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Hypertension

April 8, 2017

High blood pressure is the main risk factor for death in Canada. One in five Canadian adults have high blood pressure and nine out of 10 Canadians will develop high blood pressure during their lifetime.

High blood pressure increases the risk of heart attack, heart failure, stroke, kidney disease, eye disease, dementia and erectile dysfunction.

Systolic blood pressure (SBP) measures the pressure when your heart beats and pumps blood. It is the top number of the blood pressure reading. Diastolic blood pressure (DBP) is the pressure when your heart relaxes and fills with blood. It is the bottom number of the blood pressure reading.

A decrease of 10 in SBP or 5 in DBP decreases the risk of heart failure by 50%, stroke by 38%, heart attack by 15% and death by 10%.

High blood pressure can be diagnosed at home or in the clinic. AOBP (automated office blood pressure) is preferred but this is not always available. In most clinics, 3 measurements are taken. The first reading is discarded and the average of the other two readings is recorded. The diagnosis of hypertension can be made over 3 to 5 visits. [hypertension diagnostic algorithm]

When blood pressure (BP) is measured at home, 2 readings are done each morning and evening for 7 days (28 readings). We then review the data, discard the first day and average out the last 6 days.

Hypertension is diagnosed when the average clinic BP is  ≥140/90 mmHg or the average home BP is  ≥135/85 mmHg.

Targets

The target for most patients will be <140/90 mmHg. Diabetics should strive for <130/80mmHg. Certain high-risk patients may qualify for intensive management*.

It is best to discuss your target blood pressure with your doctor. Blood pressure targets are highly individualized and will differ depending on various factors. Adults aged 60 years and older tend to have several coexisting problems and more permissive targets are sometimes used. http://bit.ly/2jYp3WB

Risk reduction

Patients with hypertension should consider reducing their risk of cardiovascular disease even further by using a statin if they have ≥3 of the following risk factors:

• Male sex
• Age ≥55 years
• Diabetes
• Tobacco use
• Previous stroke or transient ischemic attack
• Peripheral arterial disease
• Albuminuria or chronic kidney disease
• Family history of premature cardiovascular disease
• Total cholesterol to high-density lipoprotein ratio ≥6
• Left ventricular hypertrophy
• Electrocardiogram abnormalities

In addition, hypertensive patients who are 50 years or older should consider low-dose aspirin.

It is common to be on several different blood pressure medications at the same time. The use of multiple medications is preferred over maximizing monotherapy because complementary drugs work together, allowing one to take lower doses with fewer side-effects. Medications are often added over time to achieve targets but two medications are sometimes introduced at the onset (e.g. if the systolic blood pressure is >20 mmHg or the diastolic blood pressure >10 mmHg above target). Triple therapy (3 medications) will usually include a diuretic.

Patients with high blood pressure should discuss increasing their dietary potassium (fresh fruit, vegetables, legumes) with a doctor or dietician. Caution is advised in those at risk of developing hyperkalaemia (eGFR <60mL/min/1.73 m2, on ACE inhibitor drugs or potassium-sparing medications, or baseline potassium level >4.5).

Changing an unhealthy deathstyle into a healthy lifestyle

  • Quit smoking
  • Strive for maintaining a healthy weight (BMI 18.5 to 24.9kg/m2)
  • Ask about the DASH diet and limit sodium intake
  • Lead an active lifestyle (150 minutes per week of moderate-intensity exercise)
  • Alcohol consumption must be in moderation
  • Focus on stress reduction

Intensive blood pressure management must be discussed with your doctor.


Doctor’s secrets …

Screen every 2 years (≥ 18 years) or annually if pre-hypertensive (120-139/80-89)

Hypertensive Urgencies and Emergencies:

Hypertensive urgency: BP ≥180/120 without target organ damage

Hypertensive emergency: BP ≥180/120 with target organ damage:

  • Hypertensive encephalopathy
  • Acute aortic dissection
  • Acute left ventricular failure
  • Acute coronary syndrome
  • Acute kidney injury
  • Intracranial hemorrhage
  • Acute ischemic stroke
  • Eclampsia of pregnancy

Diagnostic tests:

  • Urinalysis
  • Blood chemistry
  • Fasting blood glucose
  • Fasting cholesterol panel
  • Standard 12-lead ECG
  • Urinary albumin in diabetics

Examples of Target Organ Damage:

  • Cerebrovascular disease
  • Stroke
  • Dementia
  • Hypertensive retinopathy
  • Left ventricular dysfunction
  • Coronary artery disease
  • Renal disease
  • Peripheral artery disease
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