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HYPERTENSION GUIDELINE
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
WORKING GROUP
CHAIRPERSON Dr. Robaayah Zambahari
Dr. Abdul Rashid A. Rahman Senior Consultant Cardiologist,
Professor of Medicine & Clinical Pharmacology National Heart Institute,
and Senior Consultant Physician, Kuala Lumpur
Cyberjaya University College of Medical
Sciences and An Nur Specialist Hospital, Dr. Zaleha Abdullah Mahdy
Selangor Professor and Senior Consultant Obstetrician
& Gynaecologist,
SECRETARY Hospital Universiti Kebangsaan Malaysia,
Dr. Sunita Bavanandan Kuala Lumpur
Consultant Nephrologist,
Kuala Lumpur Hospital, Dr. Hj. Azhari Rosman
Kuala Lumpur Consultant Cardiologist & Electrophysiologist,
National Heart Institute,
HYPERTENSION GUIDELINE WORKING GROUP
CONTRIBUTORS
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TABLE OF CONTENTS
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
Introduction v
Resistant Hypertension
OBJECTIVE
This Training Module is developed to assist the ‘trainers’ to:
1. Deliver the key content and messages of the CPG systematically.
2. Demonstrate the applicability of CPG recommendations in clinical practice via interactive case
discussions.
3. Offer implementation strategies for effective hypertension management based on key elements
of the Wagner Chronic Care Model.
Target Audience:
All levels of health care providers involved with the care of hypertensive patients in both primary
care and secondary care settings.
INTRODUCTION
Clinical Questions
In tandem with the main CPG, the clinical questions to be addressed in this training module include:
1. What are the current best practices in the management of a patient with hypertension?
2. How can hypertension management be done in tandem with the overall strategy to manage
global vascular risk of a patient?
3. How can we improve the outcome of care for hypertensive patients?
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TRAINING MODULE FOR HEALTH CARE PROVIDERS
chronic conditions in primary care (Adapted from the Wagner Chronic Care
Model and WHO Innovative Care for Chronic Conditions Framework):
Clinical information • Develop national# and local chronic disease MACRO LEVEL#
systems registries.* • Policy makers
• Use electronic medical record and
appointment system.* MESO LEVEL*
• Use electronic prescribing, reminder and • Primary Health Care
alerts on potential drug interaction and test Team
results.*
• Create paper-based registries and MICRO LEVEL*
comprehensive medical records in resource- • Individual doctors and
limited setting.* allied health care
providers
Patient self- • Empower patients and their families with MESO LEVEL*
management knowledge, skills and confidence to take • Primary Health Care
support effective control over their chronic Team
• Provide self-management tools, and
routinely assess problems and MICRO LEVEL*
accomplishments.* • Individual doctors and
• Establish ongoing collaborative effort allied health care
between care team and patients for providers
long term benefit.* • Patients and families
Key Elements Implementation Strategies Level of actions
INTRODUCTION
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
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TRAINING MODULE FOR HEALTH CARE PROVIDERS
Teaching
Duration
No Topic Objective Content Learning
(minutes)
Method
patients in self-managing
hypertension
• Key messages
INTRODUCTION
and Stroke rapid reduction of BP in • Management based on CPG case (45 minutes
patients with acute stroke recommendation discussion interactive
• To highlight the appropriate • Summary of evidence for the discussion +
choice of pharmacological recommendation 15 minutes
treatment according to • Key messages Q&A)
current evidence
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TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
Teaching
Duration
Topic Objective Content Learning
(minutes)
Method
Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
PRESENTATION OUTLINE
• Epidemiology of Hypertension
• Definition
• Measurement of Blood Pressure
• Diagnosis & Classification
• Evaluation & Assessment
• Management Algorithm
• Cardiovascular Risks Stratification
• Therapeutic Lifestyle Modification
• Pharmacological Agents
• The Wagner Chronic Care Model
• Key messages
Slide 2
INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA
An Estimated 972 million individuals worldwide suffer from hypertension in the year 2000.
Kearney et al.
Global burden of hypertension: analysis of worldwide data. Lancet 2005; 365 (9455):217-23
Slide 3
THE RISING EPIDEMIC OF HYPERTENSION
Slide 4
NHMS III : AWARENESS RATE
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MANAGEMENT OF HYPERTENSION (3rd Edition)
INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA
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TRAINING MODULE FOR HEALTH CARE PROVIDERS
Slide 6
Slide 5
NHMS III : TREATMENT RATES
Slide 8
INITIAL ASSESSMENT
Slide 9
DIAGNOSIS & CLASSIFICATION
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Slide 10
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
EVALUATION
3. To assess lifestyle and identity other cardiovascular risk factors and/or concomitant
disorders that may affect treatment and prognosis.
INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA
Slide 11
MEDICAL HISTORY
Slide 13
Note : Should be repeated 6-12 monthly thereafter (except for Chest X-Ray)
• Hypertension
• Cigarette smoking
• Central obesity (waist circumference > 90 cm for men, > 80 cm for women)
• Physical inactivity
• Dyslipidaemia
• Diabetes mellitus
• Microalbuminuria
• Estimated GFR < 60 mL/min
• Age (> 55 years for men, > 65 years for women)
• Family history of premature cardiovascular disease (men < 55 years or women < 65 years)
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Slide 15
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
SECONDARY CAUSES
• Sleep apnoea
• Drug-induced or drug-related
• Chronic kidney disease
• Primary aldosteronism
• Renovascular disease
• Chronic steroid therapy and Cushing syndrome
• Phaeochromocytoma
• Acromegaly
• Thyroid or parathyroid disease
• Coarctation of the aorta
• Takayasu Arteritis
Slide 16
INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA
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MANAGEMENT OF HYPERTENSION (3rd Edition)
INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA
TRAINING MODULE FOR HEALTH CARE PROVIDERS
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Slide 18
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
Co-existing Previous MI or
No RF TOD or TOD or RF
Condition Previous Stroke
No TOD RF (1-2), (≥ 3) or Clinical
BP Levels or Diabetes
No TOC No TOC atherosclerosis
(mmHg) Mellitus (DM)
SBP 120-139
and/or Low Medium High Very High
DBP 80-89
SBP 140-159
and/or Low Medium High Very High
DBP 90-99
SBP 160-179
and/or Medium High Very High Very High
DBP 100-109
INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA
SBP 180-209
and/or High High Very High Very High
DBP 100-119
SBP ≥ 210
and/or Very High Very High Very High Very High
DBP ≥ 120
Target blood
Category
pressure (mmHg)
Uncomplicated hypertension < 140/90
Hypertension in high risk groups: DM, History of CVD < 130/80
Diabetics with proteinuria of > 1g/24 hours < 125/75
Once target BP is achieved, follow-up at 3-6 month interval is appropriate.
Slide 20
THERAPEUTIC LIFESTYLE MODIFICATION
Weight As far as possible aim for an ideal Body Mass Index [Weight
reduction (kg)/Height2 (m)] – for Asians, the normal range has been proposed
to be 18.5 to 23.5 kg/m2. However a weight loss as little as 4.5 kg
significantly reduces BP
Smoking
cessation Cessation of smoking is important in the overall management of
the patients with hypertension in reducing cardiovascular risk
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Slide 21
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
ANTIHYPERTENSIVE AGENTS
Minimum Maximum
Formulation dose dose Remarks
Diuretics
ß-blockers
Miscellaneous
Prazosin (α-blocker) 0.5 mg BD 10 mg BD • Doxazosin is useful in patient
Doxazosin 1 mg OD 16 mg OD with benign prostatic hypertrophy
Labetalol 100 mg BD 800 mg TDS • In elderly, start Labetolol with
Carvedilol 12.5 mg OD 50 mg OD 50mg BD
Methyldopa 125 mg BD 1 gm BD
Slide 22
PHARMACOLOGICAL MANAGEMENT OF STAGE 1 HYPERTENSION
β-blockers are no longer recommended for first line monotherapy in this group of
patients.
However, it may be considered in younger people, particularly those who are intolerant or
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Slide 24
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
ACEls + diuretics Appropriate for concurrent heart failure, diabetes mellitus and
INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA
stroke
ARBs + diuretics Appropriate for concurrent heart failure and diabetes mellitus
Slide 25
CHOICE OF HYPERTENSIVE AGENTS IN PATIENTS WITH CONCOMITANT
CONDITIONS
Peripheral
Concomitant disease Diuretics ß-blockers ACEIs CCBs α-blockers ARBs
If BP is still > 140/90 mmHg with combination of 3 drugs (including a diuretic at near
maximal doses) - check on the possible causes of resistant HPT:
• Non-compliance
• Secondary hypertension
• White coat hypertension
• Excessive salt or liquorice intake
• Drug interaction
• Complications of long standing hypertension e.g nephrosclerosis, loss of aortic
distensibility and atherosclerotic renal artery stenosis
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TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
Slide 29
6 ELEMENT OF CHRONIC CARE MODEL
1. Health care Create policies with a clear focus to improve chronic disease care.
organization Goals, values & incentives to care providers must be aligned
& policies with payers & MOH
2. Community Patients & care providers need linkages with community
resources resources such as home care, exercise program and support
groups
3. Self Empower patients with knowledge and skills to enhance
management confidence to self-care. Build quality relationship through
support effective communication
4. Delivery system Multi-disciplinary practice team with clear division of labour;
redesign planned management and visits
5. Decision support Translate evidence based clinical practice guideline
recommendations into daily clinical practice and improve access
to specialist expertise
6. Clinical Computerized system to remind & prompt actions; support
information shared care among multiple professionals, provide feedback to
system health care personel and track progress
Slide 30
Multi Disciplinary
Roles and Responsibilities
Team Members
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Slide 32
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
Multi Disciplinary
Roles and Responsibilities
Team Members
Slide 33
Multi Disciplinary
Roles and Responsibilities
Team Members
Slide 35
KEY PRACTICE POINTS
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MANAGEMENT OF HYPERTENSION (3rd Edition)
INTRODUCTION & OVERVIEW OF HPT BURDEN IN MALAYSIA
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Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
VISIT 1
Case 1
• Present to the clinic with acute URTI symptoms
• BP 138/88 mmHg
• Smoking 20 cig x 20 years
• Beer 1-2/day
• Sedentary lifestyle
• Father hypertensive, hyperlipidaemic, AMI and CABG (age 68).
• Wt 91kg, Ht 170cm, BMI 31.5, WC 97cm
INTERACTIVE CASE DISCUSSION 1
DIAGNOSIS AND MANAGEMENT OF PRE-HYPERTENSION
Slide 2
DISCUSSION POINT
Slide 3
HPT is a silent disease; 64% of cases remain undiagnosed. Therefore, BP should be
measured at every chance encounter.
• Explain to him that his BP is slightly high (best is < 120/80 mmHg). Explain the
significance of the reading and the importance of confirming the diagnosis
• Assess cardiovascular risk factors:
- Smoking
- Obesity
- Sedentary lifestyle
- FH of hypertension and CVD
• Order further tests:
- UFEME
- Fasting lipids
- Renal profile
- ECG
• Arrange follow-up visit in 3 month
Slide 5
Slide 6
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
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Slide 7
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
DEFINITION OF PREHYPERTENSION
Slide 8
DISCUSSION POINT 2
Slide 9
ALGORITHM FOR THE MANAGEMENT OF HYPERTENSION
Slide 10
CARDIOVASCULAR RISK STRATIFICATION
Co-existing Previous MI or
No RF TOD or TOD or RF
Condition Previous Stroke
No TOD RF (1-2), (≥ 3) or Clinical
BP Levels or Diabetes
No TOC No TOC atherosclerosis
(mmHg) Mellitus (DM)
SBP 120-139
and/or Low Medium High Very High
DBP 80-89
SBP 140-159
and/or Low Medium High Very High
DBP 90-99
SBP 160-179
and/or Medium High Very High Very High
DBP 100-109
SBP 180-209
and/or High High Very High Very High
DBP 100-119
Slide 12
VISIT 2: SUMMARY OF MANAGEMENT PLAN FOR MR. A
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Slide 13
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
DISCUSSION POINT 3
Slide 14
THERAPEUTIC LIFESTYLE MODIFICATION
Weight Aim for an ideal BMI (<23 kg/m2) or ideal wt (<66.5 kg). However a
reduction weight loss as little as 4.5 kg significantly reduces BP
INTERACTIVE CASE DISCUSSION 1
DIAGNOSIS AND MANAGEMENT OF PRE-HYPERTENSION
Slide 15
MOTIVATIONAL INTERVIEWING
Rollnick S, Miller WR, Butler CC. Motivational interviewing in health care: Helping patients change behaviour.
New York: Guilford Press, 2008
Slide 16
MOTIVATIONAL INTERVIEWING USING CHANGE STRUCTURED CONSULTATION
Slide 17
http:/www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf.
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TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
Slide 19
http:/www.moh.gov.my/v/diet
Slide 20
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TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
VISIT 1
Slide 2
DISCUSSION POINT 1
Slide 3
HPT is a silent disease; 64% of cases remain undiagnosed. Therefore, BP should be
measured at every chance encounter.
Slide 5
VISIT 2: BP REVIEW
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Slide 8
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
EVALUATION
Slide 9
INTERACTIVE CASE DISCUSSION 2
DIAGNOSIS AND MANAGEMENT OF STAGE 1 HYPERTENSION
Slide 10
VISIT 2: PHYSICAL EXAMINATION FINDINGS
• BMI 26 kg/m2
• Waist circumference (WC) 88 cm
• Fundoscopy normal
• Cardiovascular examinations – normal
• Chest examinations – normal
• Abdominal examinations – normal
• Neurological examinations – normal
Slide 11
BASELINE INVESTIGATIONS
Note : Should be repeated 6-12 monthly thereafter (except for Chest X-Ray)
Slide 12
Slide 13
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
DISCUSSION POINT 3
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INTERACTIVE CASE DISCUSSION 2 MANAGEMENT OF HYPERTENSION (3rd Edition)
DIAGNOSIS AND MANAGEMENT OF STAGE 1 HYPERTENSION
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TRAINING MODULE FOR HEALTH CARE PROVIDERS
Slide 14
ALGORITHM FOR THE MANAGEMENT OF HYPERTENSION
Slide 15
CARDIOVASCULAR RISK STRATIFICATION
Co-existing Previous MI or
No RF TOD or TOD or RF
Condition Previous Stroke
No TOD RF (1-2), (≥ 3) or Clinical
BP Levels or Diabetes
No TOC No TOC atherosclerosis
(mmHg) Mellitus (DM)
SBP 120-139
and/or Low Medium High Very High
DBP 80-89
SBP 140-159
and/or Low Medium High Very High
DBP 90-99
SBP 160-179
and/or Medium High Very High Very High
DBP 100-109
SBP 180-209
and/or High High Very High Very High
SBP ≥ 210
and/or Very High Very High Very High Very High
DBP ≥ 120
Slide 16
DISCUSSION POINT 4
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Slide 17
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
Therapeutic lifestyle modification is the first line treatment in all patients with Hypertension
Weight Aim for an ideal BMI (<23 kg/m2) or ideal wt (<66.5 kg). However a
reduction weight loss as little as 4.5 kg significantly reduces BP
Slide 18
PHARMACOLOGICAL MANAGEMENT OF STAGE 1 HYPERTENSION
Slide 19
CHOICE OF FIRST LINE MONOTHERAPY
Slide 20
BLOOD PRESSURE TREATMENT TARGETS
Slide 21
VISIT 2: SUMMARY OF MANAGEMENT PLAN FOR MR. MN
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Slide 22
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
VISIT 3: FOLLOW UP
Slide 23
INTERACTIVE CASE DISCUSSION 2
DIAGNOSIS AND MANAGEMENT OF STAGE 1 HYPERTENSION
DISCUSSION POINT 5
Slide 24
PHARMACOLOGICAL MANAGEMENT OF STAGE 1 HYPERTENSION
Slide 25
VISIT 3: SUMMARY OF MANAGEMENT PLAN FOR MR. MN
• Educate regarding the state of his BP control - treatment target < 140/90 mmHg is still
not achieved
• Re-emphasize therapeutic lifestyle modification:
- Smoking cessation, healthy eating, exercise
• Increase the dose of ACE Inhibitor
• Recheck Renal Profile within 2 weeks
• Review after 1 month
- If well-controlled – continue treatment, review 3-6 monthly
- If uncontrolled – see algorithm for management of Stage 1 HPT
• Continue long-term follow up
• Assess CV risks annually
Slide 26
• Monotherapy can lower BP to < 140/90 mmHg in 40%- 60% of patients with mild to
moderate HPT
β-blockers – no longer recommended for 1 line monotherapy in newly diagnosed
Slide 27
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
KEY LEARNING POINTS
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INTERACTIVE CASE DISCUSSION 2 MANAGEMENT OF HYPERTENSION (3rd Edition)
DIAGNOSIS AND MANAGEMENT OF STAGE 1 HYPERTENSION
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TRAINING MODULE FOR HEALTH CARE PROVIDERS
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Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
VISIT 1
Slide 2
INTERACTIVE CASE DISCUSSION 3
DIAGNOSIS AND MANAGEMENT OF STAGE 2 HYPERTENSION & RESISTANT HYPERTENSION
DISCUSSION POINT 1
Slide 3
DIAGNOSIS
• Exercised 3x/week
• Not known to have any medical problem
• No family history of premature CVD
• BMI= 22.8 kg/m2
Slide 6
DISCUSSION POINT 2
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Slide 7
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
Co-existing Previous MI or
No RF TOD or TOD or RF
Condition Previous Stroke
No TOD RF (1-2), (≥ 3) or Clinical
BP Levels or Diabetes
No TOC No TOC atherosclerosis
(mmHg) Mellitus (DM)
SBP 120-139
and/or Low Medium High Very High
DBP 80-89
SBP 140-159
and/or Low Medium High Very High
DBP 90-99
SBP 160-179
and/or Medium High Very High Very High
DBP 100-109
INTERACTIVE CASE DISCUSSION 3
DIAGNOSIS AND MANAGEMENT OF STAGE 2 HYPERTENSION & RESISTANT HYPERTENSION
SBP 180-209
and/or High High Very High Very High
DBP 100-119
SBP ≥ 210
and/or Very High Very High Very High Very High
DBP ≥ 120
Slide 8
10 YEAR CV RISK ESTIMATION
Medium 10-20%
High 20-30%
DISCUSSION POINT 3
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Slide 11
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
CHOICE OF PHARMACOTHERAPY
Effective Combination
β-blockers + diuretics
β-blockers + CCBs
CCBs + ACEIs/ARBs
ACEIs + diuretics
ARBs + diuretics
INTERACTIVE CASE DISCUSSION 3
DIAGNOSIS AND MANAGEMENT OF STAGE 2 HYPERTENSION & RESISTANT HYPERTENSION
Slide 12
CHOICE OF ANTIHYPERTENSIVE AGENTS IN PATIENTS WITH
CONCOMITANT CONDITIONS
β-blockers Peripheral
Concomitant disease Diuretics ACEIs CCBs α-blockers ARBs
Target blood
Category
pressure (mmHg)
Uncomplicated HPT < 140/90
Hypertension in high risk groups < 130/80
Diabetics with proteinuria of (> 1 g/24 hours) < 125/75
Once target BP is achieved, follow-up at 3-6 month interval is appropriate.
• Explain to him that he has Stage 2 HPT and he has medium CV risk
• Deliver therapeutic lifestyle modification advice
• Educate regarding potential complications, the need to start medication and his
treatment target
• Initiate therapy with 2 drugs e.g. CCB + ACEi
• Review monthly until target BP is achieved
Slide 15
VISIT 2
Slide 16
DISCUSSION POINT 4
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Slide 17
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
RESISTANT HYPERTENSION
• Possible causes:
- Non-compliance
Pseudoresistance
- White coat HPT
- Poor diet control*
- Complications of long standing HPT
- Secondary HPT
Slide 18
INTERACTIVE CASE DISCUSSION 3
DIAGNOSIS AND MANAGEMENT OF STAGE 2 HYPERTENSION & RESISTANT HYPERTENSION
• Exclude pseudoresistant:
- Is patient adherent with prescribed regimen?
- Obtain home/ ambulatory BP to exclude white coat effect
• Identify contributing lifestyle factors & drug interaction:
- Obesity, physical inactivity, excessive alcohol/ salt intake, low-fiber diet, NSAIDs &
stimulants etc
• Look for secondary causes of HPT
• Exclude complications of long-standing HPT
Slide 19
VISIT 2: FURTHER INFORMATION
Slide 21
Slide 23
RESISTANT HPT : WHEN TO REFER?
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Slide 24
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
• Stage 2 HPT is defined as SBP 160-179 and/or DBP 100-109 mmHg, based on ≥ 2 BP
readings at ≥ 2 clinic visits
• Therapeutics lifestyle changes should be recommended for all individuals with HPT and
pre-HPT
• Combination of at least 2 drugs is recommended once diagnosis is confirmed
• Once BP is controlled, most patients will require lifelong treatment
• If BP is still > 140/90 mmHg with 3 drugs (including diuretics at optimal doses), patients
by definition have resistant HPT
INTERACTIVE CASE DISCUSSION 3
DIAGNOSIS AND MANAGEMENT OF STAGE 2 HYPERTENSION & RESISTANT HYPERTENSION
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Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
VISIT 1
• Came to the clinic c/o mild, intermittent throbbing
headaches
• No alarm symptom Case 4
• Diagnosed to have HPT 10 years ago
• Defaulted on her follow up since the last 5 years
as she felt well
• BMI 25 kg/m2, Waist Circumference (WC) 80cm
• BP 194/110 mmHg
INTERACTIVE CASE DISCUSSION 4
DIAGNOSIS AND MANAGEMENT OF STAGE 3 HYPERTENSION
Slide 2
DISCUSSION POINT 1
Slide 3
VISIT 1: FURTHER HISTORY
Slide 5
FUNDOSCOPY
Slide 6
VISIT 1: FURTHER EXAMINATION FINDINGS
Slide 7
URGENT INVESTIGATIONS
• Electrocardiogram (ECG)
• Urinalysis (UFEME)
• Random blood glucose
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Slide 8
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
• Urinalysis – proteinuria 2+
Slide 9
ECG RESULTS
Slide 10
DISCUSSION POINT 2
Slide 12
MANIFESTATIONS OF TOD/TARGET ORGAN COMPLICATION (TOC)
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Slide 13
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
Co-existing Previous MI or
No RF TOD or TOD or RF
Condition Previous Stroke
No TOD RF (1-2), (≥ 3) or Clinical
BP Levels or Diabetes
No TOC No TOC atherosclerosis
(mmHg) Mellitus (DM)
SBP 120-139
and/or Low Medium High Very High
DBP 80-89
SBP 140-159
and/or Low Medium High Very High
DBP 90-99
SBP 160-179
and/or Medium High Very High Very High
DBP 100-109
INTERACTIVE CASE DISCUSSION 4
DIAGNOSIS AND MANAGEMENT OF STAGE 3 HYPERTENSION
SBP 180-209
and/or High High Very High Very High
DBP 100-119
SBP ≥ 210
and/or Very High Very High Very High Very High
DBP ≥ 120
Slide 14
TREATMENT OPTIONS FOR HYPERTENSIVE URGENSIES (ORAL)
Slide 15
Rapid reduction of BP (within minutes to hours) in asymptomatic severe HPT or hypertensive
urgencies is best avoided as it may precipitate ischaemic events.
Slide 16
VISIT 1: SUMMARY OF MANAGEMENT PLAN FOR MRS. ZBL
• Explain to her that she has Stage 3 HPT (Hypertensive Urgencies) with very high CV
risk
• Explain the significance of the diagnosis and the importance to stabilize her blood
pressure
• Give nifedipine 10mg tablet orally as a stat dose (BP measured again after 30
minutes bed rest : 186/100 mmHg)
• Explain to her that she needs to be admitted to the nearest hospital as her BP
remains high
Slide 17
VISIT 2: BP REVIEW
Slide 18
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
DISCUSSION POINT 3
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Slide 19
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
Therapeutic lifestyle modification is the first line treatment in all patients with Hypertension
Weight Aim for an ideal BMI (<23 kg/m2) or ideal wt (<66.5 kg). However a
reduction weight loss as little as 4.5 kg significantly reduces BP
Slide 20
BLOOD PRESSURE TREATMENT TARGETS
Target blood
Category
pressure (mmHg)
Uncomplicated HPT < 140/90
Hypertension in high risk groups < 130/80
Diabetics with proteinuria of (> 1 g/24 hours) < 125/75
Once target BP is achieved, follow-up at 3-6 month interval is appropriate.
Slide 21
SUMMARY OF MDM. ZBL’S PROBLEMS:
Slide 22
VISIT 2: SUMMARY OF MANAGEMENT PLAN FOR MDM. ZBL
• Educate regarding the state of her BP control - treatment target < 130/80 mmHg
Slide 23
DISCUSSION POINT 4
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Slide 24
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
Cause Example
Renal parenchymal disease • Chronic pyelonephritis • Primary glomerulonephritis
• Tubulointerstitial nephritis
Coarctation of Aorta -
Pre-eclampsia/eclampsia -
Slide 25
WAYS TO ACHIEVE TREATMENT CONCORDANCE
Slide 26
KEY LEARNING POINTS
• Stage 3 HPT is defined as SBP > 180 and/or DBP 110 mmHg, based on > 2 BP readings
at > 2 clinic visits
• Rapid reduction of BP (within minutes to hours) in asymptomatic severe hypertension or
hypertensive urgencies is best avoided as it may precipitate ischaemic events
• Emphasis on the therapeutic lifestyle intervention must be done at every clinic visit
• Combination therapy is recommended in patients presenting with stage 2 hypertension or
beyond
• If BP is still > 140/90 mmHg with 3 drugs (including diuretics at maximum doses),
patients by definition have resistant HPT
63
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Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
VISIT 1
Slide 2
INTERACTIVE CASE DISCUSSION 5
HYPERTENSION AND DIABETES
Slide 3
VISIT 1: INVESTIGATION RESULTS FROM THE GP
• HbA1c 11.5%
• FBS 10.8 mmol/L
• LDL-C 3.6 mmol/L
• TG 1.75 mmol/L
• Urine albumin 2+, repeat in the clinic 1+
• Renal function normal
• Liver function normal
• ECG stat in the clinic normal
Slide 4
DISCUSSION POINT 1
Slide 6
HOW COMMON IS HYPERTENSION IN PATIENTS WITH DIABETES MELLITUS?
Hypertension should be detected and treated early in the course of diabetes mellitus to
• prevent cardiovascular disease and
• delay the progression of renal disease and
Slide 8
VISIT 1: FURTHER HISTORY
• Eat at the factory cafeteria 4 times per day (breakfast, morning snack, lunch &
afternoon snack) with teh tarik 3 times per day
• Unable to drive company lorry due to vision problem (loss of income)
• No time to do exercise
• Compliant to his medication
• No home sugar or BP monitoring
• Wife has recently been diagnosed to have breast cancer
• Mother had hypertension & diabetes, died of stroke (aged 60)
65
66
Slide 9
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
DISCUSSION POINT 2
Slide 10
CARDIOVASCULAR RISK STRATIFICATION
Co-existing Previous MI or
No RF TOD or TOD or RF
Condition Previous Stroke
No TOD RF (1-2), (≥ 3) or Clinical
BP Levels or Diabetes
No TOC No TOC atherosclerosis
(mmHg) Mellitus (DM)
INTERACTIVE CASE DISCUSSION 5
HYPERTENSION AND DIABETES
SBP 120-139
and/or Low Medium High Very High
DBP 80-89
SBP 140-159
and/or Low Medium High Very High
DBP 90-99
SBP 160-179
and/or Medium High Very High Very High
DBP 100-109
SBP 180-209
and/or High High Very High Very High
DBP 100-119
SBP ≥ 210
and/or Very High Very High Very High Very High
DBP ≥ 120
Slide 12
THERAPEUTICS LIFESTYLE MODIFICATION-REGULAR PHYSICAL EXERCISE
• General advice on cardiovascular health would be for “milder” exercise, such as brisk
walking for 30 – 60 minutes at least 3 times a week
Slide 14
PHARMACOLOGICAL MANAGEMENT
67
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Slide 15
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
CHOICE OF ANTIHYPERTENSIVES
• Certain classes of antihypertensive drugs may compromise diabetic control & aggravate
its complications
Drugs Adverse
Slide 16
ANGIOTENSIN CONVERTING ENZYME INHIBITORS (ACEIs)
1. Drugs of choice based on extensive data attesting to their cardiovascular and renal
protective effects in diabetic patients
2. In addition they do not have adverse effects on lipid and carbohydrate metabolism
3. If an ACEI is not tolerated, an ARB should be considered
Slide 17
ANGIOTENSION RECEPTOR BLOCKERS (ARBs)
Slide 19
CALCIUM CHANNEL BLOCKERS (CCBs)
Slide 20
Slide 21
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
• Tight BP control should take precedence over the class of antihypertensive drug used
• The BP should be targeted to < 130/80 mmHg
• There are suggestions that a lower target BP may be necessary to maximally protect
against the development and progression of cardiovascular and renal disease
• The BP should be lowered even further to < 125/75 mmHg in the presence of
proteinuria of > 1 g/24 hours
69
70
Slide 22
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
RECOMMENDATIONS
1. ACEIs are the agents of choice for patients with diabetes without proteinuria
2. ACEIs or ARBs are the agents of choice for patients with diabetes and proteinuria
3. ß-blockers, diuretics or CCBs may be considered if either of the above cannot be used
Slide 23
BLOOD PRESSURE TREATMENT TARGETS
Target blood
Category
pressure (mmHg)
Uncomplicated HPT < 140/90
INTERACTIVE CASE DISCUSSION 5
HYPERTENSION AND DIABETES
Slide 24
VISIT 1: SUMMARY OF MANAGEMENT PLAN FOR MR. LM’S HYPERTENSION
1. Explain regarding the diagnosis of hypertension, its contribution of risk to diabetic complications
2. Educate regarding the need of BP treatment, target of < 130/80 mmHg, choice of
medication, potential heart & kidneys protection vs. side effects
3. Empower patient to self-manage through diet and exercise, home monitoring of sugar & BP
4. Commence ACEI as single antihypertensive agent
5. Arrange renal profile to be done within 2 weeks
6. Review after 1 month
Slide 25
VISIT 2: FOLLOW UP AT 1 MONTH LATER
Slide 27
DISCUSSION POINT 4
• Inform him that his treatment target < 130/80 mmHg is still not achieved
• Set personalized treatment goals with him
– Increase walking to 30 min three times a week
– Reduce outside food to 2 times per day to control oil & salt intake
– BP monitoring at least twice per week targeting < 130/80
• Emphasize on low salt diet & praise him for walking every weekend
71
72
Slide 29
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
Slide 30
INTERACTIVE CASE DISCUSSION 5
HYPERTENSION AND DIABETES
Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
REVIEW VISIT 1
Slide 2
DISCUSSION POINT 1
Slide 3
METABOLIC SYNDROME DIAGNOSIS
Slide 4
BLOOD PRESSURE TREATMENT TARGETS
Target blood
Category
pressure (mmHg)
Uncomplicated HPT < 140/90
Hypertension in high risk groups < 130/80
Diabetics with proteinuria of (> 1 g/24 hours) < 125/75
Once target BP is achieved, follow-up at 3-6 month interval is appropriate.
Slide 5
CHOICE OF PHARMACOTHERAPY
ß-blockers and thiazide diuretics have the potential to increase the incidence of new
onset diabetes, and this should be taken into consideration when choosing drugs for
patients diagnosed with Metabolic Syndrome.
• Explain to him that he has Metabolic syndrome and the significance of the diagnosis in
relation to CV risks. Explain that his BP is still not controlled (target < 130/80 mmHg)
• Discuss lifestyle modifications e.g. exercise, diet and weight reduction
• Discuss about his medication and explain that it is unsuitable for his condition. Discuss
changing his medication to ACE Inhibitor or CCB
• Commence him on statin
75
76
Slide 7
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
REVIEW VISIT 2
Slide 8
INTERACTIVE CASE DISCUSSION 6
HYPERTENSION AND METABOLIC SYNDROME
DISCUSSION POINT 2
Slide 9
REVIEW VISIT 2: SUMMARY OF MANAGEMENT PLAN
Slide 11
DISCUSSION POINT 3
• Discuss the factors which may prevent this patient from achieving targets (weight/ BP)
77
78
Slide 12
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
REVIEW VISIT 3
• Mr. AH brings along his wife who wants to help him. She is afraid of losing him
• Has been doing more exercise at home by walking to the local shops to get the newspaper
• His wife is trying to cook healthier meals
• Now smokes 15/day
• No side effect with ACE Inhibitor, CCB or Statin
• BP checked 130/80 mmHg
• Lost 2 kg since last appointment
• He’s happy with his progress
• Still waiting for his appointment with dietician
Slide 13
INTERACTIVE CASE DISCUSSION 6
HYPERTENSION AND METABOLIC SYNDROME
• Continue to give encouragement and motivation for his positive lifestyle changes
• Get his wife involved in giving him encouragement and support
• Chase up his dietician appointment
• If BP remain controlled, continue with 3-6 monthly follow up
• Review his CV and DM risks annually
Slide 14
SUMMARY OF EVIDENCE
Slide 15
KEY LEARNING POINTS
Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
• Mr. M
• 53-year-old
• Male
VISIT 1
Slide 2
INTERACTIVE CASE DISCUSSION 7
HYPERTENSION AND CARDIOVASCULAR DISEASE
VISIT 1
Slide 3
DISCUSSION POINT 1
Slide 4
TIPS FOR DISCUSSION POINT 1
• Try to have an outline for your points and be clear of the reasons for your points
• Write down your answer, you don’t have to write down your name. Discuss you answer
with the person you are comfortable with.
• Tell us your answer once you are ready
(10 minutes)
Slide 5
WHAT WOULD BE YOUR AIMS IN THIS CONSULTATION IN RELATION TO
HYPERTENSION MANAGEMENT?
Slide 6
WHAT WOULD BE YOUR AIMS IN THIS CONSULTATION IN RELATION TO
2. Check for target control: BP < 130/80 mmHg, and other CVD risk factors
Slide 7
WHAT WOULD BE YOUR AIMS IN THIS CONSULTATION IN RELATION TO
HYPERTENSION MANAGEMENT?
81
82
Slide 8
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
Slide 9
DISCUSSION POINT 2
• For each of these aims below (or your own aims), what are your actions?
INTERACTIVE CASE DISCUSSION 7
HYPERTENSION AND CARDIOVASCULAR DISEASE
Slide 10
HISTORY TAKING: ASK FOR
1. Symptoms of IHD, heart failure: NYHA class, claudication, history of stroke and
admission
2. Any consultation with specialist care and what care has he been receiving?
3. How has he been with the control of HPT, is he aware of his blood pressure and any
form of home blood pressure monitoring?
4. Any side effects from the medication, any problems (including personal preferences,
disruption of daily routine) in taking the medication?
Slide 11
PHYSICAL EXAMINATIONS
Slide 13
VISIT 1: FURTHER HISTORY
83
84
Slide 15
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
VISIT 1: INVESTIGATIONS
• The levels of blood urea and serum creatinine were normal, K+ = 4.8 mmol/L
• Fasting blood sugar = 5.3 mmol/L
• Urine dipstix: normal reading for protein, no cell/cast was noted
• Cholesterol profile:
• TC 5.7 mmol/L HDL-C 0.9 mmol/L
• TG 1.8 mmol/L LDL-C 3.6 mmol/L
• ECG (next slide)
Slide 16
INTERACTIVE CASE DISCUSSION 7
HYPERTENSION AND CARDIOVASCULAR DISEASE
Slide 17
HE WAS OBVIOUSLY NOT TREATED TO TARGET
Parameters Targets
BP < 130/80 mmHg
LDL-C (as the primary target) 3.4 mmol/L
BMI < 23.0 kg/m2
WC < 90 cm
Slide 18
DISCUSSION POINT 3
Slide 19
WHAT IS YOUR DIAGNOSIS FOR HIM NOW?
Slide 21
RECOMMENDATIONS
• Hypertensive patients with LVH should receive an ARB as the first line treatment
• In CHD, β-blockers, ACEIs and long acting CCBs are the drugs of choice
• β-blockers, ACEIs, and aldosterone antagonists should be considered in patients
with CHD especially in post myocardial infarction and when associated with LV
dysfunction
• β-blockers need to be cautiously used in patients with peripheral vascular disease.
• They are contraindicated in patients with severe PVD
• Diuretics, ACEIs, β-blockers, ARBs, and aldosterone antagonists are drugs of choice
for heart failure.
• ARB is indeed the correct choice
• β-blockers may not be a suitable choice for him!
85
86
Slide 22
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
PHARMACOLOGICAL MANAGEMENT
β-blockers Peripheral
Concomitant disease Diuretics ACEIs CCBs α-blockers ARBs
Slide 23
INTERACTIVE CASE DISCUSSION 7
HYPERTENSION AND CARDIOVASCULAR DISEASE
DISCUSSION POINT 4
Slide 24
WHAT WILL BE THE BEST CHOICE THEN?
• Perindopril (ACE-I) 2 mg (has to re-start the regime as he has not been taking Losartan)
• HCT 12.5 mg OM
• Simvastatin 80 mg ON
• Felodipine 5 mg OM (explore the option of fixed dose combinatio therapy)
Slide 25
KEY LEARNING POINTS
Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
VISIT 1
Slide 2
INTERACTIVE CASE DISCUSSION 8
HYPERTENSION AND STROKE
Slide 3
DISCUSSION POINT 1
Slide 5
MANIFESTATIONS OF TOD/TARGET ORGAN COMPLICATION (TOC)
89
90
Slide 6
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
Slide 7
HYPERTENSION AND STROKE
Blood pressure is the most consistent and powerful predictor of stroke and high blood
pressure is the most important modifiable cause of stroke. BP levels are continously
associated with the risk for stroke. Although both SBP and DBP are associated with stroke,
SBP is more predictive. In the Asia Pacific region, up to 66% of stroke can be attributed to
hypertension.
Slide 8
DISCUSSION POINT 2
Slide 10
TREATMENT OF HYPERTENSION IN ACUTE STROKE
91
92
Slide 11
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
Recommendations
• Lowering blood pressure is the key to both primary and secondary prevention of stroke
• In acute stroke, lowering BP is best avoided in the first few days unless
hypertensive emergencies co-exist
• In primary prevention, the benefits of BP lowering is seen in both normotensive and
hypertensive patients
• ACEI- or ARB- based treatment is preferred in secondary prevention
Slide 12
INTERACTIVE CASE DISCUSSION 8
HYPERTENSION AND STROKE
Slide 13
VISIT 1: SUMMARY OF MANAGEMENT PLAN FOR MR. AK
• Explain the diagnosis to the patient and his son – Hypertensive Emergency presenting
with Stroke (Right Hemiparesis)
• Explain the importance of hospital admission and the importance of confirming the
type of stroke (haemorrhagic/Infarct)
• Arrange and prepare for hospital admission:
1. Secure intravenous line
2. Inform the receiving hospital
3. Send by ambulance, accompanied by paramedics
Slide 14
VISIT 2: BP REVIEW
• Mr. AK came back to the clinic 1 month after being discharged from the hospital
• Stable but no improvement of symptoms
• Still has residual weakness of right side of body and slurred speech
• Tolerating oral fluids and soft diet
• Using diapers due to mobility problems but no incontinence
• Appointment with physiotherapist: twice per week
• Appointment with neurologist: in 4 months
Slide 15
VISIT 2: BP REVIEW
• He brought along a discharged letter from the hospital which contains the
following informations:
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Slide 16
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
Slide 17
VISIT 2: PHYSICAL EXAMINATION FINDINGS
INTERACTIVE CASE DISCUSSION 8
HYPERTENSION AND STROKE
• BMI: 26 kg/m2
• Waist circumference (WC): 88 cm
• BP: 140/90 mmHg
• Fundoscopy : normal
• Cardiovascular examinations - normal
• Chest examinations – normal
• Abdominal examinations – normal
• Neurological examinations – Right side UL/LL: Power 3+/5, hypertonia, reflexes brisk,
sensation: normal
• Plantar: up going
Slide 18
DISCUSSION POINT 3
Co-existing Previous MI or
No RF TOD or TOD or RF
Condition Previous Stroke
No TOD RF (1-2), (≥ 3) or Clinical
BP Levels or Diabetes
No TOC No TOC atherosclerosis
(mmHg) Mellitus (DM)
SBP 120-139
and/or Low Medium High Very High
DBP 80-89
SBP 140-159
and/or Low Medium High Very High
DBP 90-99
SBP 160-179
and/or Medium High Very High Very High
DBP 100-109
SBP 180-209
and/or High High Very High Very High
DBP 100-119
SBP ≥ 210
and/or Very High Very High Very High Very High
DBP ≥ 120
95
96
Slide 20
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
Slide 21
THERAPEUTIC LIFESTYLE MODIFICATION
Therapeutic lifestyle modification is the first line treatment in all patients with Hypertension
Weight Aim for an ideal BMI (<23 kg/m2) or ideal wt (<66.5 kg). However a
reduction weight loss as little as 4.5 kg significantly reduces BP
Slide 23
BLOOD PRESSURE TREATMENT TARGETS
Target blood
Category
pressure (mmHg)
Uncomplicated HPT < 140/90
HPT in high risk groups: DM, History of CVD < 130/80
Diabetics with proteinuria of (> 1 g/24 hours) < 125/75
Once target BP is achieved, follow-up at 3-6 month interval is appropriate.
* Almost all individuals with 0-1 risk factor have a 10 year risk < 10%, thus 10 year risk
assessment in there individials with 0-1 risk factor is not necessary.
** These include individuals with multiple risk factors but a 10 year risk of CHD of < 20%
*** After 8-12 weeks of TLC
Stroke
Stroke is the 3rd leading cause of mortality in Malaysia. Evidence for the role of elevated
serum cholesterol in the pathogenesis of stroke is lacking. Fibrates and statins are safe and
should be considered in all patients presenting with strokes or transient ischaemic attacks.
97
98
Slide 25
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
• Educate him regarding the risk of recurrent stroke and the need to modify his very high CV risk
• Educate regarding BP treatment target < 130/80 mmHg, choice of medication –
potential benefits vs side effects
• Empower patient to self-manage through therapeutic lifestyle modification and self
home BP monitoring.
• Continue ACE Inhibitor and Diuretic
• Add another agent e.g. CCB – as his BP is still uncontrolled
• Continue statin and aspirin
• Monitor Renal Profile, Fasting Serum Lipid and LFT
• Review monthly until target BP is achieved
• Review 3 monthly once target BP is achieved
• Continue long-term follow up
• Assess CV risks annually
INTERACTIVE CASE DISCUSSION 8
HYPERTENSION AND STROKE
Slide 26
PRIMARY PREVENTION OF STROKE
• Trials have shown that a 10 mmHg reduction in SBP or a 5 mmHg reduction in DBP in
hypertensive patient can lead to a 34% reduction in the risk of stroke.
• ß-blockers, diuretics, CCBs, ACEIs and ARBs have been shown to reduce risk and
mortality of stroke.
Slide 27
SUMMARY OF EVIDENCE - HYPERTENSION AND STROKE
• Blood pressure is the most consistent and powerful predictor of stroke and high blood
pressure is the most important modifiable cause of stroke
• β-blockers, diuretics, CCBs, ACEIs, and ARBs have been shown to reduce the risk
and mortality of stroke
• Calcium channel blockers in particular, provided significantly better protection against
stroke compared with diuretics and/or β-blockers in Asian and Caucasian populations.
Combination of an ACEI and diuretics has been shown to reduce stroke recurrence in
both normotensive and hypertensive patients when treatment was started at least two
weeks after the stroke
• The morbidity and mortality from further strokes were also shown to be significantly
lower in patients receiveing ARBs compared to CCBs for the same level of BP control
• In haemorrhagic stroke, in general, it is best to avoid lowering BP in the first few days
after a stroke unless there is evidence of accelerated hypertension or patients presenting
concurrently with hypertensive emergencies
Slide 28
KEY LEARNING POINTS
• Therapeutics lifestyle changes should be recommended for all individuals with HPT and pre-HPT
• Blood pressure is the most consistent and powerful predictor of stroke and high blood
pressure is the most important modifiable cause of stroke
• Lowering blood pressure is the key to both primary and secondary prevention of stroke
• Rapid reduction of BP (within minutes to hours) in asymptomatic severe hypertension or
hypertensive urgencies is best avoided as it may precipitate ischaemic events
• In primary prevention, a CCB-based therapy is preferred in secondary prevention, the
benefits of BP lowering is seen in both normotensive and hypertensive patients ACEI- or
ARB- based treatment is preferred in secondary prevention
99
INTERACTIVE CASE DISCUSSION 8 MANAGEMENT OF HYPERTENSION (3rd Edition)
HYPERTENSION AND STROKE
100
TRAINING MODULE FOR HEALTH CARE PROVIDERS
102
Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
REVIEW VISIT 1
• BMI 26 kg/m2
• Respiratory, Cardiovascular, GIT and CNS examinations–unremarkable
Slide 2
DISCUSSION POINT 1
Slide 3
DEFINITION OF HYPERTENSION IN THE ELDERY IS THE SAME AS IN
THE GENERAL POPULATION
Target blood
Category
pressure (mmHg)
Uncomplicated HPT < 140/90
HPT in high risk groups: DM, History of CVD < 130/80
Diabetics with proteinuria of (> 1 g/24 hours) < 125/75
Once target BP is achieved, follow-up at 3-6 month interval is appropriate.
Slide 5
CHOICE OF PHARMACOTHERAPY
• Educate Mr. MR regarding his uncontrolled systolic BP (170/76 mmHg) and its impact
• Negotiate the management plan:
1. Advice on therapeutic lifestyle change – to lose weight by exercise and modest
salt reduction.
2. Change his medication - stop the nifedipine, change to hydrochlorothiazide 12.5 mg
Slide 7
REVIEW VISIT 2
103
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Slide 8
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
DISCUSSION POINT 2
Slide 9
REVIEW VISIT 2: SUMMARY OF MANAGEMENT PLAN
Slide 10
REVIEW VISIT 3
Slide 11
DISCUSSION POINT 3
Slide 12
REVIEW VISIT 3: SUMMARY OF MANAGEMENT PLAN
• HPT magnifies risk for CVD in the elderly compared with younger populations
• SBP is a better predictor of CV events than DBP especially in the elderly
• SBP increases linearly with age leading to an increase of isolated systolic hypertension
in the elderly
• In patients with marked SBP and not tolerating treatment well, reducing SBP to below
160 mmHg initially is acceptable. Subsequently attempts should be made to reduce BP
to target level
Slide 14
SUMMARY OF EVIDENCE (2)
• Several RCT have shown that treatment of hypertension in the elderly up to the age of
84 years reduces CV morbidity and mortality, particularly stroke
• For those > 85 years, benefit of treating hypertension prevents the fatal and debilitating
consequences of hypertension such as stroke, heart failure and dementia. (HYVET TRIAL
2008)
• Salt restriction is especially effective in the elderly due to greater sensitivity to sodium
• Five major classes of antihypertensive drugs (diuretics, ß-blockers, CCBs, ACEIs and
ARBs) have been shown to reduce CV events in the elderly
• In older patients with isolated systolic hypertension, diuretics are preferred because
Slide 16
SUMMARY OF EVIDENCE (4)
• Several trials using CCBs have shown benefits particularly in stroke reduction
• ACEi are the drugs of choice for those with concomitant left ventricular systolic
dysfunction, post MI or DM
• ARBs have also been shown to reduce fatal and non-fatal strokes in hypertensive
patients aged 65 years or older
105
106
Slide 17
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
• The starting dose of HPT medications in older patients should be at the lowest available
• In order to maximise adherence, the drug regime should be as simple as possible
• The elderly tend to be on polypharmacy – drug interactions should be taken into
account when considering antihypertensive treatment
Slide 18
KEY LEARNING POINTS
• In those patients with marked SBP and not tolerating treatment well, reducing SBP to
below 160 mmHg initially is acceptable. Subsequently, attempts should be made to
reduce BP to target levels
• Weight loss and modest salt reduction are effective in the elderly because of their greater
sensitivity to sodium
• Five major classes of drugs have been shown to reduce CV events in the elderly
(diuretics, β-blockers, CCBs, ACEi and ARBs)
• ACEi are the drugs of choice for those with concomitant left ventricular systolic
dysfunction, post MI and DM
108
Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
• Mdm NH • G1P0
• 35 years old • Housewife
VISIT 1
Slide 2
DISCUSSION POINT 1
Slide 3
VISIT 1: SUMMARY OF MANAGEMENT PLAN FOR MDM. NH
Slide 4
VISIT 2: BP REVIEW
Slide 6
HYPERTENSION IN PREGNANCY
Slide 7
DIAGNOSIS
An increase of 15 mmHg and 30 mmHg diastolic and systolic BP levels above baseline BP
is no longer recognized as hypertension if absolute values are below 140/90 mmHg.
Korotkoff V should now be used as the cut-off point for diastolic BP, and Korotkoff IV
Slide 8
BASELINE INVESTIGATIONS
• Biochemical investigations:
– Platelet count, hematocrit
– Serum uric acid and creatinine
– Liver function test
– UFEME
– OGTT
– 24 hour urine protein
• Other relevant investigation TRO secondary causes
109
110
Slide 9
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
Slide 10
INTERACTIVE CASE DISCUSSION 10
HYPERTENSION IN PREGNANCY
• BP 140/90 mmHg
• Normal weight gain
• Fundoscopy normal
• Cardiac & respiratory examinations – normal
• Symphysis fundal height – 21 cm
• Neurological examinations – normal
Slide 11
VISIT 2: BASELINE INVESTIGATION RESULTS
• Renal Profile: Urea 3.2 , Sodium 132, Potassium 3.5, Chloride 101 (all in mmol/L),
Creatinine 65 µmol/L
• Serum uric acid: 200 µmol/L
• Full Blood Count: Hb 11.5 g/dL, wbc 4500/mL, platelet 211,000/mL
• OGTT: 5.3/7.0 mmol/L
• Urinalysis - albumin negative
Slide 12
DISCUSSION POINT 3
HDP
Preeclampsia
Preeclamsia-
Gestational HPT Chronic HPT superimposed on
eclampsia
chronic HPT
Slide 14
CLASSIFICATION OF HDP
HYPERTENSION IN PREGNANCY
iv. Neurological problems: convulsions (eclampsia), hyperreflexia with clonus or severe
headaches, persistent visual disturbances (scotoma).
v. Haematological disturbances: thrombocytopenia, coagulopathy, haemolysis.
vi. Fetal growth restriction.
2. Gestational hypertension: hypertension alone, detected for the first time after 20 weeks
pregnancy. The definition is changed to “transient” when pressure normalizes postpartum.
3. Chronic hypertension: hypertension diagnosed prior to gestational week 20; or presence
of hypertension preconception, or de novo hypertension.
4. Preeclampsia superimposed on chronic hypertension:
This can be diagnosed by the appearance of any of the following in a woman with
chronic hypertension:
i) De novo proteinuria after gestational week 20.
ii) A sudden increase in the severity of hypertension.
iii) Appearance of features of preeclampsia-eclampsia.
iv) A sudden increase in proteinuria in women who have preexisting proteinuria early in gestation.
111
112
Slide 16
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
DISCUSSION POINT 4
Slide 17
MANAGEMENT
Red Code - Mild pre eclampsia and more than 36 weeks gestation
- Severe pre eclampsia
- Eclampsia
Yellow Code - Mild pre eclampsia and less than 36 weeks gestation
Slide 18
VISIT 2: SUMMARY OF MANAGEMENT PLAN FOR MDM. NH
Slide 19
VISIT 3: FOLLOW UP
Slide 21
VISIT 3: SUMMARY OF MANAGEMENT PLAN FOR MDM. NH
Slide 22
ANTIHYPERTENSIVE DRUGS COMMONLY USED IN PREGNANCY
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Slide 23
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
SEVERE PREECLAMPSIA
Must be promptly identified so that the patient can be urgently admitted to hospital for close
observation and timely delivery. The Royal College of Obstetrician and Gynecology (RCOG)
defines severe pre eclampsia as follows:
1. Systolic BP 170 mmHg or diastolic BP 110 mmHg (acute hypertensive crisis in
pregnancy) on two occasions, with proteinuria of 1 g/day.
2. Diastolic BP 100 mmHg on two occasions, with significant proteinuria (1+ on dipstick),
with two or more signs or symptoms of imminent eclampsia:
a. severe headache h. abnormal liver enzymes (elevated ALT
b. visual disturbance or AST)
c. epigastric pain and/or vomiting i. HELLP syndrome (haemolysis,
d. clonus elevated liver enzymes, low platelets)
e. Papilloedema j. intrauterine growth restriction (IUGR)
f. liver tenderness k. pulmonary oedema and/or congestive
g. platelet count below 100,000/cmm cardiac failure
INTERACTIVE CASE DISCUSSION 10
HYPERTENSION IN PREGNANCY
Slide 24
ANTICONVULSANTS IN PREECLAMPSIA-ECLAMPSIA
Parenteral magnesium sulphate is currently the drug of choice for the prevention of eclampsia
and to abort an eclamptic fit. The alternative is intravenous diazepam (intravenous bolus 10
mg slowly over 10-15 minutes followed by infusion), bearing in mind that it is inferior in efficacy
compared to magnesium sulphate.
Slide 25
POSTPARTUM CARE
• Advised to have BP checked regularly at local clinics if there is a significant delay in their
scheduled hospital follow-up
• In these patients, the dose of antihypertensive should be tailed down gradually and not
stopped suddenly
• De novo onset of hypertension or aggravation of BP levels during the postpartum period,
can occur
• These patients should be promptly referred to hospital especially if there is significant
proteinuria. Eclampsia may occur in the postpartum period
• Chronic hypertension is diagnosed when the hypertension and/or proteinuria fails to
disappear within three months postpartum
Slide 26
KEY LEARNING POINTS
115
INTERACTIVE CASE DISCUSSION 10 MANAGEMENT OF HYPERTENSION (3rd Edition)
HYPERTENSION IN PREGNANCY
116
TRAINING MODULE FOR HEALTH CARE PROVIDERS
118
Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
VISIT 1
Slide 2
INTERACTIVE CASE DISCUSSION 11
HYPERTENSION AND OCP
DISCUSSION POINT 1
Slide 3
VISIT 1- FURTHER HISTORY
Slide 4
VISIT 1- PHYSICAL EXAMINATIONS
Slide 6
VISIT 1
Problem List
• Stage 1 hypertension on COC
• Passive smoker, poor diet control, sedentary lifestyle
• Stressful at work and home
Slide 7
DISCUSSION POINT 3
Slide 8
VISIT 1- FURTHER ACTIONS
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Slide 9
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
Slide 10
INTERACTIVE CASE DISCUSSION 11
HYPERTENSION AND OCP
SUMMARY OF EVIDENCE
• A woman who develops hypertension while using COC should be advised to stop taking
them and should be offered alternative forms of contraception
• Blood pressure should be reviewed regularly, at least every six months
Slide 11
KEY LEARNING POINTS
Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
VISIT 1
Slide 2
VISIT 1: FURTHER HISTORY
Slide 3
VISIT 1: PHYSICAL EXAMINATIONS AND BASELINE INVESTIGATIONS
Result
BMI 22 kg/m2, WC= 75 cm
Neck - no goitre, no carotid bruit
Heart and lung - normal
Abdomen and pelvic - normal
Legs - normal
Other systems – normal
FBG 5.5 mmol/L, Fasting serum lipid normal
Urine microalbumin negative
ECG normal
Slide 4
DISCUSSION POINT 1
Slide 5
DIAGNOSIS & CLASSIFICATION OF HYPERTENSION
Co-existing Previous MI or
No RF TOD or TOD or RF
Condition Previous Stroke
No TOD RF (1-2), (≥ 3) or Clinical
BP Levels or Diabetes
No TOC No TOC atherosclerosis
Mellitus (DM)
SBP 140-159
and/or Low Medium High Very High
DBP 90-99
SBP 160-179
and/or Medium High Very High Very High
DBP 100-109
SBP 180-209
and/or High High Very High Very High
DBP 100-119
SBP ≥ 210
and/or Very High Very High Very High Very High
DBP ≥ 120
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Slide 7
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
• Her BP was checked again twice (15 minutes apart) on this visit: 160/100 mmHg
Slide 8
DISCUSSION POINT 2
Slide 9
INTERACTIVE CASE DISCUSSION 12
HYPERTENSION AND HORMONE REPLACEMENT THERAPY
The Women’s Health Initiative (WHI) trial involving 98, 705 women aged 50-79 years,
concluded that the use of HRT increased cardiovascular events. Conjugated equine
estrogen (CEE), alone or in combination with medroxyprogesterone acetate, was used in the
study. In view of this, greater caution and closer monitoring is required for hypertensive
patients on CEE.
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Slide 12
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
CHOICE OF PHARMACOTHERAPY
Effective Combination
β-blockers + diuretics
β-blockers + CCBs
CCBs + ACEIs/ARBs
ACEIs + diuretics
ARBs + diuretics
Slide 13
INTERACTIVE CASE DISCUSSION 12
HYPERTENSION AND HORMONE REPLACEMENT THERAPY
Target blood
Category
pressure (mmHg)
Uncomplicated HPT < 140/90
HPT in high risk groups: DM, History of CVD < 130/80
Diabetics with proteinuria of (> 1 g/24 hours) < 125/75
Once target BP is achieved, follow-up at 3-6 month interval is appropriate.
Slide 14
VISIT 1: SUMMARY OF MANAGEMENT PLAN FOR MDM. OKL
• Explain to her that she has an underlying Stage 1 HPT which is now worsening.
• Initiate therapy with 2 drugs e.g. CCB + ACEi
• Discuss the option of continuing HRT and advise to have regular Pap smear and
mammogram
• Re-emphasize on therapeutic lifestyle modification
• Educate regarding potential complications, the need to start medication and her
treatment target
• Review monthly until target BP is achieved
• Review 3-monthly once target BP is achieved
• Re-assess CV risks annually
Slide 15
A NOTE ON HORMONE REPLACEMENT THERAPY-PROGYLUTON
• 11 white tab each containing Calendar pack of Oestradiol valerate 2 mg, 10 brown tab
each containing Norgestrel 500 mcg, Oestradiol Valerate 2 mg
• Before starting treatment, a thorough general medical (including blood pressure
measurement, urine test for sugar and, if necessary, special liver tests), and
gynaecological examination (including the breasts and a cytological smear) should be
carried out to detect any diseases requiring treatment or any risks and, above all, to rule
out pregnancy. Control examinations are recommended at about 6-monthly intervals
• Progyluton is not a contraceptive. Where applicable contraception should be practised
with non-hormonal methods
Slide 16
SUMMARY OF EVIDENCE
Slide 17
KEY LEARNING POINTS
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
• Stage 1 HPT is defined as SBP 140 and/or DBP 90 mmHg or greater, based on > 2 BP
readings at > 2 clinic visits
• HRT is safe in hypertensive women. The presence of hypertension is not a
contraindication to oestrogen based hormonal replacement therapy (HRT)
• Untreated or sub-optimally controlled hypertension leads to increased cardiovascular,
cerebrovascular and renal morbidity and mortality
• Decision to commence pharmacological treatment should be based om global
cardiovascular risks and not on the level of blood pressure (BP) per se
• All women treated with HRT should have their BP monitored every six months including
regular gynaecological examination, mammogram and cervical smear
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INTERACTIVE CASE DISCUSSION 12 MANAGEMENT OF HYPERTENSION (3rd Edition)
HYPERTENSION AND HORMONE REPLACEMENT THERAPY
128
TRAINING MODULE FOR HEALTH CARE PROVIDERS
130
Slide 1
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
• Invasive Measurement
Slide 2
WORKSHOP ON BP (BP MEASUREMENT TECHNIQUE & SKILLS)
Slide 3
STEPS TO BP MEASUREMENT
• Rest the patient, back rested on the chair and arm supported at heart level, no coffee
or smoking 30 minutes before
• Wrap the cuff properly
• Palpate the brachial or radial artery
• Inflate the bladder until the pulse disappear and inflate another 30 mmHg
• Deflate the cuff slowly until the pulse is felt again (estimated SBP)
• Bladder inflated to 30 mmHg above the estimated SBP
STEPS TO BP MEASUREMENT
131
MANAGEMENT OF HYPERTENSION (3rd Edition)
WORKSHOP ON BP (BP MEASUREMENT TECHNIQUE & SKILLS)
132
TRAINING MODULE FOR HEALTH CARE PROVIDERS
Slide 9
Slide 8
Slide 7
THE SPHYGMOMANOMETER
AUTOMATED SPHYGMOMANOMETER
Slide 10
OTHER METHODS OF MEASUREMENT
• Aneroid sphygmomanometer
• Automated ambulatory BP devices
• Validated by either BHS or AAMI methods
Slide 11
AMBULATORY BP
Indicated in:
• suspected ‘white coat’ hypertension
• borderline hypertension
• labile hypertension
Slide 12
Slide 13
DETECTING POSTURAL HYPERTENSION
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Slide 14
TRAINING MODULE FOR HEALTH CARE PROVIDERS
MANAGEMENT OF HYPERTENSION (3rd Edition)
Slide 15
AUSCULTATORY GAPS
• It is a normal phenomenon
seen in elderly
WORKSHOP ON BP (BP MEASUREMENT TECHNIQUE & SKILLS)
Slide 16
CHANGE IN BP WITH DAILY ACTIVITIES
Slide 17
KEY LEARNING POINTS
2. With regards to the management of pre-hypertension, the following statement(s) is/are true:
A. All patients should be managed with therapeutic lifestyle modification
B. Patients should be followed up at least once every 2 years
C. Decisions regarding pharmacological treatment should be based on the individual’s global
cardiovascular risk
D. Pharmacological treatment is indicated in pre-hypertensive patients at low cardiovascular risk
PRE-TEST AND POST-TEST QUESTIONNAIRE (MCQs)
1. Madam Y has recently been diagnosed with stage 1 hypertension. She is a heavy smoker and her
total cholesterol is 6.8 mmol/L. The following statement(s) is/are true regarding her condition and
management:
A. She has a medium cardiovascular risk
B. Her target blood pressure is < 140/90 mmHg
C. Pharmacological treatment should commence with combination of 2 drugs at low dose
D. β-blocker is recommended for first line therapy for this patient
E. Thiazide diuretic is contraindicated in her case
2. The following statement(s) is/are true with regards to the management of stage 1 hypertension:
A. In patients without target organ damage, an observational period of 3-6 months on lifestyle
modification is recommended
B. Monotherapy can lower the blood pressure to < 140/90 mmHg in 40-60% of cases
C. Increasing the dose of the initial drug is an option if patient shows response but target BP is not
achieved
D. Monotherapy should be continued for at least 6 months before a second drug can be added
E. Substituting the drug with another class is recommended when the drug is not tolerated
TOPIC 4: DIAGNOSIS AND MANAGEMENT OF STAGE 2 HYPERTENSION &
RESISTANT HYPERTENSION
1. For patients with stage 2 hypertension, the target blood pressure of < 140/90 mmHg is
recommended if they have:
A. History of tobacco smoking
B. Diabetes mellitus
C. Chronic kidney disease
D. Central obesity
E. Cardiovascular disease
2. Below is/are the recommended antihypertensive combination(s) for patients with stage 2
hypertension and heart failure:
A. β-blocker + ACEi
B. β-blocker + CCB
C. CCB + ACEi
D. ACEI + diuretic
E. ARB + diuretic
1. A 48-year-old woman is evaluated for hypertension. Physical examination showed BP: 182/86
mmHg. She does not give history of headaches. Fundoscopy showed that she has Grade 3
Hypertensive retinopathy. Her home blood pressure measurements remain the same results as
above. Which of the following statement(s) is/are true :
A. She is having Hypertensive Urgencies
B. Patient can be reassured of her blood pressure readings
C. She needs to be referred to the nearest hospital for initiating antihypertensive agent
D. She can be managed as outpatient with just home blood pressure monitoring
E. She may need hospital admission if her blood pressure remains elevated after 30 minutes of rest
3. The following statement(s) is/are correct regarding the management of Stage 3 Hypertension:
A. Patient’s blood pressure target is < 140/90 mmHg if there is no target organ complication
B. Non-adherence to therapy is an important cause of uncontrolled blood pressure
C. Monotherapy is sufficient to get the blood pressure to target
D. Fundoscopy and an ECG evaluation are needed for assessments of their target organ damage
or complication
E. There is no role of therapeutic lifestyle changes for these patients
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TRAINING MODULE FOR HEALTH CARE PROVIDERS
1. A 54-year-old man with type 2 diabetes has had intermittent mild headaches for the past one
month. He is now euglycemic with oral hypoglycemic agents and lifestyle modifications. His older
sister has had hypertension and has been taking antihypertensive medications for several years.
Physical exam reveals an afebrile medium size man with a BP of 158/96 mm Hg (average of 2
readings), normal and regular peripheral pulses, hard exudates and narrowing of the arterioles on
fundoscopic exam, and no carotid bruits. Lungs are clear and neurologic exam is also normal. His
recent test result show the following: fasting plasma glucose, 5.8 mmol/L; HbA1c, 6.9%; normal
urinalysis; and normal electrocardiogram (ECG).
Which of the following(s) would you consider for treatment of this patient?
A. A thiazide-type diuretic
B. A combination of a β-blocker and thiazide-type diuretic
C. A combination of a β-blocker and an ACE inhibitor
D. A combination of a calcium channel blocker and an ACE inhibitor
E. A combination of a thiazide-type diuretic and a ARB
3. Which of the following statements regarding management of hypertensive patient with type 2
diabetes mellitus is/are TRUE?
A. When the systolic blood pressure is > 20 mmHg above goal or diastolic blood pressure is > 10
mmHg above goal, monotherapy is recommended
B. Many patients require 3 or more antihypertensive medications to achieve blood pressure goal
C. All patients with diabetes and hypertension should be treated with calcium channel blocker
D. They need less stringent blood pressure goal
E. Pharmacotherapy is indicated in patients with microalbuminuria
2. In the drug management for patients with Hypertension and Metabolic Syndrome.
A. Thiazide Diuretics is recommended as first line agent
B. ß-blockers should be avoided
C. ACE Inhibitor is a recommended drug of choice
D. Calcium Channel Blocker should be avoided
E. Combination therapy is considered safe
1. A 56-year-old man presented with intermittent left pain calf pain worsen on prolong walking. He has
no significant past medical history. His blood pressure was 140/90 mmHg. The left dorsalis pedis
pulse was weaker than the right side. Which of the following statement(s) is/are correct?
A. His risk of stroke is high
B. Electrocardiography is an optional investigation
C. He should be called back within a week to confirm his status of hypertension
D. Atenolol is an appropriate anti-hypertensive
E. His target blood pressure is < 140/90 mmHg
2. Which of the following scenario(s) is/are correctly paired with the optimal choice of anti-
hypertensives given?
A. A 60-year-old woman with congestive cardiac failure secondary to prolong uncontrolled
hypertensive: Atenolol
B. A 50-year-old man with primary stage II hypertension and left ventricular hypertrophy: Losartan
C. A 70-year-old man with primary hypertension and significant Q wave in his electrocardiogram at
the anterior chest leads: Amlodipine
D. A 45-year-old man with primary hypertension and recent myocardial infarct: Perindopril
E. A 66-year-old woman with uncontrolled hypertension and congestive heart failure NYHA classII
who are already on T. Perindopril 4 mg daily: Metoprolol
3. The following(s) is/are necessary in the assessment of patient presented with symptoms of heart
failure and prolong hypertension:
1. Ahmad, a 45-year-old businessman presented to the health clinic with left sided body weakness of
1 day duration. His vital signs are as below:
BP : 190/110 mmHg
PR : 90 beats/min
Temp : 36.5˚C
RR : 14 breaths/min
The following statement(s) is/are correct regarding Ahmad’s condition:
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TRAINING MODULE FOR HEALTH CARE PROVIDERS
3. Mr. Tan a 58-year-old pensioner had history of ischaemic stroke 5 years ago. His current medications
MANAGEMENT OF HYPERTENSION (3rd Edition)
are Aspirin 150 mg OD and Hydrochlorothiazide 25mg OD. The following statement(s) is/are correct:
A. CCB provides better protection than Thiazide Diuretic regarding secondary prevention
B. It is recommended to withhold his Hydrochlorothiazide if his blood pressure ranges from
110-120/70-80 mmHg
C. Perindopril is the preferred choice
D. His target LDL level is < 3.4 mmol/L
E. His target blood pressure control is < 140/90 mmHg
1. Based on current evidence, the following class(es) of drugs has / have been shown to reduce
cardiovascular events in the elderly:
A. Calcium channel blockers
B. Ace inhibitors
C. β-blockers
D. Diuretics
E. α-blockers
2. When prescribing antihypertensive agents in the elderly, the following rule(s) is/are important:
A. Start with low dose
B. Go slow on increasing the dose
C. Combination preparation is encouraged
D. The target BP is below 130/80 mm Hg
E. In patients with marked systolic hypertension, reducing SBP below 160 mmHg is initially
acceptable
3. In patients with postural hypertension, the following BP should be used as a guide to treatment
decisions:
A. Standing BP
B. Sitting BP
C. Lying BP
D. Supine BP
E. Ambulatory BP
1. Which of the following(s) is/are the risk factor(s) for developing high blood pressure in pregnancy?
A. First pregnancy
B. Previous history of hypertension during pregnancy
C. Twin pregnancy
D. Diabetes Mellitus
E. Poor weight gain
2. What is/are the complication(s) of hypertension in pregnancy?
A. Fits
B. Stroke
C. Placenta accreta
D. Stillborn
E. Disseminated intravascular coagulopathy
1. The following statement(s) is/are true regarding hypertension and oral contraceptives:
A. Baseline blood pressure is essential before initiating combined oral contraceptive (COC)
B. Progestrogene only pills (POP) are known to raise blood pressure
C. Incidence of hypertension is reported to be higher in woman taking COC
D. Women who develop hypertension while using COC are advisable to continue using COC
provided their blood pressure is monitored regularly
E. Low dose COC is a recommended alternative for patients with hypertension who wish to
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TRAINING MODULE FOR HEALTH CARE PROVIDERS
ANSWER
TOPIC 2: DIAGNOSIS 2. A. F 3. A. T 2. A. T
AND MANAGEMENT B. F B. T B. T
OF PRE-HYPERTENSION C. T C. T C. F
D. T D. F D. T
1. A. T E. T E. T E. T
B. F
C. T TOPIC 6: TOPIC 9: 3. A. T
D. T HYPERTENSION AND HYPERTENSION AND B. F
E. T DIABETES STROKE C. T
D. T
2. A. T 1. A. F 1. A. F E. T
B. F B. F B. T
C. T C. F C. F TOPIC 12:
D. F D. T D. F HYPERTENSION AND
E. T E. T E. T OCP
TOPIC 3: DIAGNOSIS 2. A. F 2. A. F 1. A. T
AND MANAGEMENT B. F B. T B. F
OF STAGE 1 C. F C. T C. T
PRE-TEST AND POST-TEST QUESTIONNAIRE (MCQs)
HYPERTENSION D. T D. F D. F
E. F E. T E. T
1. A. T
B. T 3. A. F 3. A. T 2. A. T
C. F B. T B. F B. F
D. F C. F C. T C. F
E. F D. F D. F D. F
E. T E. F E. F
2. A. T
B. T TOPIC 7: 4. A. T
C. T HYPERTENSION AND B. T TOPIC 13:
D. F METABOLIC C. F HYPERTENSION AND
E. T SYNDROME D. T HORMONE
E. F REPLACEMENT
TOPIC 4: DIAGNOSIS 1. A. T THERAPY
AND MANAGEMENT B. T TOPIC 10:
OF STAGE 2 C. T HYPERTENSION IN 1. A. T
HYPERTENSION & D. T THE ELDERLY B. T
RESISTANT E. F C. F
HYPERTENSION 1. A. T D. T
2. A. F B. T E. F
1. A. T B. T C. T
B. F C. F D. T 2. A. T
C. T D. T E. F B. F
D. T E. T C. T
E. T 2. A. T D. F
3. A. T B. T E. F
2. A. T B. F C. F
B. F C. F D. F
C. F D. T E. T
D. T E. T
E. T 3. A. T
TOPIC 8: B. F
3. A. T HYPERTENSION AND C. F
B. T CARDIOVASCULAR D. T
C. F DISEASE E. F
D. T
E. T 1. A. T TOPIC 11:
B. F HYPERTENSION IN
TOPIC 5: DIAGNOSIS C. F PREGNANCY
AND MANAGEMENT D. F
OF STAGE 3 E. F 1. A. T
HYPERTENSION B. T
2. A. F C. T
1. A. T B. T D. T
B. F C. F E. F
C. F D. T
D. F E. F
E. T