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Hypertension

Hypertension . M HASANZADEH . MD, MUMS OCT 2009. Abbreviations. Overview. Definition, classification of hypertension (HTN) Goals of therapy Compelling indications Lifestyle modifications Treatment Hypertensive crisis Monitoring antihypertensive drug therapy. Hypertension.

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Hypertension

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  1. Hypertension M HASANZADEH . MD, MUMS OCT 2009

  2. Abbreviations

  3. Overview • Definition, classification of hypertension (HTN) • Goals of therapy • Compelling indications • Lifestyle modifications • Treatment • Hypertensive crisis • Monitoring antihypertensive drug therapy

  4. Hypertension • Persistent elevation of arterial blood pressure (BP) • National Guideline • 7th Report of the Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) • ~72 million Americans (31%) have BP > 140/90 mmHg • Most patients asymptomatic • Cardiovascular morbidity & mortality risk directly correlated with BP; antihypertensive drug therapy reduces cardiovascular & mortality risk Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42(6):1206–1252.

  5. Guidelines in measuring BP • Condition: -Posture (sitting,supine,standing) -Circumstances (no caffeine.no smoking) • Equipment: -Cuff size -Manometer • Technique: -number of readings -Performance -recordings

  6. Target-Organ Damage • Brain: stroke, transient ischemic attack, dementia • Eyes: retinopathy • Heart: left ventricular hypertrophy, angina • Kidney: chronic kidney disease • Peripheral Vasculature: peripheral arterial disease

  7. Etiology • Essential hypertension: • > 90% of cases • hereditary component • Secondary hypertension: • < 10% of cases • common causes: chronic kidney disease, renovascular disease • other causes: Rx drugs, street drugs, natural products, food, industrial chemicals

  8. Causes of 2˚ Hypertension • Diseases • chronic kidney disease • Cushing's syndrome • coarctation of the aorta • obstructive sleep apnea • parathyroid disease • pheochromocytoma • primary aldosteronism • renovascular disease • thyroid disease

  9. Causes of 2˚ Hypertension • Prescription drugs:   • prednisone, fludrocortisone, triamcinolone • amphetamines/anorexiants: phendimetrazine, phentermine, sibutramine • antivascular endothelin growth factor agents • estrogens: usually oral contraceptives • calcineurin inhibitors: cyclosporine, tacrolimus • decongestants: phenylpropanolamine & analogs • erythropoiesis stimulating agents: erythropoietin, darbepoietin

  10. Causes of 2˚ Hypertension • Prescription drugs: • NSAIDs, COX-2 inhibitors • venlafaxine • bupropion • bromocriptine • buspirone • carbamazepine • clozapine • ketamine • metoclopramide

  11. Causes of 2˚ Hypertension • Situations: • β-blocker or centrally acting α-agonists • when abruptly discontinued • β-blocker without α-blocker first when treating pheochromocytoma • Food substances:   • sodium • ethanol • licorice

  12. Causes of 2˚ Hypertension • cocaine • cocaine withdrawal • ephedra alkaloids (e.g., ma-huang) • “herbal ecstasy” • phenylpropanolamine analogs • nicotine withdrawal • anabolic steroids • narcotic withdrawal • methylphenidate • phencyclidine • ketamine • ergot-containing herbal products • St. John's wort • Street drugs, other natural products:  

  13. Arterial Pressure Determinants

  14. Mechanisms of Pathogenesis • Increased cardiac output (CO): • increased preload: • increased fluid volume • excess sodium intake • renal sodium retention • venous constriction: • excess RAAS stimulation • sympathetic nervous system overactivity

  15. Mechanisms of Pathogenesis • Increased peripheral resistance (PR): • functional vascular constriction: • excess RAAS stimulation • sympathetic nervous system overactivity • genetic alterations of cell membranes • endothelial-derived factors • structural vascular hypertrophy: • excess RAAS stimulation • sympathetic nervous system overactivity • genetic alterations of cell membranes • endothelial-derived factors • hyperinsulinemia due to obesity, metabolic syndrome

  16. Arterial Blood Pressure • Sphygmomanometry: indirect BP measurement • MAP = 1/3 (SBP) + 2/3 (DBP) • BP = CO x TPR MAP: Mean Arterial Pressure SBP: Systolic Blood Pressure DBP: Diastolic Blood Pressure BP: Blood Pressure CO: Cardiac Output TPR: Total Peripheral Resistance

  17. Adult Classification Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42(6):1206–1252.

  18. SYSTEMIC HYPERTENSION • CLASSIFICATION • OPTIMAL <120 <80 • NORMAL <130 <85 • HIGH NORMAL 130-139 85-89

  19. HYPERTENSION

  20. Clinical Controversy • White coat hypertension: elevated BP in clinic followed by normal BP reading at home • Aggressive treatment of white coat hypertension is controversial • Patients with white coat hypertension may have increased CV risk compared to those without such BP changes

  21. Classification for Adults • Classification based on average of > 2 properly measured seated BP measurements from > 2 clinical encounters • If systolic & diastolic blood pressure values give different classifications, classify by highest category • > 130/80 mmHg: above goal for patients with diabetes mellitus or chronic kidney disease • Prehypertension: patients likely to develop hypertension

  22. Classification of blood pressure for adult • JNC7 JNC6 SBP and/or DBP • Normaloptimal <120and <80 • Prehypertension ___ 120_139 or 80_89 • ____ normal <130 and <85 • ____ high-normal 130_139 or 85_89 • Hypertension: hypertension: • Stage 1 stage 1 140-159 or 90-99 • stage 2 >/=160 or >/=100 • _____ stage 2 160-179 or 100-109 • _____ stage 3 >/=180 or >/=110

  23. Clinical Controversy • Ambulatory BP measurements may be more accurate & better predict target-organ damage than manual BP measurements using a sphygmomanometer in a clinic setting (gold standard) • many patients may be misdiagnosed, misclassified • poor technique, daily BP variability, white coat HTN • Validated ambulatory BP monitoring: role in the routine HTN management unclear

  24. Investigation of the New Hypertensive • History and examination • Exclude secondary Hypertension • Urea and electrolytes • FBS and ESR • ECG • Lipid profile • Chest x-ray no longer routinely indicated

  25. LABORATORY TESTS FOR HTN • BASIC TESTS FOR INITIAL EVALUATION: • ALWAYS INCLUDED • USUALL INCLUDED • SPECIAL STUDIES

  26. LABORATORY TESTS FOR HTN • ALWAYS INCLUDED TESTS: • URINE FOR PROTEIN,BLOOD,GLUCOSE. • MICROSCOPIC URINALYSIS. • HEMATOCRIT. • SERUM POTASSIUM. • SERUM CREATININE OR BUN. • FASTING GLUCOSE. • TOTAL CHOLESTROL. • EKG

  27. LABORATORY TESTS FOR HTN • USUALLY INCLUDED TESTS: • TSH • WBC • HDL,LDL,TG • SERUM CALC& PHOS • CHEST X RAY &ECHO

  28. LABORATORY TESTS FOR HTN • SPECIAL STUDIES TO SCREEN FOR SECONDARY HTN: • 1 . RENOVASCULAR DISEASE: • ACE INHIBITOR RADIONUCLEIDE RENAL SCAN,RENAL DUPLEX DOPPLER FLOW STUDIES ,MRI ANGIOGRAPHY. • 2 . PHEOCHROMOCYTOMA: • 24-h URINE ASSAY FOR: CREATININE,METANEPHRINES,&CATHECH

  29. LABORATORY TESTS FOR HTN • SPECIAL STUDIES TO SCREEN FOR SECONDARY HTN: • 3 .CUSHING SYNDROME: • OVERNIGHT DEXAMETHASONE • SUPRESSION TEST. • 24-h URINE CORTISOL & CREATININE. • 4 .PRIMARY ALDOSTRONISM: • PLASMA ALDOSTRONE:RENIN ACTIVITY

  30. BLACK RACE YOUTH MALE GENDER SMOKING DM OBESITY ALCOHOL INTAKE HYPERCHOLESTROLEMIA EVIDENCE OF END ORGAN DAMAGE(LVH,LVSTRAIN,MI,CHF) RETINAL HEMORR&EXODATE PAPILLEDEMA RENAL:IMP REN FUN CVA RISK FACTORS FOR ADVERS PROGNOSIS IN HTN

  31. HYPERTENSION • EMERGENCY • URGENCY • ACCELERATED • MALIGNANT

  32. Treatment Goals • Reduce morbidity & mortality • Select drug therapy based on evidence demonstrating risk reduction Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42(6):1206–1252.

  33. 2007 AHA Recommendations • More aggressive BP lowering for high risk patients Rosendorff C, Black HR, Cannon CP, et al. Treatment of hypertension in the prevention and management of ischemic heart disease: A scientific statement from the American Heart Association Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and Prevention. Circulation 2007;115(21):2761–2788.

  34. ALLHAT • Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) • Primary endpoints • fatal CHD • nonfatal MI • Secondary endpoints • other hypertension-related complications • HF • stroke ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002;288(23):2981–2997.

  35. ALLHAT • Prospective, double-blind trial • randomized patients to: • chlorthalidone • amlodipine • doxazosin • lisinopril-based therapy • 42,418 patients: age > 55 yr with HTN + 1 additional CV risk factor (mean subject participation 4.9 years) • Thiazide-type diuretics remain unsurpassed for reducing CV morbidity & mortality in most patients ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002;288(23):2981–2997.

  36. JNC7 Recommendations • Thiazide-like diuretics preferred 1st line therapy based on clinical trials showing morbidity & mortality reductions • ALLHAT confirms 1st line role of thiazide diuretics • Compelling indications: comorbid conditions where specific drug therapies provide unique long-term benefits based on clinical trials • drug therapy recommendations are in combination with or in place of a thiazide diuretic Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42(6):1206–1252.

  37. Clinical Controversy • Avoiding Cardiovascular Events through COMbination Therapy in Patients LIving with Systolic Hypertension (ACCOMPLISH) • Endpoint: composite of death from CV causes, hospitalization for angina, nonfatal MI or stroke, coronary revascularization, & resuscitation after cardiac arrest • Prospective, double-blind, industry sponsored trial • randomized patients to benazepril + amodipdine or benazepril + HCTZ • 11,506 patients with HTN & high CV risk • Combination benazepril + amlodipine superior to benazepril + HCTZ for reducing CV events in high risk patients Jamerson KA, Weber MA, Bakris GL, et al. Benazepril plus amlodipine or hydrochlorothiazide for hypertension. N Engl J Med. 2009;359(23):2417-2428.

  38. Compelling Indications • Heart Failure • Post Myocardial Infarction • High Coronary Disease Risk • Diabetes Mellitus • Chronic Kidney Disease • Recurrent Stroke Prevention

  39. Recommendations & Evidence • Strength of recommendations • A: good, B: moderate, C: poor • Quality of evidence • 1: more than 1 properly randomized, controlled trial • 2: at least 1 well-designed clinical trial with randomization; cohort or case-controlled analytic studies; dramatic results from uncontrolled experiments or subgroup analyses • 3: opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert communities

  40. ACE: angiotensin-converting enzyme; ARB: angiotensin receptor blocker; CCB: calcium channel blocker; • DBP: diastolic blood pressure; SBP: systolic blood pressure

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  42. Lifestyle Modifications DASH, Dietary Approaches to Stop Hypertension. aEffects of implementing these modifications are time and dose dependent and could be greater for some patients. DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM: Pharmacotherapy:APathophysiologic Approach, 7th Edition: http://www.accesspharmacy.com/

  43. Clinical Controversy • Prehypertension: patients do not have HTN but at risk for developing it • Trial of Preventing Hypertension (TROPHY) showed treating prehypertension with candesartan decreased progression to stage 1 hypertension • Unknown whether managing prehypertension with drug therapy and lifestyle modifications decreases CV events or if this approach is cost-effective Julius S, Nesbitt SD, Egan BM, et al. Feasibility of treating prehypertension with an angiotensin-receptor blocker. N Engl J Med 2006;354(16):1685–1697.

  44. Hypertension in Pregnancy • Important to differentiate preeclampsia from chronic, transient, & gestational hypertension • Preeclampsia: >140/90 mmHg after 20 weeks’ gestation with proteinuria • restricted activity, bed rest, close monitoring beneficial • definitive treatment: delivery • Methyldopa: drug of choice

  45. Chronic HTN in Pregnancy DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM: Pharmacotherapy:APathophysiologic Approach, 7th Edition: http://www.accesspharmacy.com/

  46. Diuretics • Exact hypotensive mechanism unknown • Initial BP drop caused by diuresis • reduced plasma & stroke volume decreases CO and BP • causes compensatory increase in peripheral vascular resistance • Extracellular & plasma volume return to near pretreatment levels with chronic use • peripheral vascular resistance becomes lower than pretreatment values • results in chronic antihypertensive effects

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