Essentials of Hypertension: Screening, Evaluation, and Management

2. اصول درمان هیپرتانسیون یا بیماری پر فشاری خون Dr. Shahrzad Shahidi Professor of Nephrology

3. The Almighty Pardons & Grants me heaven Even if I don't know a single letter about: Crutz Feld Jacob’s Disease Tsutsugamushi Fever Crigler-NajjarSyndrome South American equine encephalitis & Many & much more rarer topics BUT …….

4. The Almighty Will drag me to hell and will not pardon My ignorance of even the minute details of HTN My indifference to apply the current knowledge My negligence in screening for HTN, TOD My despondency about preventing TOD My inadequacy in maintaining my patients as normo-tensive as possible – (This is applicable to all common diseases)

5. Results of BP Screenings • Recheck in 2 yrs if nml • Recheck in 1 yr if Pre–HTN • Stage 1 - Confirm in 2 mos • Stage 2 - Confirm in 1 mo • If > 180 / 110, treat now

6. Goals of Therapy • Reduce CVD & renal morbidity & mortality. • Achieve SBP goal especially in persons >50 years of age.

17. Patient Evaluation • Evaluation of patients with documented HTN has three objectives: • Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guides treatment. • Reveal identifiable causes of high BP. • Assess the presence or absence of target organ damage and CVD.

18. Laboratory Tests • Routine Tests • ECG • Urinalysis • Blood glucose, & hematocrit • Serum K, Cr, or the corresponding estimated GFR, Ca • Lipid profile, after 9- to 12-hour fast, that includes HDL & LDL & TG • Optional tests • Measurement of urinary albumin excretion or Alb/Cr ratio • More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved

19. Lifestyle Modification:effect on BP

20. Beta-blockers • Are not a preferred initial therapy for HTN. • May be considered in younger people, particularly: • Intolerance or contraindication to ACEI & ARB • Women of child-bearing potential • People with evidence of increased sympathetic drive • If therapy is initiated with a beta-blocker & a second drug is required, add a calcium-channel blocker rather than a thiazide-like diuretic to reduce the person’s risk of developing DM.

21. dIURETICS • When using further diuretic therapy for resistant HTN: Monitor blood Na, K & renal function within 1 month & repeat as required thereafter.

22. For adequate control of B.P. Do you think we can control most of the patients of HTN with: One drug Two drugs Three drugs Can’t control In most of the patients Two drugs are required for adequate control More so if the initial BP is 20/10 above the goal

23. 2/3 of patients with HTN will need at least 2 medicines for BP control

24. HTN – Why Combinations ? • If goal BP is not achieved by a single drug in full dose • Then adding another agent will help achieve the goal BP • Two agents sometimes nullify each others side effects • Fixed dose combinations will reduce the no. of tablets • Once daily formulations are good for compliance • Sustained release or LA formulations for 24 h BP control • If 3 drugs can’t achieve goal BP :Resistant HTN

25. 2013 ESH/ESC Guidelines for the management of HTN

26. Green continuous : preferred combinations • Green dashed: useful combination • Black dashed lines: possible but less well tested combinations • Red : not recommended combination.

27. In patients with resistant HTN, adding drugs to drugs should be done with attention to results & any compound overtly ineffective or minimally effective should be replaced, rather than retained in an automatic step-up multiple-drug approach

28. Adherence to Medication According to Frequency of Doses Osterberg, L. et al. N Engl J Med 2005

29. Pearls • For resistant HTN – sit down & take a good Hx: • How much water, coffee, milk, juice, tea, ice – anything liquid do you drink daily. • Food preferences & salt intake • Drugs/Alcohol • Compliance

30. Causes of Resistant HTN • Improper BP measurement • Excess Na intake • Inadequate diuretic therapy • Medication • Inadequate doses • Drug actions & interactions: NSAIDs, illicit drugs, sympathomimetics, OCP • OTC drugs & herbal supplements • Excess alcohol intake • Identifiable causes of HTN JNC 7 Express. JAMA. 2003

32. Steroids Estrogens NSAIDS Phenylpropanolamines Cyclosporine/Tacrolimus Erythropoietin Sibutramine Methylphenidate Ergotamine Ketamine Desflurane Carbamazepine Bromocryptine Metoclopramide Antidepressants Venlafaxine Buspirone Clonidine Drug-Induced HTN: Prescription Medications

33. Drug-Induced HTN: Street Drugs & Herbal Products • Cocaine • Ma huang “herbal ecstasy” • Nicotine • Anabolic steroids • Narcotic withdrawal • Methylphenidate • Phencyclidine • Ketamine • Ergot-containing herbal products • St John’s wort

34. Food Substances Sodium Chloride Ethanol Licorice Tyramine-containing foods (with MAOI) Chemicals Lead Mercury Thallium & other heavy metals Lithium salts Substances Associated with HTN

35. Follow-up & Monitoring • Patients should return for follow-up & adjustment of medications every 1-2 months until the BP goal is reached • After BP at goal & stable, follow-up visits at 3- to 6-month intervals • More frequent visits for stage 2 HTN or with complicating comorbid conditions • Continue to encourage self BP monitoring • Serum K & Cr monitored 1–2 times per year JNC 7 Express. JAMA. 2003

36. Non - Adherence • Misunderstanding of Condition • Denial of illness / Asymptomatic • Lack of patient involvement in care plan • Unexpected adverse effects of medicine • Too many f / u visits, lab requests

37. Keys to Achieving BP control • • BP checks at every patient care encounter • –Including optometry, OB-GYN, etc • • BP clinic (Non-MD clinic) • –Free & frequent visits, walk ins welcome • –Removing all barriers for patients • • Simple algorithm – easy for providers & patients • –One BP goal (<140/90) for all patients • –Emphasis on combination pills (lisinopril / HCTZ) • –Emphasis on getting to target BP control quickly • • Feedback on Performance / Transparency

38. New Features and Key Messages • The most effective therapy prescribed by the careful clinician will control HTN only if patients are motivated. • Motivation improves when patients have positive experiences with, & trust in, the clinician. • Empathy builds trust & is a potent motivator. • The responsible physician’s judgment remains paramount.

39. Cases

40. Case 1: Diagnosis AB is a 56 yo female with no significant PMH. Her BMI is 26 & she has a FHx positive for Type 2 DM. Her BP measured on 2 consecutive clinic visits is 132/84. What is AB’s BP classification? • Normal • Prehypertensive • Stage 1 Hypertension • Stage 2 Hypertension

41. Case 1: Therapy What therapy should be initiated for AB? • Enalapril 5 mg PO daily • Hydrochlorothiazide 25 mg PO daily • No therapy is indicated • Lifestyle modifications including weight loss & DASH eating plan should be encouraged

42. Case 1: Goal of Therapy What is the goal of lifestyle modification in AB? • Goal BP < 140/90, the goal is to get to goal • Goal BP < 130/80, the goal is to get to goal • Improve patients quality of life • Prevent onset of hypertension

43. Case 1: 5 years later AB, now 59 y, returns to clinic with marginal success at lifestyle changes. Her BP has repeatedly measured around 146/92. What is AB’s BP classification? • Normal • Prehypertensive • Stage 1 Hypertension • Stage 2 Hypertension

44. Case 1: 5 years later AB, now 59, returns to clinic with marginal success at lifestyle changes. Her BP has repeatedly measured around 146/92. What should be done? • Enalapril 5 mg PO daily • Hydrochlorothiazide 25 mg PO daily • No therapy is indicated • Reinforce lifestyle modifications including weight loss and the DASH eating plan.

45. Case 2: Goal of Therapy CD is a 50 yo black male with diet controlled type 2 diabetes. Consecutive BP measurements during recent clinic visits are 162/98 and 158/96. He is diagnosed with Stage 2 Hypertension. What is the goal of therapy for CD? • Goal BP <140/90 • Goal BP <130/80 • Slow the progression of diabetic renal disease by reducing BP to <125/80 • Improve patients quality of life

46. Case 2: Therapy What therapy should be initiated for CD? • A 6 month trial of lifestyle changes should be initiated immediately • Hydrochlorothiazide 25 mg PO daily • Enalapril 10 mg PO daily • Enalapril / Hydrochlorothiazide 5/12.5 mg PO daily