Hypertension and cardiac failure IN PHC - PowerPoint Presentation

1. Hypertension and cardiac failure IN PHC Tonjeni AlupheliRikhotso ClifordVokwana Vuyiseka

2. Definition Hypertension is in the simplest definition is a cardiovascular disease that occurs when there is a persistently elevated blood pressure , hence the layman term “high blood pressure “. BP = Cardiac output X total peripheral resistance Blood pressure reacts to changes in the environment to maintain organ perfusion over a wide variety of conditions. The primary factors determining the blood pressure are the sympathetic nervous system, the renin-angiotensin-aldosterone system, and the plasma volume (largely mediated by the kidneys).

3. Definition continued According to eml guidelines Blood Pressure > 140/90mmHgMeasured on 2/3 Separate OccasionsMinimum of 2 Days Apart

4. Definitions and classification of office BP (mmHg) Adapted from South African Hypertension guidelines 2014The high-normal group is at higher CV risk and is also at risk of developing HTN, but does not require drug treatment .Stage Systolic BP (mmHg) Diastolic BP (mmHg)Normal < 120< 80Optimal120–12980-84High normal 130–13985-89Grade 1 140–15990-99Grade 2 160–179100-109Grade 3 ≥ 180≥ 110Isolated systolic ≥ 140< 90

5. Aetiological classification I. Primary (Essential hypertension in 95 percent of cases) The cause is not known.It is poorly understood but is most likely the result of numerous genetic and environmental factors

6. Aetiological classification continuation II. Secondary 1. Renal diseases a) Glomerulonephritis b) Renovascular disease, particularly renal artery stenosis . 2. Endocrine disease a) Phaeochromocytoma b) Conn’s syndrome (Primary aldosteronism)c) Cushing’s syndrome d) Acromegaly e) Hyperthyroidism 3. CVS-Coarctation of the aorta4. Drugs, e.g. oral contraceptives, corticosteroids, cyclosporin

7. Risk factors for hypertension Age – Advancing age is associated with increased blood pressure, particularly systolic blood pressure, and an increased incidence of hypertension.Obesity High-sodium diet – Excess sodium intake ( >6 g/day) Excessive alcohol consumption and smoking Sedentary lifestyle Race – Hypertension tends to be more common, be more severe, occur earlier in life, and be associated with greater target-organ damage in blacks. Family history – Hypertension is about twice as common in subjects who have one or two hypertensive parentsCo-existing disorders such as diabetes, and hyperlipidaemia

8. Presentation Symptoms (rare) Silent Killer Headache in the morning (occipital region)DizzinessIn severe hypertension symptoms such as epistaxis and blurred vision can occurSignsElevated BPHypertensive retinopathy (flame shaped hemorrhage and cotton wool spots, yellow hard exudates on fundoscopy)Signs of long standing hypertension (LVH with a Displaced Apex,S4)

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10. Central Nervous SystemStrokeSubarachnoid HemorrhageHypertensive EncephalopathyNeurological SymptomsDisorientationRetinaCentral Vein ThrombosisRetinopathyHeartCHDLV HypertrophyLV FailureKidneysProteinuriaProgressive Renal Failure

11. Investigations Test at diagnosis Urine dipstick (protein if dipstick + send blood for Creatinine and GFR ) Body Mass Index (Cardiovascular risk assessment ) Waist circumference HGT ECG (LVH)FundoscopyYearly monitoring Urea , Creatinine and electrolytes ( particularly K if pt is on an ACEI or GFR <30ML/minLipid profile HGT Annual urine dipsticks BMIFundoscopy Only per indicationChest x-rayRenal ultrasound.Endocrine studies

12. Management of Hypertension Aim: To minimize the risks of developing hypertensive complications .A universal goal of antihypertensive treatment is < 140/90 mmHg regardless of CV risk and underlying co-morbidities.Types of management:Non-pharmacologicalpharmacological

13. Non pharmacological managementLifestyle modification according to the SAHG 2014ModificationRecommendation Appr decrease in SBPWeight reduction BMI 18.5–24.9 5–20 per 10 kg Dash diet ↓ fat intake, ↑ fruit and vegetables8–14Dietary Na+< 100 mmol or 6 g NaCl/day2–8Physical activity Brisk walking for 30 minutes per day most days 4–9 Moderation of alcohol No more than two drinks per day2-4TaboccoComplete cessation -

14. Pharmacological Management

15. Drug class indications and contra-indications

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17. Stepwise treatment without compelling indicationsStep 1 (BP 140-159/90-99mmHg without any existing disease and No major risk factors) Lifestyle Modification AND BP measured within 3 Months <140/90mmHgStep 2(BP 140-159/90-99mmHg without any existing disease and No major risk factors and failure of lifestyle modification alone to reduce BP in 3 months) Lifestyle Modification AND Hydrochlorothiazide (Ridaq) 12.5mg Daily AND BP measured within 1 Month, it should be <140/90mmHg

18. Step 3 ( Failure to achieve targets in step 2 after 1 month despite adherence to therapy) Lifestyle Modification AND HCT (Ridaq) 12.5mg Daily AND Long Acting Calcium Channel Blocker (Amlodipine) 5mg Daily OR ACEI e.g Enalpril 10 mg po daily and BP Control within 1 Month (<140/90mmHg)

19. Step 4 ( Failure of step 3 after 1 month of adhrerence , increase the dose of the 2nd antihypertensive medicine)Lifestyle Modification AND HCT (Ridaq) 12.5mg Daily AND ACE-I (Enalapril 20mg Daily OR Long Acting Calcium Channel Blocker (Amlodipine) 10mg Daily ANDBP Control within 1 Month

20. Step 5 ( Failure of step 4 and add a 3rd antihypertensive medication )Lifestyle Modification ANDHCT (Ridaq) 12.5mg Daily ANDACE-I (Enalapril) 20mg Daily AND Long Acting Calcium Channel Blocker (Amlodipine) 5mg Daily ANDBP Control within 1 Month

21. Step 6 : Failure of step 5 after 1 month of adherence , increase the dose of the third antihypertensive medication Lifestyle Modification ANDHCT (Ridaq) 12.5mg Daily ANDACE-I (Enalapril) 20mg Daily AND Long Acting Calcium Channel Blocker (Amlodipine) 10mg Daily ANDBP Control within 1 Month

22. Step 7 : Failure of step 6 after 1 month , increase the dose of HCTZ and add a 4th antihypertensive medicationLifestyle Modification ANDHCT (Ridaq) 25mg Daily ANDACE-I (Enalapril) 20mg Daily AND Long Acting Calcium Channel Blocker (Amlodipine) 10mg Daily ANDSpironolactone, oral, 25 mg daily ( spironolactone can cause severe hyperkalemia and should be used only when serum K can be monitored , do not use if GFR <30ml/min)BP Control within 1 MonthIf not controlled- Refer

23. Hypertensive crisis Two spectrums : Hypertensive urgency or hypertensive emergency Hypternsive urgency : Severe elevated BP(>180/120mmhg) without target organ damage. (kidney, retina, heart , brain)Hypertensive emergency : Severe elevated BP with target organ damage

24. Hypertensive emergency It is often an acute elevation of BP associated with acute and ongoing organ damage to the kidneys, brain, heart, eyes (grade 3 or 4 retinopathy) or vascular system. These patients need rapid (within minutes to a few hours) lowering of BP to safe levels. A 25% reduction in BP is recommended in the first 24 hours. Oral therapy is instituted once the BP is more stable.Refer all HYPTERNSIVE EMERGENCIES to a hospital

25. Hypertensive urgency A markedly elevated BP: systolic BP > 180 mmHg and/or a diastolic BP > 130 mmHg without target organ damage Ideally should be treated in the hospital .Commence treatment with two oral agents and aim to lower the diastolic BP to 100 mmHg slowly over 48 to 72 hours. This BP lowering can be achieved with the use of the following drugs :Long acting ccb ( amlodipine ) ACEI ( in low doses ) – to be avoided in pt with severe hyponatremia (less than 130mmol/l)Beta-blocker Directic

26. Resistant hypertension HTN that remains > 140/90 mmHg despite the use of three antihypertensive drugs in a rational combination at full doses and including a diuretic.Before classifying a patient as having resistant hypertension ensurePatient is complaint to the medication .Emphasis on diet modification (salt, smoking cessation , ethanol intake , exercise )Ensure that the doses are correct Once all the above are done laboratory and imaging investigations can be done

27. Congestive Cardiac failure Heart failure is a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood.In laymans terms congestive heart failure is failure of heart to pump out blood adequately – this disregards that heart failure is due to mutlifactroial factors .

28. Signs and symptoms of ccf

29. Classification There are 3 well known classifications of heart failure 1. Systolic vs Diastolic heart failure 2. Heart failure with reduced ejection fraction vs Heart failure with Preserved ejection fraction 3.High output failure vs Low output failure

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31. Severity grading The New York Heart Association (NYHA) classification system categorizes heart failure on a scale of I to IV, [2]  as follows:Class I: No limitation of physical activityClass II: Slight limitation of physical activityClass III: Marked limitation of physical activityClass IV: Symptoms occur even at rest; discomfort with any physical activity

32. inveSTIGationsDiagnostic : CXR – cardiomegaly , pulmonary effusion , signs of interstitial oedema ECG : ischaemic changes , ventricular hypertrophy ECHOBLOOD –BNPSupportive : FBC /LFT/U and E /TFT

33. Mangement considerationIdentify and treat the cause At Initial diagnosis : Always access ABCs Give Furosemide 40mg orally/IV , insert a catheter then refer to the hospital for further work –up and management

34. Step by step approach in Management (once patient is stepped down to the clinic)S T E P 1 : Diuretic plus ACE-inhibitor Start on Hydrochlorothiazide, oral, 25–50 mg daily. If significant volume overload or abnormal renal function – loop diuretic Furosemide, oral, daily :Initial dose is 40 mg po dly Enalapril 2.5 mg po dly titrate gradually till max of 10 mg po dly Always check contra-indications before commencing the medications

35. STEP 2 : After titration of ACE-inhibitor add beta-blocker Carvedilol : Starting dose: 3.125 mg twice daily. o Increase dose at two-weekly intervals by doubling the daily dose until a maximum of 25 mg twice daily, if tolerated. Up-titration can take several months. Should treatment be discontinued for >14 days, reinstate therapy as above. Do not use atenolol for cardiac failure. (Cardioselective beta-1-adrenergic antagonists in heart failure patients, atenolol can increase the end-diastolic pressure and left ventricular fiber lengths - conversely resulting in increased oxygen demand-worsening heart failure ).

36. S T E P 3 : Add Aldosterone receptor antagonists Spironolactonen 25 mg po dly , if patient remains symptomatic despite optimal therapy CAUTION Spironolactone can cause severe hyperkalemia and should only be used when serum potassium can be monitored. Do not use together with potassium supplements. Do not use in kidney failure (Do not use if eGFR < 30 mL/min).

37. STEP 4: Symptomatic CCF despite above-mentioned therapy: Refer to hospital for step up therapy with digoxin.In addition which patients are to be referred to HospitalInitial assessment and initial treatment Poor response to treatmentSuspected Infective endocarditis Patients with prostetic heart valve

38. Hypertension and ccfAccording to the Framingham Study, hypertension accounts for about one quarter of heart failure cases. In the elderly population, as many as 68% of heart failure cases are attributed to hypertensionUncontrolled and prolonged elevation of BP can lead to a variety of changes in the myocardial structure, coronary vasculature, and conduction system of the heart. These changes in turn can lead to the development of left ventricular hypertrophy (LVH), coronary artery disease (CAD)

39. TAKE HOME MESSAGE Hypertension and CCF is a major cause of morbidity and mortality however it is still under-diagnosed and undertreated.Both are easy to diagnose and easy to treatIt is of paramount importance that all patients should be examined Take each consultation as an opportunity to educate the patient about their condition , importance of compliance and emphasis of lifestyle modification.

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41. REFERENCES Flack JM, Sica DA, Bakris G, et al. International Society of Hypertension in Blacks. Management of high blood pressure in blacks: an update of high blood pressure in blacks consensus statement. Hypertension 2010; 56: 780–800KhrystineW , PharmD et al. Managign hypertension in primary care.Available from www.ncbi.nlm.nih.gov/pmc/articles/PMC6788646/ [accessed in January 2021]Ponikowski P et al . 2016 ECS Guidelines for diagnosis and treatment of acute and chronic heart failure. Available from www.hefssa.org [accessed in January 2021]Seedat YK, BL Rayner, Yosuf Veriava. South African Hypertensive guidelines .Available from https://www.hypertension.org.za/uploads/files/SA-HPT-guidlelines-2014.pdf [accessed in January 2021]

42. Case study 55 year old male , chronic smoker (5 pack year history ) , hypertensive on medication( Ridaq 12.5 mg po dly and Atenolol 25mg po nocte ) miner by profession, presents with 5 day history of headache, dyspnoea associated with intermittent dizziness. On examination : BP 175/90mmhg , Pulse is 70bmp, regular rhythm , grade 2 bilateral pitting oedema CVS : normal Resp : Bibasal crepitations . Abdo : Ascites 1.Assess according the biopsychosocial model 2. Management according to the biopsychosocial model