet flat on the floor for a minimum of
  five minutes prior to taking a reading.
• The patient should not be on any adrenergic
  stimulants, such as those found in many cold
  medications.

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Blood Pressure MeasurementFor OSCE Setting

• 1. Initially, ensure that you have all the
  necessary equipment. This is a sphygmomanometer,
  a stethoscope.

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• 2. It is important when measuring blood pressure
  to build a rapport with your patient so as to
  prevent 'White Coat Syndrome' which may give you
  an inaccurately high reading. Rapport is one of
  the most important features or characteristics of
  unconscious human interaction. Being "on the same
  wavelength" as the person with whom you are
  talking.

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• Ensure you introduce yourself to the patient,

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• explain the procedure answering any questions
  they may have, and
• ask for their consent.
• You should also explain to them that they may
  feel some discomfort as you inflate the cuff, but
  that this will be shortlived.
• Make sure they are sitting comfortably, with
  their arm rested.

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• 3. Next, as with all clinical procedures, it is
  vital that you wash your hands with alcohol rub.

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• 4. You should ensure that you have the correct
  cuff size for your patient. A different cuff size
  may be required for obese patients and children.

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• 5. Wrap the cuff around the patient's upper arm
  ensuring the arrow is in line with the brachial
  artery. This should be determined by feeling the
  brachial pulse. The cuff should be at the level
  of the heart.

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• 6. Next you need to determine a rough value
  for the systolic blood pressure. This can be done
  by palpating the brachial or radial pulse and
  inflating the cuff until the pulse can no longer
  be felt.
• The reading at this point
• should be noted and the
• cuff deflated.

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• 7. Now that you have a rough value, the true
  value can be measured. Place the diaphragm of
  your stethoscope over the brachial artery and
  re-inflate the cuff
• to 20-30 mmHg higher
• than the estimated value
• taken before.

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• Then deflate the cuff at 2-3 mmHg per second
  until you hear the first Korotkov sound - this is
  the systolic blood pressure. Continue to deflate
  the cuff until the sounds disappear, the 5th
  Korotokov sound - this is the diastolic blood
  pressure.

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• 8. If the blood pressure is greater than 140/90,
  you should wait for 1 minute and re-check.
• 9. Furthermore, you should explain to your
  examiner that you would want to check the blood
  pressure standing to check for a significant drop
  (gt20 mmHg after 2 minutes). This would suggest a
  postural hypotension.
• 10. Finally, you should give the reading to the
  patient and thank them.

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• Two measurements should be made at least 5
  minutes apart, and, if there is a discrepancy of
  more than 5 mmHg, a third reading should be done.
  The readings should then be averaged. An initial
  measurement should include both arms.
• In elderly patients who particularly when treated
  may show orthostatic hypotension, measuring
  lying, sitting and standing BP may be useful.

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• Systolic hypertension is defined as an elevated
  systolic blood pressure. If systolic blood
  pressure is elevated with a normal diastolic
  blood pressure, it is called isolated systolic
  hypertension. Systolic hypertension may be due to
  reduced compliance of the aorta with increasing
  age