hypertension
HYPERTENSION
Hypertension is the medical term for high blood pressure. Persistent high blood pressure can lead to increased strain to the heart and arteries that can eventually cause organ damage.
To classify the blood pressure, it must be based on ≥2 properly measured, seated blood pressure readings on each of ≥2 office visits.
Goals of therapy are to manage hypertension that can maintain the patient's normal blood pressure and identify and treat all reversible risk factors.

Patient Education

High Normal or Elevated Blood Pressure

  • Warn patients with high normal or elevated BP that they are at high risk for developing hypertension
  • Inform them that lifestyle modification may reduce this risk
  • Advise those with DM and kidney disease that they are candidates for drug therapy if lifestyle modification fails to decrease their BP to goal
  • Periodic follow-up (eg every 3-6 months) is recommended to detect and treat hypertension as early as possible

All Patients

  • Patients need to be highly motivated to establish and maintain a healthy lifestyle and to take prescribed antihypertensive medications
  • If diagnosis of hypertension is not made, measure the patient’s clinic BP at least annually thereafter
    • More frequent BP measurement for patients whose clinic BP is close to 130/80 mmHg
  • Patients should be made aware that lowering BP can decrease death from stroke, coronary events, HF, along with decreasing the progression of renal failure
    • All causes of mortality can be reduced with effective antihypertensive management
  • Encourage measuring BP at home
  • Work with the patient to establish the goal of therapy
  • The patient’s cultural beliefs may influence their attitude and the physician needs to be sensitive when handling these issues

BP Measurement and Monitoring

  • Before taking BP measurements, advise patients to:
    • Avoid exercise, caffeine intake and smoking 30 minutes prior to measurement
    • Remove any clothing that can hinder cuff placement
    • Make sure the logbook is within reach
    • Make sure all devices to be used are working properly (tubes, cuff, batteries, stethoscope)
    • Avoid crossing legs, talking and any sudden movements during the measurement
  • Advise patients about different BP measuring devices:
    • Make sure devices to be used are professionally validated
    • Devices that measure BP from the brachial artery are preferred than those that read from distal sites (fingers, wrists)
    • Electronic BP devices are preferred to be used
    • Advise patients to have their mercurial/aneroid apparatus checked every 1-2 years and every 6 months for electronic devices 
  • Inform patients about appropriate cuff sizes (refer to table below)
  • RECOMMENDED CUFF SIZES
    Arm Circumference Description Cuff Size
    22-26 cm Small Adult 12x22 cm
    27-34 cm Adult 16x30 cm
    35-44 cm Large Adult 16x36 cm
    45-52 cm Adult Thigh 16x42 cm
  • Instruct patients on how to do self-measurement/monitoring of BP. Advise them to:
    • Measure at the same time in the morning and evening
    • Find a quiet room with a comfortable chair
    • Rest for at least 5 minutes before taking BP measurement
    • Sit down with back supported, feet on the floor, arm supported horizontally, and BP cuff at the level of the heart
    • When using a sphygmomanometer, slowly inflate the cuff while palpating the brachial artery. When the pulse disappears (SBP), slowly deflate the cuff, taking note when the pulse reappears (DBP)
    • Now with the use of a stethoscope, reinflate the cuff 20 mmHg above the previous SBP, then deflate the cuff by 1-2 mmHg/second. Inform the patient that when a tapping sound is heard, this is the SBP, and when it disappears, this is the DBP
    • Follow instructions on how to use electronic devices properly. Stay still while the apparatus takes the BP reading
    • Wait for 1-2 minutes, then take another BP measurement
    • Write the results in the logbook immediately after each reading

Lifestyle Modification

  • Considered the cornerstone of hypertension prevention and treatment
  • BP-lowering effects can be equivalent to drug monotherapy; major drawback is diminishing patient compliance over time
  • Effects include:
    • Prevention or delay of hypertension among nonhypertensive individuals
    • Prevention of or delay in the use of drug therapy among those in stage 1 or grade 1 hypertension
    • Contribute to BP reduction among hypertensive patients already on drug therapy, allowing for the reduction of the doses and number of antihypertensive agents
  • May also contribute to the control of other medical conditions and CV risk factors
  • Annual follow-up is recommended to detect and treat hypertension as early as possible

Weight Reduction and Maintenance

  • Helpful in treating hypertension, DM and lipid disorders, especially among overweight or obese patients
  • Maintenance of a healthy body weight (BMI of about 23 kg/m2) and waist circumference (<90 cm in men; <80 cm in women)
    • SBP is reduced by 1 mmHg with a weight loss of 1 kg from baseline
  • Should use a multidisciplinary approach that includes regular exercise and appropriate diet
    • Increase intake of polyunsaturated fatty acids and decrease total and saturated fat
  • Weight loss and exercise are recommended in patients also because of the relationship between obesity and obstructive sleep apnea
    • Continuous positive airway pressure (CPAP) therapy may also be used to reduce obstructive sleep apnea

Salt Restriction

  • There is evidence that a causal relationship between BP and salt intake exists
    • Excessive salt intake may contribute to resistant hypertension
    • Mechanisms include increasing peripheral vascular resistance and extracellular volume
  • A daily intake of 5-6 g of salt is recommended for the general population; optimal goal is <1.5 g/day 
    • Studies have shown that a salt reduction to about 5 g/day results in a modest (1-2 mmHg) SBP-lowering effect among normotensive individuals while this effect is more pronounced (4-5 mmHg) among hypertensive individuals
  • Effects of salt reduction is seen more among older people, among black population, and in patients with metabolic syndrome, DM or CKD

Other Dietary Changes

  • Advise patients to consume whole grains and proteins from plant sources, soluble fiber, low-fat daily products
  • Replace traditional diet with fresh vegetables and fruits
    • Consumption of fruits among overweight patients should be done with caution due to possible high carbohydrate content of some fruits which may promote weight gain
  • Potassium supplementation (3.5-5 g/day) is recommended except in patients with CKD or patients using drugs that decrease excretion of potassium

Regular Exercise

  • Regular aerobic exercise can contribute in both in the prevention and management of hypertension, and in lowering risk of CV morbidity and mortality
  • Patients may be advised to engage in at least 30 minutes of moderate-intensity dynamic aerobic exercise (eg walking, cycling, jogging, swimming) for 5-7 days weekly

Moderate Alcohol Consumption

  • Discourage excessive alcohol consumption since great amounts can raise BP
  • Limit alcohol consumption:
    • Among hypertensive men: To <20-30 g of ethanol/day (<140 g/week or <14 units/week)
    • Among hypertensive women: To <10-20 g of ethanol/day (<80 g/week or <8 units/week)

Smoking Cessation

  • Since smoking is a major CV risk factor, patients must be advised to stop this habit
  • Also a most effective lifestyle measure for preventing CVDs, including myocardial infarction, stroke and peripheral vascular diseases
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