Diagnosis of hypertension

One high reading does not mean you have high blood pressure. It is necessary to measure your blood pressure at different times, while you are resting comfortably for at least five minutes. To make the diagnosis of hypertension, at least three readings that are elevated are usually required

1. Diagnosis of hypertension

2. WHY HYPERTENSION IS SO IMPORTANT ? Chronic disease Noncommunicable disease high BP remains the leading cause of death worldwide one of the world's great public health problems MOST OF THE PEOPLE HAVE IT [90% by age of 78] MOST OF THE PEOPLE FEAR it treatment IS LIFELONG BP IS NOT CONTOLLED -85% 40% OF STROKE death AND 16% OF cvd death women after menopause worse than men to own this

3. Who will going to have it ?

4. DEFINE

5. OUT PATIENT CLINIC HTN Hypertension is defined as a usual office BP of 140/90 mm Hg or higher but should be confirmed by home and ambulatory blood pressure measurement if there is any suspicion of white coat

6. Different guidelines have different cut off epidemiologic data show continuous positive relationships between the risk of coronary artery disease (CAD) and stroke deaths with systolic or diastolic BP down to values as low as 115 or 75 mm Hg

7. Staging of htn

8. Different method –different cut off

9. Modified from Gabb GM, Mangoni A, Anderson CS, et al. Guideline for the diagnosis and management of hypertension in adults—2016. Med J Aust 2016;205:85.

10. MEASUREMENT OF BP OFFICE [PRONE FOR WHITE COAT] HOME[MOST CORRECT ] AMBULATORY [24HOURS ]

11. Indication for ambulatory bp measurement office BP of 140/90 mm Hg or higher on at least three separate office visits, with two measurements made at each visit at least two out-of-office BP readings lower than 140/90 mm Hg no evidence of target-organ damage

12. TOOLS TO MEAUSRE SPIMGOMANOMETRE USING MERCURY COLUMN :OFFICE ,HOME,ICU Aneroid meter [ opd /house/ambulatory] Oscillometer method [ icu ]

13. S Cuff size and placement The cuff size should have a bladder width that is approximately 40 percent of the circumference of the upper arm, measured midway between the olecranon and the acromion The length of the cuff bladder should encircle 80 to 100 percent of the circumference of the upper arm midway between the olecranon and the acromion The bladder width-to-length should be at least 1:2

14. Where to tie bp cuff AVOID STIMULANT DRINKING QUIET ROOM 2CM ABOVE ANTECUBETAL FOSSA 3-5 minutes rest Right arm seating position Palpate ARM IS AT THE LEVEL OF HEART MERCURY MANOMETER AT THE LEVEL OF HEART Use the bell of the stethoscope

15. Allowing the arm to hang below the heart will elevate BP levels by the added hydrostatic pressure induced by gravity (as much as 10 to 12 mmHg in adults)

16. Walk one step at a time The cuff should be inflated to 20 to 30 mmHg above the anticipated systolic BP (SBP) deflated slowly at a rate of 2 to 3 mmHg per heartbeat The systolic BP is equal to the pressure at which the brachial pulse can first be heard by auscultation (Korotkoff phase I) muffling (Korotkoff phase IV) is diastolic bp for adult Phase V is recommended for DBP determination in children

17. Number of measurements    The BP should be taken at least twice on each visit the measurements separated by one to two minutes to allow the release of trapped blood If the second value is more than 5 mmHg different from the first, continued measurements should be made until a stable value is attained The recorded value on the patient's chart should be the average of the last two measurements 

18. Oscillometer devices    Automated oscillometric devices measure mean arterial BP based upon pressure oscillations of the brachial artery wall as the cuff is deflated SBP and DBP measurements are calculated based on the mean BP Easy to use decrease in observer bias higher compared with readings obtained by auscultation A high bp should be confirmed by sphygmomanometer

19. Must mention END ORGAN DAMGE MI STROKE RENAL FAILURE AORTIC DISSECTION HEART FAILURE Loss of vision

20. Isolated systolic htn Systolic >140 and diastolic <90 mmhg represent an exaggeration of this age-dependent stiffening process ISH is more common in women associated prominently with heart failure with preserved systolic function those with BP in the high-normal range (prehypertension) will more likely develop ISH after 55 years of age

21. Hypertensive emergency Severe hypertension (usually a diastolic blood pressure above 120 mmHg) evidence of acute end-organ damage is defined Hypertensive emergencies can be life-threatening require immediate treatment usually with parenteral medications in a monitored setting

22. Hypertensive urgency Severe hypertension (usually a diastolic blood pressure above 120 mmHg) in asymptomatic not experiencing acute end-organ damage Most cases of asymptomatic blood pressure elevations can be addressed in the office setting without referral to a higher level of care

23. Resistant hypertension blood pressure that is not controlled to goal despite adherence to an appropriate regimen of three antihypertensive drugs of different classes (including a diuretic) in which all drugs are prescribed at suitable antihypertensive doses Blood pressure that requires at least four medications to achieve control is considered controlled resistant hypertension.

24. Refractory hypertension Bp is not controlled even using up to 5 drugs ,one of which is diuretic

25. ACCLERATED HTN Accelerated hypertension  is defined as a recent significant increase over baseline BP that is associated with target organ damage. This is usually seen as vascular damage on funduscopic examination, such as flame-shaped hemorrhages or soft exudates, but without papilledema

26. MALIGNANT HTN defined as a recent significant increase over baseline BP that is associated with target organ damage. This is usually seen as vascular damage on funduscopic examination, such as flame-shaped hemorrhages or soft exudates, but with papilledema

27. Renovascular htn Due to renal artery stensosis

28. Pregnancy induced htn Beyond 20 week of pregnancy

29. Investigation

30. Features Suggestive of Pheochromocytoma Hypertension, Persistent or Paroxysmal Markedly variable blood pressures (± orthostatic hypotension) Sudden paroxysms (± subsequent hypertension) in relation to: Stress: anesthesia , angiography, parturition Pharmacologic provocation: histamine, nicotine, caffeine, beta blockers, glucocorticoids, tricyclic antidepressants Manipulation of tumors : abdominal palpation, urination Rare patients persistently normotensive Unusual settings Childhood, pregnancy, familial Multiple endocrine adenomas: medullary carcinoma of the thyroid (MEN-2), mucosal neuromas (MEN-2B) Von Hippel–Lindau syndrome

31. Neurocutaneous lesions: neurofibromatosis Associated Symptoms Sudden spells with headache, sweating, palpitations, nervousness, nausea, vomiting Pain in chest or abdomen Associated Signs Sweating, tachycardia, arrhythmia, pallor, weight loss

32. Which patient may have htn women >65 years Smoking Dyslipidemia (LDL-C >115 mg/ dL ) Impaired fasting glucose (102-125 mg/ dL ) or abnormal glucose tolerance test result Family history of premature cardiovascular disease Abdominal obesity Diabetes mellitus

33. From subclinical end organ damage Left ventricular hypertrophy Carotid wall thickening or plaque Low estimated glomerular filtration rate ≤60 mL/min/1.73 m 2 Microalbuminuria Ankle-brachial BP index <0.9

34. Established Target Organ Damage Cerebrovascular disease: ischemic stroke, cerebral hemorrhage , transient ischemic attack Heart disease: myocardial infarction, angina, coronary revascularization, heart failure Renal disease: diabetic nephropathy, renal impairment Peripheral arterial disease Advanced retinopathy: hemorrhages or exudates, papilledema

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