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Objectives

Objectives. Cure Pathologic Fear of Hypertension Create Rational Approach to Drug Choice Complement Rational Choice with Pearls Consolidate new information with cases. Those who do not have high blood pressure at age 55 face a 90 percent chance of developing it during their lifetimes.

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Objectives

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  1. Objectives • CurePathologic Fear of Hypertension • CreateRational Approach to Drug Choice • ComplementRational Choice with Pearls • Consolidatenew information with cases

  2. Those who do not have high blood pressure at age 55 face a 90 percent chance of developing it during their lifetimes. • So high blood pressure is a condition that most people have at some point in their lives. • 90% of Americans over 65 have hypertension or Prehypertension

  3. If you cannot prevent disease You can at least cause Dys-Ease

  4. Your Blood pressure is 128/84 While drug treatment is recommended if your BP is at or above 140/90, new medical guidelines state that a normal BP for most adults is less than 120/80. Ask your doctor what is right for you.

  5. The risk of cardiovascular disease begins at 115/75 In individuals aged 40 to 70 years, each 20/10 mm Hg increase in blood pressure doubles the risk of cardiovascular disease, including heart attack, stroke or kidney disease This program includes: A free 30 day trial of Diovan, Diovan HCT and Lotrel, 3 medications proven to help lower blood pressure.

  6. 180/100 115/75 High Risk Low Risk

  7. 115/75

  8. We’re Doomed, We’re Doomed

  9. Home Blood Pressures

  10. Hypertension • The Silent Killer

  11. 69% of people who have a heart attack, 77% of people who have a first stroke, and 74% of people with chronic CHF have high blood pressure.

  12. 95% of people who have a heart attack, 95% of people who have a first stroke, and 95% of people with chronic CHF Have eaten pickles in the previous 10 years

  13. http://cybersmokeblog.blogspot.com/2013/03/do-you-agree-to-tell-whole-truth-and.htmlhttp://cybersmokeblog.blogspot.com/2013/03/do-you-agree-to-tell-whole-truth-and.html

  14. Hypertension Outcomes

  15. So What does it mean • 45 Year Old Female • Cholesterol 200 • Non-Smoker • Systolic of 190 • 10 Year Risk? • 2% Risk of Heart Attack • 1.4% if treated

  16. So What does it mean • 65 Year Old Male • Cholesterol 200 • Non-Smoker • Systolic of 155 • 10 Year Risk? 90% Chance of Going 10 years with NO heart attack 92.8% If they Are Treated • 10% Risk of Heart Attack • 7.2% if treated

  17. So What does it mean • 65 Year Old Male • Cholesterol 200 • Smoker • Systolic of 180 • 10 Year Risk? 75% Chance of Going 10 years with NO heart attack 82% If they Are Treated • 25% Risk of Heart Attack • 18% if treated

  18. But Aggressive Is Better Right? • Accord Trial NEJM 2010;362:17 • Diabetes PLUS • Heart Disease • OR • Albuminuria • OR • Hypertrophy • OR • Two Risk Factors

  19. But Aggressive Is Better • Accord Trial NEJM 2010;362:17 • Systolic of <120 vs Systolic of <140 • Achieved 119 vs 133

  20. But Aggressive Is Better Right? • Accord Trial NEJM 2010;362:17 • Outcome: • nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes • Followed Almost 5 years

  21. But Aggressive Is Better Right? • Accord Trial NEJM 2010;362:17 • Composite Outcome: • 1.87 vs 2.09 p=0.2 • Death • 1.28 vs 1.19

  22. But Aggressive Is Better Right? • Accord Trial NEJM 2010;362:17 • Stroke: • 0.32 vs 0.53 p=0.01

  23. Cochrane ReviewAggressive is Better? • Seven trials (22,089 subjects) -4/-3 better • …at present there is no evidence to support aiming for a blood pressure target lower than 140/90 mmHg in any hypertensive patient.

  24. Fear Of Hypertension Fear of Hypertension

  25. Rational Approach to Treat HTN

  26. Two Major Divisions of HTN • High Renin • Low Renin

  27. High Renin • Intuitive • Renin AngiotensinAldosterone • Sympathetic Nervous System • Angiotensin Vasoconstriction • Aldosterone Sodium and Water

  28. High Renin • Characteristics • Systolic and Diastolic Equally Elevated • Higher Hemoglobin • Younger • High Stress? • White?

  29. Low Renin • Not Intuitive • Why is Renin Low? • Flaws in Sodium Excretion •  Volume • Paradoxical  Aldosterone • Stiff Arteries & Volume Excess

  30. Low Renin • Characteristics • Isolated Systolic Hypertension • Older • Women • African American • Diabetes

  31. So What?

  32. Stimulate RAA Inhibit RAA Diuretics CCB’s ACE’s / ARB’s Beta Blockers ?

  33. Salt and Hypertension • Salt retaining Steroids • Corticosteroids • Anabolic Steroids • Oral contraceptives • Estrogens • NSAIDS

  34. 46 year old AA female HCTZ Chlorthalidone Or Indapamide • Weight 276 pounds • BP 170/90 • Blood sugars run 200-250 • Glucophage 500mg BID • Micronase 5mg qd • Zestril 20mg qd • Complaining of palpitations.

  35. She has Diabetes!!You can’t do that, Can You??

  36. Transition Good Question !!

  37. https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcSZnyeB7hSiohvoaUK2XPf8I3RkGhJcnxmgTzAxVstB5KyIxXmChttps://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcSZnyeB7hSiohvoaUK2XPf8I3RkGhJcnxmgTzAxVstB5KyIxXmC https://encrypted-tbn3.gstatic.com/images?q=tbn:ANd9GcRJ9hLG9bZqehwMhM3Au6sq1xi4x8gb1LY-PnnvCiqbwv7HJeJW

  38. Diuretics 0 12.5 25 50 100

  39. Diuretics • Lasix for Hypertension • Only if: • Serious Edema • CrCl < 30 • Torsemide probably better

  40. Alpha Blockers • Women: Only the ones with Prostate Glands • Men: only the ones with BIG Prostate Glands • When in Doubt, Cut It Out.

  41. Clonidine • All the outcomes data are on the next slide

  42. Atenolol is Dead

  43. Hydralazine https://www.toledoblade.com/image/2013/01/09/670x_b1_a4-3_cCM_z_cT/Cedar-Point-GateKeeper.jpg

  44. Resistant Hypertension • Causes • Drugs • Street Drugs • Sleep Apnea • Renal Artery Stenosis

  45. Resistant Hypertension • The Situation • All 4 Classes added • Still No Joy • Add Spironolactone • Especially if the potassium is on the low side

  46. Last Pearl • The number one cause of Resistant Hypertension https://encrypted-tbn3.gstatic.com/images?q=tbn:ANd9GcR7w6eOwm6ymMSLZxuF_7PpZ-oCCQo8xh_oJKrxhdtC4PfFtYWr

  47. A Couple Stories

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