2 Hypertension guidelines Seventh report of Joint National Committee on prevention, detection, evaluation & treatment of high BP(JNC7) JAMA May 2003; WHO/ISH statement on Mx. of HT J HT 2003; 21: Canadian recommendation Mx HTCan J Cardiol Jan 2004; 20: 55-9 British HT Society HT Mx (BHS-IV) BMJ Mar 2004: 328: ESC HT guidelines 2007 Eur Heart J 2007;28: BHS NICE guidelines Aug ESH/ESC guidelines of arterial HT 2013 (735 ref., 72 pages) JNC JAMA Dec 2013
3 Office blood pressure category in 2013 Mancia G ESH/ESC guidelines. Eur H J doc /euheartj/eht151
4 Measure Office blood pressure, take care of: Mancia G ESH/ESC guidelines. Eur H J doc /euheartj/eht151
5 Definitions: NICE 2011 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.
15 Use of anti-hypertensive treatment 30-y CVD risk ~10% 30-year risk score for cardiovascular disease 30-year risk score for cardiovascular disease WITH BMI WITH BMI PLEASE ENTER RISK FACTORS UNITS THE VALUES NOTES SEX m/f m AGE years 56 SBP mmhg 110 SMOKE y/n n TRTBP y/n n BMI kg/m² 23.6 DIAB y/n n PLEASE ENTER RISK FACTORS UNITS THE VALUES NOTES SEX m/f m AGE years 56 SBP mmhg 110 SMOKE y/n n TRTBP y/n y BMI kg/m² 23.6 DIAB y/n n Your Risk 34% Full CVD Optimal 32% Normal 38% Your Risk 50% Full CVD Optimal 32% Normal 38% Your Risk 22% Hard CVD Optimal 21% Normal 25% Your Risk 31% Hard CVD Optimal 21% Normal 25% Hard CVD: coronary death, myocardial infarction, fatal or non-fatal stroke Full CVD: hard CVD or coronary insufficiency, angina pectoris, transient ischemic attack, intermittent claudication or congestive heart failure
16 Prospective open cohort study with routinely collected data from general practice (n=531), 1 Jan 1993 to 31 Mar 2008: National QRESEARCH database. Participants 2.3 million pts aged (> 16 million person years), 2.22 million: white or ethnic group not recorded, : south Asian, : black African, : black Caribbean, and : Chinese or other Asian or other ethnic groups cardiovascular events.
19 Patients aged years who were free of cardiovascular disease and not taking statins between 1 January 1994 and 30 April 2010: in the derivation dataset, and in the validation dataset.
21 If I am on Anti-HT drug
22 Lifestyle changes in all HT Mancia G ESH/ESC guidelines. Eur H J doc /euheartj/eht151
33 Malignant HT is HT emergency Mancia G ESH/ESC guidelines. Eur H J doc /euheartj/eht151 SBP>180+DBP>120 mmhg. with ischemic OD (retina, kidney, heart or brain) Long-term prognosis remains poor, esp. renal function is severely reduced IV. infusion & titrated, to avoid excessive hypotension and further ischemic OD: Labetalol, sodium nitroprusside, nicardipine, nitrates and furosemide
39 HT urgencies vs. Reactive HT Isolated large BP elevations without acute OD (hypertensive urgencies) often associated with treatment discontinuation or reduction as well as with anxiety should not be considered an emergency but treated by reinstitution or ntensification of drug therapy and treatment of anxiety.
53 Dietary salt reduction & future CVD Bibbins-Domingo K. N Engl J Med 2010;362:590-9 CHD Policy Model: quantify benefits of potentially achievable, population-wide dietary salt reduction 3 g /d (1200 mg of Na/d). Estimated rates & costs of CVD in subgroups by age, sex & race; compared effects of salt reduction with other interventions to reduce CVD risk Determined cost-effectiveness of salt reduction as compared with HT Rx with medications.
54 Dietary salt reduction vs. interventions Bibbins-Domingo K. N Engl J Med 2010;362:590-9 Interventions CHD incidence Total death Salt reduction 1 g/d 3 g/d % % % % Smoking 3.7 % 4.3 % cessat n Weight loss 5.3 % 2.0 % Statin Rx 1 ry Px 5.3 % 0.3 % HT Med Rx 9.3 % 4.1 % Projected estimated of population intervention on Annual Reduction in CV events (% change from expected)
55 Gradual salt reduction: cost-effectiveness Bibbins-Domingo K. N Engl J Med 2010;362:590-9 ทำเอง (ลดเกล อ) ค มค ำ กว ำ ก นยำ ลดควำมด น
58 Case 1 : Physical examination A Thai female, good consciousness BP 150/80 mmhg PR 90/min regular BT 37.0 C RR 16 / min HEENT : not pale, no icteric sclerae Heart : PMI at 5 th ICS, lateral to MCL normal s1s2, no murmur Lung : normal breath sound, no adventitious sound
59 Case 1 : Physical examination Abdomen : not distend, soft Ext : no edema liver & spleen can t be palpable Movement : involuntary nonrhythmic hyperkinetic movement of Rt shoulder,arm,wrist,hand,leg distal > proximal Neuro : good consciousness & orientation CN : pupil 3 mm RTL BE EOM full, no facial weakness no tongue deviation, Other: neg.
60 Case 1 : Physical examination Motor : grade V all DTR 1+ all BBK no response bilateral Clonus negative bilateral Sensation : PPS intact Finger to nose & heel to knee intact No trunkal ataxia No dysdiadokokinesia
61 Case 1 : investigations CBC : Hb 14.8 g/dl Hct 42.8% Wbc 7,840 (N 54 L35 M 6.4) Plt 153,000 BS 631 mg/dl BUN 22 Cr 1.0 Na 121 K 3.8 Cl 77 CO 2 34 Ca 9.3 alb 3.9 CT scan: lacunar infarction
62 OPD card of last follow up (1 month before admission) S: สบายด O: BP 140/90 A: HT P: RM 3 months