hpt training module oct 2010

© Ministry of Health, Malaysia 2010

First published 2010

Disease Control DivisionMinistry of Health, MalaysiaLevel 6, Block E10, Parcel EFederal Government Administration Centre62590 PUTRAJAYA

Tel: 03-8883 4145 Fax: 03-8888 6277

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CHAIRPERSONDr. Abdul Rashid A. RahmanProfessor of Medicine & Clinical Pharmacologyand Senior Consultant Physician,Cyberjaya University College of MedicalSciences and An Nur Specialist Hospital,Selangor

SECRETARYDr. Sunita BavanandanConsultant Nephrologist,Kuala Lumpur Hospital,Kuala Lumpur

Dr. Anis Salwa KamaruddinPrincipal Assistant Director,Desease Control Division,Ministry of Health,Putrajaya

Dr. Chia Yook ChinProfessor of Primary Care Medicine and Senior Consultant Primary Care Physician,University Malaya Medical Centre,Kuala Lumpur

Dr. Fan Kin SingConsultant Nephrologist,Gleanagles Intan Medical Centre,Kuala Lumpur

Dr. Ghazali AhmadConsultant Nephrologist and Head of Department,Department of Nephrology,Kuala Lumpur Hospital,Kuala Lumpur

Dr. Khoo Ee MingProfessor of Primary Care Medicine andSenior Consultant Primary Care Physician,University Malaya Medical Centre,Kuala Lumpur

Dr. Khalid YusoffProfessor of Medicine and Senior Consultant CardiologistUniversity Technology MARA, Selangor

Dr. Robaayah ZambahariSenior Consultant Cardiologist,National Heart Institute,Kuala Lumpur

Dr. Zaleha Abdullah MahdyProfessor and Senior Consultant Obstetrician& Gynaecologist,Hospital Universiti Kebangsaan Malaysia,Kuala Lumpur

Dr. Hj. Azhari RosmanConsultant Cardiologist & Electrophysiologist,National Heart Institute,Kuala Lumpur

Dr. Chua Chin TeongConsultant Nephrologist,Selangor

Dr. Faridah Aryani Md. YusofClinical Trial Pharmacist andPharmacoeconomist,Clinical Research Centre,Kuala Lumpur Hospital,Kuala Lumpur

Dr. Guna SegaranConsultant Obstetrician and Gynaecologist,Damansara Specialist Hospital,Selangor

Dr. Khoo Kah LimConsultant Cardiologist,Pantai Medical Centre,Kuala Lumpur

Dr. Lim Yam NgoConsultant Paediatric Nephorologist,Kuala Lumpur Hospital,Kuala Lumpur

Dr. Yap Piang KianConsultant Physician & Endocrinologist,Subang Jaya Medical Centre,Selangor

HYPERTENSION GUIDELINEWORKING GROUP

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Associate Professor Dr. Anis Safura RamliConsultant Family Medicine Specialist,Head of Primary Care Medicine Discipline,Faculty of Medicine,Universiti Teknologi MARA (UiTM),Sungai Buloh Campus

Dr. Ng. Kien KeatSenior Lecturer & Family Medicine Specialist,Primary Care Medicine Discipline, Faculty of Medicine,Universiti Teknologi MARA (UiTM),Sungai Buloh Campus

Dr. Mastura IsmailConsultant Family Medicine Specialist,Klinik Kesihatan Seremban 2, Negeri Sembilan

Dr. Feisul Idzwan MustaphaPublic Heath Specialist and Senior Principal Assistant Director,Disease Control Division, Ministry of Health, Malaysia

Dr. Norhayati Ab. ShatarMedical Officer,Principal Assistant Director,Disease Control Division, Ministry of Health, Malaysia

EDITORS

Professor Dr. Teng Cheong LiengSenior Consultant Family Medicine Specialist,International Medical University (IMU), Bukit Jalil

Associate Professor Dr. Tong Seng FahConsultant Family Medicine Specialist,Universiti Kebangsaan Malaysia (UKM), Bangi

Associate Professor Dr. Anis Safura RamliConsultant Family Medicine Specialist,Universiti Teknologi Mara (UiTM), Sungai Buloh

Dr. Mastura IsmailConsultant Family Medicine Specialist, Klinik Kesihatan Seremban 2, Negeri Sembilan

Dr. Suhazeli AbdullahConsultant Family Medicine Specialist,Klinik Kesihatan Marang, Terengganu

Dr. Verna Lee Kar MunSenior Lecturer & Family Medicine Specialist, International Medical University (IMU), Bukit Jalil

Dr. Chew Boon HowSenior Lecturer & Family Medicine Specialist,Universiti Putra Malaysia (UPM), Serdang

Dr. Ambigga Devi S. KrishnapillaiSenior Lecturer & Family Medicine Specialist, Universiti Teknologi Mara (UiTM), Sungai Buloh

Dr. Maizatullifah MiskanSenior Lecturer & Family Medicine Specialist, Universiti Teknologi Mara (UiTM), Sungai Buloh

Dr. Ng Kien KeatSenior Lecturer & Family Medicine Specialist, Universiti Teknologi Mara (UiTM), Sungai Buloh

Dr. Mazapuspavina Md. YasinSenior Lecturer & Family Medicine Specialist, Universiti Teknologi Mara (UiTM), Sungai Buloh

Dr. Farnaza AriffinSenior Lecturer & Family Medicine Specialist, Universiti Teknologi Mara (UiTM), Sungai Buloh

Dr. Nafiza Mat NasirSenior Lecturer & Family Medicine Specialist, Universiti Teknologi Mara (UiTM), Sungai Buloh

CONTRIBUTORS

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TABLE OF CONTENTSHypertension Guideline Working Group ii

Editors & Contributors iii

Introduction v

Topic 1 Introduction & Overview of Hypertension Burden in Malaysia 1

Topic 2 Diagnosis and Management of Pre-hypertension 21

Topic 3 Diagnosis and Management of Stage 1 Hypertension 31

Topic 4 Diagnosis and Management of Stage 2 Hypertension & 43Resistant Hypertension

Topic 5 Diagnosis and Management of Stage 3 Hypertension 53

Topic 6 Hypertension and Diabetes 63

Topic 7 Hypertension and Metabolic Syndrome 73

Topic 8 Hypertension and Cardiovascular Disease 79

Topic 9 Hypertension and Stroke 87

Topic 10 Hypertension in the Elderly 101

Topic 11 Hypertension in Pregnancy 107

Topic 12 Hypertension and Oral Contraceptive Pills 117

Topic 13 Hypertension and Hormone Replacement Therapy 121

Topic 14 Workshop on Blood Pressure Measurement 129(Techniques & Skills)

Appendix Pre-test and Post-test questionnaires (MCQs) 135

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INTRODUCTIONThe Clinical Practice Guidelines (CPG) on the Management of Hypertension (3rd Edition) waspublished in February 2008 and the Quick Reference (QR) for Health Care Providers was publishedin January 2010.

OBJECTIVE

This Training Module is developed to assist the ‘trainers’ to:1. Deliver the key content and messages of the CPG systematically.2. Demonstrate the applicability of CPG recommendations in clinical practice via interactive case

discussions.3. Offer implementation strategies for effective hypertension management based on key elements

of the Wagner Chronic Care Model.

This document contains the following:1. CD-ROM containing the powerpoint presentations.2. Introduction and summary of training module content.3. Interactive case discussions in the beginning of each topic.4. Pre-test and post-test questionnaire (MCQs).5. Evaluation feedback of the training session.

Target Audience:All levels of health care providers involved with the care of hypertensive patients in both primarycare and secondary care settings.

Clinical QuestionsIn tandem with the main CPG, the clinical questions to be addressed in this training module include:1. What are the current best practices in the management of a patient with hypertension?2. How can hypertension management be done in tandem with the overall strategy to manage

global vascular risk of a patient?3. How can we improve the outcome of care for hypertensive patients?

Key Recommendations for Successful Implementation of this TrainingModule:1. Use interactive group discussion methods, rather than didactic way of teaching.2. Gauge the learning and language used (English/Malay/Others) to the level of target audience

(suited to various levels of health care providers).3. Use problem-based facilitating methods.4. Encourage participants to familiarize themselves with the CPG and the QR prior to the training

session (prerequisite).5. Emphasize teamwork.6. Allow participants to express their ideas, concerns and expectations openly.7. Address issues constructively.8. Obtain systematic feedback from participants.

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Key implementation strategies to improve outcome for patients withchronic conditions in primary care (Adapted from the Wagner Chronic CareModel and WHO Innovative Care for Chronic Conditions Framework):

Delivery system • Redesign the delivery system using MESO LEVEL* redesign multidisciplinary care teams, supported by • District Health Office

mutually understood care plan and • Primary Health Care pathways.* Team

• Define roles and tasks among team members.*

• Stratify patients by risks and provide case management for those who are most at risk.*

• Involve secondary care specialists and create mutually agreed shared care plans for patients with severe complications and end-stage disease.*

Clinical information • Develop national# and local chronic disease MACRO LEVEL#

systems registries.* • Policy makers• Use electronic medical record and

appointment system.* MESO LEVEL*• Use electronic prescribing, reminder and • Primary Health Care

alerts on potential drug interaction and test Team results.*

• Create paper-based registries and MICRO LEVEL*comprehensive medical records in resource- • Individual doctors and limited setting.* allied health care

providers

Decision support • Embed evidence-based clinical guidelines MESO LEVEL*recommendations into the structure of • Primary Health Care day-to-day decision-making process e.g. Team electronic reminders, academic detailing, etc.* MICRO LEVEL*

• Make patients aware of the evidence- • Individual doctors and based guidelines recommendations e.g. allied health care treatment targets, choice of therapy, etc.* providers

Patient self- • Empower patients and their families with MESO LEVEL*management knowledge, skills and confidence to take • Primary Health Care support effective control over their chronic Team

• Provide self-management tools, and routinely assess problems and MICRO LEVEL* accomplishments.* • Individual doctors and

• Establish ongoing collaborative effort allied health care between care team and patients for providerslong term benefit.* • Patients and families

Key Elements Implementation Strategies Level of actions

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Healthcare • Become the agent of change to transform ALL LEVELS@

organization chronic disease care.@

involvement • Restructure health care system and policy MACRO LEVEL#

with a clear focus to improve chronic • Policy makers disease care.#

• Create universal funding mechanism to MESO LEVEL*improve access and equity.# • Primary Health Care

• Provide incentives for achieving clinical Team targets, enhancing preventive care, or otherquality improvement activities.#

• Perform ongoing clinical audit as part ofquality assurance programme to improvechronic care quality.*

Community • Develop link with community resources MESO LEVEL* resources which provide self-management support • Primary Health Care

e.g. self-help groups, non-governmental Team organizations, etc.*

MICRO LEVEL*• Individual doctors and

allied health care providers

• Patients and families

Key Elements Implementation Strategies Level of actions

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No

Summary of Training Module Content

Topic Objective ContentTeachingLearningMethod

Duration(minutes)

1. Introduction • To provide an overview of • Epidemiology of Hypertension Lecture 60& Overview HPT burden in Malaysia • Definition and classification of (45 minutes of CPG on • To provide the knowledge hypertension introductoryHypertension based regarding definition, • Measurement of blood pressure lecture + Management diagnosis, assessment, • Diagnosis and assessment 15 minutes

CV risk stratification and • Cardiovascular risk stratification Q&A) management of HPT • Algorithm for the management of

• To offer implementation hypertension strategies for effective • Lifestyle modification advicehypertension management • Pharmacological Agents based on key elements of • The Wagner Chronic Care Model the Wagner Chronic Care • Roles and responsibilities of Mode multidisciplinary care team in

managing hypertension• Roles and responsibilities of

patients in self-managing hypertension

• Key messages

2. Diagnosis and • To highlight the importance • Case scenario 1 Interactive 60management of opportunistic screening • Management based on CPG case (45 minutesof Pre- for Pre-hypertension recommendation discussion interactivehypertension • To highlight the importance • Summary of evidence for the discussion +

of therapeutic lifestyle recommendation 15 minutesmodification in the • Key messages Q&A)management ofPre-hypertension

3. Diagnosis and • To highlight the importance • Case scenario 2 Interactive 60 management of opportunistic screening • Management based on CPG case (45 minutes of Stage 1 of blood pressure recommendation discussion interactiveHypertension • To highlight the importance • Summary of evidence for the discussion +

of performing CV risk in recommendation 15 minutes guiding treatment • Key messages Q&A)

4. Diagnosis and • To highlight the importance • Case scenario 3 Interactive 60management of combination treatment • Management based on CPG case (45 minutesof Stage 2 in the management of recommendation discussion interactiveHypertension Stage 2 Hypertension • Summary of evidence for the discussion + and Resistant • To highlight the importance recommendation 15 minutes Hypertension of identifying resistant • Key messages Q&A)

hypertension

5. Diagnosis and • To highlight the importance • Case scenario 4 Interactive 60management of hypertensive urgencies • Management based on CPG case (45 minutesof Stage 3 and emergencies recommendation discussion interactiveHypertension • To highlight the importance • Summary of evidence for the discussion +

of assessing for target organ recommendation 15 minutesdamages/complications • Key messages Q&A)

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No Topic Objective ContentTeachingLearningMethod

Duration(minutes)

6. Hypertension • To highlight the importance • Case scenario 5 Interactive 60and Diabetes of aggressive BP control in • Management based on CPG case (45 minutes Mellitus Diabetes recommendation discussion interactive

• To highlight the appropriate • Summary of evidence for the discussion + choice of pharmacological recommendation 15 minutestreatment according to • Key messages Q&A)current evidence

7. Hypertension • To highlight the importance • Case scenario 6 Interactive 60 and Metabolic of diagnosing MetS • Management based on CPG case (45 minutesSyndrome • To highlight the importance recommendation discussion interactive (MetS) of treating HPT in MetS • Summary of evidence for the discussion +

recommendation 15 minutes• Key messages Q&A)

8. Hypertension • To appreciate HPT as a • Case scenario 7 Interactive 60and major risk factor to many • Management based on CPG case (45 minutesCardiovascular cardiovascular diseases recommendation discussion interactiveDisease • To make an appropriate • Summary of evidence for the discussion +

choice of recommendation 15 minutesanti-hypertensive • Key messages Q&A)medication in patientswith concomitant cardiovascular disease

• To be aware of the targets for treatment

9. Hypertension • To highlight the danger of • Case scenario 8 Interactive 60 and Stroke rapid reduction of BP in • Management based on CPG case (45 minutes

patients with acute stroke recommendation discussion interactive• To highlight the appropriate • Summary of evidence for the discussion +

choice of pharmacological recommendation 15 minutestreatment according to • Key messages Q&A)current evidence

10. Hypertension • To highlight the importance • Case scenario 9 Interactive 60in the Elderly of treating systolic • Management based on CPG case (45 minutes

HPT in elderly recommendation discussion interactive• To address the issues of • Summary of evidence for the discussion +

polypharmacy in elderly recommendation 15 minutes• Key messages Q&A)

11. Hypertension • To highlight the • Case scenario 10 Interactive 60in Pregnancy classifications of • Summary of evidence for the case (45 minutes

Hypertension in Pregnancy recommendation discussion interactive• To highlight the importance • Summary of evidence for the discussion +

of identifying those at risks recommendation 15 minutes of developing Hypertension • Key messages Q&A)in Pregnancy

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Topic Objective ContentTeachingLearningMethod

Duration(minutes)

12. Hypertension • To highlight the important • Case scenario 11 Interactive 60and Oral interaction between BP • Management based on CPG case (45 minutesContraceptive and OCP recommendation discussion interactivePills • Summary of evidence for the discussion +


13. Hypertension • To highlight the important • Case scenario 12 Interactive 60and Hormone interaction between BP • Management based on CPG case (45 minutesReplacement and HRT recommendation discussion interactiveTherapy • Summary of evidence for the discussion +


14. Workshop on • To demonstrate accurate • Hands-on skills training Workshop 5 60BP techniques of BP Lecture:measurement measurements Lecture 20 minutes(technique followed by Hands-on:and skills) hands-on 40 minutes

training

15. Assessment • To test the knowledge of • 15 T/F MCQs Pre-test and 60of knowledge participants pre and post • 15 Single Best Answer (SBA) post test

training Questions questionnaire

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Slide 1

PRESENTATION OUTLINE

• Epidemiology of Hypertension• Definition • Measurement of Blood Pressure• Diagnosis & Classification• Evaluation & Assessment • Management Algorithm• Cardiovascular Risks Stratification• Therapeutic Lifestyle Modification• Pharmacological Agents• The Wagner Chronic Care Model• Key messages

Slide 2

GLOBAL BURDEN FOR HYPERTENSION

An Estimated 972 million individuals worldwide suffer from hypertension in the year 2000.Kearney et al.

Global burden of hypertension: analysis of worldwide data. Lancet 2005; 365 (9455):217-23

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Slide 3

THE RISING EPIDEMIC OF HYPERTENSION

National Health Morbidity Surveys I, II & III (1986-2006)

Slide 4

NHMS III : AWARENESS RATE

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Slide 5

NHMS III : TREATMENT RATES

Slide 6

NHMS III : CONTROLLED RATE

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Slide 7

DEFINITION

Hypertension is defined as persistent elevation of systolic BP of 140 mmHg or greaterand/or diastolic BP of 90 mmHg or greater.

Slide 8

INITIAL ASSESSMENT

Slide 9

DIAGNOSIS & CLASSIFICATION

Initial BP (mmHg)

Systolic Diastolic

Follow-up recommended to confirm diagnosis and/orreview response to treatment.

< 130 and < 85

130-139 and 85-89

140-159 and/or 90-99

160-179 and/or 100-109

180-209 and/or 110-119

Recheck in one year

Recheck within 3-6 months

Confirm within two months and treat if medium, high or veryhigh risks

Evaluate within one month and treat when confirmed

Look for symptoms and sign of hypertensive urgency oremergency, if asymptomatic, evaluate within one week andtreat whan confirmed

≥ 210 and/or ≥ 120 Initiate drug treatment immediately

Optimal

Prehypertension

Stage 1 HPT

Stage 2 HPT

Stage 3 HPT

< 120

120-139

140-159

160-179

≥ 180

and

and/or

and/or

and/or

and/or

< 80

80-89

90-99

100-109

≥ 110

Diagnosis ofhypertension ismade based on theaverage of two ormore readings,taken at two ormore visits to thehealth careproviders

Category Systolic (mmHg) Diastolic (mmHg)IN

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Slide 10

EVALUATION

EVALUATION OF NEWLY DIAGNOSED HYPERTENSIVE PATIENTS

Evaluation should include through history, physical examination and relevantinvestigations.

Three main objectives:

1. To exclude secondary causes of hypertension

2. To ascertain the presence of target organ damage (TOD)

3. To assess lifestyle and identity other cardiovascular risk factors and/or concomitant disorders that may affect treatment and prognosis.

Slide 11

MEDICAL HISTORY

• duration and level of elevated BP if known• symptoms of secondary causes of hypertension• symptoms of target organ damage, e.g. coronary heart disease (CHD) and

cerebrovascular disease• symptoms of concomitant disease that will affect prognosis or treatment, e.g. diabetes

mellitus, renal disease and gout• family history of hypertension, CHD, stroke, diabetes, renal disease or dyslipidaemia• dietary history including salt, fat, caffeine and alcohol intake• drug history of either prescribed or over-the-counter medication (NSAIDS, nasal

decongestants) and herbal treatment• lifestyle and environmental factors that will affect treatment and outcome, e.g.

smoking, physical activity, work stress and excessive weight gain since childhood

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Slide 12

PHYSICAL EXAMINATIONS

• general examination: height, weight and waist circumference• two or more BP measurements separated by two minutes with the patient either supine

or seated; and after standing for at least one minute• measure BP on both arms• fundoscopy• look for carotid bruit, abdominal bruit, presence of peripheral pulses and radio-femoral

delay• cardiac examination• chest examination for evidence of cardiac failure• abdominal examination for renal masses, aortic aneurysm and abdominal obesity• neurological examination to look for evidence of stroke• signs of endocrine disorders, e.g. Cushing syndrome, acromegaly and thyroid disease

Slide 13BASELINE INVESTIGATIONS

• Full blood count• Urinalysis• Urine albumin excretion or albumin/creatinine ratio• Renal profile and serum uric acid• Fasting blood sugar• Fasting lipid profile• Electrocardiogram (ECG)• Chest X-ray (if clinically indicated)

Note : Should be repeated 6-12 monthly thereafter (except for Chest X-Ray)

Slide 14

CARDIOVASCULAR RISK FACTORS

• Hypertension• Cigarette smoking• Central obesity (waist circumference > 90 cm for men, > 80 cm for women)• Physical inactivity• Dyslipidaemia• Diabetes mellitus• Microalbuminuria• Estimated GFR < 60 mL/min• Age (> 55 years for men, > 65 years for women)• Family history of premature cardiovascular disease (men < 55 years or women < 65 years)

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Slide 15

SECONDARY CAUSES

• Sleep apnoea• Drug-induced or drug-related• Chronic kidney disease• Primary aldosteronism• Renovascular disease• Chronic steroid therapy and Cushing syndrome• Phaeochromocytoma• Acromegaly• Thyroid or parathyroid disease• Coarctation of the aorta• Takayasu Arteritis

Slide 16

TARGET ORGAN DAMAGE & COMPLICATIONS

MANIFESTATIONS OF TOD/TARGET ORGAN COMPLICATION (TOC)

Cardiac

Cerebrovascular

Peripheralvasculature

Renal

Retinopathy

Organ System Manifestations

Left ventricular hypertrophy (LVH), coronary heart disease (CHD),heart failure

Transient ischaemic attack (TIA), stroke

Absence of one or more major pulses in extremities (exceptdorsalis pedis) with or without intermittent claudication

GFR < 60ml/min/1.73m2, proteinuria (≥1+), microalbuminuria (2 outof 3 positive tests over a period of 4-6 months)

Haemorrhages or exudates, with or without papilloedema

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Slide 17

ALGORITHM FOR THE MANAGEMENT OF HYPERTENSION

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Slide 18

CARDIOVASCULAR RISK STRATIFICATION

Co-existingCondition

BP Levels(mmHg)

SBP 120-139and/or

DBP 80-89Low Medium High Very High

SBP 140-159 and/or


SBP 160-179 and/or

DBP 100-109Medium High Very High Very High

SBP 180-209 and/or

DBP 100-119High High Very High Very High

SBP ≥ 210 and/or

DBP ≥ 120Very High Very High Very High Very High

No RFNo TODNo TOC

TOD orRF (1-2),No TOC

TOD or RF (≥ 3) or Clinicalatherosclerosis

Previous MI orPrevious Stroke

or DiabetesMellitus (DM)

Risk Level Risk of major CV event in 10 years Management

Low < 10% Lifestyle changes

Medium 10-20% Drug treatment and lifestylechanges

High 20-30% Drug treatment and lifestylechanges

Very High > 30% Drug treatment and lifestylechanges

TOD : LVH, Retinopathy, Proteinuria / TOC : Heart Failure, Renal Failure)Risk Factors (RF): additional RF (smoking, TC > 6.5 mmol/L, family history of premature vascular disease) Clinicalatherosclerosis (CHD, carotid stenosis, peripheral vascular disease, TIA, stroke)MI: Mycardial Infarction

Green Yellow Orange RedLegend:

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Slide 19

BLOOD PRESSURE TREATMENT TARGETS

Category Target blood pressure (mmHg)

Uncomplicated hypertension < 140/90

Hypertension in high risk groups: DM, History of CVD < 130/80

Diabetics with proteinuria of > 1g/24 hours < 125/75

Once target BP is achieved, follow-up at 3-6 month interval is appropriate.

Slide 20

THERAPEUTIC LIFESTYLE MODIFICATION

Therapeutic lifestyle modification is the first line treatment in all patientswith hypertension.

Weightreduction

As far as possible aim for an ideal Body Mass Index [Weight(kg)/Height2 (m)] – for Asians, the normal range has been proposedto be 18.5 to 23.5 kg/m2. However a weight loss as little as 4.5 kgsignificantly reduces BP

Salt intake

An intake of < 100 mmol of sodium or 6g of sodium chloride aday is recommended (equivalent to < 1 1/4 teaspoonfuls of salt or3 teaspoonfuls of monosodium glutamate)

Alcohol intake

Standard advice is to restrict intake to no more than 21 units formen and 14 units for women per week (1 unit equivalent to 1/2 apint of beer or 100 ml of wine or 20 ml of proof whisky)

Physical activity

General advice on cardiovascular health would be for “milder”exercise, such as brisk walking for 30 – 60 minutes at least 3times a week

DietA diet rich in fruits, vegetables and dairy products with reducedsaturated and total fat can substantially lower BP (11/6 mmHg inhypertensive patients and 4/2 mmHg in patients with high normalBP)

Smoking cessation Cessation of smoking is important in the overall management of

the patients with hypertension in reducing cardiovascular risk

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Slide 21

ANTIHYPERTENSIVE AGENTS

Formulation Minimumdose

Maximumdose Remarks

Diuretics

Chlorothiazide 250 mg OD 500 mg OD • Potassium should be closely Hydrochlorothiazide 25 mg OD 200 mg OD monitored.Amiloride/hydrochlorothiazide 1 tablet OD 4 tablet OD • Used with care in patient with gout.

5mg/50mgIndapamide SR 1.5 mg OD 1.5 mg OD • Potassium sparing diuretics may Indapamide 2.5 mg OD 2.5 mg OD cause hyperkalemia if given withTriamterene/hydrochlorothiazide 1 tablet BD 2 tablet BD ACEIs/ARBs/renal insufficiency.

50mg/25mg

ß-blockers

Atenolol 50 mg OD 100 mg OD • Contraindicated in patient with Bisoprolol 5 mg OD 10 mg OD COAD, severe Peripheral Metoprolol 50 mg BD 200 mg BD Vascular Disease and heart Propranolol 40 mg BD 320 mg BD block.

Calcium Channel Blockers (CCBs)

Amlodipine 5 mg OD 10 mg OD • Verapamil may reduce heart rate Diltiazem 30 mg TDS 60 mg TDS and use with care with ß-blockersDiltiazem SR 90 mg BD 90 mg BDFelodipine 2.5 mg OD 10 mg ODLercanidipine 10 mg OD 20 mg ODNifedipine 10 mg TDS 30 mg TDSNifedine SR 30 mg OD 120 mg ODVerapamil 80 mg BD 240 mg TDSVerapamil CR 200 mg OD 200 mg BD

ACE Inhibitors (ACEIs)

Captopril 25 mg BD 50 mg TDS • Contraindicated in pregnancy and Enalapril 2.5 mg OD 20 mg BD bilateral renal artery stenosisLisinopril 5 mg OD 80 mg OD • Check serum creatinine before Perindopril 2 mg OD 8 mg OD initiation and repeat 2 weeks after Ramipril 2.5 mg OD 10 mg OD initiationQuinapril 2.5 mg OD 40 mg BD • ACEIs should be stopped if rise in

creatinine > 30% from baseline

Angiotensin Receptor Blockers (ARBs)

Candesartan 8 mg OD 16 mg OD • Contraindicated in pregnancy and Irbesartan 150 mg OD 300 mg OD bilateral renal artery stenosisLosartan 50 mg OD 100 mg ODTelmisartan 20 mg OD 80 mg ODValsartan 80 mg OD 160 mg ODOlmesartan 20 mg OD 40 mg OD

Miscellaneous

Prazosin (α-blocker) 0.5 mg BD 10 mg BD • Doxazosin is useful in patientDoxazosin 1 mg OD 16 mg OD with benign prostatic hypertrophyLabetalol 100 mg BD 800 mg TDS • In elderly, start Labetolol with Carvedilol 12.5 mg OD 50 mg OD 50mg BDMethyldopa 125 mg BD 1 gm BD

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Slide 22

PHARMACOLOGICAL MANAGEMENT OF STAGE 1 HYPERTENSION

Slide 23

CHOICE OF FIRST LINE MONOTHERAPY

In patients with newly diagnosed uncomplicated hypertension who have no compellingindications, choice of first line monotherapy includes ACEIs, ARBs, CCBs and Diuretics.

β-blockers are no longer recommended for first line monotherapy in this group ofpatients.

However, it may be considered in younger people, particularly those who are intolerant orcontraindicated to ACEI or ARB, women of child bearing potential and patients withevidence of increased sympathetic drive.

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Slide 24

PHARMACOLOGICAL MANAGEMENT OF STAGE 2 HYPERTENSIONInitiating therapy with the right combination of at least 2 drugs isrecommended.

EFFECTIVE ANTIHYPERTENSIVE COMBINATION

Effective combination Comments

ß-blockers + diuretics Benefits proven in the elderly, cost-effective. However, may increase the risk of new onset diabetes

ß-blockers + CCBs Relatively cheap, appropriate for concurrent CHD

CCBs + ACEls/ARBs Appropriate for concurrent dysliplidaemias and diabetes mellitus

ACEls + diuretics Appropriate for concurrent heart failure, diabetes mellitus and stroke

ARBs + diuretics Appropriate for concurrent heart failure and diabetes mellitus

Slide 25

CHOICE OF HYPERTENSIVE AGENTS IN PATIENTS WITH CONCOMITANTCONDITIONS

Diabetes mellitus (without nephropathy) + +/- +++ + +/- ++

Diabetes mellitus (with nephropathy) ++ +/- +++ ++* +/- +++

Gout +/- + + + + +

Dyslipidaemia +/- +/- + + + +

Coronary heart disease + +++ +++ ++ + ++

Heart failure +++ +++# +++ +@ + +++

Asthma + - + + + +

Peripheral vascular disease + +/- + + + +

Non-diabetic renal impairment ++ + +++ +* + ++

Renal artery stenosis + + ++$ + + ++$

Elderly with no co-morbid conditions +++ + + +++ +/- +

Very elderly (> 80 years old) with no +++ + ++ + +/- +co-morbid conditions

Concomitant disease Diuretics ß-blockers ACEIs CCBs Peripheral α-blockers ARBs

The grading of recommendation from (+) to (+++) is based on increasing levels of evidence and/or current widely accepted practice+/- Use with care- Contraindicated* Only non-dihydropyridine CCB# Metoprolol, bisoprolol, carvedilol – dose needs to be gradually titrated@ Current evidence available for amlodipine and felodipine only$ Contraindicated in bilateral renal artery stenosis

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Slide 26

RESISTANT HYPERTENSION

If BP is still > 140/90 mmHg with combination of 3 drugs (including a diuretic at nearmaximal doses) - check on the possible causes of resistant HPT:• Non-compliance• Secondary hypertension• White coat hypertension• Excessive salt or liquorice intake• Drug interaction• Complications of long standing hypertension e.g nephrosclerosis, loss of aortic

distensibility and atherosclerotic renal artery stenosis

Slide 27

SEVERE HYPERTENSION

Severe hypertension is defined as BP > 180/110mm Hg(persistent elevation after 30 minutes bed rest)

Asymptomatic severeHPT• Incidental findings• Non-specific

symptoms likeheadache, dizziness,lethargy

Management• Most can be

managed asoutpatient

• Review existing drugregime andcompliance

• For newly-diagnosed,consider admissionfor evaluation

• For established HPT,admit if complianceremains a problem

Hypertensiveurgencies• Presents with grade III

or IV retinal changes,or proteinuria ≥ 2+,but no overt organfailure

Management• Initial treatment

should aim for 25%reduction in BP over24 hours but notlower than 160/90mmHg

• Combination therapyis often necessary(see table below)

• Admit patient if BPremain > 180/110mmHg

Hypertensiveemergencies• Presents with

symptoms and signsof TOC e.g. acuteheart failure,subarachnoidhaemorrhage, acutecoronary syndromes

Management • All patient should be

admitted• Aim to reduce BP by

25% over 3-12 hoursbut not lower than160/90 mmHg

• Best achieved withparenteral drugs

Possible clinical scenarios

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Slide 28

THE CHRONIC CARE MODEL

Slide 29

6 ELEMENT OF CHRONIC CARE MODEL

No. Elements Explanation

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1. Health care Create policies with a clear focus to improve chronic disease care.organization Goals, values & incentives to care providers must be aligned & policies with payers & MOH

2. Community Patients & care providers need linkages with community resources resources such as home care, exercise program and support

groups

3. Self Empower patients with knowledge and skills to enhance management confidence to self-care. Build quality relationship throughsupport effective communication

4. Delivery system Multi-disciplinary practice team with clear division of labour; redesign planned management and visits

5. Decision support Translate evidence based clinical practice guidelinerecommendations into daily clinical practice and improve access to specialist expertise

6. Clinical Computerized system to remind & prompt actions; support information shared care among multiple professionals, provide feedback to system health care personel and track progress

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Slide 30

Multi DisciplinaryTeam Members

Roles and Responsibilities

Doctors • Lead the multidisciplinary team• Negotiate and create care pathways to work with other members

of the team• Perform a complete history and physical examination• Review investigation results• Ascertain the presence or absence of TOD/TOC• Identify other CV risk factors and/or concomitant disorders that

affect treatment and prognosis• Assess global CV risks for individual patient• Exclude secondary causes of HPT in suspected cases• Explain to patient regarding achievement of control targets • Make therapeutic decisions• Emphasize the advice given by other allied team members• Assess and address patient’s ideas, concerns and expectations• Offer psychosocial support where appropriate

Slide 31



Nurses • Conduct anthropometric measurements• Coordinate baseline/ relevant investigations• Assess lifestyle – diet, exercise and smoking status• Educate patient regarding hypertension, cardiovascular risks and

potential complications• Educate patient regarding control targets • Counsel patient regarding therapeutic lifestyle modification• Arrange follow-up as per care pathway• Track and remind defaulters• Assess and address patient’s ideas, concerns and expectations• Offer psychosocial support where appropriate

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Slide 32



MA • Conduct anthropometric measurements• Coordinate baseline/ relevant investigations as agreed in the care

pathway• Assess lifestyle – diet, exercise and smoking status• Continue drug treatment if BP controlled• Discuss with doctor if BP not controlled• Educate patient regarding hypertension, cardiovascular risks and

potential complications• Educate patient regarding control targets • Counsel patient regarding therapeutic lifestyle modification• Arrange follow-up as per care pathway• Track and remind defaulters• Assess and address patient’s ideas, concerns and expectations• Offer psychosocial support where appropriate

Slide 33



Pharmacists

Dieticians

• Educate patient regarding antihypertensive medication, itspotential benefits and side effects

• Monitor side-effects• Assess adherence to medication• Assess and address patient’s ideas, concerns and expectations of

the medications

• Perform detail dietary assessment• Educate patient regarding calorie intake• Counsel regarding healthy dietary habit• Counsel regarding weight management where appropriate• Assess and address patient’s ideas, concerns and expectations

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Slide 34

KEY LEARNING POINTS

• Hypertension (HPT) is defined as persistant elevations of SBP of ≥ 140mmHg and/orDBP ≥ 90 mmHg

• In 2006, prevalence of HPT in Malaysia was 42.6% among those aged ≥ 30 years• HPT is a silent disease; 64% of cases remain undiagnosed. Therefore, BP should be

measured at every chance encounter• Untreated or sub-optimally controlled HPT leads to increased cardiovascular,

cerebrovascular and renal morbidity and mortality• A SBP of 120-139 and/or DBP of 80-90mm Hg is defined as pre-HPT and should be

treated in certain high risk groups• Therapeutics lifestyle changes should be recommended for all individuals with HPT and

pre-HPT• Decision to commence pharmacological treatment should be based on global

cardiovascular risks and not on the level of blood pressure (BP) per se• In patients with newly diagnosed uncomplicated HPT who have no compelling

indications, choice of first line monotherapy includes ACEIs, ARBs, CCBs and Diuretics.ß-blockers are no longer recommended as first line monotherapy

• Only 26% of treated patients achieve target BP• Combination therapy is often required ti achieve target and may be instituted early

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Slide 35

KEY PRACTICE POINTS

• Produce a prepared, proactive health care team to manage chronic conditions• Create effective clinical information systems e.g. disease registry, comprehensive

medical records• Translate CPG recommendations into daily clinical practice• Empower patients to self-manage their conditions• Perform continuous quality improvement activities e.g. Clinical Audit

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Slide 1

DISCUSSION POINT

• How do you confirm the diagnosis?• What would you do next?

• Mr. A• 38 years old• Male

• Divorced with 3 children• Delivery Man

VISIT 1

• Present to the clinic with acute URTI symptoms• BP 138/88 mmHg• Smoking 20 cig x 20 years• Beer 1-2/day• Sedentary lifestyle• Father hypertensive, hyperlipidaemic, AMI and CABG (age 68). • Wt 91kg, Ht 170cm, BMI 31.5, WC 97cm

Slide 2

Slide 3

HPT is a silent disease; 64% of cases remain undiagnosed. Therefore, BP should bemeasured at every chance encounter.

RECOMMENDATIONS FOR FOLLOW-UP BASED ON INITIAL BLOODPRESSURE MEASUREMENTS FOR ADULTS

Initial BP (mmHg)

Systolic Diastolic


< 130 and < 85

130-139 and 85-89

140-159 and/or 90-99

160-179 and/or 100-109

180-209 and/or 110-119

Recheck in one year






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Case 1

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Slide 4

VISIT 1: FURTHER ACTIONS

• Explain to him that his BP is slightly high (best is < 120/80 mmHg). Explain thesignificance of the reading and the importance of confirming the diagnosis

• Assess cardiovascular risk factors:- Smoking- Obesity- Sedentary lifestyle- FH of hypertension and CVD

• Order further tests:- UFEME- Fasting lipids- Renal profile- ECG

• Arrange follow-up visit in 3 month

Slide 5

VISIT 2: BP REVIEW

• Mr. A came back to the clinic after 3 months• BP checked again in this visit – 138/88 mmHg (no change)• Renal profile and serum uric acid – normal• Fasting glucose normal• Fasting lipid profile normal• Urinalysis and UACR - normal• ECG – normal

Slide 6

DIAGNOSIS AND CLASSIFICATION OF HYPERTENSION

Mr. A’s average BP taken at the 2 visits = 138/88 mmHg

Optimal

Prehypertension

Stage 1 HPT

Stage 2 HPT

Stage 3 HPT

< 120

120-139

140-159

160-179

≥ 180

and

and/or

and/or

and/or

and/or

< 80

80-89

90-99

100-109

≥ 110


Category Systolic (mmHg) Diastolic (mmHg)

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Slide 8

DISCUSSION POINT 2

• How do you manage Mr. A?

Slide 9

Slide 7

DEFINITION OF PREHYPERTENSION

Prehypertension is a defined as systolic BP (SBP) 120 to 139 or dictolic BP (SBP) 80 to 89mmHg, based on 2 or more properly measured seated BP readings on each of 2 or moreoffice visits.11


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Slide 10

Slide 11

Therapeutic lifestyle intervention should recommended for all patients with preHPT.

There is presently inadequate evidence for pharmacological intervention in preHPT patientsat low or moderate total CV risks.



BP Levels(mmHg)

SBP 120-139and/or


SBP 140-159 and/or


SBP 160-179 and/or


SBP 180-209 and/or


SBP ≥ 210 and/or


No RFNo TODNo TOC





Slide 12

VISIT 2: SUMMARY OF MANAGEMENT PLAN FOR MR. A

• Educate regarding the diagnosis of Prehypertension and his CV risk stratification – medium risk

• Empower patient to self-manage through therapeutic lifestyle modification usingmotivational interviewing techniques - MR. A is motivated to stop smoking, reduce hisalcohol intake and reduce his weight

• Refer to the smoking cessation clinic• Provide information and leaflet on DASH eating plan• Review after 3 months and assess CV risks annually


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Slide 13

DISCUSSION POINT 3

• How do you deliver therapeutic lifestyle modification advice?• How can you influence him to change his unhealthy lifestyle?

Slide 14


Weightreduction

Aim for an ideal BMI (<23 kg/m2) or ideal wt (<66.5 kg). However aweight loss as little as 4.5 kg significantly reduces BP

Salt intake


Alcohol intake

Standard advice is to restrict intake to no more than 21 units formen and 14 units for women per week (1 unit equivalent to 1/2 apint of beer or 100ml of wine or 20ml of proof whisky)

Physical activity

General advice on cardiovascular health would be for “milder”exercise, such as brisk walking 30 mins daily

DietA diet rich in fruits, vegetables and dairy products with reducedsaturated and total fat can substantially lower BP (11/6 mmHg inhypertensive patients and 4/2 mmHg in patients with high normal BP)

Smoking cessation

Cessation of smoking is important in the overall management ofthe patients with hypertension in reducing cardiovascular risk

Slide 15

MOTIVATIONAL INTERVIEWING

A collaborative person centred guidance strategy to elicit and strengthen motivation tochange. The goal is to increase intrinsic motivation, rather than to impose it externally. The‘spirit’ of Motivational Interviewing:• Collaborative: partnership between patients and health care providers• Evocative: evocating patient’s own motivation for change• Honouring autonomy: acceptance that patient make his/her own choice

Rollnick S, Miller WR, Butler CC. Motivational interviewing in health care: Helping patients change behaviour.New York: Guilford Press, 2008

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Slide 16

MOTIVATIONAL INTERVIEWING USING CHANGE STRUCTURED CONSULTATION

CHECK : checking patient perspectivesHEAR : hearing what the patient saysAVOID : avoiding unsolicited adviceNOTE : noting the patient’s intentions and goalsGIVE : giving feedback to the patient when requestedEND : ending the interview with a summary of the patient’s plan

Slide 17

http:/www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf.

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Slide 18

BEWARE OF HIDDEN SALTS

• Most salts/sodium are added duringfood processing, cooking and eating

• Very little are naturally occuring in diet

Slide 19http:/www.moh.gov.my/v/diet

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Slide 20

Slide 21

SUMMARY OF EVIDENCE

• 37% of Malaysian population has Pre-HPT (NHMS II, 1996)• 2/3 of patients with pre-HPT progressed to stage 1 Hypertension over 4 year period

(TROPHY Study)• Pre-HPT tends to cluster with other CVD risk factors• Obesity and weight gain contributes to the progression• All pre-HPT should be managed with therapeutic lifestyle modification• Decisions regarding pharmacological treatment should be based on individual’s global

CVD risk

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Slide 22

KEY LEARNING POINTS

• HPT is a silent disease; 64% of cases remain undiagnosed. Therefore, BP should bemeasured at every chance encounter

• PreHPT is defined as SBP 120-139 and/or DBP 80-89 mmHg, based on ≥ 2 BP readingsat ≥ 2 clinic visits

• Therapeutics lifestyle changes should be recommended for all individuals with HPT andpre-HPT

• Decision to commence pharmacological treatment should be based on globalcardiovascular risks and not on the level of blood pressure (BP) per se

• There is presently inadequate evidence for pharmacological intervention in preHPTpatients at low or moderate total CV risks

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Slide 1

• Mr. MN• 40 years old• Male

• Married with 3children

• Clerk

VISIT 1

• Came to the clinic c/o of sore throat• Otherwise well – no other symptom• Smoker – 20 cigarettes a day• Temperature 36.5° C, BP 150/90 mmHg

• Throat and chest examinations – unremarkable

• Diagnosis of viral URTI was made and symptomatic treatment was given

Slide 2

DISCUSSION POINT 1

• What would you do now?• How do you explain your plan to the patient?

Slide 3

HPT is a silent disease; 64% of cases remain undiagnosed. Therefore, BP should bemeasured at every chance encounter.

RECOMMENDATIONS OF FOLLOW-UP BASED ON INITIAL BLOODPRESSURE MEASUREMENTS FOR ADULTS

Initial BP (mmHg)

Systolic Diastolic


< 130 and < 85

130-139 and 85-89

140-159 and/or 90-99

160-179 and/or 100-109

180-209 and/or 110-119

Recheck in one year






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Slide 4

VISIT 1: FURTHER ACTIONS

• Explain to him that he has a raised BP (150/90 mmHg)• Explain the significance of the reading and the importance of confirming the diagnosis• Advise to stop smoking• Negotiate the management plan:

1. Arrange to see the nurse/AMO for BP check within 1 month 2. Arrange baseline investigations3. Arrange follow-up visit within 2 months

Slide 5

VISIT 2: BP REVIEW

• Mr. MN came back to the clinic after 2 months• Feeling very well generally• BP checked by nurse a month ago – 148/90 mmHg• BP checked again in this visit – 150/92 mmHg

Slide 6

DISCUSSION POINT 2

• What is the diagnosis?• What is your next step of action?

Slide 7

DIAGNOSIS AND CLASSIFICATION OF HYPERTENSION

Mr. MN’s average BP taken at the 3 visits = 149/90 mmHg

Optimal

Prehypertension

Stage 1 HPT

Stage 2 HPT

Stage 3 HPT

< 120

120-139

140-159

160-179

≥ 180

and

and/or

and/or

and/or

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Slide 8

EVALUATION

EVALUATION OF NEWLY DIAGNOSED HYPERTENSIVE PATIENTSEvaluation should include through history, physical examination and relevantinvestigations.

Three main objectives:1. To exclude secondary causes of hypertension.2. To ascertain the presence of target organ damage (TOD).3. To assess lifestyle and identity other cardiovascular risk factors and/or concomitant

disoders that may affect treatment and prognosis.

Slide 9

VISIT 2: FURTHER HISTORY

• Still smoking 20 cigarettes a day and not ready to stop• Eat out regularly with family and friends• No time to do any exercise• No significant past medical history • Not on any regular medication• Mother (aged 70) has hypertension• No family history of heart attacks or strokes• No symptoms to suggest target organ damage, e.g. chest pain, blurred vision• No symptoms to suggest secondary causes of hypertension

Slide 10

VISIT 2: PHYSICAL EXAMINATION FINDINGS

• BMI 26 kg/m2

• Waist circumference (WC) 88 cm• Fundoscopy normal• Cardiovascular examinations – normal • Chest examinations – normal• Abdominal examinations – normal• Neurological examinations – normal

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Slide 11

BASELINE INVESTIGATIONS

• Full blood count• Urinalysis• Urine albumin excretion or albumin/creatinine ratio• Renal profile and serum uric acid• Fasting blood sugar• Fasting lipid profile• Electrocardiogram (ECG)• Chest X-ray (if clinically indicated)

Note : Should be repeated 6-12 monthly thereafter (except for Chest X-Ray)

Slide 12

VISIT 2: BASELINE INVESTIGATION RESULTS

• Renal Profile and serum uric acid - normal• Full Blood Count - normal • Fasting Blood Sugar 5.4 mmol/l• Fasting Lipid Profile:

- Total cholesterol 6.7 mmol/l- Triglycerides 2.0 mmol/l- HDL 0.9 mmol/l- LDL 3.4 mmol/l

• Urinalysis and UACR - normal• ECG - normal

Slide 13

DISCUSSION POINT 3

• How do you manage Mr. MN?• What is your next step of action

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Slide 14


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Slide 15



BP Levels(mmHg)

SBP 120-139and/or


SBP 140-159 and/or


SBP 160-179 and/or


SBP 180-209 and/or


SBP ≥ 210 and/or


No RFNo TODNo TOC










TOD : LVH, Retinopathy, Proteinuria / TOC : Heart Failure, Renal Failure)Risk Factors (RF): additional RF (smoking, TC > 6.5 mmol/L, family history of premature vascular disease) Clinicalatherosclerosis (CHD, carotid stenosis, peripheral vascular disease, TIA, stroke)MI: Mycardial Infarction

Slide 16

DISCUSSION POINT 4

• How do you deliver therapeutic lifestyle modification advice?• How do you commence pharmacotherapy?• Which antihypertensive agent would you choose as first line?• What is the target blood pressure?• When would you see him again?


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Slide 17


Therapeutic lifestyle modification is the first line treatment in all patients with Hypertension

Weightreduction


Salt intake


Alcohol intake


Physical activity



Smoking cessation


Slide 18


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Slide 19

CHOICE OF FIRST LINE MONOTHERAPY

• In patients with newly diagnosed uncomplicated hypertension who have nocompelling indications, choice of first line monotherapy includes ACEIs, ARBs, CCBsand Diuretics

• β-blockers are no longer recommended for first line monotherapy in this group ofpatients

• However, it may be considered in younger people, particularly those who are intolerantor contraindicated to ACEI or ARB, women of child bearing potential and patientswith evidence of increased sympathetic drive

Slide 20



Uncomplicated hypertension < 140/90

Hypertension in high risk groups: DM, History of CVD < 130/80

Diabetics with proteinuria of > 1 g/24 hours < 125/75


Slide 21

VISIT 2: SUMMARY OF MANAGEMENT PLAN FOR MR. MN

• Educate regarding the diagnosis of Stage 1 Hypertension, its associated CV risk factors and potential complications

• Educate regarding BP treatment target < 140/90 mmHg, choice of medication – potential benefits vs side effects

• Empower patient to self-manage through therapeutic lifestyle modification.• Commence a single antihypertensive agent at low dose e.g. ACE Inhibitor• Commence statin therapy for mixed dyslipidaemia• Arrange Renal Profile to be done within 2 weeks (post ACEi)• Review after 1 month

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Slide 22

VISIT 3: FOLLOW UP

• Mr. MN came for review after 1 month• His Renal Profile was normal• Feeling very well generally• No side effect of ACE Inhibitor or statin• Still smoking• Dietary habit – no change• Started to do some gardening and walk around his neighborhood BP checked again in

this visit – 146/86 mmHg• BMI and WC – no change

Slide 23

DISCUSSION POINT 5

• What is the state of his BP control?• How would you manage Mr. MN at this stage?• What is your next step of action?

Slide 24


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Slide 25

VISIT 3: SUMMARY OF MANAGEMENT PLAN FOR MR. MN

• Educate regarding the state of his BP control - treatment target < 140/90 mmHg is still not achieved

• Re-emphasize therapeutic lifestyle modification:- Smoking cessation, healthy eating, exercise

• Increase the dose of ACE Inhibitor• Recheck Renal Profile within 2 weeks • Review after 1 month

- If well-controlled – continue treatment, review 3-6 monthly- If uncontrolled – see algorithm for management of Stage 1 HPT

• Continue long-term follow up• Assess CV risks annually

Slide 26

SUMMARY OF EVIDENCE

• Monotherapy can lower BP to < 140/90 mmHg in 40%- 60% of patients with mild tomoderate HPT

• β-blockers – no longer recommended for 1 line monotherapy in newly diagnoseduncomplicated HPT

• Meta-analysis has shown that ß-blockers is not as effective in lowering BP and inprevention of stroke compared to other agents

• Incidence of new-onset diabetes with β-blockers is also higher compared to other drugs

Slide 27

KEY LEARNING POINTS

• HPT is a silent disease; 64% of cases remain undiagnosed. Therefore, BP should be measured at every chance encounter

• Stage 1 HPT is defined as SBP 140-159 and/or DBP 90-99 mmHg, based on ≥ 2 BP readings at ≥ 2 clinic visits

• Therapeutic lifestyle changes should be recommended for all individuals with HPT and pre-HPT

• Decision to commence pharmacologica treatment should be based on global cardiovascular risks and not on the level of blood pressure (BP) per se

• In patients with newly diagnosed uncomplicated HPT who have no compelling indicatons, choice of first line monotherapy includes ACEIs’ ARBs, CCBs and Diuretics. ß-blockers are no longer recommended as first line monotherapy

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Slide 1

• Mr. NKH• 45 years old• Male

• Teacher• Non-smoker

VISIT 1

• Came to the clinic with referral letter • Found to have high BP in a health screening

campaign (160/100 mmHg) • Remained well & asymptomatic• BP checked again in this visit – 164/100 mmHg

Slide 2

DISCUSSION POINT 1

• What is your diagnosis?• How would you evaluate his problem?

Slide 3

DIAGNOSIS

CLASSIFICATION OF BLOOD PRESSURE (adults ≥ 18 years)

Optimal

Prehypertension

Stage 1 HPT

Stage 2 HPT

Stage 3 HPT

< 120

120-139

140-159

160-179

≥ 180

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and/or

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< 80

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Slide 4

EVALUATION

EVALUATION OF NEWLY DIAGNOSED HYPERTENSIVE PATIENTSEvaluation should include through history, physical examination and relevantinvestigations.

Three main objectives:1. To exclude secondary causes of hypertension.2. To ascertain the presence of target organ damage (TOD).3. To assess lifestyle and identity other cardiovascular risk factors and/or concomitant

disoders that may affect treatment and prognosis.

Slide 5

VISIT 1: FURTHER INFORMATION

• Exercised 3x/week • Not known to have any medical problem• No family history of premature CVD• BMI= 22.8 kg/m2

• Other physical examinations: unremarkable• Normal ECG & urine analysis• Normal diabetic & dyslipidaemia screening

Slide 6

DISCUSSION POINT 2

• How would you risk-stratify him?• Can you estimate his 10-year CV risk?• How would you manage this patient?

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Slide 8

10 YEAR CV RISK ESTIMATION

Slide 7



BP Levels(mmHg)

SBP 120-139and/or


SBP 140-159 and/or


SBP 160-179 and/or


SBP 180-209 and/or


SBP ≥ 210 and/or


No RFNo TODNo TOC





Risk Level Risk of major CV event in 10 years

Low < 10%

Medium 10-20%

High 20-30%

Very High > 30%



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Slide 9


Slide 10

DISCUSSION POINT 3

• How do you commence pharmacotherapy?• What drugs would you consider?• What is his BP treatment target?• When would you see him again?

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Slide 11

CHOICE OF PHARMACOTHERAPY

Pharmalogical management of stage 2 hypertensionInitiating therapy with the right combination of at least 2 drugs is recommended

Effective Combination

β-blockers + diuretics

β-blockers + CCBs

CCBs + ACEIs/ARBs

ACEIs + diuretics

ARBs + diuretics

Slide 12

CHOICE OF ANTIHYPERTENSIVE AGENTS IN PATIENTS WITHCONCOMITANT CONDITIONS

Diabetes mellitus (without nephropathy) + +/- +++ + +/- ++

Diabetes mellitus (with nephropathy) ++ +/- +++ ++* +/- +++

Gout +/- + + + + +

Dyslipidaemia +/- +/- + + + +


Heart failure +++ +++# +++ +@ + +++

Asthma + - + + + +


Non-diabetic renal impairment ++ + +++ +* + ++

Renal artery stenosis + + ++$ + + ++$

Elderly with no co-morbid conditions +++ + + +++ +/- +

Very elderly (> 80 years old) with no +++ + ++ + +/- +co-morbid conditions

Concomitant disease Diuretics β-blockers ACEIs CCBs Peripheral α-blockers ARBs

The grading of recommendation from (+) to (+++) is based on increasing levels of evidence and/or current widely accepted practice+/- Use with care- Contraindicated* Only non-dihydropyridine CCB# Metoprolol, bisoprolol, carvedilol – dose needs to be gradually titrated@ Current evidence available for amlodipine and felodipine only$ Contraindicated in bilateral renal artery stenosis

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Slide 14

VISIT 1: SUMMARY OF MANAGEMENT PLAN FOR MR. NKH

• Explain to him that he has Stage 2 HPT and he has medium CV risk• Deliver therapeutic lifestyle modification advice• Educate regarding potential complications, the need to start medication and his

treatment target• Initiate therapy with 2 drugs e.g. CCB + ACEi• Review monthly until target BP is achieved• Review 3-monthly once target BP is achieved• Re-assess CV risks annually

Slide 15

VISIT 2

• Mr. NKH continued his follow-up at a GP• Treated with 3 anti-HPTs (Felodipine 10 mg od + FORTZAAR® 100-50) for 6 months• Reason for re-visit: request to continue treatment• BP remained uncontrolled (150/90 mmHg)• Asymptomatic• Normal physical examination

Slide 13



Uncomplicated HPT < 140/90

Hypertension in high risk groups < 130/80

Diabetics with proteinuria of (> 1 g/24 hours) < 125/75


Slide 16

DISCUSSION POINT 4

• What is your diagnosis?• What are the possible causes would you consider?• How would you evaluate this patient?

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Slide 17

RESISTANT HYPERTENSION

BP remains > 140/90 mmHg *with 3 anti-HPTs (including if possible a diuretic)

* > 130/80 mmHg in patients with diabetes or chronic kidney disease

• Possible causes:- Non-compliance

Pseudoresistance- White coat HPT- Poor diet control*- Complications of long standing HPT- Secondary HPT

*excessive sodium intake, excessive liquorice intake and drug interactions

Slide 18

EVALUATION OF RESISTANT HYPERTENSION

• Exclude pseudoresistant:- Is patient adherent with prescribed regimen?- Obtain home/ ambulatory BP to exclude white coat effect

• Identify contributing lifestyle factors & drug interaction:- Obesity, physical inactivity, excessive alcohol/ salt intake, low-fiber diet, NSAIDs &

stimulants etc• Look for secondary causes of HPT • Exclude complications of long-standing HPT

Slide 19


• Mr. NKH is compliant with the treatment regime• No sleeping problem identified• No White Coat effect detected• Like to enjoy taking high salt diet• Normal renal profile• Normal U/S ABD & KUB• No secondary causes/complications of HPT detected

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Slide 20

DISCUSSION POINT 5

• How would you manage this patient?• How would you maximize his concordance to the treatment plan?• When would you consider to refer this patient?

Slide 21

VISIT 2: SUMMARY OF MANAGEMENT PLAN FOR MR. NKH

• Explain to him that he has resistant hypertension• Strengthen therapeutic lifestyle modification advice• Reverse contributing factors (reduce salt intake)• Re-educate regarding his potential complications & treatment target• Continue & optimize his current treatment regime (CCB + ARB + Diuretic)• Review monthly until target BP is achieved• Review 3-monthly once target BP is achieved• Re-assess CV risks annually

Slide 22

WAYS TO ACHIEVE TREATMENT CONCORDANCE

• Develop rapport with patients• Regard patients as partners in managing their conditions• Educate patient regarding their conditions• Influence behaviour change through motivational interviewing skills• Check on drug adverse effects regularly• Adhere to CPG recommendations

Slide 23

RESISTANT HPT : WHEN TO REFER?

• Refer to specialist for known or suspected secondary cause(s) of hypertension• Refer to specialist if BP remains uncontrolled after 6 months of treatment• Refer if you are not sure

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Slide 24

KEY LEARNING POINTS

• Stage 2 HPT is defined as SBP 160-179 and/or DBP 100-109 mmHg, based on ≥ 2 BP readings at ≥ 2 clinic visits

• Therapeutics lifestyle changes should be recommended for all individuals with HPT and pre-HPT

• Combination of at least 2 drugs is recommended once diagnosis is confirmed• Once BP is controlled, most patients will require lifelong treatment• If BP is still > 140/90 mmHg with 3 drugs (including diuretics at optimal doses), patients

by definition have resistant HPT

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Slide 1

• Mdm. ZBL• 48 years old• Smoker

• Married with 5 children

• Housewife

VISIT 1• Came to the clinic c/o mild, intermittent throbbing

headaches• No alarm symptom• Diagnosed to have HPT 10 years ago• Defaulted on her follow up since the last 5 years

as she felt well

• BMI 25 kg/m2, Waist Circumference (WC) 80cm

• BP 194/110 mmHg

Slide 2

DISCUSSION POINT 1

• What further history would you elicit from this patient?• Comment on the physical examination findings?• Give other relevant physical examinations needed to be performed?• What investigations would you arrange for this patient?

Slide 3


• Smokes 10 cigs a day for the past 20 years• Loves to cook and family loves her food • No time to do any exercise - busy with family routines• Has been buying her antihypertensive ‘tablets’ from the pharmacy on and off

• Currently not on any medication

• Mother (aged 75) has hypertension

• No family history of heart attack or stroke• No symptoms to suggest target organ damage (e.g. chest pain, blurred vision)• No symptoms to suggest secondary causes of HPT

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Slide 4

VISIT 1: FURTHER EXAMINATION FINDINGS

• Cardiovascular examination – S1 S2 heard, Grade 2 systolic murmur best heard at left sternal edge

• Respiratory examination-normal• Other systems revealed no significant abnormality

Slide 5

FUNDOSCOPY

Grade III hypertensiveretinopathy - note the flamehemorrhage (rupturedmicroaneurysm) directly superiorto the optic disc (pale area at 5o'clock). The white lesions(arrow) are well demarcated andrepresent hard exudates(increased vessel permeability).There is no papilledema.

Slide 6

VISIT 1: FURTHER EXAMINATION FINDINGS

• BP checked again after 30 minutes bed rest: 190/108 mmHg

Slide 7

URGENT INVESTIGATIONS

• Electrocardiogram (ECG)• Urinalysis (UFEME)• Random blood glucose

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Slide 8

VISIT 1: INVESTIGATION RESULTS

• Urinalysis – proteinuria 2+

Slide 9

ECG RESULTS

Slide 10

DISCUSSION POINT 2

• What is the diagnosis?• How many target organ damages/ complications has she got?• Could you estimate her global CV risk?• How would you manage this patient?

ECG showed thepresence of LVH – tall Rwave in V6 with T waveinversions in V4-V6(strain patterns)

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Slide 11

SEVERE HYPERTENSION

Severe hypertension is defined as BP > 180/110 mmHg(persistent elevation after 30 minutes bed rest)



Management• Most can be managed

as outpatient• Review existing drug

regime andcompliance




or IV retinal changes,or proteinuria ≥ 2+, butno overt organ failure












Slide 12


Cardiac

Cerebrovascular


Renal

Retinopathy


Left ventricular hypertrophy (LVH), coronary heart disease (CHD),heart failure.

Transient ischaemic attack (TIA), stroke.

Absence of one or more major pulses in extremities (exceptdorsalis pedis) with or without intermittent claudication.

GFR < 60ml/min/1.73m2, proteinuria (≥1+), microalbuminuria (2 outof 3 positive tests over a period of 4-6 months).

Haemorrhages or exudates, with or without papilloedema.

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Slide 14

TREATMENT OPTIONS FOR HYPERTENSIVE URGENSIES (ORAL)

Slide 15

Rapid reduction of BP (within minutes to hours) in asymptomatic severe HPT or hypertensiveurgencies is best avoided as it may precipitate ischaemic events.

Slide 13



BP Levels(mmHg)

SBP 120-139and/or


SBP 140-159 and/or


SBP 160-179 and/or


SBP 180-209 and/or


SBP ≥ 210 and/or


No RFNo TODNo TOC





Drug

Captopril

Nifedipine

Labetalol

Dose

25 mg

10-20 mg

200-400 mg

Onset of action (hr)

0.5

0.5

2.0

Duration (hr)

6

3-5

6

Frequency (hr)

1-2 hrs

1-2 hrs

4 hrs


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Slide 16

VISIT 1: SUMMARY OF MANAGEMENT PLAN FOR MRS. ZBL

• Explain to her that she has Stage 3 HPT (Hypertensive Urgencies) with very high CV risk

• Explain the significance of the diagnosis and the importance to stabilize her blood pressure

• Give nifedipine 10mg tablet orally as a stat dose (BP measured again after 30 minutes bed rest : 186/100 mmHg)

• Explain to her that she needs to be admitted to the nearest hospital as her BP remains high

Slide 17

VISIT 2: BP REVIEW

• Mdm. ZBL came back to the clinic 1 week after being discharged from the hospital.• Feeling well generally• She brought along a discharge summary from the hospital which contains the

following informations:Medications: - Amlodipine 10 mg daily

- Perindopril 8 mg daily- Simvastatin 40 mg nocte

Investigations: - FBS 5.8 mmol/l, Renal Profile normal.- TC 6.7, TG 2.6, HDL 1.3, LDL 3.4 (all in mmol/litres).- Liver Function Test normal- Urine Microalbumin positive- Awaiting ECHO appointment

• BP examination done in the clinic – 156/90 mmHg

Slide 18

DISCUSSION POINT 3

• Summarise her current problems.• How would you manage this lady now?• What is her target blood pressure?

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Slide 19



Weightreduction


Salt intake


Alcohol intake


Physical activity



Smoking cessation


Slide 20







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Slide 21

SUMMARY OF MDM. ZBL’S PROBLEMS:

1. Uncontrolled hypertension (Target BP < 130/80)2. Very high CV risk with multiple TODs (LVH, proteinuria and Grade III Hypertensive Retinopathy 3. Overweight4. Sedentary lifestyle5. Smoker6. Unhealthy dietary habit

Slide 22

VISIT 2: SUMMARY OF MANAGEMENT PLAN FOR MDM. ZBL

• Educate regarding the state of her BP control - treatment target < 130/80 mmHg• Re-emphasize therapeutic lifestyle modification• Influence behaviour change through motivational interviewing techniques• Add another type of antihypertensive agent e.g. thiazide diuretics• Review monthly until target BP is achieved• Review 3-monthly once target BP is achieved• Consider resistant HPT if BP remains uncontrolled with 3 agents (including diuretics at

maximum dose)• Assess CV risks annually

Slide 23

DISCUSSION POINT 4

• What is the commonest cause of severe HPT?• How would you maximize her concordance to the treatment plan?

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Slide 24

COMMON CAUSES OF SEVERE HYPERTENSIONThe most common cause of severe hypertension is still long standing poorly controlledessential hypertension

Slide 25

WAYS TO ACHIEVE TREATMENT CONCORDANCE

• Develop rapport with patients• Regard patients as partners in managing

their conditions• Educate patient regarding their conditions

• Influence behaviour change throughmotivational interviewing techniques

• Check on drug adverse effects regularly• Adhere to CPG recommendations

Slide 26

KEY LEARNING POINTS

• Stage 3 HPT is defined as SBP > 180 and/or DBP 110 mmHg, based on > 2 BP readings at > 2 clinic visits

• Rapid reduction of BP (within minutes to hours) in asymptomatic severe hypertension or hypertensive urgencies is best avoided as it may precipitate ischaemic events

• Emphasis on the therapeutic lifestyle intervention must be done at every clinic visit• Combination therapy is recommended in patients presenting with stage 2 hypertension or

beyond• If BP is still > 140/90 mmHg with 3 drugs (including diuretics at maximum doses),

patients by definition have resistant HPT

Renal parenchymal disease

Systematic disorders withrenal involvement

Renovascular

Endocrine

Drug

Coarctation of Aorta

Pre-eclampsia/eclampsia

• Chronic pyelonephritis • Primary glomerulonephritis• Tubulointerstitial nephritis

• Systemic lupus • Systemic sclerosis erythematosus • Vasculitides

• Atherosclerotic disease • Polyarteritis nodosa• Fibromuscular dysplasia

• Pheochromocytoma • Conn Syndrome (primary • Cushing syndrome hyperaldosteronism)

• Cocaine • Cyclosporin • Amphetamines • Clodine withdrawal

-

-

Cause Example

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Slide 1

• Mr. LM• 51-year-old

• Married with 4 girls• Lorry driver for a

paint factory

VISIT 1

• Referred by a GP to the health clinic for insulin initiation

• c/o tiredness & blurring of vision for 2 weeks• Diabetes since 2005, on Metformin 1 g BD, Gliclazide

80mg BD & Simvastatin 40 mg ON• Poor adherence to low sugar diet & exercise• Non-smoker & non-alcoholic

Slide 2

VISIT 1: PHYSICAL EXAMINATIONS

• Blood pressure 140/90 mmHg (average of 2 readings)• Weight 74 kg & Height 170 cm, BMI 25.6kg/m2

• Bilateral cataracts • Peripheral neuropathy of both lower limbs

Slide 3

VISIT 1: INVESTIGATION RESULTS FROM THE GP

• HbA1c 11.5%• FBS 10.8 mmol/L

• LDL-C 3.6 mmol/L

• TG 1.75 mmol/L• Urine albumin 2+, repeat in the clinic 1+• Renal function normal

• Liver function normal

• ECG stat in the clinic normal

Slide 4

DISCUSSION POINT 1

• What are his problems?• How would you tell him?

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Slide 5

SUMMARY OF MR. LM’S CLINICAL PROBLEMS

• Uncontrolled diabetes with- Nephropathy- Cataract? retinopathy- Peripheral neuropathy

• Unhealthy diet and low physical activity• Dyslipidemia• Hypertension

Slide 6

HOW COMMON IS HYPERTENSION IN PATIENTS WITH DIABETES MELLITUS?

• The Hypertension in Diabetes Study Group reported a 39% prevalence of hypertension among newly diagnosed diabetic patients

• In half of the diabetes patients, the elevated BP presents before the onset of microalbuminuria

• Strongly associated with obesity • Hypertension is frequently present as a component of the metabolic syndrome

Slide 7

DIAGNOSIS

Hypertension should be detected and treated early in the course of diabetes mellitus to • prevent cardiovascular disease and • delay the progression of renal disease and • delay diabetic retinopathy

Slide 8


• Eat at the factory cafeteria 4 times per day (breakfast, morning snack, lunch & afternoon snack) with teh tarik 3 times per day

• Unable to drive company lorry due to vision problem (loss of income)• No time to do exercise• Compliant to his medication • No home sugar or BP monitoring• Wife has recently been diagnosed to have breast cancer• Mother had hypertension & diabetes, died of stroke (aged 60)

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Slide 9

DISCUSSION POINT 2

• How do you manage Mr. LM?• What is your next step of action?

Slide 10



BP Levels(mmHg)

SBP 120-139and/or


SBP 140-159 and/or


SBP 160-179 and/or


SBP 180-209 and/or


SBP ≥ 210 and/or


No RFNo TODNo TOC










TOD : LVH, Retinopathy, Proteinuria / TOC : Heart Failure, Renal FailureRisk Factors (RF): additional RF (smoking, TC > 6.5 mmol/L, family history of premature vascular disease) Clinicalatherosclerosis (CHD, carotid stenosis, peripheral vascular disease, TIA, stroke)MI: Mycardial Infarction


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Slide 11

THERAPEUTICS LIFESTYLE MODIFICATION-DIETARY COUNSELING

• Dietary counseling should be targeted to: - Achieve an optimal body weight- Achieve an agreed glycaemic control- Manage concomitant dyslipidaemia

• Moderate dietary sodium restriction to enhance the effects of BP lowering drugs especially ACEIs and ARBs

• Further sodium restriction, with or without a diuretic, may be necessary in the presence of nephropathy or when the BP is difficult to control

Slide 12

THERAPEUTICS LIFESTYLE MODIFICATION-REGULAR PHYSICAL EXERCISE

• General advice on cardiovascular health would be for “milder” exercise, such as brisk walking for 30 – 60 minutes at least 3 times a week

Slide 13

DISCUSSION POINT 3

• Would you commence antihypertensive agent?• Which antihypertensive agent would you choose and why?• What is his target blood pressure?• How soon would you see him again?

Slide 14

PHARMACOLOGICAL MANAGEMENT

• Pharmacological treatment should be initiated when:1. The BP is persistently > 130/80 mmHg

or2. There is a presence of microalbuminuria or overt proteinuria even if the BP is not

elevated

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Slide 15

CHOICE OF ANTIHYPERTENSIVES

• Certain classes of antihypertensive drugs may compromise diabetic control & aggravate its complications

Drugs Adverse

Diuretics 1. High doses will decrease insulin responsiveness2. Dyslipidaemia

ß-blockers 1. Masking of early symptoms of hypoglycaemia2. Slowing of recovery from hypoglycaemia3. Aggravation of symptoms of peripheral vascular disease4. Dyslipidaemia

Peripheral β-blockers / 1. Worsening of orthostatic hypertensionCentrally acting drugs

Slide 16

ANGIOTENSIN CONVERTING ENZYME INHIBITORS (ACEIs)

1. Drugs of choice based on extensive data attesting to their cardiovascular and renal protective effects in diabetic patients

2. In addition they do not have adverse effects on lipid and carbohydrate metabolism3. If an ACEI is not tolerated, an ARB should be considered

Slide 17

ANGIOTENSION RECEPTOR BLOCKERS (ARBs)

1. Reported to be superior to conventional non-ACEI antihypertensive drugs in slowing the progress of diabetic nephropathy at both the i. microalbuminuric stage andii. overt nephropathy stage

2. They have been shown to be of similar efficacy as ACEIs but better tolerated 3. There have been no reports of adverse effects on carbohydrate and lipid metabolism

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Slide 18

DIURETICS

1. Can be added on when monotherapy is inadequate2. The lowest possible dose should be used to minimise adverse metabolic effects3. Adverse metabolic effects from higher doses have been reportedly reduced when used

in combination with an ACEI or an ARB

Slide 19

CALCIUM CHANNEL BLOCKERS (CCBs)

1. Can be added on when monotherapy is inadequate2. Do not have significant adverse metabolic effects or compromise diabetic control3. Nondihydropyridine CCBs may be more superior to dihydropyridine CCBs in reducing

proteinuria in diabetic nephropathy

Slide 20

β-BLOCKERS & PERIPHERAL α-BLOCKERS

1. ß-blockers may be used when ACEIs, ARBs or CCBs cannot be used or when there are concomitant compelling indications

2. Peripheral α-blockers do not have adverse effects on carbohydrate or lipid metabolismbut orthostatic hypotension due to autonomic neuropathy may be aggravated

Slide 21

TARGET BLOOD PRESSURE

• Tight BP control should take precedence over the class of antihypertensive drug used • The BP should be targeted to < 130/80 mmHg• There are suggestions that a lower target BP may be necessary to maximally protect

against the development and progression of cardiovascular and renal disease • The BP should be lowered even further to < 125/75 mmHg in the presence of

proteinuria of > 1 g/24 hours

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Slide 22

RECOMMENDATIONS

1. ACEIs are the agents of choice for patients with diabetes without proteinuria2. ACEIs or ARBs are the agents of choice for patients with diabetes and proteinuria3. ß-blockers, diuretics or CCBs may be considered if either of the above cannot be used

Slide 23







Slide 24

VISIT 1: SUMMARY OF MANAGEMENT PLAN FOR MR. LM’S HYPERTENSION

1. Explain regarding the diagnosis of hypertension, its contribution of risk to diabetic complications2. Educate regarding the need of BP treatment, target of < 130/80 mmHg, choice of

medication, potential heart & kidneys protection vs. side effects3. Empower patient to self-manage through diet and exercise, home monitoring of sugar & BP4. Commence ACEI as single antihypertensive agent5. Arrange renal profile to be done within 2 weeks6. Review after 1 month

Slide 25

VISIT 2: FOLLOW UP AT 1 MONTH LATER

• Feeling very well generally, no new complaint• No side effect of ACEI or insulin• Had visited the ophthalmologist, reply letter stated he has immature cataract and

moderate to severe non-proliferative diabetic retinopathy in both eyes, laser therapy done, and follow-up in 3 months

• Still taking 4 meals in the factory cafetaria but able to keep ONE teh tarik a day, and reduced some oily & salty food as he claimed he cannot control the menu

• Started to walk 20 to 30 minutes around his neighborhood every weekend

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Slide 26


• Home glucose monitoring 5 – 8 mmol/L• Home BP monitoring 120 - 130/80 - 90 mmHg• BMI and WC – no change • BP in the clinic 130/80 mmHg• Renal profile was normal• Fasting blood sugar 6 mmol/L• Urine protein 1+

Slide 27

DISCUSSION POINT 4

• What is the state of his BP control?• How would you manage Mr. LM at this stage?• What is your next step of action?

Slide 28

VISIT 2: FURTHER MANAGEMENT FOR MR. LM

• Inform him that his treatment target < 130/80 mmHg is still not achieved• Set personalized treatment goals with him

– Increase walking to 30 min three times a week– Reduce outside food to 2 times per day to control oil & salt intake– BP monitoring at least twice per week targeting < 130/80

• Emphasize on low salt diet & praise him for walking every weekend• Increase the dose of ACEI or add a low dose diuretics

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Slide 29

VISIT 2: FURTHER MANAGEMENT FOR MR. LM

• Plan to review after 1 month– If well-controlled – continue treatment, review 3-6 monthly– If uncontrolled – check adherence, change/adjust medications 2 to 4 weekly till

target achieved• Inform & emphasize needs for long-term follow up• Educate importance of

– CV risks assessment annually– Complication assessment 6-monthly

Slide 30

KEY LEARNING POINTS

• About 2 in 5 people with recently diagnosed diabetes will have hypertension• About 1 in 2 patients will have hypertension before the diagnosis of microalbuminuria • Antihypertensive should be initiated when the BP is persistently > 130/80 mmHg or there

is microalbuminuria / proteinuria• ACEIs / ARBs are the agents of choice for patients with diabetes• The BP should be targeted to < 130/80 mmHg or to < 125/75 mmHg if the proteinuria

> 1 g/24 hours

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Slide 1

• Mr. AH• 50 years old• Male


• Food hawker

REVIEW VISIT 1

• Came to the clinic for routine review of blood pressure

• On ß-blocker and thiazide diuretic• Smoker – 20 cigarettes a day• Otherwise well, no significant past medical history• BMI 30 kg/m2, Waist Circumference (WC) 98 cm• BP 152/90 mmHg, other examinations – normal• FBS 5.8 mmol/l, Renal Profile normal• TC 6.7, TG 2.6, HDL 1.3, LDL 3.4 (all in mmol/litres)

Slide 2

DISCUSSION POINT 1

• What is the diagnosis?• What is the target blood pressure?• Comment on his current medication.• How do you manage this patient?• How do you explain your plan to the patient?

Slide 3

METABOLIC SYNDROME DIAGNOSIS

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Slide 4







Slide 5


ß-blockers and thiazide diuretics have the potential to increase the incidence of newonset diabetes, and this should be taken into consideration when choosing drugs forpatients diagnosed with Metabolic Syndrome.

Slide 6

REVIEW VISIT 1: SUMMARY OF MANAGEMENT PLAN

• Explain to him that he has Metabolic syndrome and the significance of the diagnosis inrelation to CV risks. Explain that his BP is still not controlled (target < 130/80 mmHg)

• Discuss lifestyle modifications e.g. exercise, diet and weight reduction• Discuss about his medication and explain that it is unsuitable for his condition. Discuss

changing his medication to ACE Inhibitor or CCB• Commence him on statin• Arrange for Renal Profile (RP), FSL, LFT, ECG and urinalysis• Arrange for a follow up in 3 months

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Slide 7

REVIEW VISIT 2

• Mr. AH came for follow up after 3 months• Tried to do more walking• Still smoking – not ready to stop• Tried to cut down on salt and fried food but finding it difficult because he works as a

food hawker• Mother aged 75 has Hypertension and Diabetes Mellitus. Father died at 65 with MI• Has been taking Perindopril 8mg once daily and Simvastatin 40 mg once daily as

prescribed in the last visit – there is no side effect• BP 142/86 mmHg, BMI 30 kg/m2, WC 97cm• TC 5.2, TG 1.6, HDL 1.3, LDL 2.4 (all in mmol/litres)• RP, LFT, ECG and urinalysis normal

Slide 8

DISCUSSION POINT 2

• How do you manage this patient at this stage?

Slide 9


• Re-emphasize the significance of having Metabolic Syndrome in relation to his CV andDM risk factors

• Educate regarding BP control – target still not achieved• Educate regarding FSL reading – target now achieved• Re-emphasize self-management through lifestyle modification (no change in BMI or WC

after 3 months)• Consider adding Calcium Channel Blocker (CCB)• Continue statin• Discuss referral to a dietician• Arrange follow up in 3 months

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Slide 11

DISCUSSION POINT 3

• Discuss the factors which may prevent this patient from achieving targets (weight/ BP)• Discuss the factors which may motivate the patient to change• What else can we do to help the patient?

Slide 10


Weightreduction

As far as possible aim for an ideal Body Mass Index [Weight(kg)/Height2 (m)] – for Asians, the normal range has been proposedto be 18.5 to 23.5 kg/m2. However a weight loss as little as 4.5 kgsignificantly reduces BP

Salt intake


Alcohol intake


Physical activity

General advice on cardiovascular health would be for “milder”exercise, such as brisk walking for 30 – 60 minutes at least 3times a week


Smoking cessation


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Slide 12

REVIEW VISIT 3

• Mr. AH brings along his wife who wants to help him. She is afraid of losing him• Has been doing more exercise at home by walking to the local shops to get the newspaper • His wife is trying to cook healthier meals• Now smokes 15/day• No side effect with ACE Inhibitor, CCB or Statin• BP checked 130/80 mmHg• Lost 2 kg since last appointment• He’s happy with his progress• Still waiting for his appointment with dietician

Slide 13


• Continue to give encouragement and motivation for his positive lifestyle changes• Get his wife involved in giving him encouragement and support• Chase up his dietician appointment• If BP remain controlled, continue with 3-6 monthly follow up• Review his CV and DM risks annually

Slide 14

SUMMARY OF EVIDENCE

Metabolic Syndrome is a cluster of risk factors predisposing to CV disease and Diabetes.A person with Metabolic syndrome is twice likely to develop heart disease and five timesmore likely to develop DM. Various components of Metabolic Syndrome should be treatedseparately.

Slide 15

KEY LEARNING POINTS

• Metabolic syndrome is a cluster of risk factors predisposing to CV disease and DM• Hypertension in Metabolic Syndrome must be treated aggressively to lower the risk.

Target BP < 130/80 mmHg• Thiazide diuretics and β-blockers are found to increase incidence of developing DM in

Metabolic Syndrome• Therapeutic lifestyle changes is key to patient management and achieving targets • It is important to treat all of the variables in Metabolic Syndrome independently

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Slide 1

• Mr. M• 53-year-old• Male

VISIT 1

• Was referred back to you from hospital with the following diagnoses:- Hypertensive heart disease- Left ventricular hypertrophy- Hypercholesterolaemia

Slide 2

VISIT 1

• These were the list of medications he was discharged with:- Losartan 50 mg OM- Simvastatin 40 mg ON- HCT 12.5 mg OM- Atenolol 50 mg OM

• The letter stated that: “kindly follow up and do the needful” • The patient expected you to prescribe the medication for him.

Slide 3

DISCUSSION POINT 1

• What would be your aims in this consultation in relation to hypertension management?• How would you tell him?

Slide 4

TIPS FOR DISCUSSION POINT 1

• Try to have an outline for your points and be clear of the reasons for your points• Write down your answer, you don’t have to write down your name. Discuss you answer

with the person you are comfortable with. • Tell us your answer once you are ready

(10 minutes)

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Slide 5

WHAT WOULD BE YOUR AIMS IN THIS CONSULTATION IN RELATION TOHYPERTENSION MANAGEMENT?

1. Assess any other target organ damageThe referral letter stated that he has hypertensive heart disease. Hence it is likely that he may suffer from various vascular related diseases like:

Ischaemic heart disease Stroke

Left ventricular hypertrophy Peripheral vascular disease

Heart failure Renal disease, secondary renal artery stenosis

Hypertensive vascular disease is a multi-organ disease. Many systems could be affected by HPT.

Slide 6


2. Check for target control: BP < 130/80 mmHg, and other CVD risk factors

Risk factors

Smoking

Wt

Waist circumference

Diet

Exercise

Cholesterol/DM

Targets

Abstinence

BMI chart ideally < 23 kg/m2

Male < 90 cm, Female < 80 cm

Low salt and possibly low cholesterol diet

30 minutes 3-5 times/day

See relevant CPG

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Slide 7


3. Assess for suitability/adherence of medications Essentially covers:i. Side-effectsii. Co-morbiditiesiii. Psycho-social issues related to treatment of HPT

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Slide 8


1. Assess any other target organ damage2. Check for target control3. Assess for suitability/adherence of medications 4. Self-management plan and holistic care (will not be discussed in details)

Slide 9

DISCUSSION POINT 2

• For each of these aims below (or your own aims), what are your actions?1. Target organ damage assessment2. Target BP control assessment3. Assessment of optimal medication/adherence

• What is your next step of action?

Slide 10

HISTORY TAKING: ASK FOR

1. Symptoms of IHD, heart failure: NYHA class, claudication, history of stroke and admission

2. Any consultation with specialist care and what care has he been receiving?3. How has he been with the control of HPT, is he aware of his blood pressure and any

form of home blood pressure monitoring?4. Any side effects from the medication, any problems (including personal preferences,

disruption of daily routine) in taking the medication?

Slide 11

PHYSICAL EXAMINATIONS

1. Observe: gait (remember the neurological complication)2. Body mass index, waist circumference3. BP, pulse (including peripheral pulses: remember to check this to detect underlying PVD;

ß-blocker effect)4. Signs of end-organ damage: e.g. heart failure etc

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Slide 12

INVESTIGATIONS

1. ECG: to look for features of LVH, IHD 2. Urine protein, KIV quantification of urine protein3. Blood: renal profile, cholesterol, fasting blood sugar level4. CXR (if it is not done)5. Further referral to cardiologist for assessment

Slide 13


• Mr. M had been having HPT for 15 years• He had not been regular with his medication apparently because of frequent traveling as

a businessman• He ended up in the hospital because of minor cuts he sustained while doing some

carpentry work at home and was subsequently noted to have uncontrolled blood pressure• His effort tolerance had been good• Quick dietary assessment did not reveal any significant issue. He exercised regularly

Slide 14

VISIT 1: PHYSICAL EXAMINATIONS

• BMI = 26 kg/m2 WC = 105 cm• BP 142/94 mmHg• PR 56 bpm• Right dorsalis pedis pulse was difficult to palpate • No sign of heart failure/cardiomegaly• You had a good look at the ankle (Do you know

the reason for examining the ankle?)

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Slide 15

VISIT 1: INVESTIGATIONS

• The levels of blood urea and serum creatinine were normal, K+ = 4.8 mmol/L• Fasting blood sugar = 5.3 mmol/L• Urine dipstix: normal reading for protein, no cell/cast was noted• Cholesterol profile:• TC 5.7 mmol/L HDL-C 0.9 mmol/L• TG 1.8 mmol/L LDL-C 3.6 mmol/L• ECG (next slide)

Slide 16

Slide 17

HE WAS OBVIOUSLY NOT TREATED TO TARGET

• What are his target?

Parameters

BP

LDL-C (as the primary target)

BMI

WC

Targets

< 130/80 mmHg

3.4 mmol/L

< 23.0 kg/m2

< 90 cm

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Slide 18

DISCUSSION POINT 3

• What is your diagnosis for him now?• Would you alter his medication or continue the same regime? Give reason.

Slide 19

WHAT IS YOUR DIAGNOSIS FOR HIM NOW?

• HPT: suboptimal control• Left ventricular hypertrophy• Hypercholesterolaemia• Possibility of peripheral vascular disease • Problems with adherence

Slide 20

WOULD YOU ALTER HIS MEDICATION OR CONTINUE THE SAMEREGIME? GIVE REASON

• He was given these medications from the hospital:1. Losartan 50 mg OM2. Simvastatin 40 mg ON3. Hydrochlorothiazide (HCT) 12.5 mg OM4. Atenolol 50 mg OM

• You were stuck and not sure which is the best. Suddenly, you thought of referring to the CPG on HPT.

Slide 21

RECOMMENDATIONS

• Hypertensive patients with LVH should receive an ARB as the first line treatment• In CHD, β-blockers, ACEIs and long acting CCBs are the drugs of choice• β-blockers, ACEIs, and aldosterone antagonists should be considered in patients

with CHD especially in post myocardial infarction and when associated with LV dysfunction

• β-blockers need to be cautiously used in patients with peripheral vascular disease. • They are contraindicated in patients with severe PVD• Diuretics, ACEIs, β-blockers, ARBs, and aldosterone antagonists are drugs of choice

for heart failure.• ARB is indeed the correct choice• β-blockers may not be a suitable choice for him!

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Slide 22

PHARMACOLOGICAL MANAGEMENT

Choice of Hypertensive drugs in patients with concomitants conditions

• Diuretic is also the correct choice

Slide 23

DISCUSSION POINT 4

• What will be the best choice then?

Slide 24

WHAT WILL BE THE BEST CHOICE THEN?

• Perindopril (ACE-I) 2 mg (has to re-start the regime as he has not been taking Losartan)• HCT 12.5 mg OM• Simvastatin 80 mg ON• Felodipine 5 mg OM (explore the option of fixed dose combinatio therapy)

Slide 25

KEY LEARNING POINTS

• The cardiovascular complications of HPT signify a long standing hypertension and possibly have other target organ damage

• There are a wide range of choices for anti-hypertensives• Appropriate choice of anti-hypertensive medication depends in co-morbidities and

complications, taking into consideration patient’s perspective• Cost and side-effect can be a significant determinants

Concomitant disease Diuretics β-blockers ACEIs CCBs Peripheral α-blockers ARBs


Heart failure +++ +++# +++ +@ + +++

Asthma + - + + + +


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Slide 1

• Mr. AK• 58 years old• Male

• Married with 5 grand children

• Retired teacher

VISIT 1

• Brought to the clinic by his son on a wheel chair• Developed right sided weakness and slurred

speech since 5 am today

Slide 2


• No vomiting, headache, fever, blurred vision, fits, incontinence• No history of injury• Known to have hypertension for 10 years• Defaulted treatment since the last 5 years and is currently not on any medication• Smokes 20 cigarettes a day• BP 210/100 mmHg, slurred speech, orientated to time, place and person• Right side UL/LL: Power 3+/5, tone normal, reflexes normal• Plantar equivocal• Cardiovascular and chest examinations – unremarkable

Slide 3

DISCUSSION POINT 1

• What is the diagnosis?

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Slide 4

SEVERE HYPERTENSION

Severe hypertension is defined as BP > 180/110mm Hg(persistent elevation after 30 minutes bed rest)





















Slide 5


Cardiac

Cerebrovascular


Renal

Retinopathy


Left ventricular hypertrophy (LVH), coronary heart disease (CHD),heart failure

Transient ischaemic attack (TIA), stroke

Absence of one or more major pulses in extremities (exceptdorsalis pedis) with or without intermittent claudication

GFR < 60ml/min/1.73m2, proteinuria (≥1+), microalbuminuria (2 outof 3 positive tests over a period of 4-6 months)

Haemorrhages or exudates, with or without papilloedema

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Slide 6

COMMON CAUSES OF SEVERE HYPERTENSION*

Slide 7

HYPERTENSION AND STROKE

Blood pressure is the most consistent and powerful predictor of stroke and high bloodpressure is the most important modifiable cause of stroke. BP levels are continouslyassociated with the risk for stroke. Although both SBP and DBP are associated with stroke,SBP is more predictive. In the Asia Pacific region, up to 66% of stroke can be attributed tohypertension.

Slide 8

DISCUSSION POINT 2

• How would you manage the patient?• How would you explain your plan to him and his son?

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Slide 9

SEVERE HYPERTENSION

Severe hypertension is defined as BP > 180/110 mmHg(persistent elevation after 30 minutes bed rest)













• Admit patient if BPremain > 180/110 mmHg








Slide 10

TREATMENT OF HYPERTENSION IN ACUTE STROKE

Recommendations• Lowering blood pressure is the key to both primary and secondary prevention of stroke• In acute stroke, lowering BP is best avoided in the first few days unless hypertensive

emergencies co-exist• In primary prevention, the benefits of BP lowering is seen in both normotensive and

hypertensive patients• ACEI- or ARB- based treatment is preferred in secondary prevention

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Slide 11

TREATMENT OF HYPERTENSION IN ACUTE STROKE

Treatment of elevated BP in acute stroke is still controversial. In general, it is best to avoidlowering BP in the first few days after a stroke unless there is evidence of accelerated

hypertension or patients presenting concurrently with hypertensive emergencies.

Recommendations• Lowering blood pressure is the key to both primary and secondary prevention of stroke• In acute stroke, lowering BP is best avoided in the first few days unless

hypertensive emergencies co-exist• In primary prevention, the benefits of BP lowering is seen in both normotensive and

hypertensive patients• ACEI- or ARB- based treatment is preferred in secondary prevention

Slide 12

TREATMENT OPTIONS FOR HYPERTENSIVE EMERGENCIES (PARENTERAL)

Slide 13

VISIT 1: SUMMARY OF MANAGEMENT PLAN FOR MR. AK

• Explain the diagnosis to the patient and his son – Hypertensive Emergency presentingwith Stroke (Right Hemiparesis)

• Explain the importance of hospital admission and the importance of confirming thetype of stroke (haemorrhagic/Infarct)

• Arrange and prepare for hospital admission:1. Secure intravenous line 2. Inform the receiving hospital3. Send by ambulance, accompanied by paramedics

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Slide 14

VISIT 2: BP REVIEW

• Mr. AK came back to the clinic 1 month after being discharged from the hospital• Stable but no improvement of symptoms• Still has residual weakness of right side of body and slurred speech• Tolerating oral fluids and soft diet• Using diapers due to mobility problems but no incontinence• Appointment with physiotherapist: twice per week• Appointment with neurologist: in 4 months

Slide 15

VISIT 2: BP REVIEW

• He brought along a discharged letter from the hospital which contains the following informations:

Diagnosis: Left Cerebral InfarctCT scan of brain: Left temporo-parietal hypodense lesion. No midline shift. Findings consistent with Left Cerebral Infarct.Medications: - Hydrochlorothiazide 25 mg daily

- Perindopril 4 mg daily- Simvastatin 40 mg nocte- Aspirin 150 mg daily

Investigations: - FBS 5.5 mmol/l, Renal Profile normal.- TC 6.5, TG 2.3, HDL 0.9, LDL 4.6 (all in mmol/litres).- Liver Function Test normal- Urine Microalbumin positive- ECG: LVH - awaiting ECHO appointment

BP upon discharge – 150/90 mmHgPlease review his blood pressure

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Slide 16


• Taken care at home by his wife and youngest daughter• Stopped smoking since incidence• Eat home-cook meal• Has been to Physiotherapy twice for mobilization exercise• Adhering to the medication given by hospital• Understand that Stroke is the complication of Hypertension• No symptoms to suggest secondary causes of hypertension

Slide 17


• BMI: 26 kg/m2

• Waist circumference (WC): 88 cm• BP: 140/90 mmHg• Fundoscopy : normal• Cardiovascular examinations - normal • Chest examinations – normal• Abdominal examinations – normal• Neurological examinations – Right side UL/LL: Power 3+/5, hypertonia, reflexes brisk,

sensation: normal• Plantar: up going

Slide 18

DISCUSSION POINT 3

• What is the level of his global CV risk stratification?• How would you manage the patient?• How do you educate the patient to prevent him from getting another stroke?• What is his target BP and cholesterol level?

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Slide 10



BP Levels(mmHg)

SBP 120-139and/or


SBP 140-159 and/or


SBP 160-179 and/or


SBP 180-209 and/or


SBP ≥ 210 and/or


No RFNo TODNo TOC










TOD : LVH, Retinopathy, Proteinuria / TOC : Heart Failure, Renal FailureRisk Factors (RF): additional RF (smoking, TC > 6.5 mmol/L, family history of premature vascular disease) Clinicalatherosclerosis (CHD, carotid stenosis, peripheral vascular disease, TIA, stroke)MI: Mycardial Infarction

CV Risk level is calculated based on his untreated BP


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Slide 20

TABLE 3. CARDIOVASCULAR RISK FACTORS

Major risk factors√ Hypertension

Cigarette Smoking Central obesity (waist circumference > 90 cm for men, > 80 cm for women)

√ Physical inactivity√ Dyslipidaemia

Diabetes mellitus√ Microalbuminuria

Estimated GFR* < 60 mL/min√ Age (> 55 years for men, > 65 years for women)

Family history of premature cardiovascular disease (men < 55 years or women < 65 years)

Target Organ DamageHeart Brain√ • Left ventricular hypertrophy √ • Stroke or transient ischemic attack

• Angina or prior myocardial infarction Chronic kidney disease• Prior coronary revascularisation Peripheral arterial disease• Heart failure Retinopathy

*GFR, glomerular filtration rate

Slide 21



Weightreduction


Salt intake

An intake of < 100 mmol of sodium or 6 g of sodium chloride aday is recommended (equivalent to < 1 1/4 teaspoonfuls of salt or3 teaspoonfuls of monosodium glutamate)

Alcohol intake


Physical activity



Smoking cessation


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Slide 22

SECONDARY PREVENTION OF STROKE

• BP lowering has been shown to reduce the risk of subsequent strokes• “ACEI + diuretic” has been shown to reduce stroke recurrence• ARBs lower the morbidity and mortality from further strokes

Slide 23




HPT in high risk groups: DM, History of CVD < 130/80



Slide 24

TARGET LDL- C LEVELS

* Almost all individuals with 0-1 risk factor have a 10 year risk < 10%, thus 10 year risk assessment in there individials with 0-1 risk factor is not necessary.

** These include individuals with multiple risk factors but a 10 year risk of CHD of < 20%

*** After 8-12 weeks of TLC

StrokeStroke is the 3rd leading cause of mortality in Malaysia. Evidence for the role of elevatedserum cholesterol in the pathogenesis of stroke is lacking. Fibrates and statins are safe andshould be considered in all patients presenting with strokes or transient ischaemic attacks.

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Slide 25

VISIT 2: SUMMARY OF MANAGEMENT PLAN FOR MR. AK

• Educate him regarding the risk of recurrent stroke and the need to modify his very high CV risk • Educate regarding BP treatment target < 130/80 mmHg, choice of medication –

potential benefits vs side effects• Empower patient to self-manage through therapeutic lifestyle modification and self

home BP monitoring.• Continue ACE Inhibitor and Diuretic• Add another agent e.g. CCB – as his BP is still uncontrolled• Continue statin and aspirin• Monitor Renal Profile, Fasting Serum Lipid and LFT• Review monthly until target BP is achieved• Review 3 monthly once target BP is achieved• Continue long-term follow up• Assess CV risks annually

Slide 26

PRIMARY PREVENTION OF STROKE

• Trials have shown that a 10 mmHg reduction in SBP or a 5 mmHg reduction in DBP in hypertensive patient can lead to a 34% reduction in the risk of stroke.

• ß-blockers, diuretics, CCBs, ACEIs and ARBs have been shown to reduce risk and mortality of stroke.

Slide 27

SUMMARY OF EVIDENCE - HYPERTENSION AND STROKE

• Blood pressure is the most consistent and powerful predictor of stroke and high blood pressure is the most important modifiable cause of stroke

• β-blockers, diuretics, CCBs, ACEIs, and ARBs have been shown to reduce the risk and mortality of stroke

• Calcium channel blockers in particular, provided significantly better protection against stroke compared with diuretics and/or β-blockers in Asian and Caucasian populations.Combination of an ACEI and diuretics has been shown to reduce stroke recurrence in both normotensive and hypertensive patients when treatment was started at least two weeks after the stroke

• The morbidity and mortality from further strokes were also shown to be significantly lower in patients receiveing ARBs compared to CCBs for the same level of BP control

• In haemorrhagic stroke, in general, it is best to avoid lowering BP in the first few days after a stroke unless there is evidence of accelerated hypertension or patients presenting concurrently with hypertensive emergencies

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Slide 28

KEY LEARNING POINTS

• Therapeutics lifestyle changes should be recommended for all individuals with HPT and pre-HPT• Blood pressure is the most consistent and powerful predictor of stroke and high blood

pressure is the most important modifiable cause of stroke• Lowering blood pressure is the key to both primary and secondary prevention of stroke• Rapid reduction of BP (within minutes to hours) in asymptomatic severe hypertension or

hypertensive urgencies is best avoided as it may precipitate ischaemic events• In primary prevention, a CCB-based therapy is preferred in secondary prevention, the

benefits of BP lowering is seen in both normotensive and hypertensive patients ACEI- orARB- based treatment is preferred in secondary prevention

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Slide 1

• Mr. MR• 70 years old• Male


• Retired teacher

REVIEW VISIT 1

• Known hypertensive since 2 years, came to the clinic for follow-up

• Previous BP ranged from SBP 160-172 mmHg and DBP 74-80 mmHg

• Also has osteoarthritis of knees and constipation occasionally

• Current medication Nifedipine 10 mg tds, Diclofenac sodium 50 mg tds(prn), Ranitidine 150 mg od (prn), Lactulose syrup 15 ml ON (prn)

• On examination: alert, conscious and oriented• PR 70/min, BP 170/76 mmHg on standing and sitting• BMI 26 kg/m2

• Respiratory, Cardiovascular, GIT and CNS examinations–unremarkable

Slide 2

DISCUSSION POINT 1

• Describe the type of hypertension in this man• Comment on his BP control status• Comment on his medications• How do you explain your management plan to the patient?

Slide 3

DEFINITION OF HYPERTENSION IN THE ELDERY IS THE SAME AS INTHE GENERAL POPULATION

Optimal

Prehypertension

Stage 1 HPT

Stage 2 HPT

Stage 3 HPT

< 120

120-139

140-159

160-179

≥ 180

and

and/or

and/or

and/or

and/or

< 80

80-89

90-99

100-109

≥ 110



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Slide 5


• Five major classes of antihypertensive drugs (diuretics, β-blockers, CCBs, ACEIs and ARBs) have been shown to reduce CV events in the elderly

• In older patients with isolated systolic hypertension, diuretics are preferred because they significantly reduce multiple endpoints

Slide 4







Slide 6


• Educate Mr. MR regarding his uncontrolled systolic BP (170/76 mmHg) and its impact• Negotiate the management plan:

1. Advice on therapeutic lifestyle change – to lose weight by exercise and modest salt reduction.

2. Change his medication - stop the nifedipine, change to hydrochlorothiazide 12.5 mg once daily.

3. Arrange annual investigations to assess CV risks.4. Arrange follow-up visit within 1 month.

Slide 7

REVIEW VISIT 2

• Mr. MR came back to the clinic after 1 month• Feeling very well generally• BP checked again in this visit – 160/72 mmHg on standing and sitting • His FBS, FSL, Renal Profile, Urine Analysis and ECG were normal

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Slide 8

DISCUSSION POINT 2

• Describe the blood pressure control status• Discuss the underlying reasons for his BP control status• What is your next step of action?

Slide 9


• Educate Mr. MR that his systolic BP is still uncontrolled • Assess his adherence to treatment• Add a long-acting CCB at the lowest dose e.g. Amlodipine 5 mg od• Arrange follow up review in 1 month

Slide 10

REVIEW VISIT 3

• Mr. MR came back to the clinic after 1 month• Feeling very well generally• BP checked again in this visit – 140/68 mmHg

Slide 11

DISCUSSION POINT 3

• What is your next step of action?

Slide 12


• Inform Mr. MR that his BP has achieved the control target • Re-emphasize lifestyle intervention• Emphasize the importance of adherence to treatment and long term follow-up• Arrange follow up every 3 months• Assess CV risks annually

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Slide 13

SUMMARY OF EVIDENCE (1)

• HPT magnifies risk for CVD in the elderly compared with younger populations• SBP is a better predictor of CV events than DBP especially in the elderly• SBP increases linearly with age leading to an increase of isolated systolic hypertension

in the elderly• In patients with marked SBP and not tolerating treatment well, reducing SBP to below

160 mmHg initially is acceptable. Subsequently attempts should be made to reduce BP to target level

Slide 14


• Several RCT have shown that treatment of hypertension in the elderly up to the age of 84 years reduces CV morbidity and mortality, particularly stroke

• For those > 85 years, benefit of treating hypertension prevents the fatal and debilitating consequences of hypertension such as stroke, heart failure and dementia. (HYVET TRIAL 2008)

Slide 15


• Salt restriction is especially effective in the elderly due to greater sensitivity to sodium• Five major classes of antihypertensive drugs (diuretics, ß-blockers, CCBs, ACEIs and

ARBs) have been shown to reduce CV events in the elderly• In older patients with isolated systolic hypertension, diuretics are preferred because

they significantly reduce multiple endpoints

Slide 16


• Several trials using CCBs have shown benefits particularly in stroke reduction• ACEi are the drugs of choice for those with concomitant left ventricular systolic

dysfunction, post MI or DM• ARBs have also been shown to reduce fatal and non-fatal strokes in hypertensive

patients aged 65 years or older

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Slide 17


• The starting dose of HPT medications in older patients should be at the lowest available• In order to maximise adherence, the drug regime should be as simple as possible• The elderly tend to be on polypharmacy – drug interactions should be taken into

account when considering antihypertensive treatment

Slide 18

KEY LEARNING POINTS

• The goals of treatment of hypertension in older patients should be the same as inyounger patients

• In those patients with marked SBP and not tolerating treatment well, reducing SBP tobelow 160 mmHg initially is acceptable. Subsequently, attempts should be made toreduce BP to target levels

• Weight loss and modest salt reduction are effective in the elderly because of their greatersensitivity to sodium

• Five major classes of drugs have been shown to reduce CV events in the elderly(diuretics, β-blockers, CCBs, ACEi and ARBs)

• ACEi are the drugs of choice for those with concomitant left ventricular systolicdysfunction, post MI and DM

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Slide 1

• Mdm NH• 35 years old

• G1P0• Housewife

VISIT 1

• Came for antenatal booking. • POA 21 weeks• UPT positive done by private GP 3 months ago• Booking BP 130/80 mmHg• Otherwise well – no other symptoms• Strong family history of hypertension• BP 140/90 mmHg• Normal physical examination

Slide 2

DISCUSSION POINT 1

• How would you manage the patient?

Slide 3

VISIT 1: SUMMARY OF MANAGEMENT PLAN FOR MDM. NH

• Explain to her that she has a raised BP (140/90 mmHg)• Explain the significance of the reading and the importance of confirming the diagnosis• Negotiate the management plan:

1. Arrange to see the nurse for E.O.D BP check for 1 week2. Arrange baseline investigations3. Advise on sign and symptoms of pre-eclampsia4. Arrange follow-up visit within 1 week

Slide 4

VISIT 2: BP REVIEW

• Mdm. NH came back to the clinic after 1 week• Feeling very well generally• BP checked by nurse over a week

– 140/90, 145/95, 140/90 mmHg• BP checked again in this visit – 140/90 mmHg• Urine albumin - nil

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Case 10

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Slide 5

DISCUSSION POINT 2

• What is the diagnosis?• What is your next step of action?

Slide 6

HYPERTENSION IN PREGNANCY

Group of diseases in which hypertension is the chief clinical manifestation in pregnancy -two distinct groups:• Normotensive women who develop pre-eclampsia syndrome• Women with chronic hypertension who are at the higher risk of developing

superimposed pre-eclampsia

Slide 7

DIAGNOSIS

Mdm. NH’s BP taken ≥ 2 visits were ≥ 140/90 mmHg

Hypertension in Pregnancy is defined as a systolic blood pressure (BP) ≥ 140 mmHg and/or a diastolic BP ≥ 90 mmHg.

An increase of 15 mmHg and 30 mmHg diastolic and systolic BP levels above baseline BPis no longer recognized as hypertension if absolute values are below 140/90 mmHg.

Korotkoff V should now be used as the cut-off point for diastolic BP, and Korotkoff IVutilized only when Korotkoff V is absent.

Slide 8

BASELINE INVESTIGATIONS

• Biochemical investigations:– Platelet count, hematocrit– Serum uric acid and creatinine– Liver function test– UFEME– OGTT– 24 hour urine protein

• Other relevant investigation TRO secondary causes

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Slide 9


• No significant past medical history • Not on any regular medication• Both parents hypertensive• Father had heart attacks at aged 60 years• No pre-eclamptic symptoms • No symptoms to suggest secondary causes of hypertension• Sedentary lifestyle• Normal diet

Slide 10


• BP 140/90 mmHg• Normal weight gain• Fundoscopy normal• Cardiac & respiratory examinations – normal• Symphysis fundal height – 21 cm• Neurological examinations – normal

Slide 11

VISIT 2: BASELINE INVESTIGATION RESULTS

• Renal Profile: Urea 3.2 , Sodium 132, Potassium 3.5, Chloride 101 (all in mmol/L), Creatinine 65 µmol/L

• Serum uric acid: 200 µmol/L• Full Blood Count: Hb 11.5 g/dL, wbc 4500/mL, platelet 211,000/mL • OGTT: 5.3/7.0 mmol/L• Urinalysis - albumin negative

Slide 12

DISCUSSION POINT 3

• How do you classify hypertension in pregnancy? • What do you think Madam NH has?

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Slide 14

CLASSIFICATION OF HDP

1. Preeclampsia-eclampsia: clinically diagnosed in the presence of de novo hypertensionafter gestational week 20, and one or more of the following:i. Significant proteinuria.ii. Renal insufficiency: serum creatinine 90 µmol/l or oliguria.iii. Liver disease: raised transaminases and/or severe right upper quadrant or epigastric pain.iv. Neurological problems: convulsions (eclampsia), hyperreflexia with clonus or severe

headaches, persistent visual disturbances (scotoma).v. Haematological disturbances: thrombocytopenia, coagulopathy, haemolysis.vi. Fetal growth restriction.

This is followed by normalisation of the BP by three months postpartum. Oedema is nolonger part of the definition of preeclampsia. Either excessive weight gain or failure to gainweight in pregnancy may herald the onset of preeclampsia.

Slide 15


2. Gestational hypertension: hypertension alone, detected for the first time after 20 weeks pregnancy. The definition is changed to “transient” when pressure normalizes postpartum.

3. Chronic hypertension: hypertension diagnosed prior to gestational week 20; or presenceof hypertension preconception, or de novo hypertension.

4. Preeclampsia superimposed on chronic hypertension:This can be diagnosed by the appearance of any of the following in a woman with chronic hypertension:i) De novo proteinuria after gestational week 20.ii) A sudden increase in the severity of hypertension.iii) Appearance of features of preeclampsia-eclampsia.iv) A sudden increase in proteinuria in women who have preexisting proteinuria early in gestation.

Slide 13


HDP

Preeclamsia-eclampsia

Gestational HPT Chronic HPTPreeclampsia

superimposed onchronic HPT

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Slide 16

DISCUSSION POINT 4

• How do you manage Mdm NH?• What is your next step of action?

Slide 17

MANAGEMENT

• Early diagnosis of Hypertension in Pregnancy is vital• Recognition of Severity - mild

- severe• Colour Coding

Red Code - Mild pre eclampsia and more than 36 weeks gestation- Severe pre eclampsia- Eclampsia

Yellow Code - Mild pre eclampsia and less than 36 weeks gestation

Slide 18


• Educate regarding the diagnosis of Hypertension in pregnancy, and potential complications• Educate regarding BP treatment target < 140/90 mmHg, choice of medication –

potential benefits vs side effects• Regular fetal and maternal surveillance• Monitor sign and symptom of impending pre-eclampsia• Empower patient to self-manage through therapeutic lifestyle modification• Address transportation problems if any• Address adverse traditional beliefs and taboos• Refer early to Obstetrician in nearest hospital for combine care

Slide 19

VISIT 3: FOLLOW UP

• Mdm. NH came for review after 2 weeks (POA 23 weeks)• Her Renal Profile was normal• Has headache and mild epigastric pain• BP checked again in this visit – 150/100 mmHg• Weight increasing • Repeat urine protein 2+

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Slide 20

DISCUSSION POINT 5

• How do you manage this lady at this stage?

Slide 21


• Educate on her BP level – BP is high and she is symptomatic (severe pre-eclampsia)• She needs to be admitted to the hospital for BP stabilization• Perform appropriate resuscitation in the clinic before transfer

Slide 22

ANTIHYPERTENSIVE DRUGS COMMONLY USED IN PREGNANCY

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Slide 23

SEVERE PREECLAMPSIA

Must be promptly identified so that the patient can be urgently admitted to hospital for closeobservation and timely delivery. The Royal College of Obstetrician and Gynecology (RCOG)defines severe pre eclampsia as follows:1. Systolic BP 170 mmHg or diastolic BP 110 mmHg (acute hypertensive crisis in

pregnancy) on two occasions, with proteinuria of 1 g/day.2. Diastolic BP 100 mmHg on two occasions, with significant proteinuria (1+ on dipstick),

with two or more signs or symptoms of imminent eclampsia:a. severe headacheb. visual disturbancec. epigastric pain and/or vomitingd. clonuse. Papilloedemaf. liver tendernessg. platelet count below 100,000/cmm

h. abnormal liver enzymes (elevated ALT or AST)

i. HELLP syndrome (haemolysis, elevated liver enzymes, low platelets)

j. intrauterine growth restriction (IUGR)k. pulmonary oedema and/or congestive

cardiac failure

Slide 24

ANTICONVULSANTS IN PREECLAMPSIA-ECLAMPSIA

Parenteral magnesium sulphate is currently the drug of choice for the prevention of eclampsiaand to abort an eclamptic fit. The alternative is intravenous diazepam (intravenous bolus 10mg slowly over 10-15 minutes followed by infusion), bearing in mind that it is inferior in efficacycompared to magnesium sulphate.

Slide 25

POSTPARTUM CARE

• Advised to have BP checked regularly at local clinics if there is a significant delay in theirscheduled hospital follow-up

• In these patients, the dose of antihypertensive should be tailed down gradually and notstopped suddenly

• De novo onset of hypertension or aggravation of BP levels during the postpartum period,can occur

• These patients should be promptly referred to hospital especially if there is significantproteinuria. Eclampsia may occur in the postpartum period

• Chronic hypertension is diagnosed when the hypertension and/or proteinuria fails todisappear within three months postpartum

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Slide 26

KEY LEARNING POINTS

1. Preconception counseling and adjustment of treatment in women with chronic hypertension.2. Recognition of women at high risk of preeclampsia and referral in early pregnancy for

screening and prophylaxis.3. Nutritional supplementation for prevention of preeclampsia and/or its complications.4. Prevention of eclampsia and other complications of preeclampsia5. Primary care providers play an important role in preventing, detecting, monitoring

and managing preeclampsia and its complications

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Slide 1

• Puan Rahmah• 35 years old• Para 4

• Last child birth 6/12 ago

• Accountant

VISIT 1

• Referred to you for BP 150/90 mmHg after 1/12 on Combine Oral Contraceptive (COC)

• Currently not breast-feeding her child• Generally well- asymptomatic• Strong family history of hypertension

Slide 2

DISCUSSION POINT 1

• What further history would you like to elicit?• What physical examinations would you perform?• List the investigation you would do?

Slide 3

VISIT 1- FURTHER HISTORY

• Blood pressure before starting COC 130/80 mmHg• History of pregnancy induce hypertension• No symptoms of secondary causes of HPT & TOD• Unhealthy diet & sedentary lifestyle• Non smoker but husband is a chronic smoker• Not on any other medication except COC• Stressful at work and at home taking care of 4 children

Slide 4

VISIT 1- PHYSICAL EXAMINATIONS

• Repeat BP 152/90 mmHg• BMI 23 kg/m2

• Urine albumin negative, RBS 5.5 mmol/L, ECG normal

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Slide 5

DISCUSSION POINT 2

• Discuss the patient’s problems

Slide 6

VISIT 1

Problem List• Stage 1 hypertension on COC• Passive smoker, poor diet control, sedentary lifestyle• Stressful at work and home

Slide 7

DISCUSSION POINT 3

• What would you do now?• How do you explain your plan to the patient?• Discuss alternative methods of contraception for this patient

Slide 8

VISIT 1- FURTHER ACTIONS

• Explain that she needs to stop the COC in order to control her BP• Advice and reinforce on therapeutic life-style change – diet, exercise, stress management• Closer monitoring of BP and CVD risk factors• Counsel on other methods of contraception e.g. IUCD, POP, injectable depots, implants

& barrier methods

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Slide 10

SUMMARY OF EVIDENCE

• A woman who develops hypertension while using COC should be advised to stop takingthem and should be offered alternative forms of contraception

• Blood pressure should be reviewed regularly, at least every six months

Slide 11

KEY LEARNING POINTS

• The incidence of hypertension is reported to be higher in women taking COC, especially in obese and older women

• Before started all woman on OCP the blood pressure must be check then monitored regularly while she is on OCP

• Woman who develops hypertension while using COC should be advised to stop taking them and should be offered alternative forms of contraception

• Progesterone Only Pills191 and low dose COC, recommended alternatives for patients with hypertension or develop hypertension and wish to continue with OCP

Slide 9

HYPERTENSION AND ORAL CONTRACEPTIVES

The incidence of hypertension is reported to be higher in women taking combined oralcontraceptives (COC), especially in obese and older women. The mechanism by which theBP rises is unknown. A women who develops hypertension while using COC should beadvised to stop taking them and should be offered alternative forms of contraceptions.Progesterone Only Pills and low dose COC are not known to raise BP nor increase the risks of myocardial infarction. They are recommended alternatives for patients withhypertension or those who develop hypertension and yet wish to continue oralcontraception. A prudent approach to the use of oral contraception would be to measurebaseline BP before initiating treatment. Blood pressure should be reviewed regularly, at leastevery six month.

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Slide 1

• Madam OKL• 52 years old


• Teacher

VISIT 1

• Came to the clinic for review• Was commenced on hormone replacement

therapy (HRT) - Progyluton® 2 months agowhen she presented with worsening hot flushes and vaginal dryness

• Last menstruation was about a year ago• Last blood tests were done 6 months ago (confirmed her postmenopausal status)• BP readings were between 140/90-150/94 mmHg for the past 6 months before she was

commenced on HRT

Slide 2


• No symptoms of CVD and TOD• Practice a prudent diet• Does regular walk every morning• Non-smoker• Taking mefenamic acid for her painful knee occasionally• Children are healthy• Parents died of ‘old age’ at 70+ years old• Living with husband

Slide 3

VISIT 1: PHYSICAL EXAMINATIONS AND BASELINE INVESTIGATIONS

ResultBMI 22 kg/m2, WC= 75 cmNeck - no goitre, no carotid bruitHeart and lung - normalAbdomen and pelvic - normalLegs - normalOther systems – normalFBG 5.5 mmol/L, Fasting serum lipid normalUrine microalbumin negativeECG normal

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Slide 4

DISCUSSION POINT 1

• What is the diagnosis?• What is her global CV risk stratification level?

Slide 5

DIAGNOSIS & CLASSIFICATION OF HYPERTENSION

Optimal

Prehypertension

Stage 1 HPT

Stage 2 HPT

Stage 3 HPT

< 120

120-139

140-159

160-179

≥ 180

and

and/or

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80-89

90-99

100-109

≥ 110



Slide 6



BP Levels(mmHg)

SBP 120-139and/or


SBP 140-159 and/or


SBP 160-179 and/or


SBP 180-209 and/or


SBP ≥ 210 and/or


No RFNo TODNo TOC






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Slide 7


• Her BP was checked again twice (15 minutes apart) on this visit: 160/100 mmHg

Slide 8

DISCUSSION POINT 2

• Summarise Mdm. OKL’s problems.• How do you manage this lady?

Slide 9

VISIT 1: SUMMARY OF PROBLEMS

• Post-menopause with persistent vasomotor symptoms• Underlying Stage 1 hypertension – worsening to Stage 2 (160/100 mmHg) since

commencing HRT• No significant co-existing CV risk factor apart from HPTIN

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Slide 10


Slide 11

HYPERTENSION AND HOME REPLACEMENT THERAPY

The presence of hypertension is not a contraindication to oestrogen-based hormonalreplacement therapy (HRT). It is recommended that all women treated with HRT should havetheir BP monitored every six months. The decision to continue or discontinue HRT in thesepatients should be individualised.

The Women’s Health Initiative (WHI) trial involving 98, 705 women aged 50-79 years,concluded that the use of HRT increased cardiovascular events. Conjugated equineestrogen (CEE), alone or in combination with medroxyprogesterone acetate, was used in thestudy. In view of this, greater caution and closer monitoring is required for hypertensivepatients on CEE.

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Slide 12


Pharmalogical management of stage 2 hypertensionInitiating therapy with the right combination of at least 2 drugs is recommended

Effective Combination

β-blockers + diuretics

β-blockers + CCBs

CCBs + ACEIs/ARBs

ACEIs + diuretics

ARBs + diuretics

Slide 14

VISIT 1: SUMMARY OF MANAGEMENT PLAN FOR MDM. OKL

• Explain to her that she has an underlying Stage 1 HPT which is now worsening.• Initiate therapy with 2 drugs e.g. CCB + ACEi• Discuss the option of continuing HRT and advise to have regular Pap smear and

mammogram• Re-emphasize on therapeutic lifestyle modification• Educate regarding potential complications, the need to start medication and her

treatment target• Review monthly until target BP is achieved• Review 3-monthly once target BP is achieved• Re-assess CV risks annually

Slide 13







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Slide 15

A NOTE ON HORMONE REPLACEMENT THERAPY-PROGYLUTON

• 11 white tab each containing Calendar pack of Oestradiol valerate 2 mg, 10 brown tab each containing Norgestrel 500 mcg, Oestradiol Valerate 2 mg

• Before starting treatment, a thorough general medical (including blood pressure measurement, urine test for sugar and, if necessary, special liver tests), andgynaecological examination (including the breasts and a cytological smear) should becarried out to detect any diseases requiring treatment or any risks and, above all, to rule out pregnancy. Control examinations are recommended at about 6-monthly intervals

• Progyluton is not a contraceptive. Where applicable contraception should be practised with non-hormonal methods

Slide 16

SUMMARY OF EVIDENCE

• The presence of hypertension is not a contraindication to oestrogen based hormonal replacement therapy (HRT)

• It is recommended that all women treated with HRT should have their BP monitored every six months

• The decision to continue or discontinue HRT in these patients should be individualized• The Women's Health Initiative (WHI) trial involving 98, 705 women aged 50-79 years,

concluded that the use of HRT increased cardiovascular events. In view of this, greater caution and closer monitoring is required for hypertensive patients on CEE

Slide 17

KEY LEARNING POINTS

• Stage 1 HPT is defined as SBP 140 and/or DBP 90 mmHg or greater, based on > 2 BP readings at > 2 clinic visits

• HRT is safe in hypertensive women. The presence of hypertension is not a contraindication to oestrogen based hormonal replacement therapy (HRT)

• Untreated or sub-optimally controlled hypertension leads to increased cardiovascular, cerebrovascular and renal morbidity and mortality

• Decision to commence pharmacological treatment should be based om global cardiovascular risks and not on the level of blood pressure (BP) per se

• All women treated with HRT should have their BP monitored every six months including regular gynaecological examination, mammogram and cervical smear

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Slide 1

GOLD STANDARD BP MEASUREMENT

• Invasive Measurement

Slide 2

MERCURY COLUMN SPHYGMOMANOMETER-GOLD STANDARD NONINVASIVE METHOD

Slide 3

STEPS TO BP MEASUREMENT

Check the machine1. The mercury meniscus – make sure it is at zero. If not, minus the baseline reading2. Inflation – deflation device

a) after 3-5 seconds of rapid inflation the mercury column should touch 200 mmHg or 40 mmHg above estimated SBP

b) ability to deflate at a rate of 2-3 mmHg per second 3. Cuff – both length and width of the bladder must be correct. The length of the bladder

must at least be 80% of the circumference of the arm and the width at least 40% the circumference of the arm

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Slide 4

BLADDER LENGTHS

Slide 5


• Rest the patient, back rested on the chair and arm supported at heart level, no coffee or smoking 30 minutes before

• Wrap the cuff properly• Palpate the brachial or radial artery• Inflate the bladder until the pulse disappear and inflate another 30 mmHg• Deflate the cuff slowly until the pulse is felt again (estimated SBP)• Bladder inflated to 30 mmHg above the estimated SBP

Slide 6


• First repetitive appearance of clear tapping sound (Korotkoff 1) is SBP. Disappearance of sound (Korotkoff V) is DBP.

• If Korotkof sound does not disappear, use Korotkof 1V (muffling) • Measure on both arm at first visit. If > 20/10 mmHg is abnormal • Measure lying and standing (after 1 minute) BP for the elderly and the diabetics

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Slide 7

CLINICAL HYPERTENSION

Slide 8

THE SPHYGMOMANOMETER

• Beware of defective machine

Slide 9

AUTOMATED SPHYGMOMANOMETER

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Slide 10

OTHER METHODS OF MEASUREMENT

• Aneroid sphygmomanometer• Automated ambulatory BP devices• Validated by either BHS or AAMI methods

Slide 11

AMBULATORY BP

Indicated in:• suspected ‘white coat’ hypertension• borderline hypertension• labile hypertension• resistant hypertension (not controlled on 3 drugs including a diuretics)• ‘hypotensive symptoms’

Slide 12

Slide 13

DETECTING POSTURAL HYPERTENSION

• BP taken both lying and at least 1 minute standing• Significant drop: SBP ≥ 20 mmHg

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Slide 14

MEASURING BILATERAL BP DIFFERENCES

• Difference of BP ≥ 20/10 mmHg• Consider: - Atherosclerosis

- Congenital co-arctation of aorta- Vasculitis: big vessels disease: Takayasu disease

Slide 15

AUSCULTATORY GAPS

• It is a normal phenomenon seen in elderly

Slide 16

CHANGE IN BP WITH DAILY ACTIVITIES

Meetings

Work

Transportation

Walking

Dressing

Chores

Telephone

+20

+16

+14

+12

+12

+11

+10

+15

+13

+9

+6

+10

+7

+7

Activities SBP DBP

Eating

Talking

Desk work

Reading

Television

Relaxing

Sleeping

+9

+7

+6

+2

+0.3

0

-10

+10

+7

+5

+2

+3.2

0

-8

Activities SBP DBP

Slide 17

KEY LEARNING POINTS

• Proper steps in blood pressure measurement is important to avoid inaccurate readings.• Optimal blood pressure measurement determines management strategies

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PRE & POST TEST QUESTIONNAIREMULTIPLE CHOICES QUESTIONS (MCQs) (TRUE/FALSE)

TOPIC 2: DIAGNOSIS AND MANAGEMENT OF PRE-HYPERTENSION

1. The following statement(s) is/are true regarding pre-hypertension:A. If left untreated, almost two thirds will progress to develop stage 1 hypertensionB. Younger individuals are associated with a higher rate of progressionC. It tends to cluster with other cardiovascular risk factorsD. Almost a third of BP-related deaths from coronary heart disease occur in pre-hypertensive

individualsE. Pre-hypertensive level of blood pressure itself is an independent cardiovascular risk factor

2. With regards to the management of pre-hypertension, the following statement(s) is/are true:A. All patients should be managed with therapeutic lifestyle modificationB. Patients should be followed up at least once every 2 yearsC. Decisions regarding pharmacological treatment should be based on the individual’s global

cardiovascular riskD. Pharmacological treatment is indicated in pre-hypertensive patients at low cardiovascular riskE. In patients with diabetes mellitus and pre-hypertension, pharmacological treatment is

required if BP is > 130/80 mmHg

TOPIC 3: DIAGNOSIS AND MANAGEMENT OF STAGE 1 HYPERTENSION

1. Madam Y has recently been diagnosed with stage 1 hypertension. She is a heavy smoker and hertotal cholesterol is 6.8 mmol/L. The following statement(s) is/are true regarding her condition andmanagement:A. She has a medium cardiovascular riskB. Her target blood pressure is < 140/90 mmHgC. Pharmacological treatment should commence with combination of 2 drugs at low doseD. β-blocker is recommended for first line therapy for this patientE. Thiazide diuretic is contraindicated in her case

2. The following statement(s) is/are true with regards to the management of stage 1 hypertension:A. In patients without target organ damage, an observational period of 3-6 months on lifestyle

modification is recommendedB. Monotherapy can lower the blood pressure to < 140/90 mmHg in 40-60% of casesC. Increasing the dose of the initial drug is an option if patient shows response but target BP is not

achievedD. Monotherapy should be continued for at least 6 months before a second drug can be addedE. Substituting the drug with another class is recommended when the drug is not tolerated

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TOPIC 4: DIAGNOSIS AND MANAGEMENT OF STAGE 2 HYPERTENSION &RESISTANT HYPERTENSION

1. For patients with stage 2 hypertension, the target blood pressure of < 140/90 mmHg isrecommended if they have: A. History of tobacco smoking B. Diabetes mellitusC. Chronic kidney diseaseD. Central obesityE. Cardiovascular disease

2. Below is/are the recommended antihypertensive combination(s) for patients with stage 2hypertension and heart failure:A. β-blocker + ACEiB. β-blocker + CCBC. CCB + ACEiD. ACEI + diureticE. ARB + diuretic

3. The following statement(s) is/are true with regards to resistant hypertension:A. It is defined when a patient’s BP is > 140/90 mmHg on 3 antihypertensive agents including a

diuretic at near maximal doseB. Non-compliance to medication must be excludedC. The commonest cause is secondary hypertensionD. Excessive salt intake is a contributing factorE. Specialist referral is required in suspected cases of renal artery stenosis

TOPIC 5: DIAGNOSIS AND MANAGEMENT OF STAGE 3 HYPERTENSION

1. A 48-year-old woman is evaluated for hypertension. Physical examination showed BP: 182/86mmHg. She does not give history of headaches. Fundoscopy showed that she has Grade 3Hypertensive retinopathy. Her home blood pressure measurements remain the same results asabove. Which of the following statement(s) is/are true :A. She is having Hypertensive UrgenciesB. Patient can be reassured of her blood pressure readingsC. She needs to be referred to the nearest hospital for initiating antihypertensive agentD. She can be managed as outpatient with just home blood pressure monitoringE. She may need hospital admission if her blood pressure remains elevated after 30 minutes of rest

2. A 56-year-old man was diagnosed with essential hypertension 6 months ago. His blood pressure remained elevated at average 174/110 mmHg. He was taking Tablet Amlodipine 5 mg daily. His blood pressure today in the clinic is 172/112 mmHg. He denied of having anyheadache or blurring of vision. There were no hypertensive retinopathy changes in his eyes. Whichof the following statement(s) is/are most appropriate for the patient at the current situation?A. He must be referred to the hospital today for further evaluation of his blood pressure readingsB. Advice him to continue to comply with his current medicineC. He has Stage 3 HypertensionD. We should ask for symptoms of limb weakness. E. We would order Urine microalbumin test

3. The following statement(s) is/are correct regarding the management of Stage 3 Hypertension:A. Patient’s blood pressure target is < 140/90 mmHg if there is no target organ complicationB. Non-adherence to therapy is an important cause of uncontrolled blood pressureC. Monotherapy is sufficient to get the blood pressure to targetD. Fundoscopy and an ECG evaluation are needed for assessments of their target organ damage

or complicationE. There is no role of therapeutic lifestyle changes for these patients

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TOPIC 6: HYPERTENSION AND DIABETES

1. A 54-year-old man with type 2 diabetes has had intermittent mild headaches for the past onemonth. He is now euglycemic with oral hypoglycemic agents and lifestyle modifications. His oldersister has had hypertension and has been taking antihypertensive medications for several years.Physical exam reveals an afebrile medium size man with a BP of 158/96 mm Hg (average of 2readings), normal and regular peripheral pulses, hard exudates and narrowing of the arterioles onfundoscopic exam, and no carotid bruits. Lungs are clear and neurologic exam is also normal. Hisrecent test result show the following: fasting plasma glucose, 5.8 mmol/L; HbA1c, 6.9%; normalurinalysis; and normal electrocardiogram (ECG).

Which of the following(s) would you consider for treatment of this patient?A. A thiazide-type diureticB. A combination of a β-blocker and thiazide-type diureticC. A combination of a β-blocker and an ACE inhibitorD. A combination of a calcium channel blocker and an ACE inhibitorE. A combination of a thiazide-type diuretic and a ARB

2. In the drug management of hypertension in diabetic patients,A. amlodipine worsens peripheral neuropathyB. atenolol causes hypoglycemia C. hydrochlorothiazide is contraindicated in the presence of proteinuriaD. perindopril prevents cardiovascular eventsE. prazocin reduces glucose metabolism

3. Which of the following statements regarding management of hypertensive patient with type 2diabetes mellitus is/are TRUE?A. When the systolic blood pressure is > 20 mmHg above goal or diastolic blood pressure is > 10

mmHg above goal, monotherapy is recommendedB. Many patients require 3 or more antihypertensive medications to achieve blood pressure goalC. All patients with diabetes and hypertension should be treated with calcium channel blockerD. They need less stringent blood pressure goalE. Pharmacotherapy is indicated in patients with microalbuminuria

TOPIC 7: HYPERTENSION AND METABOLIC SYNDROME

1. Which of the criterion/criteria below is/are TRUE for Metabolic SyndromeA. Waist circumference of > 90 in men and > 80 in womenB. Raised Blood pressure > 130/85 mmHgC. Fasting blood sugar of > 6.1 mmol/LD. Raised Triglyceride and Low HDLE. Raised Triglyceride and Raised LDL

2. In the drug management for patients with Hypertension and Metabolic Syndrome.A. Thiazide Diuretics is recommended as first line agentB. ß-blockers should be avoidedC. ACE Inhibitor is a recommended drug of choiceD. Calcium Channel Blocker should be avoidedE. Combination therapy is considered safe

3. Which of the statement(s) below regarding Metabolic Syndrome is/are TRUEA. It is associated with increased risk of developing cardiovascular diseaseB. It is associated with increased risk of developing diabetes insipidusC. Lifestyle modification is not as important as drug managementD. It requires education for patients to achieve target BP of < 130/80 mmHgE. Weight loss management is crucial in reversing risk of Metabolic Syndrome

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TOPIC 8: HYPERTENSION AND CARDIOVASCULAR DISEASE

1. A 56-year-old man presented with intermittent left pain calf pain worsen on prolong walking. He hasno significant past medical history. His blood pressure was 140/90 mmHg. The left dorsalis pedispulse was weaker than the right side. Which of the following statement(s) is/are correct?A. His risk of stroke is highB. Electrocardiography is an optional investigationC. He should be called back within a week to confirm his status of hypertensionD. Atenolol is an appropriate anti-hypertensiveE. His target blood pressure is < 140/90 mmHg

2. Which of the following scenario(s) is/are correctly paired with the optimal choice of anti-hypertensives given?A. A 60-year-old woman with congestive cardiac failure secondary to prolong uncontrolled

hypertensive: AtenololB. A 50-year-old man with primary stage II hypertension and left ventricular hypertrophy: LosartanC. A 70-year-old man with primary hypertension and significant Q wave in his electrocardiogram at

the anterior chest leads: AmlodipineD. A 45-year-old man with primary hypertension and recent myocardial infarct: PerindoprilE. A 66-year-old woman with uncontrolled hypertension and congestive heart failure NYHA classII

who are already on T. Perindopril 4 mg daily: Metoprolol

3. The following(s) is/are necessary in the assessment of patient presented with symptoms of heartfailure and prolong hypertension:A. Urine proteinB. Heamoglobin levelC. Chest X-rayD. Doppler ultrasound of peripheral arteries in the lower limbE. Serum potassium and sodium

TOPIC 9: HYPERTENSION AND STROKE

1. Ahmad, a 45-year-old businessman presented to the health clinic with left sided body weakness of 1 day duration. His vital signs are as below:BP : 190/110 mmHgPR : 90 beats/minTemp : 36.5˚CRR : 14 breaths/minThe following statement(s) is/are correct regarding Ahmad’s condition:A. Ahmad is categorized under Hypertensive UrgenciesB. Oral Captopril can be given to lower Ahmad’s blood pressureC. Aspirin is recommendedD. He can be treated as an out-patientE. He needs oxygen supplementation for cerebral protection

2. The following statement(s) is/are correct regarding hypertension and stroke:A. Dyslipidaemia is a better predictor of stroke compared to blood pressureB. Drug treatment is recommended in previous history of Transient Ischaemic Attack (TIA)C. In haemorrhagic stroke presented with BP > 180/110 mmHg, immediate reduction of BP is best

avoidedD. Diastolic blood pressure (DBP) is more predictive for strokeE. ß-blockers have been shown to reduce risk and mortality of stroke

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3. Mr. Tan a 58-year-old pensioner had history of ischaemic stroke 5 years ago. His current medicationsare Aspirin 150 mg OD and Hydrochlorothiazide 25mg OD. The following statement(s) is/are correct:A. CCB provides better protection than Thiazide Diuretic regarding secondary prevention B. It is recommended to withhold his Hydrochlorothiazide if his blood pressure ranges from

110-120/70-80 mmHgC. Perindopril is the preferred choiceD. His target LDL level is < 3.4 mmol/LE. His target blood pressure control is < 140/90 mmHg

4. The following statement(s) is/are correct regarding Stroke:A. In Asia Pacific region, about 2/3 of strokes attributed to hypertensionB. Combination of an ACE-Inhibitor and diuretic has been shown to reduce recurrent stroke.C. Treatment with aspirin alone is sufficientD. In primary prevention, the risk of stroke is significantly reduced with 10 mmHg reduction of

systolic blood pressureE. In severe hypertensive with acute stroke, blood pressure lowering to < 160/90 mmHg is

mandatory

TOPIC 10: HYPERTENSION IN THE ELDERLY

1. Based on current evidence, the following class(es) of drugs has / have been shown to reducecardiovascular events in the elderly:A. Calcium channel blockersB. Ace inhibitorsC. β-blockersD. DiureticsE. α-blockers

2. When prescribing antihypertensive agents in the elderly, the following rule(s) is/are important:A. Start with low doseB. Go slow on increasing the doseC. Combination preparation is encouragedD. The target BP is below 130/80 mm HgE. In patients with marked systolic hypertension, reducing SBP below 160 mmHg is initially

acceptable

3. In patients with postural hypertension, the following BP should be used as a guide to treatmentdecisions:A. Standing BPB. Sitting BPC. Lying BPD. Supine BPE. Ambulatory BP

TOPIC 11: HYPERTENSION IN PREGNANCY

1. Which of the following(s) is/are the risk factor(s) for developing high blood pressure in pregnancy?A. First pregnancyB. Previous history of hypertension during pregnancyC. Twin pregnancy D. Diabetes MellitusE. Poor weight gain

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2. What is/are the complication(s) of hypertension in pregnancy?A. Fits B. StrokeC. Placenta accretaD. StillbornE. Disseminated intravascular coagulopathy

3. Which of the following(s) is/are the sign(s) of pre-eclampsia?A. Sudden increase in weight (> 1 kg per week)B. Polyuria C. Epigastric pain D. Visual disturbance such as blurred visionE. Nausea and vomiting

TOPIC 12: HYPERTENSION AND ORAL CONTRACEPTIVE PILLS

1. The following statement(s) is/are true regarding hypertension and oral contraceptives:A. Baseline blood pressure is essential before initiating combined oral contraceptive (COC)B. Progestrogene only pills (POP) are known to raise blood pressureC. Incidence of hypertension is reported to be higher in woman taking COCD. Women who develop hypertension while using COC are advisable to continue using COC

provided their blood pressure is monitored regularlyE. Low dose COC is a recommended alternative for patients with hypertension who wish to

continue oral contraception

2. The following contraceptive method(s) is/are known to raise blood pressure:A. Combined oral contraceptive (COC)B. Intrauterine Devices (IUDs)C. Progesterone only pills (POP)D. MirenaE. Low dose COC

TOPIC 13: HYPERTENSION AND HORMONE REPLACEMENT THERAPY

1. In the management of a hypertensive post-menopausal women on hormone replacement therapy: A. The decision to continue or discontinue HRT in these patients should be individualisedB. Physician should be aware that the use of HRT increased the risk of recurrent cardiovascular

eventsC. Monitoring of every three months is recommended if BP is uncontrolledD. Cardiovascular risk stratification should be done annually E. Pap smear should be done bi-annually up to 65 years of age

2. A hypertensive woman on hormone replacement therapy is at risk for:A. Breast cancerB. Colorectal cancerC. Venous thromboembolismD. Osteoporosis E. Gall-bladder disease

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PRE & POST TEST QUESTIONNAIREMULTIPLE CHOICES QUESTIONS (MCQs) (TRUE/FALSE)

ANSWER

TOPIC 2: DIAGNOSISAND MANAGEMENTOF PRE-HYPERTENSION

1. A. TB. FC. TD. TE. T

2. A. TB. FC. TD. FE. T

TOPIC 3: DIAGNOSISAND MANAGEMENTOF STAGE 1HYPERTENSION

1. A. TB. TC. FD. FE. F

2. A. TB. TC. TD. FE. T

TOPIC 4: DIAGNOSISAND MANAGEMENTOF STAGE 2HYPERTENSION &RESISTANTHYPERTENSION


2. A. TB. FC. FD. TE. T

3. A. TB. TC. FD. TE. T

TOPIC 5: DIAGNOSISAND MANAGEMENTOF STAGE 3HYPERTENSION

1. A. TB. FC. FD. FE. T

2. A. FB. FC. TD. TE. T

TOPIC 6:HYPERTENSION ANDDIABETES

1. A. FB. FC. FD. TE. T

2. A. FB. FC. FD. TE. F

3. A. FB. TC. FD. FE. T

TOPIC 7:HYPERTENSION ANDMETABOLICSYNDROME

1. A. TB. TC. TD. TE. F

2. A. FB. TC. FD. TE. T

3. A. TB. FC. FD. TE. T

TOPIC 8:HYPERTENSION ANDCARDIOVASCULARDISEASE

1. A. TB. FC. FD. FE. F

2. A. FB. TC. FD. TE. F

3. A. TB. TC. TD. FE. T

TOPIC 9:HYPERTENSION ANDSTROKE

1. A. FB. TC. FD. FE. T

2. A. FB. TC. TD. FE. T

3. A. TB. FC. TD. FE. F

4. A. TB. TC. FD. TE. F

TOPIC 10:HYPERTENSION INTHE ELDERLY


2. A. TB. TC. FD. FE. T

3. A. TB. FC. FD. TE. F

TOPIC 11:HYPERTENSION INPREGNANCY


2. A. TB. TC. FD. TE. T


TOPIC 12:HYPERTENSION ANDOCP

1. A. TB. FC. TD. FE. T

2. A. TB. FC. FD. FE. F

TOPIC 13:HYPERTENSION ANDHORMONEREPLACEMENTTHERAPY

1. A. TB. TC. FD. TE. F

2. A. TB. FC. TD. FE. F

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hpt training module oct 2010

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