EMERGENCY MEETING
FOR PHILHEALTH REQUIREMENTS
CLINICAL PRACTICE GUIDELINES ON
HYPERTENSION
CLINICAL PATHWAYS ON
HYPERTENSION
MAKATI MEDICAL CENTER
DEPARTMENT OF MEDICINE
SECTION OF CARDIOLOGY
DIAGNOSIS OF HYPERTENSION
• Patients with a blood pressure of 140/90
mm Hg or higher, recorded on at least 2
separate occasions at rest.
BP MEASUREMENTS:
Steps in taking blood pressure:
• Snug application of compression cuff
• Palpation of radial artery as compression cuff is inflated
• Palpation of radial artery as cuff is deflated as 2 – 3 mm Hg
per heartbeat
• Careful placement of stethoscope bell
• Inflation of compression cuff above systolic pressure
• Deflation of the cuff at a rate of 2 – 3 mm Hg per heartbeat
to determine systolic and diastolic blood pressure.
BP MEASUREMENTS:
Must Remember:
• Position of the patient.
– The patient may be sitting or lying. When the patient is
recumbent, the cuff is essentially at cardiac level. If the patient is
sitting, the arm and forearm should be supported on a tabletop at
heart level.
• If the patient can rest for a while before the blood
pressure is taken, it would seem preferable to use the
lying position.
• The difference in the reading obtained in both positions
ordinarily should not be significant. At times the
pressure may be much lower when the patient is
standing and whenever this condition is suspected,
readings should be taken in the lying, sitting and
standing positions
DIAGNOSTIC EVALUATION
FAMILY AND CLINICAL HISTORY
1.
2.
3.
4.
5.
6.
Duration and previous level of high BP
Indications of secondary hypertension
Risk Factors
Symptoms of Organ Damage
Previous antihypertensive therapy (efficacy, adverse events)
Personal, Family, Environmental Factors
PHYSICAL EXAMINATIONS
1.
2.
3.
Signs suggesting secondary hypertension
Signs of organ damage
Evidence of visceral obesity
CLASSIFICATION OF HYPERTENSION
Adapted from JNC VII Guidelines for Hypertension
BLOOD PRESSURE (BP)
STAGE
SYSTOLIC BP (mm Hg)
DIASTOLIC BP (mm Hg)
NORMAL
< 120
< 80
PREHYPERTENSION
120 – 139
80 -89
STAGE 1
HYPERTENSION
140 – 159
90 – 99
STAGE 2
HYPERTENSION
> 160
> 100
LAB INVESTIGATIONS (FOR NEW PATIENTS
OR PATIENTS LOST TO FOLLOW UP)
ROUTINE TESTS
Fasting Plasma Glucose
Serum total cholesterol, LDL cholesterol, HDL cholesterol, Triglycerides
Serum Potassium, Uric Acid, Creatinine
Estimated creatinine clearance (cockgraft-Fault formula) or glomerular filtration rate
(MDRD) Formula
Complete Blood Count
Urinalysis (Complemented by microalbuminuria; dipstick test and microscopic
examination)
Electrocardiogram
Chest X-Ray
Adapted from the Compendium of Abridged ESC Guidelines 2008.
LAB INVESTIGATIONS (FOR NEW PATIENTS
OR PATIENTS LOST TO FOLLOW UP)
RECOMMENDED TESTS
Echocardiogram
Carotid Ultrasound
Quantitative proteinuria (if dipstick test is positive)
Ankle Brachial Index (ABI)
Fundoscopy
Glucose Tolerance Test (If fasting plasma glucose > 5.6 mmol/L ) (100 mg/dL)
Home and 24 hour ambulatory BP monitoring
Pulse wave velocity measurement (where available)
**if clinically indicated
LAB INVESTIGATIONS (FOR NEW PATIENTS
OR PATIENTS LOST TO FOLLOW UP)
EXTENDED EVALUATION
Further search for cerebral, cardiac, renal and vascular damage
Mandatory in complicated hypertension
Search for secondary hypertension when suggested by history, physical examination
or routine tests; measurement of renin, aldosterone, corticosteroids, catecholamines in
plasma and/or urine; arteriographies; renal and adrenal ultrasound, computer assisted
tomography; magnetic resonance imaging
CRITERIA FOR HOSPITAL ADMISSION
1.
2.
Patients with hypertensive emergencies/ urgency should be admitted to the
hospital
Symptomatic Stage 2 Hypertension
(associated with severe headache, shortness of breath, epistaxis or severe
anxiety)
HYPERTENSIVE
EMERGENCY
HYPERTENSIVE
URGENCY
Severe elevations in blood pressure (BP) that are
complicated by evidence of progressive target organ
dysfunction, and will require immediate BP reduction
Severe elevations of BP but without evidence of
progressive target organ dysfunction and would be better
defined as severe elevations in BP without acute,
progressive target organ damage
Clinical Characteristics
of the Hypertensive Emergency
BLOOD PRESSURE
Usually > 220/140 mm Hg
FUNDOSCOPIC FINDINGS
Hemorrhages, exudates, papilledema
NEUROLOGIC STATUS
Headache, Confusion, Somnolence, Stupor, Visual loss,
Seizures, Foacl neurologic deficits, coma
CARDIAC FINDINGS
Prominent apical pulsation, cardiac enlargement,
congestive heart failure
RENAL SYMPTOMS
Azotemia, Proteinuria, Oliguria$
GI SYMPTOMS
Nausea, Vomiting
TREATMENT:
For Stage I Hypertension
THIAZIDE DIURETICS (for most)
May consider ACE-I, ARB, BB, CCB
Are the drugs of choice (if without
compelling indications)
A SECOND DRUG:
POTASSIUM SPARING DIURETICS
ALDOSTERONE RECEPTOR BLOCKERS
BETA BLOCKERS
ACE INHIBITORS
ANGIOTENSIN II ANTAGONIST
CALCIUM CHANNEL BLOCKERS
ALPHA I BLOCKERS
CENTRAL ALPHA II AGONISTS
DIRECT VASODILATORS
ADDITIONAL COMBINATION DRUG:
ACE I + CCB
Either as a separate prescription or in
fixed dose combinations with thiazide
diuretics may be used when the BP
remains uncontrolled or when BP is > 20
mm Hg above systolic goal or 10 mm Hg
above diastolic goal.
TREATMENT:
For Hypertension with Compelling Indications
DRUG
COMPELLING INDICATIONS
DIURETICS
Heart failure, High coronary disease risk,
diabetes, recurrent stroke prevention
BETA BLOCKERS
Post Myocardial Infarction, Heart Failure,
High Coronary Disease Risk, Diabetes
ACE INHIBITORS
Heart Failure, High coronary disease risk,
diabetes, Recurrent stroke prevention,
Chronic kidney disease, post MI
ANGIOTENSIN RECEPTOR BLOCKER
HCeart Failure, diabetes, chronic kidney
disease
CALCIUM CHANNEL BLOCKER
High coronary disease risk, Diabetes
ALDOSTERONE ANTAGONIST
Heart Failure, Post MI
For Stage 2 Hypertension (JNC VII) – SBP > 160 mm Hg/ DBP > 100 mm
Hg we may use initially the following medications:
CLONIDINE or CAPTOPRIL
CLONIDINE
75 mcg tablet
sublingual every 15
mintues for a
maximum of 3 doses
Is a centrally acting alpha-adrenergic agonist with onset of action 30 to 60
minutes after oral administration, and maximal effects are usually seen
within 2 to 4 hours. The most common adverse effect in the acute setting
is drowsiness affecting up to 45% of patients. Clonidine may be a poor
choice monitoring of mental status is important. Dry mouth is a common
complaint, and lightheadedness is occasionally observed.
CAPTOPRIL
25 mg
tabletSublingual
every 15 minutes for
a maxiumum of 3
doses
An angiotensin-converting enzyme inhibitor, is well tolerated and can
effectively reduce BP in a hypertensive urgency. Given by mouth, captopril
is usually effective within 15 to 30 minutes and may be repeated in 1 to 2
hours, depending on the response. The drug has been administered
sublingually. In which case the onset of action is within 10 to 20 minutes
with a maximal effect reached within 1 hour. Administration may lead to
acute renal failure in patients with high grade bilateral renal artery stenosis,
and some reflex tachycardia may be observed.
If unresponsive to sublingual medications then the following formulary
parenteral drugs may be used for hypertensive emergencies, vasodilators
(Sodium nitroprusside, nicardipine HCl, Nitroglycerine, Hydralazine Hcl and
adrenergic inhibitor – Esmolol Hcl) and titrate accordingly
AGENT
DOSE
ONSET/ DURATION OF
ACTION (AFTER
DISCONTINUATION)
PRECAUTIONS
NITROGLYCERINE
5 – 100 ug as IV
infusion
2 – 5 minutes/ 5 – 10
minutes
Headache, tachycardia,
vomiting, flushing,
methemoglobinemia
NICARDIPINE
5 – 15 mg/ hr IV
infusion
1 – 5 minutes/ 15 – 30
minutes, but may
exceed 12 hours after
prolonged infucion
Tachycardias, nausea,
vomiting, headache,
increased intracranial
pressure; hypotension
protracted after
prolonged infusions
If unresponsive to sublingual medications then the following formulary parenteral
drugs may be used for hypertensive emergencies, vasodilators (Sodium
nitroprusside, nicardipine HCl, Nitroglycerine, Hydralazine Hcl and adrenergic
inhibitor – Esmolol Hcl) and titrate accordingly
AGENT
DOSE
ONSET/ DURATION OF
ACTION (AFTER
DISCONTINUATION)
PRECAUTIONS
HYDRALAZINE
5 – 20 mg as IV bolus or 10 10 minutes IV > 1 hour
Tachycardia, headache,
to 40 mg IM; repeat every
20 - 30 minutes IM/ 4 – 6 vomiting, aggravation of
angina pectoris, sodium
4 – 6 hours
hours
and water retention and
increased intracranial
pressure
ESMOLOL
500 ug/ kg bolus injection
IV or 50 to 100
ug/kg/minute by infusion.
May repeat bolus after
5 minutes or increase
infusion rate to 300 ug/ kg/
min
1 – 5 minutes/ 15 – 30
minutes
First degree heart
block, congestive heart
failure, asthma
• For HYPERTENSIVE EMERGENCIES – The 1st drug to be given
ASAP to lower Blood Pressure to 2/3 of Systolic Blood Pressure
• For HYPERTENSIVE PATIENTS with suspected NEUROLOGIC
COMPONENT – Keep Blood pressure at least 140 – 160 mm Hg
until patient stabilizes
• OVERLAP
• Shift if FIRST DRUG of choice is not effective and patient is not
responding.
Clinical Pathways for Hypertension
Stage 2 – SBP > 160 mm Hg/ DBP > 100 mm Hg
1st 15 minutes
2nd 15 minutes
3rd 15 minutes
ASSESSMENT
Initial evaluation
• Include Neurologic Evaluation
Assessed Severity
• Hypertensive Urgency
• Hypertensive Emergency
• Stage 2 Hypertension
Risk Factors
Assessed
Response to treatment
assessed
DIAGNOSTICS
Baseline
Laboratory tests
Stat 5 (Na, K, FBS,
Hb, Hct)
12 Lead ECG
Additional hypertensive work-up upon
consultants discretion:
TREATMENTS/
MEDICATIONS
Clonidine 75 mcg tablet sublingual Clonidine 75 mcg
or Captopril 25 mg tablet sublingual tablet sublingual or
Captopril 25 mg tablet
Insert IV access
sublingual
TEACHING
Start parenteral antihypertensive
Patients are oriented briefed on the signs and symptoms of hypertension
• For Hypertensive urgency, control BP to at least 2/3 of SBP within 24 hours
• For Symptomatic Stage 2 Hypertension, control symptoms and discharge with
maintenance medications
• Upon discharge:
1. Patient education – lifestyle management
2. Home medications (anti-hypertensive medications)
3. Schedule for follow-up
Clinical Pathway: Hypertensive Emergencies and Urgencies
Is the patient pregnant or
up to 2 weeks postpartum?
NO
Toxidrome present?
Flushing, increased BP/HR?
YES
YES
Diagnosis: Consider
Eclampsia vs preeclampsia
Diagnosis: Cathecholamine excess?
Possibilities:
-Pheochromocytoma
-Cocaine / sypmathomimetics
-Antihypertensive withdrawal
Emergent labor & delivery
Emergent OB consult
NO
Chest pain or SOB present?
NO
Mental status changes with a
focal neurological deficit?
NO
Diagnosis:
Hypertensive encephalopathy
YES
Diagnosis:
Stroke
YES
Diagnosis:
-Acute myocardial infarction
-Aortic dissection
-Acute left ventricular failure
Hypertensive Urgency
1. Repeat BP elevated
2. Active, ongoing end-organ damage ruled out
3. History of HTN-related end-organ damage
Treatment options for patients on HTN meds:
1. Restart if non-compliant
2. Increase dose
3. Add another antihypertensive
(Indeterminate)
Treatment options for patients not on HTN meds:
1. Give oral meds
2. Not starting any meds
(Indeterminate)
1. Observe for several hrs
2. Repeat BP
3. Follow-up in 24-72 hrs
Algorithm for Treatment of
Hypertension
Lifestyle Modification
Not At Goal Blood Pressure (<140/90 mmHg)
(<130/80 mmHg for those with Diabetes or
Chronic Kidney Disease)
Initial Drug Choices
Without Compelling
Indications
Stage 1
Hypertension
(SBP 140-159 or
DBP 90-99 mmHg)
Thiazide-type diuretics
for most. May consider
ACEI, ARB, BB, CCB, or
combination
With Compelling
Indications
Stage 2
Hypertension
(SBP ≥ 160 or
DBP ≥ 100-99 mmHg)
Two-drug combination
for most. (usually
thiazide-type diuretic and
ACEI, or ARB, BB, or CCB)
Drugs for the compelling
indications
Other antihypertensive
drugs (diuretics, ACE,
ARB, BB, CCB) as needed
Not at Goal Blood
Pressure
Optimize dosages or add additional drugs until goal blood pressure is
achieved. Consider consultation with hypertension specialist