Accurate blood pressure measurement in the office
description
Transcript of Accurate blood pressure measurement in the office
The Seventh ReportThe Seventh Reportof the Joint National Committee on of the Joint National Committee on
the the
Prevention, Detection, Prevention, Detection, Evaluation, and Treatment Evaluation, and Treatment
of High Blood Pressureof High Blood PressureInternal Medicine/PediatricsInternal Medicine/Pediatrics
Noon conference seriesNoon conference seriesJuly 31, 2006July 31, 2006
Accurate blood pressure measurement in Accurate blood pressure measurement in the officethe office
Patient positionPatient position Patient should be seated in a chair (not on an Patient should be seated in a chair (not on an
examination table) for 5 minutesexamination table) for 5 minutes Feet on floorFeet on floor Arm supported at heart levelArm supported at heart level
Appropriate size cuffAppropriate size cuff Cuff bladder encircling at least 80% of the armCuff bladder encircling at least 80% of the arm
Classification of high blood pressure in Classification of high blood pressure in adultsadults
Classification is based on 2 measurments Classification is based on 2 measurments made at 2 separate office visitsmade at 2 separate office visits
NormalNormal Systolic Systolic 120 AND diastolic 120 AND diastolic 80 80
PrehypertensionPrehypertension Systolic 120-129 OR diastolic 80-89Systolic 120-129 OR diastolic 80-89 Increased risk for progression to hypertensionIncreased risk for progression to hypertension
Stage 1 hypertensionStage 1 hypertension Systolic 140-159 OR diastolic 90-99Systolic 140-159 OR diastolic 90-99
Stage 2 hypertensionStage 2 hypertension Systolic Systolic 160 OR diastolic 160 OR diastolic 100 100
Management of hypetensionManagement of hypetension
Reduction of cardiovascular and renal morbidity Reduction of cardiovascular and renal morbidity and mortalityand mortality
In patients In patients withwith diabetes mellitus diabetes mellitus oror renal renal disease, the target blood pressure is disease, the target blood pressure is 130/80 130/80
In patients In patients withoutwithout diabetes mellitus or renal diabetes mellitus or renal disease, the target blood pressure is disease, the target blood pressure is 140/90 140/90
Primary focus should be directed toward Primary focus should be directed toward achieving the achieving the systolicsystolic blood pressure goal blood pressure goal Most patients will achieve the diastolic pressure goal Most patients will achieve the diastolic pressure goal
once the systolic pressure is at goalonce the systolic pressure is at goal
Goals of pharmacotherapyGoals of pharmacotherapy
Management of hypetensionManagement of hypetension
Dietary Approaches to Stop Dietary Approaches to Stop Hypertension (DASH) dietHypertension (DASH) diet
Dietary sodium reductionDietary sodium reduction Independent of DASH dietIndependent of DASH diet
Physical activityPhysical activityModeration of alcohol consumptionModeration of alcohol consumption
Lifestyle modificationsLifestyle modifications
Management of hypetensionManagement of hypetension
For a 2100 kcal/day eating plan:For a 2100 kcal/day eating plan: Total fat: 27% of caloriesTotal fat: 27% of calories
Saturated fat: 6% of caloriesSaturated fat: 6% of caloriesProtein: 18% of caloriesProtein: 18% of caloriesCarbohydrate: 55% of caloriesCarbohydrate: 55% of caloriesCholesterol: 150 mgCholesterol: 150 mgSodium: 2,300 mgSodium: 2,300 mgPotassium: 4,700 mgPotassium: 4,700 mgCalcium: 1,250 mgCalcium: 1,250 mgMagnesium: 500 mgMagnesium: 500 mgFiber: 30 gFiber: 30 g
Dietary Approaches to Stop Hypertension (DASH diet)Dietary Approaches to Stop Hypertension (DASH diet)
Management of hypertensionManagement of hypertension
Thiazide-type diuretics should be used as initial Thiazide-type diuretics should be used as initial therapy for most patientstherapy for most patients Certain comorbidities are “compelling indciations” for the Certain comorbidities are “compelling indciations” for the
use of other drugs as initial monotherapy (see below)use of other drugs as initial monotherapy (see below) Most patients will require Most patients will require drugs to achieve drugs to achieve
target blood pressuretarget blood pressure If blood pressure is If blood pressure is 20/10 mmHg above target, 20/10 mmHg above target,
consider consider initiatinginitiating therapy with 2 drugs (separately therapy with 2 drugs (separately or in combination)or in combination) Consider the risk of orthostatic hypotension in such Consider the risk of orthostatic hypotension in such
patients who also have diabetes mellitus, autonomic patients who also have diabetes mellitus, autonomic neuropathy, etc neuropathy, etc
PharmacotherapyPharmacotherapy
Management of hypertensionManagement of hypertension
Patients should return at approximately monthy Patients should return at approximately monthy intervals until target blood pressure is reachedintervals until target blood pressure is reached
After blood pressure is stable at target, After blood pressure is stable at target, monitoring can usually be done at 3-6 month monitoring can usually be done at 3-6 month intervalsintervals
Serum potassium and creatinine should be Serum potassium and creatinine should be monitored at least 1-2 times per yearmonitored at least 1-2 times per year
Cormorbidities (diabetes mellitus, congestive Cormorbidities (diabetes mellitus, congestive heart failure, etc) may influence the monitoring heart failure, etc) may influence the monitoring scheduleschedule
MonitoringMonitoring
Management of hypertensionManagement of hypertension
Target blood pressure Target blood pressure 130/80 mmHg 130/80 mmHg Combinations of Combinations of 2 medications are usually 2 medications are usually
necessarynecessary ACE and ARBS slow the progression of non-ACE and ARBS slow the progression of non-
diabetic (as well as diabetic) kidney diseasediabetic (as well as diabetic) kidney disease Limited creatine elevation (Limited creatine elevation ( 35% above baseline) is 35% above baseline) is
acceptable (unless hyperkalemia develops)acceptable (unless hyperkalemia develops)
……with diabetes mellituswith diabetes mellitus
Management of hypertensionManagement of hypertension
Target blood pressure Target blood pressure 130/80 mmHg 130/80 mmHg Combinations of Combinations of 3 medications are usually 3 medications are usually
necessarynecessary ACE and ARBS slow the progression of diabetic ACE and ARBS slow the progression of diabetic
nephropathynephropathy
with chronic kidney diseasewith chronic kidney disease
Management of hypertensionManagement of hypertension
Stable angina pectorisStable angina pectoris Beta blockers are first-line therapyBeta blockers are first-line therapy
Calcium-channel blockers are an alternative to beta blockersCalcium-channel blockers are an alternative to beta blockers Acute coronary syndrome (unstable angina or Acute coronary syndrome (unstable angina or
myocardial infarction)myocardial infarction) Beta blockerBeta blocker ACE inhibitorsACE inhibitors
Post-myocardial infarctionPost-myocardial infarction Beta blockerBeta blocker ACE inhibitorACE inhibitor Aldosterone antagonistsAldosterone antagonists (lipid management and aspirin therapy)(lipid management and aspirin therapy)
with ischemic heart diseasewith ischemic heart disease
Management of hypertensionManagement of hypertension
Asymptomatic ventricular dysfunctionAsymptomatic ventricular dysfunction ACE inhibitorsACE inhibitors Beta blockesBeta blockes
Symptomatic ventricular dysfunctionSymptomatic ventricular dysfunction ACE inhibitors and ARBsACE inhibitors and ARBs Beta blockersBeta blockers Aldosterone blockersAldosterone blockers (loop diurectics)(loop diurectics)
……with congestive heart failurewith congestive heart failure
Management of hypertensionManagement of hypertension
Have a reduced response to monotherapy with…Have a reduced response to monotherapy with… Beta blockersBeta blockers ACE inhibitorsACE inhibitors ARBSARBS
……compared withcompared with DiureticsDiuretics Calcium channel blockersCalcium channel blockers
Combinations that include a diuretic largely Combinations that include a diuretic largely eliminate these differenceseliminate these differences
Incidence of angioedema 2-4 times greater than Incidence of angioedema 2-4 times greater than in other ethnic groupsin other ethnic groups
In African AmericansIn African Americans
Key messagesKey messages In persons older than 50 years, systolic blood
pressure greater than 140 mmHg is a much more important cardiovascular disease (CVD) risk factor than diastolic blood pressure.
The risk of CVD beginning at 115/75 mmHg doubles with each increment of 20/10 mmHg; individuals who are normotensive at age 55 have a 90 percent lifetime risk for developing hypertension.
Individuals with a systolic blood pressure of 120–139 mmHg or a diastolic blood pressure of 80–89 mmHg should be considered as prehypertensive and require health-promoting lifestyle modifications to prevent CVD.
Key messages (continued)Key messages (continued) Thiazide-type diuretics should be used in drug
treatment for most patients with uncomplicated hypertension, either alone or combined with drugs from other classes. Certain high-risk conditions are compelling indications for the initial use of other antihypertensive drug classes (angiotensin converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, calcium channel blockers).
Most patients with hypertension will require two or more antihypertensive medications to achieve goal blood pressure (<140/90 mmHg, or <130/80 mmHg for patients with diabetes or chronic kidney disease).
Certain high-risk conditions are compelling indications for the initial use of other antihypertensive drug classes (angiotensin converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, calcium channel blockers).
Key messages (continued)Key messages (continued) Thiazide-type diuretics should be used in drug
treatment for most patients with uncomplicated hypertension, either alone or combined with drugs from other classes. Certain high-risk conditions are compelling indications for the initial use of other antihypertensive drug classes (angiotensin converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, calcium channel blockers).
Most patients with hypertension will require two or more antihypertensive medications to achieve goal blood pressure (<140/90 mmHg, or <130/80 mmHg for patients with diabetes or chronic kidney disease).
If blood pressure is >20/10 mmHg above goal blood pressure, consideration should be given to initiating therapy with two agents, one of which usually should be a thiazide-type diuretic.
Key messagesKey messages • The most effective therapy prescribed by
the most careful clinician will control hypertension only if patients are
motivated. Motivation improves when patients have positive experiences
with, and trust in, the clinician. Empathy builds trust and is a potent
motivator. • In presenting these guidelines, the
committee recognizes that the responsible physician’s judgment remains paramount.
Key messagesKey messages • The most effective therapy prescribed by
the most careful clinician will control hypertension only if patients are
motivated. Motivation improves when patients have positive experiences
with, and trust in, the clinician. Empathy builds trust and is a potent
motivator. • In presenting these guidelines, the
committee recognizes that the responsible physician’s judgment remains paramount.
Key messagesKey messages The most effective therapy prescribed by
the most careful clinician will control hypertension only if patients are motivated. Motivation improves when patients have positive experiences with, and trust in, the clinician. Empathy builds trust and is a potent motivator.
In presenting these guidelines, the committee recognizes that the responsible physician’s judgment remains paramount.
QuestionQuestionCategoryCategory SystolicSystolic
pressurepressureDiastolic Diastolic pressurepressure
NormalNormal
PrehypertensiPrehypertensiononStage 1 Stage 1 hypertensionhypertensionStage 2 Stage 2 hypertensionhypertension
QuestionQuestionIndicationIndication((assume no comorbidity)assume no comorbidity)
Recommended initial Recommended initial therapytherapy
PrehypertensionPrehypertension
HypertensionHypertension
Stage 1 hypertensionStage 1 hypertension
Stage 2 hypertensionStage 2 hypertension
QuestionQuestionComorbidityComorbidity Recommended initial Recommended initial
therapytherapyDiabetes mellitusDiabetes mellitus
HypertensionHypertension
Ischemic heart Ischemic heart diseasediseaseCongestive heart Congestive heart failurefailure