Hypertension

Hypertension free pdf ebook was written by on May 16, 2005 consist of 29 page(s). The pdf file is provided by www.bop.gov and available on pdfpedia since April 08, 2011.

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Hypertension pdf




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Hypertension - page 1
Hypertension June, 2004 (reformatted May, 2005) (Federal Bureau of Prisons - Clinical Practice Guidelines) Clinical guidelines are being made available to the public for informational purposes only. The Federal Bureau of Prisons (BOP) does not make any promise or warrant these guidelines for any other purpose, and assumes no responsibility for any injury or damage resulting from the reliance thereof. Proper medical practice necessitates that all cases are evaluated on an individual basis and treatment decisions are patient-specific.
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Hypertension - page 2
Hypertension June, 2004 (reformatted with minor changes May, 2005) (Federal Bureau of Prisons - Clinical Practice Guidelines) Table of Contents 1. Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2. Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Diagnostic criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diagnostic monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1 2 2 3. Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 4. Baseline Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Medical history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Physical examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Calculation of body mass index (BMI) . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Diagnostic evaluations - routine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Diagnostic evaluations - supplemental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 5. Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Primary prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Lifestyle modifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Dietary management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Smoking cessation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Alcohol use and illicit drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Pharmacologic treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Special treatment considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Ischemic heart disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Heart failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Chronic kidney disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Cerebrovascular disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Demographic factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Geriatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Asthma/COPD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 i
Hypertension - page 3
Federal Bureau of Prisons Clinical Practice Guidelines Hypertension June, 2004 Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hormone replacement therapy and oral contraceptives . . . . . . . . . . . . . . . Treatment failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Hypertensive crises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 11 11 11 6. Periodic Evaluations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 7. Health Care Staff Resources and Self Assessment . . . . . . . . . . . . . . 13 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Appendices Appendix 1: Classification and Management of Hypertension with Lifestyle Modifications and Drug Therapy . . . . . . . . . . . . . . . . . 15 Appendix 2: Recommended Antihypertensive Drugs for Compelling Indications . . . . 16 Appendix 3: Other Drug Treatment Considerations For Hypertensive Inmates . . . . . 17 Appendix 4: Causes of Treatment Failure in Hypertension . . . . . . . . . . . . . . . . 18 Appendix 5: Patient Education Program - Hypertension . . . . . . . . . . . . . . . . . 19 Appendix 6: Inmate Fact Sheet - Hypertension . . . . . . . . . . . . . . . . . . . . . . 24 Appendix 7: Inmate Fact Sheet - Reducing Dietary Sodium . . . . . . . . . . . . . . . 25 Appendix 8: Resources - Management of Hypertension . . . . . . . . . . . . . . . . . 26 ii
Hypertension - page 4
Federal Bureau of Prisons Clinical Practice Guidelines Hypertension June, 2004 1. Purpose The Federal Bureau of Prisons, Clinical Practice Guidelines for Hypertension provide recommendations for the medical management of inmates with hypertension. 2. Diagnosis Diagnostic criteria: Hypertension is diagnosed with an accurately measured systolic blood pressure (SBP) of 140 mm Hg or greater or a diastolic blood pressure (DBP) of 90 mm Hg or greater. A lower diagnostic threshold for intervention (SBP of 130 mm Hg or greater or a DBP of 80 mm Hg or greater) is indicated for persons with diabetes and/or renal disease. Methodology: Hypertension detection begins with the proper measurement of blood pressure. Measurements are optimally taken with a mercury sphygmomanometer; otherwise, a recently calibrated aneroid manometer or validated electronic device can be used. Diagnostic measurements of blood pressure should not be taken when inmates are taking antihypertensive drugs, when acutely ill, following the recent consumption of caffeine or use of nicotine, or during other situations where the reading may be falsely elevated or depressed from baseline. Blood pressure should be measured using the following guidelines: Inmates should be seated in a chair with their backs supported and their arms bared and supported at heart level. Ideally the inmate should sit quietly in this position for at least 5 minutes before the blood pressure is measured. Inmates ideally should refrain from smoking, eating, or ingesting caffeine during the 30 minutes prior to the measurement. Under certain circumstances (e.g., older persons, persons with coexisting cardiovascular disease, congestive heart failure, peripheral arterial disease or diabetes) measuring blood pressure in the supine and standing positions may be helpful diagnostically. The appropriate cuff size (12-14 cm wide for an average adult, 15 cm wide cuff on an obese arm) must be used to ensure accurate measurement. The bladder within the cuff should be about 80% of the circumference of arm, almost long enough to encircle the arm. Cuffs that are too short or too narrow may give falsely high readings. Using a regular-size cuff on an obese arm may lead to a false diagnosis of hypertension. The majority of males require a large blood pressure cuff. The blood pressure should at first be estimated by palpation, by obtaining the radial artery pulse and rapidly inflating the cuff until the radial pulse disappears. The estimated pressure plus 30 mm Hg should be the target for inflation and should prevent discomfort from an unnecessarily high cuff pressure. After inflating the cuff, the cuff should be deflated rapidly to the targeted pressure, then deflated slowly at a rate of 2-3 mm Hg per second. The first detected sound is used to define SBP. The disappearance of sound is used to define DBP. 1
Hypertension - page 5
Federal Bureau of Prisons Clinical Practice Guidelines Hypertension June, 2004 The blood pressure should be taken in both arms at least once. The normal difference in blood pressure between arms is 5 mm Hg or less and sometimes as much as 10 mm Hg. Subsequent readings should be measured on the arm with the higher pressure. A pressure difference of more than 10-15 mm Hg between arms suggests arterial compression or obstruction on the side with the lower pressure and warrants further evaluation. Screening: Inmates should be screened for hypertension during intake and periodic physical examinations and during evaluations by BOP health care providers during sick call and chronic care clinic evaluations. Elevated readings should be reconfirmed on repeat visits as discussed below. Diagnostic monitoring: Inmates diagnosed with hypertension should be monitored through individualized follow-up evaluations with a frequency dependent on the inmate’s medical history, cardiovascular risk factors, symptoms, and the degree of hypertension detected. The following guidelines should be considered for monitoring inmates’ blood pressures: If SBP is < 120 mm Hg and DBP is < 80 mm Hg: inmates should have their blood pressure rechecked at their next periodic physical examination. If SBP is 120-139 mm Hg or DBP is 80-89 mm Hg: inmates without cardiovascular disease or risk factors should be given information and education regarding lifestyle modification, and have their blood pressure rechecked in one year. Inmates with cardiovascular risk factors should be reevaluated during the next 6 months with repeated blood pressure measurements and should be referred to a clinician for classification and baseline evaluation if elevated blood pressure readings are confirmed. Inmates age 40 or older who have blood pressures in this range should also be screened for diabetes. If SBP is 140-159 mm Hg or DBP is 90-99 mm Hg: inmates should have their blood pressure rechecked within 2 months and if hypertension is confirmed should be referred to a clinician for classification and baseline evaluation. If SBP is $160 mm Hg or DBP is $ 100 mm Hg: inmates should have their blood pressure rechecked within one month or as soon as medically indicated, and if hypertension is confirmed should be referred to a clinician for classification and baseline evaluation. If SBP is $180 mm Hg or DBP is $110 mm Hg: inmates should be evaluated for signs or symptoms of acute target organ damage (see Hypertensive Crises, below). Symptomatic inmates should be managed as a hypertensive emergency case or hypertensive urgency case. If the inmate is asymptomatic, he/she should be referred to a clinician immediately for confirmation of BP elevation and initiation of antihypertensive therapy, usually with two drugs (a thiazide plus either a beta-blocker or an ACE inhibitor as first choices.) 2
Hypertension - page 6
Federal Bureau of Prisons Clinical Practice Guidelines Hypertension June, 2004 3. Classification Blood pressure measurements in adults are classified into the following four categories: Normal: SBP <120 and DBP <80 Prehypertension: SBP 120-139 and DBP 80-89 Stage 1 Hypertension: SBP 140-159 or DBP 90-99 Stage 2 Hypertension: SBP $160 or DBP $100 Classifying hypertension should be based on at least 2 or more appropriately measured readings after initially measuring a high blood pressure reading. The higher stage should be used to classify blood pressure status when systolic and diastolic blood pressures fall into different categories. In addition to classifying stages of hypertension on the basis of average blood pressure levels, clinicians should specify the presence or absence of target organ disease and cardiovascular risk factors, since these factors are important for classification and treatment purposes. 4. Baseline Evaluation Objectives: The evaluation of persons with documented hypertension has three major objectives: 1) to identify known causes of high blood pressure; 2) to assess the presence or absence of target organ damage and cardiovascular disease, the extent of the disease, and the response to therapy; 3) to identify other cardiovascular risk factors, concomitant disorders or lifestyle concerns that may define prognosis and guide treatment. Data for evaluation are acquired through medical history, physical examination, laboratory tests, and other diagnostic procedures. In general, the data derived from the initial history, physical examination and limited testing are sufficient to screen for secondary causes of hypertension. Further diagnostic testing should be undertaken only when clinically indicated on a case by case basis when signs or symptoms of secondary hypertension are suggested by the medical history or physical examination, or when blood pressure control is not achieved with more than two appropriate medications. Medical history: The baseline medical history for inmates diagnosed with hypertension should be conducted by a clinician and include the following: Documentation of age, sex, and race, since end organ damage is much more common in the elderly, males, and African-Americans 3
Hypertension - page 7
Federal Bureau of Prisons Clinical Practice Guidelines Hypertension June, 2004 • Identification of associated cardiovascular risk factors: ! cigarette smoking ! dyslipidemia ! diabetes mellitus ! obesity (body mass index > 30-- see BMI calculation below) ! family history of premature cardiovascular disease (< age 55 in men, < 65 in women) ! microalbuminuria or estimated GFR < 60 ml/min • Review of initial diagnosis of hypertension if previously detected and its treatment including the following: ! age at onset, stage of hypertension when initially detected, course of development and progression (sudden vs. gradual change), reliability of documentation, and associated symptoms ! treatment history, including medications, dosages, responses to therapies, and drug side effects Review of family history for history of hypertension, coronary artery disease, diabetes mellitus, renal disease, dyslipidemia, and diseases related to secondary causes of high blood pressure, such as pheochromocytoma, MEN syndrome type II (medullary carcinoma of the thyroid and multiple endocrine neoplasia syndrome), neurofibromatosis, renal disease (e.g., polycystic kidney disease) Review of medication history and habits: use of prescribed, over-the-counter medications (e.g., oral contraceptives, decongestants, diet pills) Degree of alcohol intake Dietary habits with attention to excessive salt intake Use of illicit drugs that may affect blood pressure such as cocaine use Attention to relevant portions of the social history: ! factors that may affect the inmate’s ability to understand or participate in treatment recommendations such as educational level, language barriers, and disabilities ! potential family or institutional stressors that may affect inmate health, such as relationships with family members and other inmates, work environment, and recent or anticipated court appearances Review of systems that focuses on the following: ! cardiovascular system: presence or absence of symptoms of angina, myocardial infarction, prior history of coronary revascularization, congestive heart failure, claudication, stroke, or transient ischemic attacks ! pulmonary system: presence or absence of symptoms of bronchospasm, asthma, or COPD 4
Hypertension - page 8
Federal Bureau of Prisons Clinical Practice Guidelines Hypertension June, 2004 ! genitourinary system: presence or absence of symptoms of renal disease (e.g., hematuria, prior calculi, nocturia, abnormal urinalysis, edema) and history of previous evaluations such as IVP studies or ultrasonography ! endocrine system: presence or absence of symptoms of pheochromocytoma (“spells” with hypertension and symptoms of headache, tachycardia and sweating), hyperthyroidism, hypothyroidism, hyperparathyroidism, Cushing's syndrome Physical examination: The baseline physical examination should include a focused evaluation for evidence of target organ damage such as left ventricular hypertrophy, arterial bruits, absent pulses, retinopathy and focal neurologic deficits. The examination should include the following: Two or more blood pressure measurements separated by two minutes should be obtained, either supine or seated, and after standing for at least two minutes. A fall in SBP of 20 mm Hg or more from the supine to standing position, especially when accompanied by symptoms, indicates orthostatic (postural) hypotension and warrants further evaluation. The two readings should be averaged. If the two readings differ by more than 5 mm Hg, additional readings should be obtained and averaged. Two measurements of leg pulses and pressures should be made at least once with every hypertensive inmate. Absent, delayed, or diminished pulses in the femoral artery with low or unobtainable arterial pressures in the lower extremities, associated with hypertension in the upper extremities suggests coarctation of the aorta and warrants further evaluation. • Height and weight • Calculation of body mass index (BMI): weight (lbs) x 703 ÷ height squared (in 2 ) (See References for link to downloadable PDA version) Funduscopic exam for evidence of retinopathy (A-V nicking, hemorrhages or exudates with or without papilledema) Examination of the neck for carotid bruits, distended veins, and thyroid palpation Heart examination of rate and rhythm, precordial heave, clicks, murmurs, gallops, and assessment for cardiomegaly Pulmonary exam for evidence of rales or wheezing Examination of the abdomen for bruits, enlarged kidneys, masses, abnormal aortic pulsation Examination of the extremities for diminished or absent peripheral arterial pulsations, femoral bruits, or edema 5
Hypertension - page 9
Federal Bureau of Prisons Clinical Practice Guidelines Hypertension June, 2004 Screening neurological exam Careful examination of skin for café-au-lait spots, xanthomas, and stigmata of Cushing's syndrome Diagnostic Evaluations - Routine : The following baseline laboratory tests should be obtained: • BUN and creatinine • Serum electrolytes • Fasting blood glucose • Fasting lipoprotein analysis • Complete Blood Count (CBC) or hematocrit • Urinalysis • Electrocardiogram (ECG) Diagnostic Evaluations - Supplemental: Other studies or procedures may be indicated to investigate potential secondary causes of hypertension, particularly in the following inmates: • Age, medical history, physical exam, severity of hypertension, or initial laboratory findings suggest such secondary causes • Blood pressures are responding poorly to drug therapy • Well-controlled hypertension with unexpected increase in blood pressures • Stage 2 hypertension • Sudden unexpected onset of hypertension • Specific clinical presentations that suggest possible renovascular hypertension include the following: ! onset prior to 30 years of age ! abdominal bruit, particularly if lateralized ! hypertension resistant to treatment ! recurrent pulmonary edema ! renal failure of unknown cause, often with normal urine sediment ! diffuse atherosclerosis in an inmate who smokes ! acute renal failure precipitated by antihypertensive therapy, particularly ACE inhibitors 6
Hypertension - page 10
Federal Bureau of Prisons Clinical Practice Guidelines Hypertension June, 2004 5. Treatment The ultimate goal of preventing and effectively controlling hypertension is to reduce morbidity and mortality by the least intrusive means possible. The primary focus of treatment should be achieving the target systolic blood pressure. Most hypertensive individuals, especially those older than age 50, will reach the DBP goal once the SBP goal is achieved. Blood pressures less than 140/90 are associated with a decrease in cardiovascular complications. Treatment to lower levels may be useful, particularly to prevent stroke, to preserve renal function, and to prevent or slow heart failure progression. The targeted blood pressure should be < 130/80 mm Hg for patients with diabetes, and < 125/75 mm Hg for patients with renal insufficiency and proteinuria > 1 gram/24 hours. Blood pressure control is achieved by lifestyle modifications and as necessary, pharmacologic treatment. Primary Prevention: All inmates should be advised during intake and periodic examinations to adopt lifestyle changes that will reduce their risk factors for cardiovascular disease. Primary prevention provides an important opportunity to interrupt or prevent hypertension and its complications based on the following considerations: • A significant portion of cardiovascular disease occurs in persons with blood pressures above normal (120/80 mm Hg) but not high enough to be diagnosed or treated as hypertension. The risk of cardiovascular disease beginning at 115/75 mm Hg doubles with each increment of 20/10 mm Hg. • Drug treatment of established hypertension has potential adverse effects on the patient. • Most persons with established hypertension do not make sufficient lifestyle changes or consistently take their medications to achieve adequate control. • Even if blood pressure is adequately treated to less than 140/90, these individuals are still at higher risk for complications compared to persons with normal blood pressure. Lifestyle modifications: Once the diagnosis of hypertension is confirmed, non- pharmacological treatment with weight reduction, sodium restriction, and increased aerobic exercise are recommended. Many persons can meet blood pressure reduction goals without prescription medications. Lifestyle modifications should be the initial treatment for inmates with pre-hypertension, unless they have diabetes mellitus or multiple cardiovascular risk factors, cardiovascular disease, or evidence of target organ damage. The implementation of lifestyle modifications, however, should not delay the initiation of antihypertensive drug therapy when medically indicated in accordance with Appendix 1 (Classification and Management of Hypertension with Lifestyle Modifications and Drug Therapy). Lifestyle modifications include the following: Dietary management 7
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