Incidental Findings; Management of patients presenting with high BP. Phil Swales

Transcription

1 Incidental Findings; Management of patients presenting with high BP Phil Swales Consultant Physician Acute & General Medicine University Hospitals of Leicester NHS Trust

2 Objectives The approach to an incidental finding of elevated Blood Pressure in an adult Diagnosis of Hypertension Hypertensive Crises Hypertensive Urgency Hypertensive Emergency

3 Hypertension Stroke Died of complications of stroke, BP 260/150mmHg Died of massive cerebral haemorrhage 68 days later. Hypertension Stroke within 4 months, MI Died of haemorrhagic stroke, 1953.

4 Case Scenario You are asked to review the President of the USA who has been found to have a BP of 260/150mmHg by his personal physician during an important conference.

5 Assessment of the Patient with Elevated BP History Examination Assess for Target/End Organ Damage Assess Cardiovascular Risk Factors Confirm diagnosis of hypertension Consider secondary causes of hypertension Initiate Management Appropriate follow-up

6 Important Aspects of the Physical Examination in the Hypertensive Patient Accurate measurement of blood pressure General appearance: distribution of body fat, skin lesions, muscle strength, GCS Fundoscopy Neck: palpation and auscultation of carotids, thyroid Heart: size, rhythm, sounds Lungs: rhonchi, crepitations Abdomen: renal masses, bruits over aorta or renal arteries, femoral pulses Extremities: peripheral pulses, oedema Neurologic assessment

7 Routine Tests for the Investigation of All Patients with Hypertension Urinalysis Bloods; Full Blood Count Biochemistry Glucose Lipid Profile 12 Lead ECG

8 Assess for Target Organ Damage Retinopathy Clinical LVH ECG-LVH CXR-Cardiomegaly ECHO-LVH/LV Mass/Diastolic Dysfunction Lab-Renal Function/Micro-albuminuria Vascular-bruits/Diminished pulses

9 Target Organ Damage

10 What do UK Hypertension guidelines advise? Diagnosis Management Severe Hypertension / Hypertensive Crises

11 Diagnosis If the clinic blood pressure is 140/90 mmhg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. National Institute for Health and Care Excellence CG 127 (2011)

12 Definitions Stage 1 hypertension: Clinic blood pressure (BP) is 140/90 mmhg or higher and ABPM or HBPM average is 135/85 mmhg or higher. Stage 2 hypertension: Clinic BP 160/100 mmhg is or higher and ABPM or HBPM daytime average is 150/95 mmhg or higher. Severe hypertension: Clinic BP is 180 mmhg or higher or Clinic diastolic BP is 110 mmhg or higher. National Institute for Health and Care Excellence CG 127 (2011)

13 CBPM 140/90 mmhg & ABPM/HBPM 135/85 mmhg Stage 1 hypertension CBPM 160/100 mmhg & ABPM/HBPM 150/95 mmhg Stage 2 hypertension Care pathway If target organ damage present or 10-year cardiovascular risk > 20% Offer antihypertensive drug treatment If younger than 40 years Consider specialist referral Offer lifestyle interventions Offer patient education and interventions to support adherence to treatment Offer annual review of care to monitor blood pressure, provide support and discuss lifestyle, symptoms and medication National Institute for Health and Care Excellence CG 127 (2011)

14 Aged under 55 years A Aged over 55 years or black person of African or Caribbean family origin of any age C 2 Step 1 Summary of antihypertensive drug treatment A + C 2 A + C + D Resistant hypertension A + C + D + consider further diuretic 3, 4 or alpha- or beta-blocker 5 Consider seeking expert advice Step 2 Step 3 Step 4 Key A ACE inhibitor or low-cost angiotensin II receptor blocker (ARB) 1 C Calcium-channel blocker (CCB) D Thiazide-like diuretic National Institute for Health and Care Excellence CG 127 (2011)

15 However, if you are in the USA US Guidance recommends a change to the definition of Hypertension *Individuals with SBP and DBP in 2 categories should be designated to the higher BP category. BP indicates blood pressure (based on an average of 2 careful readings obtained on 2 occasions ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults

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17 But what if the BP is Severely Elevated? Severe hypertension: Clinic systolic blood pressure 180 mmhg or clinic diastolic blood pressure 110 mmhg; treat promptly National Institute for Health and Care Excellence CG 127 (2011)

18 Hypertensive Crises The terms malignant hypertension and accelerated hypertension have been replaced by hypertensive urgency or hypertensive emergency. Blood pressure higher than 180 mm Hg systolic and/or 110 mm Hg diastolic is considered severe hypertension a designation that includes hypertensive urgency and hypertensive emergency. The actual BP level may not be as important as the rate of BP rise; patients with chronic hypertension can often tolerate higher BP levels than previously normotensive individuals.

19 Hypertensive Crises Hypertensive urgency and emergency are differentiated by the absence or presence of acute end-organ damage, respectively.

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21 Causes of Hypertensive Crises From: Improving Survival of Malignant Hypertension Patients Over 40 Years Am J Hypertens. 2009;22(11): doi: /ajh Am J Hypertens 2009 by the American Journal of Hypertension, Ltd.American Journal of Hypertension, Ltd.

22 Prognosis of Malignant Hypertension Harrington et al, 1959

23 Five-year survival by decade of diagnosis. MHT, malignant phase hypertension. From: Improving Survival of Malignant Hypertension Patients Over 40 Years Am J Hypertens. 2009;22(11): doi: /ajh Am J Hypertens 2009 by the American Journal of Hypertension, Ltd.American Journal of Hypertension, Ltd.

24 What Do the Guidelines Say?

25 Clinical Assessment Generic assessment of patient Severity Target organ damage Pointers towards secondary hypertension Current treatment Medicine Intolerance / Adherence OTC / Illicit drugs Clinical examination including appropriate BP measurement Baseline investigations

26 First Key Clinical Decision 1. Admit to an intensive, high dependency or coronary care unit for IV anti-hypertensive treatment to lower the BP over the next few minutes to hours. 2. Admit the patient for oral anti-hypertensive treatment ensuring the patient will be regularly monitored and reviewed aiming to lower the BP over 24 hours. 3. Advise oral anti-hypertensive treatment and allow patient home with appropriate follow-up arrangements.

27 Hypertensive Urgency - Treatment Hypertensive Urgency: Goal: Reduce BP to <160/100 over several hours to day Elderly at high risk of ischemia from rapid reduction of BP, therefore slower reduction in BP in this patient population Previously treated hypertension: Increase dose of existing med or add another med Reinstitution of med in non-compliant patients

28 Hypertensive Urgency - Treatment Hypertensive Urgency continued: Previously untreated hypertension: Slow reduction of BP (one to two days): Calcium Channel Blocker (eg Nifedipine MR followed by Amlodipine), ACE inhibitor, (β-blocker) (oral antihypertensives usually enough) Some experts recommend: Initiate two agents or a combination agent (one being a thiazide diuretic) Rationale: Most patients with BP >20/10 above goal will require two agents to control their BP

29 Hypertensive Emergency - Treatment Hypertensive Emergency: Patient will need admission (ideally CCU/HDU) Goal: Lower Diastolic BP to approximately over 2-6 hours; max initial fall not to exceed 25% More aggressive decrease can lead to ischemic stroke, myocardial ischemia, acute kidney injury Parenteral antihypertensives recommended over oral agents in initial treatment of hypertensive emergency GTN Sodium Nitroprusside (caution about cyanide toxicity) Labetalol Nicardipine

30 Hypertensive Emergencies Special Situations; Acute Coronary Syndrome BP targets: follow the general rule NOTE: analgesia and pain control can influence BP Use of IV GTN is first line / Alternatives include: IV β-blockers (esmolol) Aortic Dissection More stringent BP target Aim mmhg systole within 30 minutes First line is IV labetolol / esmolol / Second line is nitroprusside or GTN Again effective opiate analgesia will positively influence BP reduction Severe Hypertension in Pregnancy (Pre-)Eclampsia may present with moderately elevated BP Treatment options include: Magnesium (seizure prevention), Labetolol, Hydralazine, Methyldopa BP target: / mmhg Phaeochromocytoma crisis IV phentolamine is α-blocker of choice / Alternative would be IV phenoxybenzamine Volume expand/rehydrate Cocaine Induced Hypertension Diazepam is 1 st line (consider phentolamine/nitroprusside/gtn)

31 Follow-Up Following discharge, BP is likely to continue to reduce gradually Early review essential with appropriate monitoring Target BP will be 140/90 or lower depending on individual patient co-morbidities

32 Summary Incidental finding of elevated BP is common Reviewed UK (and mentioned US) guidelines for diagnosis of hypertension Reviewed UK guidance for management of uncomplicated hypertension Special situation Severe Hypertension Differentiate Hypertensive Urgency from Emergency on the basis of acute end-organ damage Can treat hypertensive urgency with oral antihypertensives, but parenteral medications required for hypertensive emergencies 25% reduction in diastolic BP over 2-6 hours for hypertensive emergencies Don t forget to start Oral antihypertensives and follow-up closely!

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