Hypertension Management (2012 CHEP Guideline)

Rational

Prevention of HTN helps to protect patients from adverse cardiovascular events such as strokes and MIs.

Epidemiology

HTN is extremely prevalent in Canada and justifies screening all individuals.

Screening

BP check on any office visit

High-normal BP (130-139/80-89) should be checked at least annually

If hypertensive emergency, can diagnose HTN on a single visit

If BP >180/110, diabetes, or any end-organ damage evident, can diagnose HTN with two separate measures on two visits to the office

If BP is 140-179/90-109, consider pt taking home BP measurements or an ABPM

If BP >140/>90 on visit 4, Dx of HTN can be made

If home BP is >135/>85 on two separate measures, Dx of HTN can be made

If ABPM has >135/>85 while awake or >130/>80 over 24 hrs, including a sleep cycle, HTN can be Dx

Diagnostic Criteria

BP >160/>100 and no cardivascular risk factors and/or evidence of end-organ damage

BP >140/>90 with cardivascular risk factors and/or evidence of end-organ damage

BP >130/>80 and diabetes

Classification

Resistant HTN: two-drug combinations of beta-blockers, ACE-I, and ARBs have been shown to have little additive antihypertensive benefit.

Risk Factors

Cardiovascular risk factors are important to consider: Male, >55 years old, smoker, type 2 diabetes, hyperlipidemia, FHx, previous stroke or TIA, LVH, EKG abnormalities, proteinuria, PVD.

Investigations

Urinalysis, Lytes, Cr, FBS, Lipids, EKG

Management

Goal of BP <140/<90 in any treated individual.  <130/<80 if a diagnosis of diabetes.  In individuals >80 years old, the target systolic BP is <150 to prevent adverse events related to treatment.

Cr and K+ should be monitored if a patient is on a combination of potassium-sparing diuretics, ACE-I, ARB, and/or direct renin inhibitors.

A diuretic should be used in a triple BP med combination if there are no contraindications.

Consider referral if BP not under control with three BP meds from separate classes.

Treatment

Non-pharmacological: DASH diet, wt loss (BMI <25 and waist circumference <102 for men and <88 for women), smoking cessation, relaxation therapies, reduced salt intake (<2300 mg/day), reduced EtOH (<=2 drinks/day).

Use Framingham risk calculator to risk-stratify.

If systolic dysfunction (defined as EF <40%), first-line BP medications are ACE inhibitors and beta-blockers.

Mineralocorticoid receptor antagonists (e.g spironolactone, eplerenone) are recommended as an add-on therapy with mortality benefit in patients with recent hospital admission for cardiovascular issues, AMI, elevated BNP, or NYHA class II-IV HF.  Patients must be monitored for hyperkalemia.

For essential, uncomplicated HTN, first-line medications include: Thiazide diuretics, ACE-I, ARB, long-acting CCB, beta-blockers (only if patient <60 years old).  If control is not achieved, add a second agent, and if still not, add a third or fourth.  An ACE-I and CCB is a preferable combination to an ACE-I and a thiazide diuretic.  Usually the combo of ACE-I and ARB is avoided unless special circumstance.

A combination of two first-line medications can be started on an individual who has a BP of >19 systolic or >9 diastolic above target.

Prognosis

Most individuals who require BP medications take them for life.

References

http://www.hypertension.ca/chep-2011-recommendations-summaries