1. HYPERTENSION

2. Hypertension 5th leading cause of morbidity in the Philippines (2005) Prevalence of 6.2% in the Filipino elderly

3. The Seventh Report of the Joint National Committee onPrevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)

5. Starting at 115/75 mmHg, CVD risk doubles with each increment of 20/10 mmHg throughout the BP range.

6. Persons who are normotensive at age 55 have a 90% lifetime risk for developing HPN.

7. Those with SBP 120–139 mmHg or DBP 80–89 mmHg should be considered prehypertensive who require health-promoting lifestyle modifications to prevent CVD.Key Messages

9. Certain high-risk conditions are compelling indications for other drug classes.

10. Most patients will require two or more antihypertensive drugs to achieve goal BP.

12. Motivation improves when patients have positive experiences with, and trust in, the clinician.

13. Empathy builds trust and is a potent motivator.

15. Definition of Hypertension BP of 140/90 recorded on at least two separate occasions

17. Each increment of 20/10 mmHg doubles the risk of CVD across the entire BP range starting from 115/75 mmHg.

19. BP Measurement Techniques

21. Patient should be seated quietly for 5 minutes in a chair (not on an exam table), feet on the floor, and arm supported at heart level.

22. Appropriate-sized cuff should be used to ensure accuracy.

23. At least two measurements should be made.

25. Ambulatory BP values are usually lower than clinic readings.

26. Awake individuals with hypertension have an average BP of >135/85 mmHg and during sleep >120/75 mmHg.

29. History Age of onset Other co-morbid conditions Ingestion of medications/supplements Family history

31. Cigarette smoking

32. Obesity* (BMI >30 kg/m2)

33. Physical inactivity

34. Dyslipidemia*

35. Diabetes mellitus*

36. Microalbuminuria or estimated GFR <60 ml/min

37. Age (older than 55 for men, 65 for women)

38. Family history of premature CVD (men under age 55 or women under age 65)*Components of the metabolic syndrome.

39. Medications that may induce/worsen hypertension Sodium-containing antacids NSAIDs, Cyclooxygenase 2 inhibitors Sympathomimetics (decongestants, anorectics) Oral contraceptives Corticosteroids Cyclosporine, tacrolimus Erythropoietin Licorice (including some chewing tobacco)

40. Physical Examination Truncal obesity, moon face, acne, other features of Cushing’s syndrome Sweaty palms, fine tremors, brisk DTRs, new onset AF Dry skin, hair loss, bradycardia Abdominal bruits Palpable bilateral flank mass Tachycardia, labile BP

42. Left ventricular hypertrophy

43. Angina or prior myocardial infarction

44. Prior coronary revascularization

45. Heart failure

46. Brain

47. Stroke or transient ischemic attack

48. Chronic kidney disease

49. Peripheral arterial disease

51. Drug-induced or related causes

52. Chronic kidney disease

53. Primary aldosteronism

54. Renovascular disease

55. Chronic steroid therapy and Cushing’s syndrome

56. Pheochromocytoma

57. Coarctation of the aorta

59. Laboratory Tests Optional Tests: Urinary albumin excretion Albumin/Creatinine ratio Work-up for other identifiable causes of Hypertension if BP control is not achieved.

60. TREATMENT

61. Goals of Therapy Reduction of cardiovascular and renal morbidity and mortality Target BP: < 140/90 < 130/80 (diabetes, renal disease)

62. Lifestyle Modification

63. Lifestyle Modification Maintain normal body weight (BMI = 18.5 to 24.9) Diet rich in fruits, vegetables, low fat dairy products with reduced content of saturated and total fat Reduce dietary sodium intake Regular aerobic physical activity Moderate alcohol consumption (men ≤ 2 drinks/day; women ≤ 1 drink/day)

64. With Compelling Indications Without Compelling Indications Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Stage 2 Hypertension(SBP >160 or DBP >100 mmHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) Stage 1 Hypertension(SBP 140–159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved.Consider consultation with hypertension specialist. Algorithm for Treatment of Hypertension Lifestyle Modifications Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices

65. Classification and Management of BP for adults *Treatment determined by highest BP category. †Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension. ‡Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.

67. More frequent visits for stage 2 HPN or with complicating comorbid conditions.

70. Other Special Situations

71. Minority populations

72. Obesity and the metabolic syndrome

73. Left ventricular hypertrophy

74. Peripheral arterial disease

75. Hypertension in older persons

76. Postural hypotension

77. Dementia

78. Hypertension in women

79. Hypertension in children and adolescents

81. Compelling Indications for Individual Drug Classes

84. Any class of drugs can be used in most PAD patients.

85. Other risk factors should be managed aggressively.

87. This population has the lowest rates of BP control.

88. Treatment, including those who with isolated systolic HPN, should follow same principles outlined for general care of HPN.

90. BP in these individuals should be monitored in the upright position.

93. Development of HPN—consider other forms of contraception.

95. Use lifestyle interventions first, then drug therapy for higher levels of BP or if insufficient response to lifestyle modifications.

96. Drug choices similar in children and adults, but effective doses are often smaller.

99. BBs useful in the treatment of atrialtachyarrhythmias/fibrillation, migraine, thyrotoxicosis (short-term), essential tremor, or perioperative HTN.

100. CCBs useful in Raynaud’s syndrome and certain arrhythmias.

102. BBs should be generally avoided in patients with asthma, reactive airway disease or 2nd or 3rd degree heart block.

103. ACEIs and ARBs are contraindicated in pregnant women or those likely to become pregnant.

104. ACEIs should not be used in individuals with a history of angioedema.

108. Excess sodium intake

109. Inadequate diuretic therapy

110. Medication

111. Inadequate doses

112. Drug actions and interactions (e.g. NSAIDs, illicit drugs, sympathomimetics, oral contraceptives)

113. OTC drugs and herbal supplements

114. Excess alcohol intake