Changing Strategies Of Treatment Of Hypertension Dr Sunita Dodani Family Medicine Department The Aga Khan University Ka

1. Changing Strategies Of Treatment Of Hypertension Dr Sunita Dodani Family Medicine Department The Aga Khan University Karachi, Pakistan

2. Objectives: At the end of this presentation, we should be able to: • Learn about recent guidelines of hypertension management. • Define hypertension by the JNC-VI guidelines. • Discuss the management steps recommended by JNC VI. • Define the provider’s role in patient compliance. • Controversies of stepped care therapy.

3. New Guidelines: • Joint National Committee (JNC) sixth report on prevention, detection, evaluation and treatment of high blood pressure (JNC-VI) - 1997. • WHO/International Society of Hypertension (ISH), Guidelines of Hypertension Management for Primary Care Physicians - 1999. • British Hypertension Society Guidelines for Hypertension Management - 1999. • Local: First report of National Task Force on Hypertension, Pakistan Hypertension League - 1998.

4. JNC-VI Guidelines: (Drawn from consensus and evidence - based findings) • Discuss hypertension treatment in step-wise-manner. • Cover treatment strategies in special population like Black Americans, pregnancy and patients with co-morbid conditions.

5. Definition: Normal pressure into 3 categories.  Abnormal pressure into 3 stages for adults > 18 and older.

6. Classification of Blood Pressurefor Adults Age 18 and Olders: Category Systolic Diastolic (mm Hg) (mm Hg) Optimal <120 and <80 Normal <130 and <85 High-normal 130-139 or 85-89 Hypertension Stage 1 140-159 or 90-99 Stage 2 160-179 or 100-109 Stage 3 > 180 or > 110

7. Changing Strategies Of Treatment Of Hypertension (Cont’d) • Elevated BP (>140/90) on 2 or more visits with BP taken 2 or more times on each visit and then averaged. • Seated in a chair with arm supported at heart level. • Must not smoke or drink caffeine for 30 minutes prior to measuring the BP. • Cuff size should encircle 80% of the patient’s arm.

8. Changing Strategies Of Treatment Of Hypertension (Cont’d) • BP measurements should be attempted only after 5 minutes of rest. • BP should be at least 2 minutes apart, averaged, and then repeated if 2 measurements differ by more than 5 mmHg. • Anxious patient may falsely give high reading (white coat hypertension).

9. Changing Strategies Of Treatment Of Hypertension(Cont’d) • BP rises in most people as they age,  BP is not considered a normal part of aging. • Isolated systolic hypertension is considered in patients with systolic BP >140 mmHg and diastolic BP <90 mmHg

10. Management: Three-pronged approach: • Lifestyle modifications. • Appropriate medications (based on the patient’s demographic and medical profile). • Professional health care support to foster compliance.

11. Life Style Modification: • Lifestyle modifications for all stages of hypertension and are the initial recommendations for both high normal and stage 1 hypertension.

12. Life Style Modifications (Cont’d): • Weight reduction also  cholesterol and DM • Patients with abdominal obesity waist size >34 cms Females >39 cms Males  Hypertension risk

13. Exercise: • Brisk walking. • 30-45 minutes at 40% - 60% of maximal activity  determined by pulse rate (220 - age x 0.4 & 0.6).

14. Changing Strategies Of Treatment Of Hypertension (Cont’d) • DASH: Dietary approaches to stop hypertension. • Like DM diet, DASH diet includes a specific number of servings and the weight of servings. • Unlike DM Diet, DASH diet does not offer the option of food exchanges. • Plant food sources • Only 2 - 3 animal protein servings/day

15. Changing Strategies Of Treatment Of Hypertension (Cont’d) •  in Dietary sodium. • Esp. for African Americans • Elderly • DM • 75 meq/day of dietary sodium or less ( 5 mmHg systolic & 2.6 mm diastolic). • Cessation of smoking. •  alcohol intake. • < 10 oz wine • < 2 oz whisky • < 24 oz beer

16. Initial Drug Therapy: Step-wise approach: 1.First line - Diuretic or -blocker. 2.New agents - Ca channel blocker, ACE inhibitor, vasodilator etc. should be considered if patient is not responsive to initial therapy or has co-morbid conditions. 3. Adrenergic agents should only be used as a last choice b/c of their side effect profile.

17. Choosing the right medication foryour patient: Choice of the treatment regimen depends on: • Degree of BP elevation. • Number of associated & concurrent risk factors. • Presence of TOD. • Clinical CVD or associated clinical conditions (ACC).

18. Risk Stratification: Risk Factors for Target Organ Damage Associated Clinical Cardiovascular Diseases (TOD) Conditions (ACC) 1. Used for risk Cerebrovascular · LVH (ECG, Echo, XR) stratification Disease : · Levels of systolic and Ischemic stroke · Proteinuria & / or slight diastolic BP Cerebral hemorhage elevation of plasma (Stages 1-3) Transient ischemic attack creatinine 1 . 2 – 2 · Men > 55 years mg/dl · Women > 65 years (106- 177 mmol/L) Heart Disease: · Smoking Myocardial Infarction · Total Cholestrol > 6.5 · Ultrasound or Angina Pectoris mmol/L radiological evidence Coronary · Diabetes of atherosclerotic revascularization · FH of premature CVD plaques Congestive Heart failure (carotid, illiac & f emoral arteries, aorta)

19. Risk Stratification (Cont’d): Risk Factors For Associated Clinical Target Organ Damage Cardiovascular Diseases Conditions (ACC) 2. Other factors Renal Diseases: adversely influencing · Diabetic nephropathy the prognosis (TOD) · Generalized or focal · Reduced HDL narrowing of the retinal · Raised LDL arteries ( retinopathy) Microalbuminuria in diabetes · Impaired GTT · Obesity · Sedentary life style · Raised fibrinogen · High risk socioeconomic & ethnic group · High risk geographic region

20. Dosage & Combination Therapy • Single daily dose  interval of 4 - 6 weeks to observe the full response, unless it is necessary to lower BP more urgently. • If drug well tolerated but response is small,  the dose or add drugs stepwise until BP control is attained. • Treatment can be stepped down later if BP falls substantially below the optimal level. • Most hypertensives require a combinations of antihypertensive therapy to achieve optimal control.

21. Dosage & Combination Therapy(Cont’d): • Drugs from different classes generally have additive effect on BP. • Submaximal doses of 2 drugs results in larger response of BP & fewer side effects eg: Diuretic + B-blocker Diuretic + ACE inhibitor Ca-channel blocker + ACE inhibitor • Fixed dose combination may be convenient and are acceptable when monotherapy is ineffective

22. Dosage & Combination Therapy(Cont’d) • In Elderly: 1. Initial drug therapy: Diuretics Ca channel blockers

23. Specific Medication Recommendations For Concurrent Medical Problems: Concurrent Recommended Intermediate Usually Not Conditions/ Drug Therapy Drug Therapy Used or Contra- Charactersticks indicated Medications ACE Inhibitors ACE Inhibitors Diuretics with care Diabetes with proteinuria Ca antagonists Angiotensin B Blockers (both types) Receptor Blockers ACE Inhibitors B Blockers Heart Failure Diuretics Ca Antagonists Carvadilol Losartin Diuretics ACE Inhibitors B Blockers Isolated Systolic Hypertension Ca Antagonists Angiotensin (non-DHP central Receptor Blockers effects), long acting forms

24. Specific Medication Recommendations For Concurrent Medical Problems: Concurrent Recommended Intermediate Usually Not Conditions/ Drug Therapy Drug Therapy Contraindicated Characteristics B Blockers (non-ISA) Diuretics DHP Ca Myocardial Infarction ACE Inhibitors; ACE Inhibitors Antagonists eg reduce mortality Receptor Blockers nifedipine after MI Non DHP,CaAntago- (immediate nists, ( Diltiazem, release can Verapamil) worsen myocardial ischemia) Diuretics Angiotensin B Blockers African American race Calcium Antagonists Receptor Blockers ACE Inhibitors (both types) B Blockers Diuretics Atrial Ca Antagonists ACE Inhibitors Tachycardia/ (Both Types) Angiotensin. Fibrillation Receptor Blockers

25. Specific Medication Recommendations For Concurrent Medical Problems:

26. Specific Medication Recommendations For Concurrent Medical Problems (Cont’d): Concurrent Recommended Intermediate Usually not Conditions/ Drug Therapy Drug Therapy used Characteristics Contraindicated Medications Essential or B Blockers ACE Inhibitors senile tremors Receptor Blocker Ca Antagonists Diuretics Hyperthyroidism B Blockers Migraine B Blockers (Non Diuretics ISA) ACE Inhibitors Calcium Receptor Blocker Antagonist DHP Calcium (non DHP) Antagonists

27. Specific Medication Recommendations For Concurrent Medical Problems (Cont’d): Concurrent Recommended Usually Not Intermediate Conditions/ Used/ Drug Therapy Drug Therapy Contraindicated Characteristics Medications Osteoporosis Thiazides Pre-operative B Blockers Hypertension Diuretics Angiotensin Prostatism ACE Inhibitors Receptor Blockers ( can’t be given with severe renal impairment) Angiotensin Renal Blockers B Receptor Insufficiency Blockers Ca Antagonists (both types)

28. WHO/ISH Guidelines for Hypertension Management Summary Points: • Use of Grades rather than stages, otherwise values choosen are same as JNC-VI. • Mild, moderate and severe are not used in the WHO-ISH guidelines - they correspond to grades 1,2 & 3. • Term borderline hypertension is subgroup of Grade 1 i.e. Systolic 140-149 Diastolic 90-94

29. British Hypertension Society Guidelines for Hypertension Management: Summary Points: • Grades rather than stages are used to classify hypertension. • Uses coronary heart disease risk accessors or risk charts. • Isolated systolic hypertension defined as systolic > 160 and diastolic < 90. • Use of aspirin (primary prevention ) in hypertension patients. • Use of statins in patients with hypertension.

30. Indications for specialist referral: • Urgent treatment indicated: Malignant hypertension, impending complications. • To investigate potential underlying causes of hypertension when initial evaluation suggests this possibility. • To evaluate therapeutic problems or failures. • Special circumstances: Unusually variable blood pressure, possible white coat hypertension, pregnancy.

31. Conclusion: • New guidelines like JNC-VI, unlike previous guidelines, has introduced the concept of aggressive blood pressure control at optimal levels. • For elderly patients , the achievement of at least 140/90 mm Hg or below blood pressure is acceptable. • Life style modification alone for those patients at relatively low overall risk for cardiovascular diseases and with drugs for those at higher risk.

32. Conclusion: (Contd…) • Diuretics or B-blockers for those as first choice with uncomplicated hypertension. • ACE inhibitors for Diabetic patients with proteinuria. • ACE inhibitors &/ 0r diuretics for patients with heart failure & systolic dysfunction. • Long-acting dihydropyridine Ca antagonist for systolic hypertension in the elderly. • Follow-up during evaluation & stabilization of treatment should be frequent to monitor BP and other risk factors. • Follow-up is important to establish good relationship with patient and to educate the patient.

33. Figure 1: Stepped Care Algorithm for treatment of Hypertension: Life style modification,Reduce wt Quit smoking,Regular exc. , Decrease sodium and alcohol Inadequate response Continue lifestyle modifica- tion,Initiate pharmacotherapy Inadequate response Increase daily dose Substitute another drug Add 2nd drug from diff.class Inadequate response Inadeq, response Refer Add 2nd or 3rd Drug

34. Changing Strategies Of Treatment Of Hypertension (Cont’d)Goal: • JNC-VI uses a lower goal BP (<140/90 mmHg) for hypertension in the elderly.

35. Changing Strategies Of Treatment Of Hypertension (Cont’d) Diuretics: •  plasma volume. • cause peripheral vasodilation. • potentiate the effect of other anti-hypertensive drugs. • Caution: Renal disease , Gout, DM, Dyslipidemia. • Start low dose. -blockers: • 1 selective : start low dose & gradually-increase. • Should not be used in COPD, CHF or  left ventricular function. ACE inhibitors: • DM with proteinuria. • CHF or myocardial infarction.

36. Stratifying risk and quantifying prognosis:

37. Which Drug treatment should be used? Compelling contra-indications Class of Drug Compelling Indications Possible Contra-indications Possible Indications Diuretics • Heart failure • Elderly • Systolic Hypertension • Diabetes • Gout • Dyslipidemias • Sexually active males • Dyslipidemia • Athletes • Physically active patients • Peripheral vascular. disease • Angina • Post MI • Tachy-arrythmias • Asthma • COPD • Heart Blocks B Blockers • Heart failure • Pregnancy • Diabetes

38. Which Drug treatment should be used Class of Drug Compelling Indications Possible Indications Compelling contra-indications Possible Contra-indications ACE Inhibitors • Heart Failure • LV. Dysfunction • After MI • Diabetic neph- ropathy • Pregnancy • Bilateral Renal artery Stenosis • Hyperkalemia • Heart Blocks Calcium Antagonists • Angina • Elderly • Systolic Hypertension Peripheral Vascular Disease Congestive Heart Failure

39. Which Drug treatment should be used Class of Drug Compelling Indiacations Possible indications Compelling contra-indications Possible Contra-indications Alpha Blockers • Prostrate Hypertrophy Orthostatic hypotension • Glucose Intolerance • Dyslipidemias Angiotensin II Antagonists • Pregnancy • Bilateral Renal artery Stenosis • Hyperkalemia • Heart Blocks • Side Effects with other drugs e.g. ACE inhibitors (cough) Heart Failure

40. References: • BMJ 1999 Sep 4; 319:630- 635 - British Hypertension Society guidelines for Hypertension management 1999; Summary NEW: 9 - 13 • Editorial - British guidelines on managing hypertension • World Health Organization- International Society of Hypertension - 1999 WHO-ISH Guidelines for the management of Hypertension - Journal of Hypertension (see on line articles, Volume 17, Issue 2, pages 151 - 183, February 1999). • The Sixth Report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure JNC-V1- PDF format from the National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health (NIH) NEW updated URL 2-11

41. References (Cont’d): • NHLBL JNC IV References Sheet. • National Guideline Clearing House - Brief Summary NEW: 2 - 11. • Archives of Internal Medicine 1997 Nov 24 BAD LINK -NEW URL -waiting for 1997 back issues to be placed on-line ? • JNC V1: timing is everything Commentary - The Lancet 15 Nov 97. • JNC - 6 Guidelines Editorial - American Journal of Kidney Diseases May 1998 • JNC Redux Editorial - American Journal of Kidney Diseases May 1998 • Treatment of hypertension; insights from the JNC V1 report. Am Fam Physician 1998 Oct 15; 58 (6; 1323 - 30 - PubMed abstract)