2022 Hypertension Lecture (Updated Guidelines).pdf
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The document outlines a presentation on hypertension and hypertensive disorders for allied health workers. It begins with an introduction and outline covering hypertension and hypertensive disorders of pregnancy. The outline discusses risk factors and diagnosis of hypertension, as well as management of hypertensive crisis. Guidelines for diagnosing and treating hypertension from sources like the 2020 Philippine CPG are also summarized.
![A VIEWPOINT AND MANAGEMENT ON
HYPERTENSION & OTHER HYPERTENSIVE DISORDERS
FOR ALLIED HEALTH WORKERS AND PRACTITIONERS
OUTLINE
HYPERTENSION
HYPERTENSIVE DISORDERS
HYPERTENSIVE CRISIS
֍ Loscalzo, J., Fauci, A., Kasper, D., Longo, D., Jameson, J.L. (2022). Harrison's principles of internal medicine (21st edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-426851-1
֍ Aronow W. S. (2017). Treatment of hypertensive emergencies. Annals of translational medicine, 5(Suppl 1), S5. https://doi.org/10.21037/atm.2017.03.34
֍ Alley WD, Schick MA. Hypertensive Emergency. [Updated 2022 May 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470371/
HYPERTENSIVE EMERGENCY
HYPERTENSIVE URGENCY
Blood Pressure
Systolic ≥ 180
and/or
Diastolic ≥ 120
Target Organ
Damage
None
• ACS/Angina/Cardiac Ischemia
• Pulmonary Edema
• Stroke/Neurologic deficits
• Acute renal failure
• Aortic dissection
• Preeclampsia /Eclampsia](https://image.slidesharecdn.com/2022hypertensionlectureupdatedguidelines-221026141644-2be81cd1/85/2022-Hypertension-Lecture-Updated-Guidelines-pdf-22-320.jpg)
![A VIEWPOINT AND MANAGEMENT ON
HYPERTENSION & OTHER HYPERTENSIVE DISORDERS
FOR ALLIED HEALTH WORKERS AND PRACTITIONERS
OUTLINE
HYPERTENSION
HYPERTENSIVE DISORDERS
PHARMACOLOGIC APPROACH
IV Medications – Hypertensive Crisis (Urgency and Emergency)
֍ Aronow W. S. (2017). Treatment of hypertensive emergencies. Annals of translational medicine, 5(Suppl 1), S5. https://doi.org/10.21037/atm.2017.03.34
֍ Alley WD, Schick MA. Hypertensive Emergency. [Updated 2022 May 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470371/
ESMOLOL
LABETALOL
CLEVIDIPINE
NICARDIPINE
NITROGLYCERIN
ISOSORBIDE DINITRATE
NITROPRUSSIDE
HYDRALAZINE
FENOLDOPAM
Calcium Channel Blocker Beta Blocker Direct Vasodilator Dopamine Agonist
2mg -2.5 mg IV as single dose
1mg/hr to Max 32mg/hr
LD 500-1000mcg/kg/min for 1 min; 50mg/kg/min to 200mg/kg/min
LD 0.3mg/kg (max single loading dose of 20mg); 0.4mg/kg/hour
5mcg/min to 20mcg/min
2mg/hr to 20mg/hr
0.3mcg/kg/min to 10mcg/kg/min
0.5mg/hr to 10mg/hr. Max 300mg /day
5mg/hour to Max 30mg/hour
Stat Doses Infusion
5mg/hour to Max 15mg/hour
2mg IV as single dose
5mg-10mg single dose IV / IM every 10-20mins](https://image.slidesharecdn.com/2022hypertensionlectureupdatedguidelines-221026141644-2be81cd1/85/2022-Hypertension-Lecture-Updated-Guidelines-pdf-23-320.jpg)
2022 Hypertension Lecture (Updated Guidelines).pdf
- 1. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS References: • Harrison’s Principle of Internal Medicine (21st Ed) • JNC 7 & 8 Hypertension Guidelines • Phil Society of Hypertension - CPG on Hypertension (2021) • AHA/ACC Guidelines on Hypertension • Stroke Society of the Philippines - Handbook of Stroke (6th Ed) • KDIGO 2021 Guidelines • Williams Obstetrics (26th Ed) • Tintinalli’s Emergency Medicine (9th Ed) M.M. Haradji Elino F.Y. Sampang R.E. Aming September 10, 2022 1:00 PM Multipurpose Hall SSGH
- 2. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS I – Hypertension A. Risk Factors & Outcome B. Diagnosis D. Hypertensive Crisis: Hypertensive Urgency and Emergency C. Management & Prevention II - Hypertensive Disorders of Pregnancy A. Chronic Hypertension and Gestational Hypertension B. Pre Eclampsia and Eclampsia
- 3. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS Hypertension ֍ Loscalzo, J., Fauci, A., Kasper, D., Longo, D., Jameson, J.L. (2022). Harrison's principles of internal medicine (21st edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-426851-1 STROKE HEART FAILURE KIDNEY FAILURE ANEURYSM ARTERY OCCLUSIVE DISEASE BLINDNESS AND RETINOPATHY PREGNANCY COMPLICATION METABOLIC SYNDROME HYPERTENSION-MEDIATED ORDAN DAMAGE
- 4. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS Hypertension Risk Factors ֍ Loscalzo, J., Fauci, A., Kasper, D., Longo, D., Jameson, J.L. (2022). Harrison's principles of internal medicine (21st edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-426851-1 ֍ Stroke Society of the Philippines (2014). SSP Handbook of Stroke - Guidelines for Prevention, Treatment, and Rehabilitation 6th Edition. GoldenPages Publishing Company. ISBN: 978-971-94968-1-6 MODIFIABLE NONMODIFIABLE • Dietary NaCl Intake • Lack of Physical Activity • Weight Gain and Obesity • Smoking and Alcohol consumption • Acculturation and Chronic Stress • Dyslipidemia and Diabetes • Sleep-Disordered Breathing • Family History of Hypertension • Old Age • Ethnicity
- 5. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS Hypertension “ is an office blood pressure (BP) of 140/90mmHg or above, typically at least twice taken on two separate days.” 2020 CPG Management of Hypertension in the Philippines ֍ Ona, D., Jimeno, C. A., Jasul, G. V., Jr, Bunyi, M., Oliva, R., Gonzalez-Santos, L. E., Mercado-Asis, L. B., Luz, V. A., Leus, A. G., Diaz, A., Santos, M. I., Belen, A. A., Bonzon, D. D., Bote-Nunez, J., Cawed-Mende, R., Chua, A. S., Javier, A., Juangco, D., Madrigal-Dy, C., Manicad, M. B., … Villanueva, N. J. (2021). Executive summary of the 2020 clinical practice guidelines for the management of hypertension in the Philippines. Journal of clinical hypertension (Greenwich, Conn.), 23(9), 1637–1650. https://doi.org/10.1111/jch.14335
- 6. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS ֍ Guideline: Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group. KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int. 2021;99(3S):S1–S87
- 7. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS ֍ Guideline: Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group. KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int. 2021;99(3S):S1–S87
- 8. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS ֍ Ona, D., Jimeno, C. A., Jasul, G. V., Jr, Bunyi, M., Oliva, R., Gonzalez-Santos, L. E., Mercado-Asis, L. B., Luz, V. A., Leus, A. G., Diaz, A., Santos, M. I., Belen, A. A., Bonzon, D. D., Bote-Nunez, J., Cawed-Mende, R., Chua, A. S., Javier, A., Juangco, D., Madrigal-Dy, C., Manicad, M. B., … Villanueva, N. J. (2021). Executive summary of the 2020 clinical practice guidelines for the management of hypertension in the Philippines. Journal of clinical hypertension (Greenwich, Conn.), 23(9), 1637–1650. https://doi.org/10.1111/jch.14335 ֍ Guideline: Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group. KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int. 2021;99(3S):S1–S87 Recommended Device See developing list of validated BP monitors www.stridebp.org Oscillometric sphygmomanometer (digital device) Aneroid sphygmomanometer (manual device)
- 9. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS SBP DBP AHA/ACC a JNC 8 b Phil CPG c <120 & <80 Normal Normal Normal 120-129 & <80 Elevated BP Prehypertension Borderline 130-139 & 80-89 Hypertension I Prehypertension 140-159 & 90-99 Hypertension II Hypertension I Hypertension ≥ 160 & ≥ 100 Hypertension II Hypertension II ≥ 180 & ≥ 120 Hypertensive Crisis* ֍ Loscalzo, J., Fauci, A., Kasper, D., Longo, D., Jameson, J.L. (2022). Harrison's principles of internal medicine (21st edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-426851-1 ֍ Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Jr, Collins, K. J., Dennison Himmelfarb, C., DePalma, S. M., Gidding, S., Jamerson, K. A., Jones, D. W., MacLaughlin, E. J., Muntner, P., Ovbiagele, B., Smith, S. C., Jr, Spencer, C. C., Stafford, R. S., Taler, S. J., Thomas, R. J., Williams, K. A., Sr, Williamson, J. D., … Wright, J. T., Jr (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension (Dallas, Tex. : 1979), 71(6), e13–e115. https://doi.org/10.1161/HYP.0000000000000065 ֍ James, P. A., Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J., Lackland, D. T., LeFevre, M. L., MacKenzie, T. D., Ogedegbe, O., Smith, S. C., Jr, Svetkey, L. P., Taler, S. J., Townsend, R. R., Wright, J. T., Jr, Narva, A. S., & Ortiz, E. (2014). 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA, 311(5), 507–520. https://doi.org/10.1001/jama.2013.284427 ֍ Ona, D., Jimeno, C. A., Jasul, G. V., Jr, Bunyi, M., Oliva, R., Gonzalez-Santos, L. E., Mercado-Asis, L. B., Luz, V. A., Leus, A. G., Diaz, A., Santos, M. I., Belen, A. A., Bonzon, D. D., Bote-Nunez, J., Cawed-Mende, R., Chua, A. S., Javier, A., Juangco, D., Madrigal-Dy, C., Manicad, M. B., … Villanueva, N. J. (2021). Executive summary of the 2020 clinical practice guidelines for the management of hypertension in the Philippines. Journal of clinical hypertension (Greenwich, Conn.), 23(9), 1637–1650. https://doi.org/10.1111/jch.14335 a American College of Cardiology/American Heart Association b 8th Joint National Commission on Hypertension c Philippine Clinical Practice Guidelines * Hypertensive Urgency if Asymptomatic, and Hypertensive Emergency if with Acute Target Damage
- 10. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS Adults with BP ≥140/90 ( ≥150/90 for ≥ 80yr old and above ) Advise Therapeutic Lifestyle Changes: Low Salt Diet, Weight Loss, Exercise, Smoking Cessation, Alcohol Abstinence, DASH, Stress Reduction With Hypertension -Mediated Organ Damage or CV Risk Equivalent, High Risk? BP Targets are achieved after 3 months? Maintain Lifestyle Change Choose any of the first line drugs as monotherapy or in combination: ACEi, ARB, CCB, Thiazide Diuretics No Yes Yes No 2020 CLINICAL PRACTICE GUIDELINES FOR THE MANAGEMENT OF HYPERTENSION IN THE PHILIPPINES
- 11. If on Monotherapy: Add a 2nd agent from 1st line Drugs If already on 2 drugs: Add another drug from 1st line choices BP Targets are achieved after 3months therapy? No Yes BP targets achieved on combination drugs? Maintain medications and monitor BP Referral to Specialist Yes No ֍ Ona, D., Jimeno, C. A., Jasul, G. V., Jr, Bunyi, M., Oliva, R., Gonzalez-Santos, L. E., Mercado-Asis, L. B., Luz, V. A., Leus, A. G., Diaz, A., Santos, M. I., Belen, A. A., Bonzon, D. D., Bote-Nunez, J., Cawed-Mende, R., Chua, A. S., Javier, A., Juangco, D., Madrigal-Dy, C., Manicad, M. B., … Villanueva, N. J. (2021). Executive summary of the 2020 clinical practice guidelines for the management of hypertension in the Philippines. Journal of clinical hypertension (Greenwich, Conn.), 23(9), 1637–1650. https://doi.org/10.1111/jch.14335
- 12. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS LIFESTYLE MODIFICATION For blood pressure control or prevention ֍ National High Blood Pressure Education Program. (2004). The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute (US). ֍ Rainforth, M. V., Schneider, R. H., Nidich, S. I., Gaylord-King, C., Salerno, J. W., & Anderson, J. W. (2007). Stress reduction programs in patients with elevated blood pressure: a systematic review and meta-analysis. Current hypertension reports, 9(6), 520–528. https://doi.org/10.1007/s11906-007-0094-3 ֍ Minami, J., Ishimitsu, T., & Matsuoka, H. (1999). Effects of smoking cessation on blood pressure and heart rate variability in habitual smokers. Hypertension (Dallas, Tex. : 1979), 33(1 Pt 2), 586–590. https://doi.org/10.1161/01.hyp.33.1.586 ֍ Stewart, S. H., Latham, P. K., Miller, P. M., Randall, P., & Anton, R. F. (2008). Blood pressure reduction during treatment for alcohol dependence: results from the Combining Medications and Behavioral Interventions for Alcoholism (COMBINE) study. Addiction (Abingdon, England), 103(10), 1622–1628. https://doi.org/10.1111/j.1360-0443.2008.02317.x 7 POINTS TO PONDER WEIGHT LOSS PHYSICAL ACTIVITY DASH * LIMIT ALCOHOL STRESS REDUCTION TOBACCO CESSATION SODIUM RESTRICTION *Dietary Approaches to Stop Hypertension
- 13. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS ֍ National High Blood Pressure Education Program. (2004). The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute (US). ֍ Rainforth, M. V., Schneider, R. H., Nidich, S. I., Gaylord-King, C., Salerno, J. W., & Anderson, J. W. (2007). Stress reduction programs in patients with elevated blood pressure: a systematic review and meta-analysis. Current hypertension reports, 9(6), 520–528. https://doi.org/10.1007/s11906-007-0094-3 ֍ Minami, J., Ishimitsu, T., & Matsuoka, H. (1999). Effects of smoking cessation on blood pressure and heart rate variability in habitual smokers. Hypertension (Dallas, Tex. : 1979), 33(1 Pt 2), 586–590. https://doi.org/10.1161/01.hyp.33.1.586 ֍ Stewart, S. H., Latham, P. K., Miller, P. M., Randall, P., & Anton, R. F. (2008). Blood pressure reduction during treatment for alcohol dependence: results from the Combining Medications and Behavioral Interventions for Alcoholism (COMBINE) study. Addiction (Abingdon, England), 103(10), 1622–1628. https://doi.org/10.1111/j.1360-0443.2008.02317.x WEIGHT LOSS PHYSICAL ACTIVITY DASH EATING PLAN SODIUM RESTRICTION LIMIT ALCOHOL STRESS REDUCTION TOBACCO CESSATION Maintain normal Body Mass Index ( BMI 18.5 – 24.9 kg/m2) Engage in Regular Physical Activity (e.g., brisk walking) ≥30min/day, most days Consume eating diet rich in fruits, vegetables, and low-fat (reduced saturated and total fat) dairy products Reduce dietary sodium intake to max of 100mmol/day (2.4g sodium or 6 g sodium chloride) Limit daily consumption to max of 1 drink for women or 2 drinks for men Practice a stress-reduction modality such as meditation Incorporate cessation modality of choice 5-20 mmHg per 10kg loss 4-9 mmHg 8-14 mmHg 2-8 mmHg 2-4 mmHg 5 mmHg 2-4 (after 1 week of cessation) MODIFICATION RECOMMENDATIONS BP REDUCTION
- 14. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS PHARMACOLOGIC APPROACH Antihypertensive Oral Medications ֍ Ona, D., Jimeno, C. A., Jasul, G. V., Jr, Bunyi, M., Oliva, R., Gonzalez-Santos, L. E., Mercado-Asis, L. B., Luz, V. A., Leus, A. G., Diaz, A., Santos, M. I., Belen, A. A., Bonzon, D. D., Bote-Nunez, J., Cawed-Mende, R., Chua, A. S., Javier, A., Juangco, D., Madrigal-Dy, C., Manicad, M. B., … Villanueva, N. J. (2021). Executive summary of the 2020 clinical practice guidelines for the management of hypertension in the Philippines. Journal of clinical hypertension (Greenwich, Conn.), 23(9), 1637–1650. https://doi.org/10.1111/jch.14335 ֍ Loscalzo, J., Fauci, A., Kasper, D., Longo, D., Jameson, J.L. (2022). Harrison's principles of internal medicine (21st edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-426851-1 CLASSES OF DRUGS ACEi ARBs CALCIUM CHANNEL BLOCKER RENIN DIRECT INHIBITOR* BETA BLOCKERS ALPHA 1 BLOCKERS* DIURETICS 1ST LINE DRUGS CENTRALLY ACTING SELDOM USED IN PHILIPPINE SETTING ALPHA 2 AGONIST
- 15. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS PHARMACOLOGIC APPROACH Antihypertensive Oral Medications ֍ Loscalzo, J., Fauci, A., Kasper, D., Longo, D., Jameson, J.L. (2022). Harrison's principles of internal medicine (21st edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-426851-1 ֍ Ona, D., Jimeno, C. A., Jasul, G. V., Jr, Bunyi, M., Oliva, R., Gonzalez-Santos, L. E., Mercado-Asis, L. B., Luz, V. A., Leus, A. G., Diaz, A., Santos, M. I., Belen, A. A., Bonzon, D. D., Bote-Nunez, J., Cawed-Mende, R., Chua, A. S., Javier, A., Juangco, D., Madrigal-Dy, C., Manicad, M. B., … Villanueva, N. J. (2021). Executive summary of the 2020 clinical practice guidelines for the management of hypertension in the Philippines. Journal of clinical hypertension (Greenwich, Conn.), 23(9), 1637–1650. https://doi.org/10.1111/jch.14335 ACEi Angiotensin-Converting Enzyme Inhibitor Common Examples Total Daily Dose Pharmacokinetics Captopril 25 to 200mg (twice daily) Onset: 15-30 mins Duration: 12 hours Enalapril 2.5 to 40mg (once daily) Onset: 1-2 hours Duration: 24 hours Perindopril 2-16mg (once daily) Onset: 1-2 hours Duration: 24 hours
- 16. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS PHARMACOLOGIC APPROACH Antihypertensive Oral Medications ֍ Loscalzo, J., Fauci, A., Kasper, D., Longo, D., Jameson, J.L. (2022). Harrison's principles of internal medicine (21st edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-426851-1 ֍ Ona, D., Jimeno, C. A., Jasul, G. V., Jr, Bunyi, M., Oliva, R., Gonzalez-Santos, L. E., Mercado-Asis, L. B., Luz, V. A., Leus, A. G., Diaz, A., Santos, M. I., Belen, A. A., Bonzon, D. D., Bote-Nunez, J., Cawed-Mende, R., Chua, A. S., Javier, A., Juangco, D., Madrigal-Dy, C., Manicad, M. B., … Villanueva, N. J. (2021). Executive summary of the 2020 clinical practice guidelines for the management of hypertension in the Philippines. Journal of clinical hypertension (Greenwich, Conn.), 23(9), 1637–1650. https://doi.org/10.1111/jch.14335 ARBs Angiotensin II Receptor Blockers Common Examples Total Daily Dose Pharmacokinetics Losartan 25 to 100mg (once or twice daily) Onset: 6 hours Duration: 12-24 hours Telmisartan 40-80mg (once daily) Onset: 1-2 hours Duration: 24 hours Candesartan 2-32mg (once or twice daily) Onset: 1-2 hours Duration: 12-24 hours Valsartan 80-320 (once or twice daily) Onset: 2 hours Duration: 12-24 hours
- 17. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS PHARMACOLOGIC APPROACH Antihypertensive Oral Medications ֍ Loscalzo, J., Fauci, A., Kasper, D., Longo, D., Jameson, J.L. (2022). Harrison's principles of internal medicine (21st edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-426851-1 ֍ Ona, D., Jimeno, C. A., Jasul, G. V., Jr, Bunyi, M., Oliva, R., Gonzalez-Santos, L. E., Mercado-Asis, L. B., Luz, V. A., Leus, A. G., Diaz, A., Santos, M. I., Belen, A. A., Bonzon, D. D., Bote-Nunez, J., Cawed-Mende, R., Chua, A. S., Javier, A., Juangco, D., Madrigal-Dy, C., Manicad, M. B., … Villanueva, N. J. (2021). Executive summary of the 2020 clinical practice guidelines for the management of hypertension in the Philippines. Journal of clinical hypertension (Greenwich, Conn.), 23(9), 1637–1650. https://doi.org/10.1111/jch.14335 Diuretics Common Examples Total Daily Dose Pharmacokinetics (Thiazide) Hydrochlorothiazide 6.25 to 50mg (once or twice daily) Onset: 2 hours Duration: 12-24 hours (Aldosterone Antagonist) Spironolactone 25-100mg (once or twice daily) Onset: 2-4 hours Duration: 12-72 hours (Loop Diuretics) Furosemide 40-80mg (once/twice/thrice daily) Onset: 30 min Duration: 6-8 hours
- 18. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS PHARMACOLOGIC APPROACH Antihypertensive Medications ֍ Loscalzo, J., Fauci, A., Kasper, D., Longo, D., Jameson, J.L. (2022). Harrison's principles of internal medicine (21st edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-426851-1 ֍ Ona, D., Jimeno, C. A., Jasul, G. V., Jr, Bunyi, M., Oliva, R., Gonzalez-Santos, L. E., Mercado-Asis, L. B., Luz, V. A., Leus, A. G., Diaz, A., Santos, M. I., Belen, A. A., Bonzon, D. D., Bote-Nunez, J., Cawed-Mende, R., Chua, A. S., Javier, A., Juangco, D., Madrigal-Dy, C., Manicad, M. B., … Villanueva, N. J. (2021). Executive summary of the 2020 clinical practice guidelines for the management of hypertension in the Philippines. Journal of clinical hypertension (Greenwich, Conn.), 23(9), 1637–1650. https://doi.org/10.1111/jch.14335 ֍ 1 Aronow W. S. (2017). Treatment of hypertensive emergencies. Annals of translational medicine, 5(Suppl 1), S5. https://doi.org/10.21037/atm.2017.03.34 Calcium Channel Blockers Common Examples Total Daily Dose Pharmacokinetics Amlodipine 5 to 10mg (once daily) Onset: 12 hours Duration: 24 hours Nifedipine 30-60mg (once or twice daily) Onset: 20-30 min Duration: 24 hours Nicardipine (IV) 5mg/hr Max: 30mg/hr1 Onset: 10 min Duration: 8 hours Verapamil 120 to 360mg (once or twice daily) Onset: 1-2 hours Duration: 12-24 hours Diltiazem 180 to 420mg (once daily) Onset: 1-2 hours Duration: 18-24 hours
- 19. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS PHARMACOLOGIC APPROACH Antihypertensive Oral Medications ֍ Loscalzo, J., Fauci, A., Kasper, D., Longo, D., Jameson, J.L. (2022). Harrison's principles of internal medicine (21st edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-426851-1 ֍ Ona, D., Jimeno, C. A., Jasul, G. V., Jr, Bunyi, M., Oliva, R., Gonzalez-Santos, L. E., Mercado-Asis, L. B., Luz, V. A., Leus, A. G., Diaz, A., Santos, M. I., Belen, A. A., Bonzon, D. D., Bote-Nunez, J., Cawed-Mende, R., Chua, A. S., Javier, A., Juangco, D., Madrigal-Dy, C., Manicad, M. B., … Villanueva, N. J. (2021). Executive summary of the 2020 clinical practice guidelines for the management of hypertension in the Philippines. Journal of clinical hypertension (Greenwich, Conn.), 23(9), 1637–1650. https://doi.org/10.1111/jch.14335 Beta Blockers Common Examples Total Daily Dose Pharmacokinetics Carvedilol 12.5 to 50mg (twice daily) Onset: 1-2 hours Duration: 12 hours Metoprolol 25-100mg (once or twice daily) Onset: 1-2 hours Duration: 6-24 hours Atenolol 25-100mg (once daily) Onset: 3 hours Duration: 24 hours Labetalol 200 to 800mg (twice daily) Onset: 20 min Duration: 12 hours
- 20. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS PHARMACOLOGIC APPROACH Antihypertensive Oral Medications ֍ Loscalzo, J., Fauci, A., Kasper, D., Longo, D., Jameson, J.L. (2022). Harrison's principles of internal medicine (21st edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-426851-1 ֍ Ona, D., Jimeno, C. A., Jasul, G. V., Jr, Bunyi, M., Oliva, R., Gonzalez-Santos, L. E., Mercado-Asis, L. B., Luz, V. A., Leus, A. G., Diaz, A., Santos, M. I., Belen, A. A., Bonzon, D. D., Bote-Nunez, J., Cawed-Mende, R., Chua, A. S., Javier, A., Juangco, D., Madrigal-Dy, C., Manicad, M. B., … Villanueva, N. J. (2021). Executive summary of the 2020 clinical practice guidelines for the management of hypertension in the Philippines. Journal of clinical hypertension (Greenwich, Conn.), 23(9), 1637–1650. https://doi.org/10.1111/jch.14335 Alpha 2 Agonist Common Example Total Daily Dose Pharmacokinetics Clonidine 100 mcg to 600 mcg (hourly to twice daily) Max 600 mcg /day Onset: 15-20 mins Duration: 6-10 hours Methyldopa 0.5 – 3g/day; Usual Preparation 250mg/tab (once or twice daily) Onset: 3-6 hour Duration: 12-24 hour
- 21. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS PHARMACOLOGIC APPROACH Combination Therapy ֍ Loscalzo, J., Fauci, A., Kasper, D., Longo, D., Jameson, J.L. (2022). Harrison's principles of internal medicine (21st edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-426851-1 ֍ National High Blood Pressure Education Program. (2004). The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute (US). ֍ Ona, D., Jimeno, C. A., Jasul, G. V., Jr, Bunyi, M., Oliva, R., Gonzalez-Santos, L. E., Mercado-Asis, L. B., Luz, V. A., Leus, A. G., Diaz, A., Santos, M. I., Belen, A. A., Bonzon, D. D., Bote-Nunez, J., Cawed-Mende, R., Chua, A. S., Javier, A., Juangco, D., Madrigal-Dy, C., Manicad, M. B., … Villanueva, N. J. (2021). Executive summary of the 2020 clinical practice guidelines for the management of hypertension in the Philippines. Journal of clinical hypertension (Greenwich, Conn.), 23(9), 1637–1650. https://doi.org/10.1111/jch.14335 ֍ Cunningham, F.G., Leveno, K.J., Dashe, J.S., Hoffman, B.L., Spong, C.Y., Casey, B.M. (2022). Williams Obstetrics (26th Edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-046274-6 Hypertension ± Heart Failure Hypertension & ACS or CAD Hypertension & Stroke Hypertension & Diabetes Hypertension & CKD ARBS or ACEi ARBS or ACEi ARBS or ACEi ARBS or ACEi ARBS or ACEi Diuretic Beta Blocker CCB CCB CCB + + + + + Beta Blocker and or CCB may add Diuretic and or CCB Diuretic and or Beta Blocker Diuretic and or Beta Blocker Diuretic and or Beta Blocker ARBS ACEi + …not a good combination, may cause profound Acute Kidney Injury. Each class may also have fetal effects for chronic hypertensive Pregnant Patients, therefore it should be avoided.
- 22. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS HYPERTENSIVE CRISIS ֍ Loscalzo, J., Fauci, A., Kasper, D., Longo, D., Jameson, J.L. (2022). Harrison's principles of internal medicine (21st edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-426851-1 ֍ Aronow W. S. (2017). Treatment of hypertensive emergencies. Annals of translational medicine, 5(Suppl 1), S5. https://doi.org/10.21037/atm.2017.03.34 ֍ Alley WD, Schick MA. Hypertensive Emergency. [Updated 2022 May 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470371/ HYPERTENSIVE EMERGENCY HYPERTENSIVE URGENCY Blood Pressure Systolic ≥ 180 and/or Diastolic ≥ 120 Target Organ Damage None • ACS/Angina/Cardiac Ischemia • Pulmonary Edema • Stroke/Neurologic deficits • Acute renal failure • Aortic dissection • Preeclampsia /Eclampsia
- 23. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS PHARMACOLOGIC APPROACH IV Medications – Hypertensive Crisis (Urgency and Emergency) ֍ Aronow W. S. (2017). Treatment of hypertensive emergencies. Annals of translational medicine, 5(Suppl 1), S5. https://doi.org/10.21037/atm.2017.03.34 ֍ Alley WD, Schick MA. Hypertensive Emergency. [Updated 2022 May 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470371/ ESMOLOL LABETALOL CLEVIDIPINE NICARDIPINE NITROGLYCERIN ISOSORBIDE DINITRATE NITROPRUSSIDE HYDRALAZINE FENOLDOPAM Calcium Channel Blocker Beta Blocker Direct Vasodilator Dopamine Agonist 2mg -2.5 mg IV as single dose 1mg/hr to Max 32mg/hr LD 500-1000mcg/kg/min for 1 min; 50mg/kg/min to 200mg/kg/min LD 0.3mg/kg (max single loading dose of 20mg); 0.4mg/kg/hour 5mcg/min to 20mcg/min 2mg/hr to 20mg/hr 0.3mcg/kg/min to 10mcg/kg/min 0.5mg/hr to 10mg/hr. Max 300mg /day 5mg/hour to Max 30mg/hour Stat Doses Infusion 5mg/hour to Max 15mg/hour 2mg IV as single dose 5mg-10mg single dose IV / IM every 10-20mins
- 24. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. ֍ Aronow W. S. (2017). Treatment of hypertensive emergencies. Annals of translational medicine, 5(Suppl 1), S5. https://doi.org/10.21037/atm.2017.03.34 HYPERTENSIVE EMERGENCY Blood Pressure Systolic ≥ 180 and/or Diastolic ≥ 120 Target Organ Damage You may suspect: May verify via: May alleviate Blood Pressure with one of the following: Shortness of Breath; Distended Neck Veins Pulmonary Congestion/Edema •Abnormal CXR-PA (Cephalization) Acute aortic dissection •Abnormal CXR-PA •Abnormal Angiogram •Transesophageal echocardiogram Chest pain, nausea, vomiting, diaphoresis Acute myocardial Infarction/ischemia •Clinical diagnosis •ECG Changes •Elevated cardiac markers NITROGLYCERIN NITROPRUSSIDE NICARDIPINE CLEVIDIPINE ESMOLOL NITROGLYCERIN NITROPRUSSIDE NICARDIPINE ESMOLOL NICARDIPINE NITROGLYCERIN ISDN ESMOLOL DIURETICS BP≥180/120 plus with Signs & Symptoms: Chest pain, back pain Unequal BP (>20 mm Hg difference) in upper extremities: Left higher than Right
- 25. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. ֍ Aronow W. S. (2017). Treatment of hypertensive emergencies. Annals of translational medicine, 5(Suppl 1), S5. https://doi.org/10.21037/atm.2017.03.34 HYPERTENSIVE EMERGENCY Blood Pressure Systolic ≥ 180 and/or Diastolic ≥ 120 Target Organ Damage BP≥180/120 plus with Signs & Symptoms: You may suspect: May verify via: May alleviate Blood Pressure with one of the following: Blurred vision Altered mental status Nausea & vomiting, Headache Neurologic deficits (motor or cranial) Hypertensive retinopathy Stroke: TIA/Infarct/Bleed Subarachnoid Hemorrhage •Abnormal CT Cranial: (Hypodense lesion for Infarct; Hyperdense lesion for Hemorrhage) •Fundoscopy: Papilledema, Retinal hemorrhages and cotton-wool spot for Increased ICP ESMOLOL NITROPRUSSIDE NICARDIPINE LABETALOL HYDRALAZINE CLEVIDIPINE FENOLDOPAM
- 26. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. ֍ Aronow W. S. (2017). Treatment of hypertensive emergencies. Annals of translational medicine, 5(Suppl 1), S5. https://doi.org/10.21037/atm.2017.03.34 HYPERTENSIVE EMERGENCY Blood Pressure Systolic ≥ 180 and/or Diastolic ≥ 120 Target Organ Damage BP≥180/120 plus with Signs & Symptoms: You may suspect: May verify via: May alleviate Blood Pressure with one of the following: Body Malaise, Decrease Urine Output, Uremic Fetor, Behavioral Change, Edema, ± Gross Hematuria Acute Kidney Failure Glomerulonephritis Nephrotic Syndrome Chronic Kidney Disease/ •Elevated serum creatinine level, proteinuria •Renal Ultrasound (Acute vs Chronic) •Other markers like Serum C3, ASO titer, ANA NITROPRUSSIDE NICARDIPINE HYDRALAZINE CLEVIDIPINE FENOLDOPAM LABETALOL
- 27. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS ֍ Tintinalli, J.E., Stapczynski, J.S., Ma, O.J., Yealy, D.M., Meckler, G.D. (2020). Tintinalli’s Emergency Medicine - A Comprehensive Study Guide (9th Edition). McGraw-Hill Education. ISBN: 978-0-07-179476-3, MHID: 0-07-179476-X. ֍ Aronow W. S. (2017). Treatment of hypertensive emergencies. Annals of translational medicine, 5(Suppl 1), S5. https://doi.org/10.21037/atm.2017.03.34 HYPERTENSIVE EMERGENCY May mimic Hypertensive Emergency Signs & Symptoms: You may suspect: May verify via: Stabilize/Abrupt Referral to Specialist (Treat Accordingly) Anxiety, palpitations, tachycardia, diaphoresis Substance Overdose / Sympathetic crisis Withdrawal Symptoms • Sympathomimetic drug use (cocaine, amphetamines) • Abrupt Cessation of Clonidine or other central acting substance; • Alcohol Withdrawal Thyroid Storm Pheochromocytoma • TSH and FT4 • Serum Metanephrines
- 28. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS Hypertension and Hypertensive Urgency Controlled ֍ Loscalzo, J., Fauci, A., Kasper, D., Longo, D., Jameson, J.L. (2022). Harrison's principles of internal medicine (21st edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-426851-1 STROKE HEART FAILURE KIDNEY FAILURE STROKE RISK REDUCTION 40% HEART FAILURE RISK REDUCTION 50% SLOWS RATE OF PROGRESSION OF KIDNEY DISEASE ANEURYSM ARTERY OCCLUSIVE DISEASE BLINDNESS AND RETINOPATHY PREGNANCY COMPLICATION METABOLIC SYNDROME ANEURYSM ARTERY OCCLUSIVE DISEASE BLINDNESS AND RETINOPATHY PREGNANCY COMPLICATION METABOLIC SYNDROME MAY PREVENT
- 29. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS KEY POINTS ֍ 1 Ona, D., Jimeno, C. A., Jasul, G. V., Jr, Bunyi, M., Oliva, R., Gonzalez-Santos, L. E., Mercado-Asis, L. B., Luz, V. A., Leus, A. G., Diaz, A., Santos, M. I., Belen, A. A., Bonzon, D. D., Bote-Nunez, J., Cawed-Mende, R., Chua, A. S., Javier, A., Juangco, D., Madrigal-Dy, C., Manicad, M. B., … Villanueva, N. J. (2021). Executive summary of the 2020 clinical practice guidelines for the management of hypertension in the Philippines. Journal of clinical hypertension (Greenwich, Conn.), 23(9), 1637–1650. https://doi.org/10.1111/jch.14335 ֍ 2 Guideline: Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group. KDIGO 2021 Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int. 2021;99(3S):S1–S87 Start Lifestyle Modification for those Adults with BP ≥130/80; Follow-up after 3 months. Start right away Monotherapy/Combination Therapy Medication with Lifestyle Modification for those adults with BP ≥140/90mmHg with comorbidities, then follow-up after 3 months. Achieve a goal of <130/80 for most adults with hypertension 1 <140/90 for adults with Hypertension with Diabetes, or Old Age ≥80 years old 1 <120/90 for adults with hypertension with CKD 2 Start Pharmacologic Treatment with Lifestyle Modification for the Elderly ≥80 years old with BP 150/90 mmHg 1 If BP goal is not achieved despite Lifestyle Modification and Monotherapy / Dual Therapy, may have Add-on Drugs of another class. Refer to Specialist if still Resistant to Maximum Dose of Triple Antihypertensive Drugs including Thiazide Diuretics.
- 30. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS I – Hypertension A. Risk Factors & Outcome B. Diagnosis D. Hypertensive Crisis: Hypertensive Urgency and Emergency C. Management & Prevention II - Hypertensive Disorders of Pregnancy A. Chronic Hypertension and Gestational Hypertension B. Pre Eclampsia and Eclampsia
- 31. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS Non Pregnant Women Pregnant SBP DBP AHA/ACC a Phil CPG b ACOG c <120 & <80 Normal Normal Normal 120-129 & <80 Elevated BP Borderline 130-139 & 80-89 Hypertension I 140-159 & 90-99 Hypertension II Hypertension Non Severe Hypertension ≥ 160 & ≥ 100 Hypertension II Severe Hypertension ֍ Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Jr, Collins, K. J., Dennison Himmelfarb, C., DePalma, S. M., Gidding, S., Jamerson, K. A., Jones, D. W., MacLaughlin, E. J., Muntner, P., Ovbiagele, B., Smith, S. C., Jr, Spencer, C. C., Stafford, R. S., Taler, S. J., Thomas, R. J., Williams, K. A., Sr, Williamson, J. D., … Wright, J. T., Jr (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension (Dallas, Tex. : 1979), 71(6), e13–e115. https://doi.org/10.1161/HYP.0000000000000065 ֍ Ona, D., Jimeno, C. A., Jasul, G. V., Jr, Bunyi, M., Oliva, R., Gonzalez-Santos, L. E., Mercado-Asis, L. B., Luz, V. A., Leus, A. G., Diaz, A., Santos, M. I., Belen, A. A., Bonzon, D. D., Bote-Nunez, J., Cawed-Mende, R., Chua, A. S., Javier, A., Juangco, D., Madrigal-Dy, C., Manicad, M. B., … Villanueva, N. J. (2021). Executive summary of the 2020 clinical practice guidelines for the management of hypertension in the Philippines. Journal of clinical hypertension (Greenwich, Conn.), 23(9), 1637–1650. https://doi.org/10.1111/jch.14335 ֍ Cunningham, F.G., Leveno, K.J., Dashe, J.S., Hoffman, B.L., Spong, C.Y., Casey, B.M. (2022). Williams Obstetrics (26th Edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-046274-6 a American College of Cardiology/American Heart Association b Philippine Clinical Practice Guidelines c American College of Obstetrics and Gynecology
- 32. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS Chronic Hypertension is a blood pressure of 140/90mmHg or above that precedes pregnancy or if it is identified before 20 weeks’ gestation. Gestational Hypertension occurs 20th week of gestation onwards, up to 12 weeks post partum. 2020 American College of Obstetricians and Gynecologists ֍ Cunningham, F.G., Leveno, K.J., Dashe, J.S., Hoffman, B.L., Spong, C.Y., Casey, B.M. (2022). Williams Obstetrics (26th Edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-046274-6
- 33. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS Preeclampsia is a pregnancy-induced hypertension that occurs on the 20th week of gestation onwards; and affects virtually every organ system that contributes greatly to maternal-fetal complications. Eclampsia a severe preeclampsia with neurologic manifestation such focal, generalized tonic-clonic or absence seizure. 2020 American College of Obstetricians and Gynecologists ֍ Cunningham, F.G., Leveno, K.J., Dashe, J.S., Hoffman, B.L., Spong, C.Y., Casey, B.M. (2022). Williams Obstetrics (26th Edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-046274-6
- 34. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS ֍ Cunningham, F.G., Leveno, K.J., Dashe, J.S., Hoffman, B.L., Spong, C.Y., Casey, B.M. (2022). Williams Obstetrics (26th Edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-046274-6 ֍ Sibai BM. Preeclampsia and hypertensive disorders. Landon MB, Galan HL, Jauniaux ERM, et al, eds. Gabbe's Obstetrics: Normal and Problem Pregnancies. 7th ed. Philadelphia, PA: Elsevier; 2021:chap 38. Hypertensive Disorder CHRONIC HYPERTENSION Findings Onset Blood Pressure ≥140/90 <20 weeks Pregnancy GESTATIONAL HYPERTENSION Blood Pressure ≥140/90 ≥ 20 weeks Pregnancy up to 12 weeks post partum PREECLAMPSIA Nonsevere ≥140/90 Severe ≥160/110 • Proteinuria • Associated Features for Severe ≥ 20 weeks Pregnancy up to 6 weeks post partum ECLAMPSIA Preeclampsia with Neurologic Symptoms/Seizure ≥ 20 weeks Pregnancy up to 48 hours post partum
- 35. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS ֍ Cunningham, F.G., Leveno, K.J., Dashe, J.S., Hoffman, B.L., Spong, C.Y., Casey, B.M. (2022). Williams Obstetrics (26th Edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-046274-6 Hypertensive Disorder Findings Onset CHRONIC HYPERTENSION WITH SUPERIMPOSED PREECLAMPSIA/ECLAMPSIA Worsening BP usually ≥ 30mmHg systolic increase and/or ≥ 15 diastolic increase and onset of proteinuria >20 weeks Pregnancy
- 36. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS Chronic Hypertension in Pregnancy ֍ Cunningham, F.G., Leveno, K.J., Dashe, J.S., Hoffman, B.L., Spong, C.Y., Casey, B.M. (2022). Williams Obstetrics (26th Edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-046274-6 Adverse Effects if prolonged and uncontrolled (≥160/110) Maternal Effects Perinatal Effects • Superimposed Preeclampsia • HELLP Syndrome • Placental abruption • Stroke • Acute Kidney Injury • Heart Failure • Hypertensive cardiomyopathy • Myocardial Infarction • Maternal Death Risk Factors • Ethnicity • Obesity • Diabetes mellitus Chronic hypertension has higher likelihood to progress to Preeclampsia than Gestational Hypertension • Stillbirth • Fetal-growth restriction • Preterm Delivery • Neonatal Death • Neonatal Morbidity • Congenital anomalies
- 37. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS PREECLAMPSIA ֍ Cunningham, F.G., Leveno, K.J., Dashe, J.S., Hoffman, B.L., Spong, C.Y., Casey, B.M. (2022). Williams Obstetrics (26th Edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-046274-6 GESTATIONAL HYPERTENSION PROTEINURIA or Dipstick 1+ UAC Ratio ≥ 0.3 24 hr Urine Sample ≥300mg Protein ≥ 140/90 mm Hg Occurred ≥ 20weeks of pregnancy Normotensive prior pregnancy or ONE OF THESE FINDINGS Headache Upper Abdominal Pain Convulsion (ECLAMPSIA) Visual Disturbances Oliguria Pulmonary Edema Elevated Serum Creatinine Elevated Serum Transaminase Thrombocytopenia <100,000 u/L Fetal Growth Restriction WORSENING BP Systolic ≥ 160 Diastolic ≥110 NONSEVERE SEVERE or or or Williams Obstetrics (26th Edition)
- 38. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS ֍ Cunningham, F.G., Leveno, K.J., Dashe, J.S., Hoffman, B.L., Spong, C.Y., Casey, B.M. (2022). Williams Obstetrics (26th Edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-046274-6 Williams Obstetrics (26th Edition) Risk Factors of Developing Preeclampsia 8.4x 5.1x 3.7x 2.9x 2.8x 2.5x 2.4x 2.1x 2.0x 1.8x 1.8x 1.2x Prior Preeclampsia Chronic Hypertension Diabetes Multifetal Gestation Body Mass Index >30 Systemic Lupus Erythematosus Prior Stillbirth Nulliparity Prior abruption Chronic Kidney Disease Assisted reproductive technology Age >35
- 39. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS ֍ Jennifer Ribowsky, C. H. (2012). Pregnancy‐induced hypertension. Clinician Reviews, 22(5), 27–32. ֍ Cunningham, F.G., Leveno, K.J., Dashe, J.S., Hoffman, B.L., Spong, C.Y., Casey, B.M. (2022). Williams Obstetrics (26th Edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-046274-6 Chronic Hypertension Hypertensive Disorder Gestational Hypertension Clinical Features • No proteinuria • BP ≥ 140/90 mm Hg <20 wk pregnancy • BP ≥ 140/90 >12 wk postpartum • No proteinuria • BP ≥ 140/90 mmHg ≥ 20 wk pregnancy • Resolved within 12 weeks postpartum • CBC, platelet count, peripheral smear • Serum ALT,AST, Creatinine, Uric acid • Lactate dehydrogenase • Urinalysis, 24-h urine protein analysis • Antenatal fetal testing (ultrasound assessment of growth and amniotic fluid level; nonstress test; umbilical artery Doppler velocimetry) Diagnostic Tests Management for in Elevated BP Nonsevere • ≥ 140/90 (Mild): Low sodium diet; once a week visits • ≥ 150/100 (Moderate): Low sodium diet; twice a week visits; assess for proteinuria, may consider oral antihypertensives Severe • ≥ 160/110: Inpatient management, obstetric consultation, start antihypertensives immediately; delivery at 37 wks or with fetal maturity; or delivery at 34 wks with maternal or fetal distress Preeclampsia (May be Superimposed or Post partum) (Eclampsia if with Focal, Generalized or Absence Seizure) Nonsevere Preeclampsia • Proteinuria ≥ 0.3g in 24-h urine sample • BP ≥ 140/90 mmHg ≥ 20 wk pregnancy Severe Preeclampsia, if with one of ff: • Systolic ≥160 or Diastolic ≥110 • Headache, Visual Disturbances, Upper abdominal pain, Oliguria, Convulsion • Pulmonary Edema • Elevated Creatinine or Transaminase • Thrombocytopenia <100,000/uL • Fetal Growth Restriction • Early-onset preeclampsia (20-34weeks) • CBC, platelet count, peripheral smear • Serum ALT,AST, Creatinine, Uric acid • Lactate dehydrogenase • Urinalysis, 24-h urine protein analysis • Antenatal fetal testing (ultrasound assessment of growth and amniotic fluid level; nonstress test; umbilical artery Doppler velocimetry) • Coagulation Test if Platelet <100,000 Nonsevere preeclampsia • Obstetric consultation (with Internist if postpartum preeclampsia) with regular monitoring; • IV / oral antihypertensives • Delivery by 37 weeks Severe preeclampsia • Consultation with maternal-fetal specialist (with Internist if postpartum preeclampsia) with regular monitoring • IV/IM magnesium sulfate & IV antihypertensives • Delivery as soon as possible • Midazolam or Lorazepam and Additional Dose of Magnesium Sulfate for Eclampsia (Preeclampsia with seizure/convulsion)
- 40. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS ֍ Jennifer Ribowsky, C. H. (2012). Pregnancy‐induced hypertension. Clinician Reviews, 22(5), 27–32. ֍ Cunningham, F.G., Leveno, K.J., Dashe, J.S., Hoffman, B.L., Spong, C.Y., Casey, B.M. (2022). Williams Obstetrics (26th Edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-046274-6 ֍ Rothberger, S., Carr, D., Brateng, D., Hebert, M., & Easterling, T. R. (2010). Pharmacodynamics of clonidine therapy in pregnancy: a heterogeneous maternal response impacts fetal growth. American journal of hypertension, 23(11), 1234–1240. https://doi.org/10.1038/ajh.2010.159 PHARMACOLOGIC APPROACH Oral Antihypertensive for Nonsevere Hypertension (<160/110) BETA BLOCKER CALCIUM CHANNEL BLOCKER DIRECT VASODILATOR ALPHA - AGONIST ARBS ACEI METHYLDOPA LABETALOL PROPANOLOL METOPROLOL HYDRALAZINE NIFEDIPINE AMLODIPINE THIAZIDE OTHER ALPHA AGONIST CLONIDINE CAPTOPRIL LOSARTAN ACEi and ARBS of any type have high predilection for fetal growth effects; Must be avoided Conflicting studies / heterogenous; Not advised 0.5 – 3g/day; Usual Preparation 250mg/tab 200 – 1200mg/day in 2 to 3 divided doses 40-160mg/day in 2 divided doses 25-100mg/day in 1-2 divided doses 50-300mg/day; in 2-4 divided doses 30-120mg/day; once daily DIURETICS 5-10mg/day; once daily 2mg/day; preferable for those on <20 weeks Gestation FIRST LINE AGENTS
- 41. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS ֍ 1 Cunningham, F.G., Leveno, K.J., Dashe, J.S., Hoffman, B.L., Spong, C.Y., Casey, B.M. (2022). Williams Obstetrics (26th Edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-046274-6 ֍ 2 Elatrous, S., Nouira, S., Ouanes Besbes, L., Marghli, S., Boussarssar, M., Sakkouhi, M., & Abroug, F. (2002). Short-term treatment of severe hypertension of pregnancy: prospective comparison of nicardipine and labetalol. Intensive care medicine, 28(9), 1281–1286. https://doi.org/10.1007/s00134-002-1406-3 ֍ 3 Aronow W. S. (2017). Treatment of hypertensive emergencies. Annals of translational medicine, 5(Suppl 1), S5. https://doi.org/10.21037/atm.2017.03.34 PHARMACOLOGIC APPROACH Urgent Control for Severe Hypertension (≥160/110) for Pregnant Patients BETA BLOCKER CALCIUM CHANNEL BLOCKER IV LABETALOL1 ORAL NIFEDIPINE1 Boluses: 10mg IV; then 20mg IV every 15-20 x 3 doses 10mg PO; then 20mg PO every 20 mins x 2 doses Infusion: 1-2 mg/min *Sublingual not recommended due to rapid fetal effects IV NICARDIPINE2 Boluses: 2-2.5mg IV q8 CALCIUM CHANNEL BLOCKER Infusion: 5-15mg/hr FIRST LINE AGENTS Either of the following * Caution: high predilection of maternal-fetal tachycardia DIRECT VASODILATOR IV HYDRALAZINE1 Boluses: 5mg IV/IM + 10mg IV/IM every 15-20 x 3 doses Infusion: 0.5-10mg/hr Ideal for Post Partum Preeclampsia
- 42. A VIEWPOINT AND MANAGEMENT ON HYPERTENSION & OTHER HYPERTENSIVE DISORDERS FOR ALLIED HEALTH WORKERS AND PRACTITIONERS OUTLINE HYPERTENSION HYPERTENSIVE DISORDERS ֍ Jennifer Ribowsky, C. H. (2012). Pregnancy‐induced hypertension. Clinician Reviews, 22(5), 27–32. ֍ Cunningham, F.G., Leveno, K.J., Dashe, J.S., Hoffman, B.L., Spong, C.Y., Casey, B.M. (2022). Williams Obstetrics (26th Edition.). New York: McGraw-Hill Education. ISBN: 978-1-26-046274-6 KEY POINTS: PREGNANT PATIENTS For Chronic Hypertension BP ≥160/110, initiate IV/Oral Pharmacologic Therapy. For regular monitoring and work-up. For Chronic Hypertension of BP ≥140/90, adopt Low Sodium Diet. Follow-up weekly. For Chronic Hypertension of BP ≥150/100, or BP ≥140/90 with comorbidities, adopt Low Sodium Diet, may start oral antihypertensive with or without low-dose aspirin for Pregnant. Follow-up twice weekly. Assess for Proteinuria Hydralazine, Labetalol are recommended first line IV agents for Severe Hypertension. Methyldopa, Hydralazine, Labetalol, and Nifedipine are recommended first line oral agents. ACEi and ARBS are not recommended agents for Hypertension control for Pregnant Patients. Magnesium sulfate is a non antihypertensive agent but acts as an anticonvulsant drug for seizure prophylaxis and only be used for Severe Preeclampsia.
- 43. Special thanks to the Sulu Sanitarium General Hospital – Public Health Unit for the distribution of this material