cardio ppt EMERGENCY MEETING FOR PHILHEALTH REQUIREMENTS headache

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					     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.   Duration and previous level of high BP
2.   Indications of secondary hypertension
3.   Risk Factors
4.   Symptoms of Organ Damage
5.   Previous antihypertensive therapy (efficacy, adverse events)
6.   Personal, Family, Environmental Factors

PHYSICAL EXAMINATIONS
1.   Signs suggesting secondary hypertension
2.   Signs of organ damage
3.   Evidence of visceral obesity
 CLASSIFICATION OF HYPERTENSION
         Adapted from JNC VII Guidelines for Hypertension
BLOOD PRESSURE (BP)    SYSTOLIC BP (mm Hg)    DIASTOLIC BP (mm Hg)
      STAGE

     NORMAL                   < 120                   < 80


 PREHYPERTENSION             120 – 139                80 -89


      STAGE 1                140 – 159               90 – 99
   HYPERTENSION

      STAGE 2                 > 160                   > 100
   HYPERTENSION
    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.   Patients with hypertensive emergencies/ urgency should be admitted to the
     hospital
2.   Symptomatic Stage 2 Hypertension
     (associated with severe headache, shortness of breath, epistaxis or severe
     anxiety)
                         Severe elevations in blood pressure (BP) that are
     HYPERTENSIVE        complicated by evidence of progressive target organ
     EMERGENCY           dysfunction, and will require immediate BP reduction

                         Severe elevations of BP but without evidence of
     HYPERTENSIVE        progressive target organ dysfunction and would be better
      URGENCY            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)      Are the drugs of choice (if without
May consider ACE-I, ARB, BB, CCB   compelling indications)

A SECOND DRUG:                     Either as a separate prescription or in
   POTASSIUM SPARING DIURETICS     fixed dose combinations with thiazide
   ALDOSTERONE RECEPTOR BLOCKERS   diuretics may be used when the BP
   BETA BLOCKERS                   remains uncontrolled or when BP is > 20
   ACE INHIBITORS                  mm Hg above systolic goal or 10 mm Hg
   ANGIOTENSIN II ANTAGONIST       above diastolic goal.
   CALCIUM CHANNEL BLOCKERS
   ALPHA I BLOCKERS
   CENTRAL ALPHA II AGONISTS
   DIRECT VASODILATORS
   ADDITIONAL COMBINATION DRUG:
      ACE I + CCB
                    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          Is a centrally acting alpha-adrenergic agonist with onset of action 30 to 60
   75 mcg tablet       minutes after oral administration, and maximal effects are usually seen
sublingual every 15    within 2 to 4 hours. The most common adverse effect in the acute setting
   mintues for a       is drowsiness affecting up to 45% of patients. Clonidine may be a poor
maximum of 3 doses     choice monitoring of mental status is important. Dry mouth is a common
                       complaint, and lightheadedness is occasionally observed.


                       An angiotensin-converting enzyme inhibitor, is well tolerated and can
    CAPTOPRIL          effectively reduce BP in a hypertensive urgency. Given by mouth, captopril
       25 mg           is usually effective within 15 to 30 minutes and may be repeated in 1 to 2
  tabletSublingual     hours, depending on the response. The drug has been administered
every 15 minutes for   sublingually. In which case the onset of action is within 10 to 20 minutes
 a maxiumum of 3       with a maximal effect reached within 1 hour. Administration may lead to
       doses           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           PRECAUTIONS
                                        ACTION (AFTER
                                      DISCONTINUATION)

NITROGLYCERINE    5 – 100 ug as IV   2 – 5 minutes/ 5 – 10    Headache, tachycardia,
                  infusion           minutes                  vomiting, flushing,
                                                              methemoglobinemia


NICARDIPINE       5 – 15 mg/ hr IV   1 – 5 minutes/ 15 – 30   Tachycardias, nausea,
                  infusion           minutes, but may         vomiting, headache,
                                     exceed 12 hours after    increased intracranial
                                     prolonged infucion       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          PRECAUTIONS
                                                  ACTION (AFTER
                                                DISCONTINUATION)
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
                4 – 6 hours                 hours                     angina pectoris, sodium
                                                                      and water retention and
                                                                      increased intracranial
                                                                      pressure
ESMOLOL         500 ug/ kg bolus injection     1 – 5 minutes/ 15 – 30   First degree heart
                IV or 50 to 100                minutes                  block, congestive heart
                ug/kg/minute by infusion.                               failure, asthma
                May repeat bolus after
                5 minutes or increase
                infusion rate to 300 ug/ kg/
                min
• 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                   Risk Factors             Response to treatment
              • Include Neurologic Evaluation      Assessed                 assessed
              Assessed Severity
              • Hypertensive Urgency
              • Hypertensive Emergency
              • Stage 2 Hypertension
DIAGNOSTICS   Baseline                             Additional hypertensive work-up upon
              Laboratory tests                     consultants discretion:
              Stat 5 (Na, K, FBS,
              Hb, Hct)
              12 Lead ECG
TREATMENTS/   Clonidine 75 mcg tablet sublingual Clonidine 75 mcg           Start parenteral anti-
MEDICATIONS   or Captopril 25 mg tablet sublingual tablet sublingual or     hypertensive
              Insert IV access                     Captopril 25 mg tablet
                                                   sublingual
 TEACHING     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                Toxidrome present?
           up to 2 weeks postpartum?       NO        Flushing, increased BP/HR?

                      YES                                              YES

       Diagnosis: Consider                                   Diagnosis: Cathecholamine excess?
            Eclampsia vs preeclampsia                        Possibilities:
                                                             -Pheochromocytoma
                                                             -Cocaine / sypmathomimetics
                                                             -Antihypertensive withdrawal
          Emergent labor & delivery
          Emergent OB consult                         NO


                                          Chest pain or SOB present?



                                          NO               YES


                    Mental status changes with a       Diagnosis:
                    focal neurological deficit?        -Acute myocardial infarction
                                                       -Aortic dissection
                                                       -Acute left ventricular failure
                      NO                  YES


       Diagnosis:                       Diagnosis:
       Hypertensive encephalopathy      Stroke
                        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:            Treatment options for patients not on HTN meds:
1. Restart if non-compliant                            1. Give oral meds
2. Increase dose                                       2. Not starting any meds
3. Add another antihypertensive                        (Indeterminate)
(Indeterminate)




                                     1. Observe for several hrs
                                     2. Repeat BP
                                     3. Follow-up in 24-72 hrs
Algorithm for Treatment of
                                                      Lifestyle Modification
       Hypertension
                                           Not At Goal Blood Pressure (<140/90 mmHg)
                                            (<130/80 mmHg for those with Diabetes or
                                                     Chronic Kidney Disease)



                                                       Initial Drug Choices



                             Without Compelling                                   With Compelling
                                 Indications                                        Indications




                     Stage 1                          Stage 2                   Drugs for the compelling
                  Hypertension                     Hypertension                        indications
                 (SBP 140-159 or                   (SBP ≥ 160 or
               DBP 90-99 mmHg)                DBP ≥ 100-99 mmHg)                Other antihypertensive
             Thiazide-type diuretics         Two-drug combination                drugs (diuretics, ACE,
             for most. May consider             for most. (usually              ARB, BB, CCB) as needed
              ACEI, ARB, BB, CCB, or        thiazide-type diuretic and
                   combination              ACEI, or ARB, BB, or CCB)




                                                        Not at Goal Blood
                                                            Pressure

                               Optimize dosages or add additional drugs until goal blood pressure is
                                   achieved. Consider consultation with hypertension specialist

				
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posted:1/26/2011
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