Hypertension

1. Hypertension Robin Felker Bloomer Hill-NCSRHC September 16, 2009

2. Outline • Epidemiology of HTN • Clinical Presentation • Symptoms • BP measurement and interpretation • Interventions • Behavior Modification • Drugs • Comorbitities and Complications • HTN at Bloomer Hill

3. Epidemiology

4. Epidemiology • Hypertension is the most common primary diagnosis in US (PDx in 35 million office visits) • Framingham Heart Study suggests that individuals who are normotensive at age 55 have a 90 percent lifetime risk for developing hypertension • In Stage I HTN, achieving a sustained 12 mmHg reduction in SBP over 10 years will prevent 1 death for every 11 patients treated • If CVD or organ damage, only 9 patients would require such BP reduction to prevent a death

5. Epidemiology • Age-adjusted prevalence of hypertension is significantly higher among blacks (39%) than among whites (29%) • Racial disparity in SBP control contributes to nearly 8,000 excess deaths annually from heart disease and stroke among blacks • Hypertension is the single largest contributor, of any medical condition, to racial disparity in adult mortality

6. Identifying HTN in the Clinic

7. Clinical Symptoms • Commonly ASYMPTOMATIC! • “Classic Sx”: Headache, epistaxis, dizziness • No more frequent in HT than non-HT patients • Flushing, sweating, blurred vision • Family history (first degree relatives) • Manifestations of organ damage • Will discuss later

8. Natural History • Essential Hypertension (95% of cases) • Age of onset: 20-50 years • Family history of hypertension (1st degree relatives) • Gradual onset, mild-to-moderate BP • Normal serum K+, urinalysis • Chronic Renal Disease (2-4%) • Increased creatinine, abnormal urinalysis • Primary aldosteronism (1-2%) • Decreased serum K+

9. Proper BP measurement • Persons should be seated quietly for at least 5 minutes in a chair (rather than on an exam table), with feet on the floor, and arm supported at heart level • Need an appropriate-sized cuff(cuff bladder encircling at least 80 percent of the arm) • Release air so needle falls 2-3 mmHg/sec • Be wary of stress, discomfort, and other evidence of “White Coat HTN” • Need elevated HTN on 2 separate occasions

10. Things to think about • Ideal PE should include • BP confirmation, with verification in the contralateral arm • Examination of the optic fundi • Body mass index(BMI)/waist circumference • Auscultation for carotid, abdominal, and femoral bruits • Palpation of the thyroid gland • Thorough examination of the heart and lungs • Examination of the abdomen for enlarged kidneys, masses, and abnormal aortic pulsation • Palpation of the lower extremities for edema and pulses • Neurological assessment

11. Things to think about • Laboratory tests • Urinalysis and serum Cr/BUN (rule out renal disease) • Serum potassium (aldosteronism) • Blood glucose level (diabetes strongly linked to HTN and renal disease) • Serum Cholesterol (global vascular screen) • ECG (to monitor for LVH)

12. Interpreting Blood Pressure

13. HTN Interventions

14. Interventions • Goal of treatment is to reduce cardiovascular and renal morbidity and mortality • A combination of lifestyle modifications and drug therapy are recommended • REMEMBER: The most effective therapy prescribed by the most careful clinician will control hypertension only if patients are motivated

15. Behavior Modifications • Lifestyle modifications are recommended even for those with near normal BP: ≥ 120/80 • Eight modifications are recommended by the AHA: • Eat a better diet, which may include reducing salt • Enjoy regular physical activity • Maintain a healthy weight • Manage stress • Avoid tobacco smoke • Understand hot tub safety • Comply with medication prescriptions • If you drink, limit alcohol

17. = Cardiac disease, renal & diabetes

18. Drugs (on the $4 list…) • Diuretics • Hydrochlorothiazide (HCTZ) and Chlorthalidone • Thiazide-like diuretics have been shown to be best first-line treatment • ACEI • Lisinopril, Enalapril, Captopril, Benazepril • ARB • BB • Atenolol, Bisoprolol, Carvedilol, Metoprolol, Naldolol, Pindolol, Propranolol, Sotalol • CCB • Diltiazem, verapamil • Most patients will need at least 2 drugs to achieve BP goals • Combos: Lisinopril-HCTZ, Enalopril-HCTZ, Atenolol-Chlorthalidone,

19. Comorbidities and Complications

20. Comorbidities: Obesity • BMI >30 is an increasingly prevalent risk factor for the development of hypertension and CVD • Intensive lifestyle modification should be pursued in these individuals • Consider drug treatment for components of metabolic syndrome • Obesity, glucose intolerance, high BP, high TGs, low HDL

21. Comorbidities : Diabetes • Target of <130/80 mmHg • Thiazide diuretics, BBs, ACEIs, ARBs, and CCBs are beneficial in reducing CVD and stroke incidence in diabetics • ACEI- or ARB-based treatments favorably affect the progression of diabetic nephropathy and reduce albuminuria

22. Old Age • Hypertension occurs in more than two-thirds of individuals after age 65 • However, this group has worst BP control • Lower initial drug doses may be indicated to avoid symptoms • But, standard recommendations should apply

23. Tx in Women • Oral contraceptives may increase BP • Risk of hypertension increases with duration of use • Women taking oral contraceptives should have their BP checked regularly • Development of hypertension is a reason to consider other forms of contraception

24. Tx in Minorities • Impact of hypertension are increased in African Americans • African-Americans develop high blood pressure at younger ages than other groups in the U.S. • Complications are more likely to develop with high blood pressure, including stroke, kidney disease, blindness, dementia, and heart disease • Reduced BP responses to monotherapy with BBs, ACEIs, or ARBs; want to include diuretic in treatment! • Differences in adherence by race may be due to affordability of medicines, personal beliefs, anticipated adverse effects, and health • BP control is lowest in Mexican American and Native American populations

25. Target organ damage • Heart • Left ventricular hypertrophy • Angina or prior myocardial infarction • Prior coronary revascularization • Heart failure • Brain • Stroke or transient ischemic attack • Chronic kidney disease • Peripheral arterial disease • Retinopathy

26. Take Home Points • Hypertension is a VERY common medical condition • Proper identification and treatment is essential to preventing CHF and target organ damage • Lifestyle modifications should start even in persons with near-normal BP (≥120/80) • Proper BP interventions include lifestyle modifications and drug interventions • Two-drug therapy may be necessary for control • First line control is usually thiazide-like diuretic • Tx of BP with comorbidities must take into account concurrent treatment of comorbid conditions

27. HTN at Bloomer Hill • It is essential to follow BP trends and address HTN in our patients • If someone has a high reading, ask about caffeine/smoking, have them sit for 5 minsand recheck BP in the exam room • Try for repeat visit in anyone with high BP, especially >140/90 • Follow-up: every 6 months for well-controlled, monthly/bi-monthly if uncontrolled, monthly with med changes • Counseling on lifestyle modifications for almost every patient is warranted! Try for discrete goals that the patient is on-board with and document them for follow-up

28. References • Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7 Express). • Drugs for hypertension. Treatment Guidelines from the Medical Letter 2009; 7(77). http://medlet-best.securesites.com.libproxy.lib.unc.edu/restrictedtg/t77.html • Fiscella K, Holt K. Racial disparity in hypertension control: tallying the death toll. Ann Fam Med 2008;6:497-502. • Lilly. Pathophysiology of Heart Disease, ed 4. • http://www.webmd.com/hypertension-high-blood-pressure/hypertension-in-african-americans