Page 333 - TNFlipTest

Toronto Notes 2019
Common Presenting Problems
Family Medicine FM35
Elevated BP Reading(s) - Office, Home, or Pharmacy
Hypertension Visit 1
History, physical examination and diagnostic tests
AOBP ≥135/85 OBPM ≥140/90
Yes
Out of Office Assessment
- ABPM (preferred)
- HBPM diagnostic series
Hypertension Visit 2 (within 1 month)
Daytime ABPM or HBPM ≥135/85 24 h ABPM ≥130/80
Yes
Hypertension
BP ≥180/110
Hypertension
No Hypertension
(Annual BP measurement recommended)
No
No
Alternate Method
(If ABPM or HBPM is not available)
White Coat Hypertension
If the average HBPM <135/85, it is advisable to perform ABPM or repeat HBPM to confirm
No Hypertension
(Annual BP measurement recommended)
OBPM: Hypertension Visit 2 ≥140 sBP or ≥90 dBP
Hypertension Visit 3
≥160 sBP or
≥100 dBP Hypertension
<160/100
Hypertension Visit 4-5
≥140 sBP or ≥90 dBP
<140/90
Hypertension
No Hypertension
(Annual BP measurement recommended)
Figure 12. Assessment of patients with hypertension
Adapted from: CHEP 2017 Guidelines. https://hypertension.ca/images/CHEP_2017/HTN_Whats_New_2017_EN.pdf
Treatment
Impact of Health Behaviour on Blood Pressure
• treattotargetBP:<140/90mmHg,<130/80mmHgifDM,sBP<150inveryelderly(>80yrs)
• optimummanagementofhypertensionrequiresassessmentofoverallcardiacrisk
• adherencetolifestylemodificationandpharmacotherapyshouldbeassessedateachvisit
• singlepillcombinationsshouldbeusedasfirstlinetreatment(regardlessoftheextentofBPelevation) • lifestylemodification(inallHTNpatients-maybesufficienttxinpatientswithstage1HTN(140-
159/90-99)) ■ diet
◆ follow Canada’s Guide to Healthy Eating (see Nutrition, FM6) and Dietary Approaches to Stop Hypertension (DASH)
◆ limit daily sodium intake to 5 g or 87 mmol per day
◆ potassium/ magnesium/calcium supplementations are NOT recommended for HTN but an
increase dietary potassium may help
■ moderate intensity dynamic exercise: 30-60 min, 4-7 x/wk; higher intensity exercise is not more
effective
■ smoking cessation
■ low-risk alcohol consumption (see Alcohol, FM12)
■ work towards a healthy BMI (18.5-24.9 kg/m2) and waist circumference (<102 cm for men, <88 cm
for women)
■ individualized cognitive behavioural interventions for stress management
• pharmacological
■ indications for therapy (caution with elderly patients):
◆ dBP ≥90 mmHg with target organ damage or independent cardiovascular risk factors
◆ dBP ≥100 mmHg or sBP ≥160 mmHg without target organ damage or cardiovascular risk factors ◆ sBP ≥140 with target organ damage
◆ sBP >130 for high risk populations (Framingham Risk >20%, age >50)
Intervention
Diet and weight control Reduced salt/ sodium intake Reduced alcohol intake (heavy drinkers)
DASH diet Physical activity Relaxation therapies
Systolic BP (mmHg)
-6.0 -5.4 -3.4
-11.4 -3.1 -3.7
Diastolic BP (mmHg)
-4.8 -2.8 -3.4
-5.5 -1.8 -3.5
■ first line antihypertensives (consider a single pill combination therapy) – see Figure 13 ■ combination therapy principles:
◆ if there is an inadequate response to therapy, consider adding another first line antihypertensive ◆ avoid combining a non-DHP CCB with a β-blocker or an ACEi with an ARB
◆ monitor potassium and creatinine when administering an ACEi/ARB with a potassium sparing
diuretic
CHEP (Canadian Hypertension Education Program) Guidelines 2014. Available from: http://www. hypertension.ca/en/chep
β-blocker
Not recommended as first line for patients of age ≥60
ACEI
Not recommended as monotherapy in people of African descent