Management of Patients Presenting with High BP

Incidental Findings; Management of patients presenting with high BP

Phil Swales

Consultant Physician Acute & General Medicine University Hospitals of Leicester NHS Trust Objectives

• The approach to an incidental finding of elevated Blood Pressure in an adult • Diagnosis of Hypertension • Hypertensive Crises – Hypertensive Urgency – Hypertensive Emergency Hypertension BP 260/150mmHg Hypertension

Stroke 1949. Died of massive Stroke within 4 Died of cerebral months, MI complications of haemorrhage 68 1948. stroke, 1965. days later. Died of haemorrhagic stroke, 1953. Case Scenario

• You are asked to review the President of the USA who has been found to have a BP of 260/150mmHg by his personal physician during an important conference. Assessment of the Patient with Elevated BP • History • Examination • Assess for Target/End Organ Damage • Assess Cardiovascular Risk Factors • Confirm diagnosis of hypertension – Consider secondary causes of hypertension – Initiate Management – Appropriate follow-up Important Aspects of the Physical Examination in the Hypertensive Patient

• Accurate measurement of blood pressure • General appearance: distribution of body fat, skin lesions, muscle strength, GCS • Fundoscopy • Neck: palpation and auscultation of carotids, thyroid • Heart: size, rhythm, sounds • Lungs: rhonchi, crepitations • Abdomen: renal masses, bruits over aorta or renal arteries, femoral pulses • Extremities: peripheral pulses, oedema • Neurologic assessment Routine Tests for the Investigation of All Patients with Hypertension

• Urinalysis

• Bloods; – Full Blood Count – Biochemistry – Glucose – Lipid Profile

• 12 Lead ECG Assess for Target Organ Damage

• Retinopathy • Clinical LVH • ECG-LVH • CXR-Cardiomegaly • ECHO-LVH/LV Mass/Diastolic Dysfunction • Lab-Renal Function/Micro-albuminuria • Vascular-bruits/Diminished pulses Target Organ Damage • What do UK Hypertension guidelines advise? – Diagnosis – Management – Severe Hypertension / Hypertensive Crises Diagnosis

If the clinic blood pressure is 140/90 mmHg or higher, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension.

National Institute for Health and Care Excellence CG 127 (2011) Definitions

• Stage 1 hypertension: • Clinic blood pressure (BP) is 140/90 mmHg or higher and • ABPM or HBPM average is 135/85 mmHg or higher.

• Stage 2 hypertension: • Clinic BP 160/100 mmHg is or higher and • ABPM or HBPM daytime average is 150/95 mmHg or higher.

• Severe hypertension: • Clinic BP is 180 mmHg or higher or • Clinic diastolic BP is 110 mmHg or higher.

National Institute for Health and Care Excellence CG 127 (2011) CBPM ≥140/90 mmHg CBPM ≥160/100 mmHg & ABPM/HBPM & ABPM/HBPM ≥ 135/85 mmHg ≥ 150/95 mmHg Stage 1 hypertension Stage 2 hypertension Care pathway

If target organ damage present or Offer antihypertensive 10-year cardiovascular risk > 20% drug treatment

Consider specialist If younger than 40 years referral

Offer lifestyle interventions

Offer patient education and interventions to support adherence to treatment

Offer annual review of care to monitor blood pressure, provide support and discuss lifestyle, symptoms and medication

National Institute for Health and Care Excellence CG 127 (2011) Aged over 55 years or black person of African or Caribbean family Aged under origin of any age Summary of 55 years antihypertensive drug treatment A C2 Step 1

Key 2 A + C Step 2 A – ACE inhibitor or low-cost angiotensin II receptor blocker (ARB)1 A + C + D Step 3 C – Calcium-channel blocker (CCB) D – Thiazide-like diuretic Resistant hypertension Step 4 A + C + D + consider further diuretic3, 4 or alpha- or beta-blocker5 Consider seeking expert advice National Institute for Health and Care Excellence CG 127 (2011) However, if you are in the USA…..

2017 - US Guidance recommends a change to the definition of Hypertension

*Individuals with SBP and DBP in 2 categories should be designated to the higher BP category. BP indicates blood pressure (based on an average of ≥2 careful readings obtained on ≥2 occasions.

2017 ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults

But what if the BP is Severely Elevated?

Severe hypertension: • “Clinic systolic blood pressure ≥180mmHg or clinic diastolic blood pressure ≥110mmHg; treat promptly”

National Institute for Health and Care Excellence CG 127 (2011) Hypertensive Crises

• The terms malignant hypertension and accelerated hypertension have been replaced by hypertensive urgency or hypertensive emergency.

• Blood pressure higher than 180 mm Hg systolic and/or 110 mm Hg diastolic is considered severe hypertension— a designation that includes hypertensive urgency and hypertensive emergency.

• The actual BP level may not be as important as the rate of BP rise; patients with chronic hypertension can often tolerate higher BP levels than previously normotensive individuals. Hypertensive Crises

• Hypertensive urgency and emergency are differentiated by the absence or presence of acute end-organ damage, respectively.

Causes of Hypertensive Crises

From: Improving Survival of Malignant Hypertension Patients Over 40 Years Am J Hypertens. 2009;22(11):1199-1204. doi:10.1038/ajh.2009.153 Am J Hypertens | © 2009 by the American Journal of Hypertension, Ltd.American Journal of Hypertension, Ltd. Prognosis of ‘Malignant Hypertension’

Harrington et al, 1959 Five-year survival by decade of diagnosis. MHT, malignant phase hypertension.

Generic assessment of patient – Severity – Target organ damage – Pointers towards secondary hypertension – Current treatment – Medicine Intolerance / Adherence – OTC / Illicit drugs – Clinical examination including appropriate BP measurement – Baseline investigations First Key Clinical Decision

1. Admit to an intensive, high dependency or coronary care unit for IV anti-hypertensive treatment to lower the BP over the next few minutes to hours.

2. Admit the patient for oral anti-hypertensive treatment ensuring the patient will be regularly monitored and reviewed aiming to lower the BP over 24 hours.

3. Advise oral anti-hypertensive treatment and allow patient home with appropriate follow-up arrangements. Hypertensive Urgency - Treatment

• Hypertensive Urgency: – Goal: Reduce BP to <160/100 over several hours to day • Elderly at high risk of ischemia from rapid reduction of BP, therefore slower reduction in BP in this patient population – Previously treated hypertension: • Increase dose of existing med or add another med • Reinstitution of med in non-compliant patients Hypertensive Urgency - Treatment

• Hypertensive Urgency continued: – Previously untreated hypertension: • Slow reduction of BP (one to two days): Calcium Channel Blocker (eg Nifedipine MR followed by Amlodipine), ACE inhibitor, (β-blocker) (oral antihypertensives usually enough)

• Some experts recommend: Initiate two agents or a combination agent (one being a thiazide diuretic) – Rationale: Most patients with BP >20/10 above goal will require two agents to control their BP Hypertensive Emergency - Treatment Hypertensive Emergency: – Patient will need admission (ideally CCU/HDU)

– Goal: Lower Diastolic BP to approximately 100-105 over 2-6 hours; max initial fall not to exceed 25% • More aggressive decrease can lead to ischemic stroke, myocardial ischemia, acute kidney injury

– Parenteral antihypertensives recommended over oral agents in initial treatment of hypertensive emergency • GTN • Sodium Nitroprusside (caution about cyanide toxicity) • Labetalol • Nicardipine Hypertensive Emergencies • Special Situations; • Acute Coronary Syndrome – BP targets: follow the general rule – NOTE: analgesia and pain control can influence BP – Use of IV GTN is first line / Alternatives include: IV β-blockers (esmolol) • Aortic Dissection – More stringent BP target – Aim 100-120 mmHg systole within 30 minutes – First line is IV labetolol / esmolol / Second line is nitroprusside or GTN – Again effective opiate analgesia will positively influence BP reduction • Severe Hypertension in Pregnancy – (Pre-)Eclampsia may present with moderately elevated BP – Treatment options include: Magnesium (seizure prevention), Labetolol, Hydralazine, Methyldopa – BP target: 130-150/80-100 mmHg • Phaeochromocytoma crisis – IV phentolamine is α-blocker of choice / Alternative would be IV phenoxybenzamine – Volume expand/rehydrate • Cocaine Induced Hypertension – Diazepam is 1st line (consider phentolamine/nitroprusside/GTN) Follow-Up

• Following discharge, BP is likely to continue to reduce gradually • Early review essential with appropriate monitoring • Target BP will be 140/90 or lower depending on individual patient co-morbidities Summary

• Incidental finding of elevated BP is common • Reviewed UK (and mentioned US) guidelines for diagnosis of hypertension • Reviewed UK guidance for management of uncomplicated hypertension • Special situation – Severe Hypertension • Differentiate Hypertensive Urgency from Emergency on the basis of acute end-organ damage • Can treat hypertensive urgency with oral antihypertensives, but parenteral medications required for hypertensive emergencies • 25% reduction in diastolic BP over 2-6 hours for hypertensive emergencies • Don’t forget to start Oral antihypertensives and follow-up closely!