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MANAGEMENT OF HYPERTENSION IN FAMILY PRACTICE

Ramesh Subramanian*

Family Physician, Chembur, Mumbai.

INTRODUCTION

Hypertension is a commonly encountered clinical condition in family practice. As it is usually asymptomatic, the onus is on the family physician to screen his patients and come to an early diagnosis. The family physician is also expected to come to a proper aetiological diagnosis, evaluate his patients for target organ damage and presence of associated conditions in addition to adequately managing them, treating emergencies and offering patient education.

Primary Screening

Opportunistic screening : All patients who visit the general practitioner should have their blood pressure checked, if they have not visited the clinic at least for a year. All patients who have readings more than 140/90 mm of Hg should be recalled for examination few weeks later. Confirmed high BP cases should be managed.

Selective screening is also done in patients with previous history or family history of hypertension, heart disease, strokes, vascular complications, people with diabetes mellitus, renal diseases, obesity and pregnant women.

Diagnosis

Hypertension is defined [1] as systolic pressure average of 140 mm of Hg or greater and/or a diastolic pressure average of 90 mm of Hg or greater. The blood pressure should be measured with a well calibrated sphygmomanometer using standard procedural guidelines.

A diagnosis of hypertension is made only after elevation of blood pressure is noted in three readings on different occasions over a period of months unless the elevation is associated with symptoms.

History

A detailed history is mandatory to identify severity of the disease and presence of other risk factors and would guide the line of management. [2] 1) age, 2) sex, 3) family history of hypertension and its complications at an early age, 4) history of cardiovascular, cerebrovascular and renal disease, 5) history of diabetes, 6) known duration and levels of blood pressure, 7) dietary habits (fats, salt), 8) smoking habits, 9) alcohol intake, 10) exercise, 11) work and home environment and exposure to stresses, 12) other associated diseases e.g. asthma, peripheral vascular disease, congestive heart failure, angina, diabetes, gout, impotence, 13) history of medicines patient is taking and history of use of oral contraceptives, corticosteroids, liquorice, non steroidal anti inflammatory drugs, MAO inhibitors, 14) results and side effects of previous antihypertensive therapy.

Physical examination

1. Proper measurement of blood pressure, 2) cardiovascular assessment for cardiac hypertrophy, signs of failure and peripheral signs of atherosclerosis, 3) neurological assessment, 4) examination of the abdomen for enlarged or tender kidneys, 6) other specific examination to look for evidence of secondary hypertension:

Prognathism, enlarged tongue, coarse features and large hands suggest acromegaly; moon facies, buffalo hump, fat trunk and striae nigrae, thin legs suggest Cushings; pulsations in neck and bruit over scapular region, delayed low amplitude femoral pulse suggest coarctation of aorta; bruit over abdomen suggests renal artery stenosis; loin pain, colic, haematuria suggest urinary tract disease; weakness of the muscles suggests Conn’s.

Fundoscopy

1. Grade 1 - mild arteriolar narrowing

2. Grade 2 - AV nicking, cupping

3. Grade 3 - Flame shaped haemorrhages or circular haemorrhages and cotton wool exudates,

4. Grade 4 - Papilloedema

Base line investigations

Baseline investigations are done to assess severity of cardiovascular disease, possible causes of hypertension, presence of other cardiovascular risk factors and basal values to judge adverse impacts of treatment.

1. Urinalysis for albumin, sugar, blood, red cells, pus cells and casts, abnormalities may indicate involvement of the kidney due to hypertension or may be a pointer to rule out kidney as a cause of hypertension.

2. Blood - CBC, ESR, BUN, creatinine, electrolytes, fasting blood sugar, uric acid, cholesterol, triglycerides and lipid profile. Elevated urea and creatinine may indicate renal involvement, low potassium may be an indicator of aldosteronism.

3. X-Ray chest for indicating cardiac size, left ventricular hypertrophy, clue to coarctation of aorta.

4. ECG may indicate presence of left ventricular hypertrophy.

Further investigations

The presence of one or more of the following features should make one suspect secondary hypertension which may call for additional investigations:

1) Hypertension under the age of 30 years, 2) clinical signs and symptoms of disease suggesting secondary hypertension, 3) raised urea or creatinine, 4) low potassium, 5) albuminuria, haematuria, glycosuria.

Additional investigations may also be called for in presence of malignant hypertension, uncontrolled hypertension or when the BP suddenly worsens or when there is sudden appearance of BP after 55 years.

• If renal aetiology/pathology is suspected, KUB, USG, IVP, renal angiography, renogram, renal biopsy may be required.

• 24 hours estimation of metanephrine and VMA and abdominal CT scan are useful in diagnosis of phaeochromocytoma.

• Plasma cortisol levels, urinary ketogenic and 17 hydroxy corticosteroid levels estimation, dexamethasone suppression test may be required in cases of suspected Cushing’s syndrome.

• Plasma aldosterone, plasma renin, urinary aldosterone levels, CT scans are done in a patient suspected of Conn’s disease.

• The clinical diagnosis of coarctation of aorta is confirmed by aortography.

• 2 D Echocardiography and Doppler studies help detect early hypertensive heart disease.

• Holter monitoring and stress testing are valuable aids in evaluating a hypertensive patient for ischaemic heart disease.

• CT scan/MRI, carotid doppler, angiography may be required for diagnosis of hypertensive cerebrovascular disease.

Classification and risk stratification [1]

Stage I : 140-159/90-99,

Stage 2 : 160-179/100-119,

Stage 3 : > 180/> 120 mm. of Hg.

Risk groups

A - no risk factors,

B - risk factors present,

C - end organ damage.

Treatment

A.  In secondary hypertension, treatment of the cause.

B. Non pharmacological treatment.

• Stage 1, group A lifestyle changes for one year before drugs

• Life style changes for all patients on drug therapy

• Diet rich in fruits, vegetables, low fat dairy foods with reduced saturated and total fats significantly lower blood pressure.

• Weight reduction in obese patients, salt restriction 4-6 gm of salt/day, avoiding salt on the table, processed food and foods with high salt content, stopping of smoking, limiting alcohol consumption to less than 30 ml/day, regular dynamic exercise, behaviour modification through relaxation exercises, biofeedback, autosuggestions, self hypnosis etc. may have beneficial effect.

C. Drug treatment

Principles of drug therapy

• The first choice may be a variety of antihypertensives from each class of drugs namely beta blockers, ACE inhibitors, calcium channel blockers, alpha blockers and diuretics.

• The choice is based on the characteristics of a patient and the presence of concomitant diseases.

• Diuretics and beta blockers are the first line of treatment of patients with uncomplicated hypertension.

• Old people with isolated systolic hypertension should be first treated with diuretics long acting calcium channel blockers are alternate choices.

• Patients with diabetes, kidney damage with hypertension should be treated with ACE inhibitors.

• Heart attacks with hypertension is a compelling indication for beta blockers and in some cases for ACE inhibitors and diuretics.

• Patient should be started on low dose of the initial drug. Long acting formulae are usually preferable and if a diuretic is not chosen as the first drug, it can enhance the effect of the other medication.

• As the cost of therapy can interfere with patient compliance, cost cutting measures like combination drugs, generic drugs etc. are advisable.

The commonly used drugs and their important features are given in Table 1.

Newer drugs

Losartan K (25-100 mg/day) Selective Angiotensin II type I receptor blocker, devoid of bradykinin related side effects like cough.

Lacidipine (2-8 mg/day) calcium channel blocker, slow onset, long action, vascular protective, antiatherogenic properties, does not cause reflex tachycardia.

Celiprolol (200-600 mg/day) third generation cardioselective beta blocker, weak vasodilator, no bronchoconstriction, favourable effect on lipid profile.

Carvedilol (12.5-25 mg/day) beta blocker with alpha mediated dilating property.

D.Treatment of associated conditions and complications of hypertension.

TABLE 1
Commonly used Antihypertensives
Drug, daily dose
Recommended in
Avoid in
Side effects
Betablockers
Atenolol 25-150 mg,

Metaprolol 50-200 mg
Young patients, anxious patients, angina, past MI, nonsmokers
Asthmatics, cardiac, decompensation, heart blocks, peripheral vasculardisease, hyperlipidemia
Bronchospasm, heart failure,
bradycardia,
fatigue hyperlipidemia,
impaired responseto hypoglycemia
Calcium channel blockers
Nifedipine 15-60 mg

Amlodipine 5-10 mg

Felodipine 5-20 mg

Nitrendipine 5-40 mg
Asthmatics, patients with concomitant angina (except nifedipine), PVD,
Heart blocks (verapamil and diltiazem)
Flushing, headaches, ankle oedema,
gum hyperplasia
ACE inhibitors
Captopril 25-150 mg,
Enalapril 2.5-15 mg,
Lisinopril 5-30 mg,

Ramipril 1.25-10 mg

Perindopril 4-8 mg
CHF, diabetes, LVH
Renal artery stenosis, pregnancy, use with caution in patients with CRF, and with diuretics
Cough, angioneurotic oedeman
Alpha blockers
Prazosin 1-5 mg

Terazosin 1-20 mg
Asthmatics, PVD, prostatic symptoms, impotence, hyperlipidemias
Severe aortic stenosis
Headache, dry mouth,
first dose syncope
Diuretics
Hydrochlorthiazide

12.5-50 mg

Indapamide 2.5-5 mg
Elderly patients, renal disease with sodium retention
Diabetics, hyperuricemia,
Hypokalemia, Hyperglycemia,Hyperuricemia,
Impotence, blood dyscrasias

E.Management of hypertensive crisis.

Hypertensive crisis may take the form of hypertensive urgency (where the BP needs to be controlled over a few days or weeks) or emergency (where the BP has to brought down over a period of hours).

Fundoscopy helps differentiate between accelerated hypertension (exudates, haemorrhages) and malignant hypertension (papilloedema).

Management of hypertensive crisis at the family physicians clinic includes treatment with sublingual nifedipine (5 mg) and sublingual captopril (6.25 to 12.5 mg). Frusemide is given if the patient has pulmonary oedema. Patient should be shifted to the hospital after initial treatment.

The drugs used in the hospital management include intravenous sodium nitroprusside, esmolol, magnesium sulphate, labetalol, enalaprilat, diazoxide and phentolamine.

Regular follow up

Regular monitoring, follow up, titration of dosage, anticipation of side effects and adjustment of therapy to ameliorate side effects of the patient are important. The concept of a ‘hypertension clinic’ where all hypertension patients are followed up on a certain day of the week/month is worth considering.

Patient education

Patient education is an important tool in sustaining patient compliance and for ensuring successful care. Any programme that does not give due importance to patient care is considered sub optimal. Patient education programme should be offered to each individual and structured to suit individual needs and at a level and language in accordance with the patients standard of education, literacy level and capacity to assimilate.

Dissemination of knowledge related to the dis ease, motivation to change lifestyle and way of living, are important. Patient has to be told that hypertension is not curable and that it is only controllable with diet, exercise, lifestyle modification and drugs. The importance of treatment is in preventing complications related to the disease. The importance of regular monitoring of the BP and regular medical follow up are stressed and reinforced at every clinic visit.

REFERENCES

    1. JNC VI report - hypertension treatment guidelines.
    2. M Paul Anand. ‘Hypertension’, API Text Book of Medicine. 1992.
    3. American heart Journal. 1995.

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