HTN – CHEP Guideline 2014

Technique for measuring BP

  1. Use calibrated sphygmomanometer or electronic device (quiet room, take at 1-2min intervals, ≥ 6, the first is taken by a health professional to verify cuff position & validity of the measurement, average latter 5)
  2. Appropriate bladder size: bladder width 40% of arm circumference & bladder length 80-100% of arm circumference
  3. Cuff 3cm above the elbow crease & bladder is centered over the brachial artery,
  4. support bare arm with the BP cuff at heart level.
  5. Resting comfortably for 5min in the seated position with back support. No talking, no crossed legs.
  6. ≥ 3 readings, discard the first and average the latter two, ≥ between readings
  7. If ? postural HoTN, BP after 2min  standing with arm supported

Auscultation

  1. 30mmHg above the level that the radial pulse is extinguished – exclude systolic auscultatory gap
  2. Bell or diaphram gently & steadily over the brachial artery
  3. Deflate ~ 2mmHg per heart beat – Korotkoff phases I and V, use IV (muffling) if V persists ~0 mmHg

Dx

  1. Hypertensive urgency: asymptomatic diastolic BP≥ 130 mmHg
  2. Hypertensive emergency: Severe elevations of BP with
    • Hypertensive encephalopathy, intracranial hemorrhage, acute ischemic stroke
    • Acute aortic dissection, acute coronary syndrome, acute LV failure
    • Acute kidney injury
    • Eclampsia
  3. ≥140/90 – schedule a HTN visit. 130-139/85-89 = high normal – annual f/u
  4. 1st HTN visit – Proper BP measuring technique. Hx and PE if indicated, and over 2 visits (visit 2 within a month):
    1. Search for end organ damage
      • Cerebrovascular dz
      • Stroke – TIA / ischemic stroke, intracranial hemorrhage, aneurysmal sub-arachnoid hemorrhage
      • Dementia – Vascular dementia, mixed vascular dementia and dementia of the Alzheimer’s type
      • hypertensive retinopathy
      • Left ventricular dysfunction / hypertrophy
      • Coronary artery dz: MI, angina pectoris, CHF
      • Renal dz: hypertensive nephropathy (GFR<60), albuminuria
      • Peripheral artery dz – intermittent claudication
    2. Search for associated CV risk factors
      • Non-modificable: age ≥ 55, male, family hx of premature cardiovascular dz (<55 men, <65 women)
      • Modificable: sedentary lifestyle, poor diet, smoking, stress, nonadherence
      • abdominal obesity, dysglycemia, dyslipidemia
    3. Assess and remove exogenous factors that can ↑ hypertension
      • Rx: NSAIDs, corticosteroids, OCP, sex hormones, sympathomimetic decongestants, calcineurin inhibitor (cyclosporin, tacrolimus), erythropoietin, antidepressants (MAOI, SNRI, SSRI), midodrine
      • Licorice root, cocaine (stimulants), salt, xs EtOH
  5. 2nd HTN visit:
    1. dx HTN if ≥180/110 or ≥140/90 with macrovascular target organ damage, DM, CKD3
    2. Pt  <180/110 w/o macrovascular target organ damage, DM, and/or CKD – 3 approaches to dx HTN:
      1.  Office manual BPs: ≥160 /100 averaged – first 3 visits, or ≥140 /90 averaged – 5 visits. 
      2.  Ambulatory BP monitoring (ABPM): awake ≥135 / 85 or mean 24 hour ≥130 / 80 
      3.  Home BP Measurement: average ≥135 / ≥ 85
        • If the average home BP < 135/85 mmHg, either repeat home monitoring to confirm the home BP is < 135/85 mmHg or perform 24-hour ABPM to confirm that the mean 24-hour ABPM is <130/80 mmHg and the mean awake ABPM is <135/85 mmHg before diagnosing white coat hypertension.

2013_CHEP_AlgorithmWeb_EN

  1. Investigations for secondary causes of hypertension should be initiated in patients with suggestive clinical and/or laboratory features (outlined below).
  2. If at the last diagnostic visit the patient is not diagnosed to be hypertensive, and has no evidence of macrovascular target organ damage, the patient’s BP should be assessed at yearly intervals.
  3. Hypertensive patients receiving lifestyle modification advice alone (nonpharmacological treatment) should be followed up at three to six month intervals.  Shorter intervals (every one or two months) are needed for patients with higher BPs.
  4. Patients on antihypertensive drug treatment should be seen monthly or every two months, depending on the level of BP, until readings on two consecutive visits are below their target (Grade D). Shorter intervals between visits will be needed for symptomatic patients and those with severe hypertension, intolerance to antihypertensive drugs or target organ damage (Grade D). Once the target BP has been reached, patients should be seen at three-to six-month intervals (Grade D).
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Posted in 47 HTN, 99 Priority Topics, Cardiac, FM 99 priority topics

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