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Hypertension 2013

Hypertension 2013. Family Medicine Richard Birtwhistle MD. CFPC Objectives- Hypertension 1 Screen for hypertension. 2 Use correct technique and equipment to measure blood pressure.

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Hypertension 2013

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  1. Hypertension 2013 Family Medicine Richard Birtwhistle MD

  2. CFPC Objectives- Hypertension • 1 Screen for hypertension. • 2 Use correct technique and equipment to measure blood pressure. • 3 Make the diagnosis of hypertension only after multiple BP readings (i.e., at different times and during different visits). • 4 In patients with an established diagnosis of hypertension, assess and re-evaluate periodically the overall cardiovascular risk and end-organ complications: • a) Take an appropriate history. • b) Do the appropriate physical examination. • c) Arrange appropriate laboratory investigations. • 5 In appropriate patients with hypertension (e.g., young patients requiring multiple medications, patients with an abdominal bruit, patients with hypokalemia in the absence of diuretics): • a) Suspect secondary hypertension. • b) Investigate appropriately. • 6 Suggest individualized lifestyle modifications to patients with hypertension. (e.g., weight loss, exercise, limit alcohol consumption, dietary changes). • 7 In a patient diagnosed with hypertension, treat the hypertension with appropriate pharmacologic therapy (e.g., consider the patient’s age, concomitant disorders, other cardiovascular risk factors). • 8 Given a patient with the signs and symptoms of hypertensive urgency or crisis, make the diagnosis and treat promptly. • 9 In all patients diagnosed with hypertension, assess response to treatment, medication compliance, and side effects at follow-up visits.

  3. Resources • Canadian Hypertension Education Program • http://www.hypertension.ca/chep • Canadian Task Force on Preventive Health Care • http://canadiantaskforce.ca/

  4. Proportion of Deaths Attributable to Leading Risk Factors World Health Organization Global Burden of Disease Study

  5. Hypertension is a Major Risk Factor Brain Stroke, TIA, Dementia hypertensive encephalopathy Eyes Retinal hemorrhage, exudate, optical disc edema, arteriolar constriction Heart Angina, MI, CHF, LVH Blood vessels Aneurysm, arterial occlusive disease Kidney ESRF

  6. What is the prevalence of Hypertension? • 5% • 10% • 20% • 30% • 50%

  7. after Joffres , Canadian Heart Health Survey (1997)

  8. Among the 19.5% with untreated hypertension, 70.2% (13.7%) were unaware of their hypertension Source: Leenen et al, CMAJ, 178(11)

  9. Impact of High-Normal BP on Risk of Cardiovascular Disease Cumulative incidence of CV events in women without hypertension according to baseline blood pressure SBP 130-139 DBP 85-89 SBP 120-129 SBP <120 mmHg Source: Vasan, RS et al. NEJM 2001;345:1291-1297.

  10. New onset hypertension in people with high normal blood pressure Julius S. NEJM 2006;354:1685-97

  11. The concept of masked hypertension 135 140 True hypertensive Masked HTN Home or Daytime ABPM SBP mmHg 135 True Normotensive White Coat HTN 140 Office SBP mmHg Derived from Pickering et al. Hypertension 2002: 40: 795-796.

  12. The prognosis of masked hypertension Prevalence of masked hypertension is approximately 10% in the general population but is higher in patients with diabetes J Hypertension 2007;25:2193-98

  13. 91% of Hypertensive Patients Have at Least 1 Additional Risk Factor Assess global cardiovascular risk in all hypertensive patients Risk factors =  Global CV risk Rantala et al. J Intern Med 1999; Wannamethee et al. J Hum Hypertens 1998

  14. The Canadian Hypertension Education Program: 2013 Recommendations Revised BP thresholds for initiating therapy More guidance in structuring exercise prescription as a component of lifestyle modification What’s new?

  15. BP thresholds for drug treatment* * lifestyle modification is recommended for all regardless of BP ** Year of incorporation into CHEP recommendations

  16. The Canadian Hypertension Education Program: 2013 Recommendations Out-of-office blood pressure measurements are important in both the diagnosis and management of hypertension The management of hypertension is all about global cardiovascular risk management and vascular protection Single pill combinations help achieve blood pressure control The most important step in prescription of antihypertensive therapy is achieving patient “buy-in” What’s old but still important?

  17. Case #1

  18. The face of very low risk hypertension • PN is a 42 year old woman. Family history of hypertension (father and mother). Cycles daily. Non-smoker. Entirely asymptomatic • BP = 148/98 mmHg (average of repeated measures) • BMI=22 kg/m2, WC=78 cm • TC 3.8 mM, LDL 2.2. mM, Fasting Blood Glucose 4.6 mM Given her elevated BP and assuming failure of other lifestyle modifications would you treat her with antihypertensive drugs?

  19. Benefit of BP lowering in the “average” hypertensive (i.e., middle aged male) Number-needed-to-treat (NNT10 yr) to prevent a CV event/death or a death from all causes by BP lowering TOD=target organ damage Ogden et al. Hypertension 2000;35:539-43

  20. What is this PN’s 10 yr. CV risk? A) low (less than 10 %) B) moderate (10-20%) C) high (greater than 20 %) So low that it’s off the scale

  21. Reducing 10 yr. CV risk from 1% with antihypertensive Rx: What’s in it? • Overall relative risk reduction with effective BP lowering ~25% • Thus, assuming PN’s 10 yr. risk is 1%, effective Rx would lower her risk 0.25% and you will need to treat 400 patients like PN for 10 years to avoid 1 MI !

  22. Case #2 • Mr. R an accountant for a large hospital is seen in clinic to follow-up on BP=158/96 taken by Occupational Health • 2 BPs during this visit 158/90 &160/90 • Interview and review of the medical chart reveals: • Height 5 ’10” and weight 190 lbs (BMI 27 kg/m2) • Review of systems normal • Social drinker (~2 glasses of wine/day) • Quit smoking 5 years ago • No routine physical activity • Married, two children Is he hypertensive?

  23. Diagnostic algorithm for hypertension HypertensionVisit1 BP Measurement, History and Physical examination Hypertensive Urgency / Emergency Hypertension Visit 2 Target Organ Damage or Diabetes or BP ≥ 180/110? Diagnosis of HTN Yes No BP: 140-179 / 90-109 Office BPM ABPM (If available) Home BPM (If available)

  24. Case #1 • Mr. R an accountant for a large hospital is seen in clinic to follow-up on BP=158/96 taken by Occupational Health • 2 BPs during this visit 158/90 &160/90

  25. Diagnostic Work-Up • Check BP at all appropriate visits (grade C) • Use standardized measurement technique: • Have patient rest for 5 minutes • Use a validated & calibrated device • Cuff encircles 80% of upper arm • Measure both arms at initial visit • Thereafter take 2 measurements on the side where BP is higher

  26. Measure here Iliac crest Waist Circumference Measurement Courtesy J.P. Després 2006

  27. Diagnostic Work-Up, cont… • History and physical • Review for CV risk factors, evidence of TOD and HTN and monitor treatment • Routine laboratory tests (grade D) • Urinalysis • CBC, blood chemistry (potassium, sodium, creatinine), fasting glucose, fasting TC, HDL, LDL, triglycerides • Standard 12-lead ECG • Lab tests for specific subgroups • Diabetes & renal disease: protein excretion • Elevated creatinine, hx of renal disease or proteinuria - renal ultrasound

  28. Hypertension Male Increasing age Peripheral arterial disease Previous stroke or TIA Microalbuminuria or proteinuria Diabetes mellitus Smoking Source: 2005 CHEP Recommendations Family history of premature CVD Chronic kidney disease Abnormal lipid profile Sedentary lifestyle Left ventricular hypertrophy Search for Cardiovascular Risk Factors

  29. Search for Target Organ Damage Cerebrovascular TIA Ischemic or Hemorrhagic Stroke Hypertensive retinopathy Left ventricular dysfunction Coronary artery disease Angina or prior MI CHF Chronic kidney disease Peripheral arterial disease

  30. TC 4.85 mmol/L LDL 3.1 mmol/L TG 2.2 mmol/L HDH 1.32 mmol/L Normal 12 lead ECG Weight 7.5 lbs since first visit No routine physical activity BP 158/100 mmHg No evidence of TOD Normal urinalysis & CBC Serum potassium=4.5 mmol/L Serum creatinine 100 mmol/L Fasting glucose=5.1 mmol/l Case #1: Visit 2 • Is he hypertensive? • What are the treatment and management options?

  31. Office BP ABPM (If available) Home BPM Hypertension visit 3 >160 SBP or >100 DBP Diagnosis of HTN Awake BP <135/85 and 24-hour <130/80 Awake BP >135 SBP or >85 DBP or 24-hour >130 SBP or >80 DBP < 135/85 >135/85 <160 / 100 ABPM or HBPM or Hypertension visit 4-5 >140 SBP or >90 DBP Diagnosis of HTN Diagnosis of HTN Continue to follow-up Continue to follow-up Diagnosis of HTN Continue to follow-up < 140 / 90 Criteria for the diagnosis of hypertension and recommendations for follow-up BP: 140-179 / 90-109 Repeat Home BPM If < 135/85 Patients with high normal blood pressure (office SBP 130-139 and/or DBP 85-89) should be followed annually.

  32. Long-acting CCB Beta- blocker* Thiazide diuretic ACEI ARB III. Summary: Treatment of Systolic-Diastolic Hypertension without Other Compelling Indications TARGET <140/90 mmHg Lifestyle modification A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mmHg systolic or >10 mmHg diastolic above target Initial therapy Dual Combination • CONSIDER • Nonadherence • Secondary HTN • Interfering drugs or lifestyle • White coat effect *Not indicated as first line therapy over 60 y Triple or Quadruple Therapy

  33. Treatment of Hypertension in Diabetes? BP Target? Choices for Drug Treatment?

  34. Treatment of Hypertension in association with Diabetes Mellitus with Nephropathy Diabetes Threshold equal or over 130/80 mmHg and TARGET below 130/80 mmHg A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mmHg systolic or >10 mmHg diastolic above target. Combining an ACEi and a DHP-CCB is recommended. ACE Inhibitor or ARB 1. ACE Inhibitor or ARB or 2. DHP-CCB or Thiazide diuretic without Nephropathy > 2-drug combinations Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB Combinations of an ACEI with an ARB are specifically not recommended in the absence of proteinuria More than 3 drugs may be needed to reach target values for diabetic patients If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control of volume is desired

  35. Hypertension in Patients with Ischemic Heart Disease BP Target? Choices for Drug Treatment?

  36. Treatment of Hypertension in Patients with Ischemic Heart Disease 1. Beta-blocker 2. Long-acting CCB Stable angina ACEI are recommended for most patients with established CAD* ARBs are not inferior to ACEI in IHD Short-acting nifedipine • • Caution should be exercised when combining a non DHP-CCB and a beta-blocker • • If abnormal systolic left ventricular function: avoid non DHP-CCB (Verapamil or Diltiazem) • Dual therapy with an ACEI and an ARB are not recommended in the absence of refractory heart failure • The combination of an ACEi and CCB is preferred *Those at low risk with well controlled risk factors may not benefit from ACEI therapy

  37. Hypertension in Patients with Stroke BP Target? Choices for Drug Treatment?

  38. TREATMENT OF HYPERTENSION IN ASSOCIATION WITH STROKEAfter the acute Phase of Stroke or TIA Strongly consider blood pressure reduction in all patients after the acute phase of stroke or TIA . Target BP < 140/90 mmHg An ACEI / diuretic combination is preferred Stroke TIA Combinations of an ACEI with an ARB are not recommended

  39. Hypertension in Patients with Chronic non-diabetic Kidney Disease BP Target? Choices for Drug Treatment?

  40. Treatment of Hypertension in Patients with Non Diabetic Chronic Kidney Disease Target BP: < 140/90 mmHg ACEI/ARB: Bilateral renal artery stenosis Chronic kidney disease and proteinuria * ACEI or ARB (if ACEI tolerated) Additive therapy: Thiazide diuretic. Alternate: If volume overload: loop diuretic Combination with other agents * albumin:creatinine ratio [ACR] > 30 mg/mmol or urinary protein > 500 mg/24hr Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB Combinations of a ACEI and a ARB are specifically not recommended in the absence of proteinuria

  41. Considerations Regarding the Choice of First-Line Therapy Use caution in initiating therapy with 2 drugs in whom adverse events are more likely (e.g. frail elderly, those with postural hypotension or who are dehydrated). ACE inhibitors, renin inhibitors and ARBs are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potential. Beta adrenergic blockers are not recommended for patients age 60 and over without another compelling indication. Diuretic-induced hypokalemia should be avoided through the use of potassium sparing agents if required. The use of dual therapy with an ACE inhibitor and an ARB should only be considered in selected and closely monitored people with advanced heart failure or proteinuric nephropathy. ACE-inhibitors are not recommended (as monotherapy)for black patients without another compelling indication.

  42. Case #3 • Mr. J is a 45 year old mechanic • Several recent office visits pre/post inguinal hernia repair • BP range 140/90-154/90 mmHg at recent office visits • Previous documented BP 122/70 mmHg • Nonsmoker • Drinks 3-4 beers/day (more on W/E) • Saturday night hockey league, no other exercise • Weight increase 20 lbs over past 5 years (BMI 28 kg/m2 )and waist circ 98 cm • Eats fast food for lunch 3-4 times/week

  43. Prevention of Hypertension Eat a healthy diet according to Canada’s Guide to Healthy Eating High in fresh fruits, vegetables, low fat dairy products, low in saturated fat and salt Physical activity: 30-60 min moderate intensity 4-7x/week Maintain a healthy body weight (BMI 18.5-24.9 kg/m2) & WC<102cm men, <88 cm women Alcohol consumption (2 drinks /day) Smoke free environment Treatment of Hypertension Eat healthy according to the DASH diet High in fresh fruits, vegetables, low fat dairy products, low in saturated fat and salt Physical activity: 30-60 min moderate intensity 4x/week or more Weight loss (>5 Kg) in those who are overweight (BMI 25) and WC<102cm men, <88 cm women Reduce alcohol consumption in those who drink excessively Smoke free environment Lifestyle Strategies

  44. Dietary Approaches to Stop Hypertension DASH Diet • Rich in fruits, vegetables, low fat dairy foods, and low in fat, total fat, cholesterol and salt • The low sodium DASH diet evaluated the effect of reducing sodium intake in combination with a DASH diet. BP fell 11.4/5.5 mmHg in hypertensive persons compared to 3.5/2.1 in normotensives Source: Appel et al. N Engl J Med 1997;336:1117. • The DASH eating plan is available at www.nhlbi.nih.gov/health/public/heart/hbp/dash

  45. Recommendations for daily salt intake 2,300 mg sodium (Na) = 100 mmol sodium (Na) = 5.8 g of salt (NaCl) = 1 level teaspoon of table salt • 80% of average sodium intake is in processed foods • Only 10% is added at the table or in cooking Institute of Medicine, 2003

  46. Case #4 The Resistant Hypertensive

  47. Case # 4 Elaine J is a 49 year old woman who has been diagnosed with hypertension for 3 years. She remains overweight (BMI 28, WC 84 cm) and has tried to increase the amount of exercise she gets. She has a busy job and 3 teen- aged children. She is currently taking Ramipril 10 mg daily Hydrochlorothiazide 25 mg daily Amlodipine 5 mg daily Her office BP on last visit was 152/97 What do you do now?

  48. Hypertension remaining uncontrolled with two or more medications always raises the concern of why, and how to obtain adequate control

  49. The Resistant Hypertensive Issues to Consider & Investigations

  50. Search for exogenous potentially modifiable factors that can induce/aggravate hypertension Prescription Drugs: NSAIDs, including coxibs Corticosteroids and anabolic steroids Oral contraceptive and sex hormones Vasoconstricting/sympathomimetic decongestants Calcineurin inhibitors (cyclosporin, tacrolimus) Erythropoietin and analogues Antidepressants: Monoamine oxidase inhibitors (MAOIs), SNRIs, SSRIs Midodrine Other: Licorice root Stimulants including cocaine Salt Excessive alcohol use

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