Hypertension diagnosis & assessment 2018

20110105 unikl rcmp pcm YFN 1
Hypertension
Diagnosis & Assessment
Dr Yap Foo Ngan
MBBS (Singapore), DCH (London), FAFP(M), FRACGP, AM(M)
Primary Care Medicine

Hypertension – Diagnosis & Assessment
► Learning objectives: At the end of the session students
will be able to –
1. explain the importance of screening for hypertension (HT)
2. explain the method of measuring blood pressure
3. classify an adult’s BP according to the current Malaysian
CPG on management of HT
4. differentiate between different causes of HT
5. assess a patient diagnosed with HT
6. explain management targets for patients with HT
7. discuss the non-pharmacological management of HT
8. discuss management in some hypertensive crises (HT
urgencies, HT emergencies, resistant HT, strokes)

Malaysian CPG on
Management of Hypertension
4th Edition 2013
► Hypertension is a silent disease.
 On the other hand complications of HT are
symptomatic.
► The majority of patients (61%) in the country
remain undiagnosed.
Blood pressure should be measured at every chance
encounter (screening).
 Untreated or sub-optimally managed, HT leads to
increased cardiovascular, cerebrovascular and renal
morbidity and mortality.

Malaysian CPG on
4th Edition 2013
► Hypertension = persistent elevation of
 systolic BP  140 mmHg, and/or
 diastolic BP  90 mmHg
► Prehypertension = Persistent elevation of
 SBP: 130 to 139 mmHg, and/or
 DBP: 85 to 89 mmHg
should be treated in certain high risk groups

Measuring BP
►Apply the cuff to the upper arm with the
centre of the bladder over the brachial
artery.
 The arrow on the cuff indicates where the
centre is.
►The stethoscope should not be placed under
the cuff.

Measuring BP
(A)Locating and palpating the radial pulse.
(B)Feeling for a collapsing radial pulse.
(C)Locating the brachial pulse with a thumb.
(D)Locating the carotid pulse with a thumb.

Measuring BP
Stethoscope should not be placed under the cuff.

Common errors in BP measurement
National Heart Foundation of Australia
http://www.heartfoundation.org.au/SiteCollectionDocuments/HypertensionGuidelines2008to2010Update.pdf
► cuff placed over clothing
► arm elevated above heart
► failure to check that both arms give comparable readings (e.g. at initial
visit)
► patient not rested before measurement
► patient talking during measurement
► failure to palpate radial pulse before auscultatory measurements
(results in failure to detect auscultatory gap)
► deflating the cuff too quickly (> 2–3 mmHg/ beat, whether using a
mercury or digital sphygmomanometer)
► re-inflating the cuff to repeat measurement before it has fully deflated
► rounding off actual reading by more than 2 mmHg when recording
measurement
► taking a single measurement

Measuring BP
►Does the patient really have hypertension?
 The following raise BP for the duration stated.
►Food ½ hr
►Cigarette 2 hrs
►Coffee/alcohol 4 – 6 hrs
►Murtagh J, Hypertension. In: General practice. Australia: McGraw-Hill Book
Company; 1994. p. 953-70.
 White coat HT – prevalence 10%
 Somon C, Everitt H, Kendrick T. Cardiology and vascular disease. In:
Oxford Handbook of General Practice. 2nd ed. New Delhi: Oxford
University Press; 2006, p316.

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Measuring BP
►Does the patient really have hypertension?
 BP measurement 3x
 Take the average
►Hypertension is defined as persistent
elevation of systolic BP of 140 mmHg or
greater and/or diastolic BP of 90 mmHg or
greater.

Classification of hypertension for adults ≥ 18
► Malaysian CPG on Management of Hypertension 4th Edition 2013
Classification Systolic (mm Hg) Diastolic
Optimal < 120 & < 80
Normal < 130 & < 85
Prehypertension 130 – 139 &/or 85 – 89
Hypertension
Stage I 140 – 159 &/or 90 – 99
Stage II 160 – 179 &/or 100 – 109
Stage III  180 &/or  110
The classification is based on the average of  2 readings.
When SBP and DBP fall into different categories, the higher
category should be selected to classify the individual’s BP.

Assessing a patient with HT
►What is the cause of his hypertension?
►Primary?
 (Essential HT)
►Secondary?

Assessing a patient with HT
►Has he developed any complications (target
organ damages) from his HT?
►Does he have other risk factors for CVS
diseases?

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Malaysian CPG on
4th Edition 2013
► DIAGNOSIS AND ASSESSMENT
► Evaluation of patients with documented hypertension has
three objectives:
1. To exclude secondary causes of hypertension
2. To ascertain the presence or absence of target organ damage.
3. To assess factors which affect prognosis and guide treatment
a) lifestyle
b) other cardiovascular risk factors or coexisting disorders
► Such information is obtained from
 history
 physical examination
 relevant laboratory investigations and other diagnostic procedures

Malaysian CPG on
4th Edition 2013
► Secondary causes of hypertension
 Sleep apnoea
 Drug-induced or drug-related causes
 Parenchymal kidney disease
 Renovascular disease
 Coarctation of the aorta
 Cushing syndrome
 Phaeochromocytoma
 Primary aldosteronism
 Thyroid
 Parathyroid disease
 Acromegaly

Malaysian CPG on
4th Edition 2013
► Target Organ Damage
 Heart
► Left ventricular hypertrophy
► Angina or myocardial infarction
► Heart failure
 Brain
► Stroke, TIA
 Peripheral arterial disease
 Hypertensive kidney disease
 Hypertensive retinopathy

Malaysian CPG on
4th Edition 2013
► Major Cardiovascular risk factors:
► Non-modifiable
 Age
► >55 years for men
► >65 years for women
 Family history of premature cardiovascular disease
► men <55 years or
► women <65 years

Malaysian CPG on
4th Edition 2013
► Major Cardiovascular risk factors:
► Modifiable
 Cigarette smoking
 Physical inactivity
 Central obesity
(waist circumference >90 cm for men, >80 cm for women)
 Hypertension
 Diabetes mellitus
 Dyslipidaemia
 Microalbuminuria
 Estimated GFR* <60 mL/min

Malaysian CPG on
4th Edition 2013
► Complete history:
► duration and level of ↑ BP if known
► symptoms of target organ damage, e.g.
 coronary heart disease (CHD)
 cerebrovascular disease
 peripheral arterial disease
► symptoms of secondary causes of HT
► symptoms of coexisting diseases that will affect prognosis
or treatment, e.g.
 diabetes mellitus
 (dyslipidaemia)
 renal disease
 bronchial asthma
 gout

Malaysian CPG on
4th Edition 2013
► Complete history:
► family history
 hypertension, CHD, stroke, diabetes, renal disease or
dyslipidaemia
► drug history
 NSAIDS, nasal decongestants
 herbal treatment
► dietary history etc
 salt, fat
 caffeine & alcohol intake
► lifestyle and environmental factors that will affect treatment
and outcome, e.g.
 smoking, physical activity, work stress and excessive weight gain
since childhood

Malaysian CPG on
4th Edition 2013
► Physical examination:
► general examination including
 colour, oedema
 height, weight, BMI
 mid-waist circumference

Malaysian CPG on
4th Edition 2013
► ≥ 2 BP measurements separated by 2 minutes
with the patient
 either supine or seated, &
 after standing for at least one minute*
► measure BP on both arms*
 @ initial assessment &
whenever indicated

Malaysian CPG on
4th Edition 2013
► peripheral pulses and radio-femoral delay
► carotid bruit, abdominal bruit
► cardiac examination
► chest examination
 e.g. for evidence of cardiac failure

Malaysian CPG on
4th Edition 2013
► abdominal examination for abdominal
obesity, renal masses, aortic aneurysm
► neurological examination
 ? evidence of stroke
► Fundoscopy
► signs of endocrine disorders, e.g. Cushing
syndrome, acromegaly and thyroid disease

Malaysian CPG on
4th Edition 2013
► The initial investigations aim to
 exclude secondary causes of hypertension
 assess extent of target organ damage (TOD)
 determine the presence of risk factors

Malaysian CPG on
4th Edition 2013
► Initial investigations
► Full blood count
► Urine full examination and microscopic examination (FEME)
► Measurement of urine albumin excretion or
albumin/creatinine ratio
► Renal function tests (urea, creatinine, serum electrolytes and
uric acid)
► Fasting plasma glucose
► Fasting lipid profile (total cholesterol, HDL cholesterol, LDL
cholesterol and triglycerides)
► Electrocardiogram
► Ultrasound of abdomen – renal abnormalities?
► Chest X-ray

Measurement Of Lipids
Malaysian CPG: Management of Dyslipidemia (4th ed) 2011
►Serum lipid levels are affected by:
 Acute stress or illness
►Eg: fever, surgery, acute myocardial infarction
 Drug
►Eg: beta-blockers, thiazides, steroids
 TG levels are influenced by
►alcohol intake in the preceding 24 hours, and
►smoking during the fasting state

Serum Lipid Profile: Fasting or Non-fasting?
Ngiam PK. Indian J Clin Biochem. 2011 Jan 29: 26(1): 96-97
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3068759/
► Fasting =
 12–14 h overnight complete dietary restriction with the exception
of water and medication
► Reasons for fasting LP
1. fasting state is essential for triglycerides estimation
(TG remains high for several hours after meal.)
Friedewald equation
(LDL cholesterol =
total cholesterol − HDL cholesterol − [triglycerides/5])
NOTE: If TG > 4.5mmol/L, this formula is not valid.
2. reference values for serum lipids are established on
fasting blood specimen

CARDIOVASCULAR RISK STRATIFICATION
CPG Management of Hypertension, 4th Edition 2013
Risk
level
Risk of
major CV event
in 10 years
Management
Low <10% Lifestyle changes
Medium 10–20%
Drug treatment and
lifestyle changes
High 20–30%
Drug treatment and
lifestyle changes
Very
High
>30%
Drug treatment and
lifestyle changes

Clinical Practice Guidelines
4th Edition 2013
►Adherence to this guideline does not
necessarily lead to the best clinical outcome
in individual patient care.
►Every health care provider is responsible for
the care of his/her unique patient based on
the clinical presentation and treatment
options available locally.

Malaysian CPG on
4th Edition 2013
► Therapeutic lifestyle changes (TLC) should
be recommended for all individuals with
hypertension and prehypertension.
► Decisions on pharmacological treatment
should be based on global vascular risks
and not on the level of blood pressure per
se.

2013 Guidelines for management of arterial hypertension
European Society of Hypertension (ESH) and European Society of Cardiology
Euro. Heart J. 2013;34:2159-219
► Appropriate lifestyle changes
 = Cornerstone for the prevention of HT
 Also important for its treatment
 BP-lowering effects of targeted lifestyle modifications
can be equivalent to drug monotherapy.

Malaysian CPG on
4th Edition 2013
► Definition of control:
 <140/90 mmHg in general
 <140/80 mmHg for patients with DM
 <130/80 mmHg for patients with
ischaemic heart disease/cerebrovascular
disease/renal impairment

Euro. Heart J. 2013;34:2159-219
► SBP control target is <140 mm Hg
 Regardless of the level of risk
 i.e. irrespective of whether there is presence of DM, chronic kidney
disease, or cardiovascular event
► For patients with diabetes
 Pushing the blood pressure of below 130 mm Hg
 no additional benefit
 more adverse events
 ‘The lower the better’ is no longer true.
 This will reduce the number of drugs that patients receive and will
avoid some adverse effects

Euro. Heart J. 2013;34:2159-219
► SBP goal for elderly patients (65 years)
 < 150 mm Hg
 Can lower to less than 140 mm Hg for "fit elderly
patients" younger than 80 years old if treatment is well
tolerated.
► DBP target
 <90 mmHg is always recommended
 except in patients with diabetes
►<85 mmHg are recommended
►Should nevertheless be considered that DBP values between 80
and 85 mmHg are safe and well tolerated.

Malaysian CPG on
4th Edition 2013
►Non-Pharmacological Management
 Body Mass Index or weight
►Asians Normal: 18.5 to 23.5 kg/m2.
►Aim for an ideal BMI [Weight (kg)/Height2 (m)]
►A weight loss as little as 4.5 kg significantly reduces
BP.

BMI
Malaysia CPG on Management of Obesity 2004
CLASSIFICATION BMI (Kg / m2) Risk of CVD
Underweight < 18.5
Low (but increased risk of other
clinical problems)
Normal range 18.5-22.9 Average
Overweight > 23.0
Pre-Obese 23.0-27.4 Increased
Obese I 27.5-34.9 Moderate
Obese II 35.0-39.9 Severe
Obese III > 40.0 Very Severe

BMI
Malaysia CPG on Management of Obesity 2004
►The following waist circumference is
associated with an increased risk of co-
morbidities:
 Men ≥ 90 cm
 Women ≥ 80 cm

Malaysian CPG on
4th Edition 2013
 Exercise
►“milder” exercise:
►brisk walking for 30 – 60 minutes at least 5 times a
week

Dietary Measure
 Diet
►A diet rich in fruits, vegetables and dairy products
with reduced saturated and total fat can substantially
lower BP
 11/6 mmHg in hypertensive patients and
 4/2 mmHg in patients with high normal BP
► (Malaysian CPG on Management of Hypertension 4th Edition 2013)

Dietary Measure
 Diet
►A dietary pattern that
 Emphasizes fruits, vegetables, whole grains, low-fat dairy
products, poultry, fish and nuts
 Limit red meat and sugary foods and beverages
 Use naturally occurring, unhydrogenated, vegetable oils
most often.
► American Heart Association [Updated:Oct 7,2015]
http://www.heart.org/HEARTORG/HealthyLiving/HealthyEating/Nutriti
on/Trans-Fats_UCM_301120_Article.jsp#

Dietary Measure
 Diet
►Current evidence suggests there is “no appreciable
relationship” between heart disease and dietary
cholesterol.
►Reduce consumption of trans fat and saturated fat to
<1% and <10% of total daily calorie intake.
 United States Department of Agriculture. Scientific Report of the 2015
Dietary Guidelines Advisory Committee. February 2015

Malaysian CPG on
4th Edition 2013
 Salt intake
►<100 mmol of sodium, or
►6g of sodium chloride a day:
 < 1 ¼ teaspoonfuls of salt; or
 3 teaspoonfuls of monosodium glutamate
►NOTE: Recommendation depends on your patient’s
own characteristics, e.g. does his occupation make
his sweat a lot?

Malaysian CPG on
4th Edition 2013
 Smoking
►Cessation ↓ cardiovascular risk substantially

Malaysian CPG on
4th Edition 2013
 Alcohol
►< 21 units for men per week
►< 14 units for women per week
►1 unit of alcohol =
 ½ pint of beer; or
 100ml of wine; or
 20ml of proof whisky

Euro. Heart J. 2013;34:2159-219
The use of antihypertensive drugs
► The main benefits are due to lowering of BP per se, and are
largely independent of the drugs employed.
► Diuretics, beta-blockers, calcium antagonists, ACE-inhibitors and
angiotensin receptor blockers
 all suitable for the initiation and maintenance of antihypertensive
treatment, either as monotherapy or in combination therapy.
► Some agents should be considered as the preferential choice in
specific conditions
 E.g. coronary heart disease, heart failure, diabetes or renal
dysfunction.

Malaysian CPG on
4th Edition 2013
► Hypertensive urgencies
 Severe HT: BP >180/110 mmHg
 grade III or IV retinal changes (accelerated and
malignant hypertension respectively)
 no overt organ failure
► Treatment
 admission
 Reduce BP by max 25% over 24 hours
 but not < 160/90 mmHg

Malaysian CPG on
4th Edition 2013
► Hypertensive emergencies
 Severe HT: BP >180/110 mmHg
 with one of more complications
►acute heart failure, dissecting aneurysm, acute coronary
syndromes, hypertensive encephalopathy, subarachnoid
haemorrhage, acute renal failure. These may occur in patients
►BP may be <180/110 mmHg, has risen rapidly
► Treatment
 Admission
 Reduce BP by max 25% over 3 to 12 hours
 but not < 160/90 mmHg

Malaysian CPG on
4th Edition 2013
► Rapid reduction in blood pressure
 May  ischaemic events (e.g. stroke, AMI)
 Avoid rapid reduction of BP (within minutes to hours) in
asymptomatic severe hypertension or hypertensive
urgencies
► Oral or sublingual drugs with rapid onset of action
(e.g. sublingual fast-acting nifedipine)
 May  excessive BP reduction  ischemic
events!

Malaysian CPG on
4th Edition 2013
►Resistant Hypertension =
 BP is not controlled on  3 drugs (including a
diuretic)
Renal sympathetic denervation is a treatment
option

Resistant hypertension and refractory hypertension
Refractory versus resistant hypertension” Curr Opin Nephrol Hypertens. 2017 Jan;26(1):14-19
► Resistant Hypertension =
 BP not controlled on ≥ 3 drugs, including a diuretic
 Affects 10-20% of patients on Rx
 Reason of resistance to Rx: Underlying persistent excess fluid
retention
► Refractory Hypertension =
 “BP not controlled on ≥ 5 drugs including a long acting thiazide
diuretic (e.g. chlorthalidone) & a mineralocorticoid receptor
antagonist (e.g. spironolactone)
 Rare: 5% of patients with resistant HT
 Reason of resistance to Rx: Underlying increased sympathetic
output
 Rx: Sympathetic inhibition (medication or device-based)

Malaysian CPG on
4th Edition 2013
►Ischemic stroke
 Avoid lower BP in 1st few days
►Unless patient has HT urgency /emergency
►Acute haemorrhagic stroke
 Safe to lower BP to < 140mmHg

Hypertension diagnosis & assessment 2018

Hypertension diagnosis & assessment 2018

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