1 / 27

Hypertension

Hypertension. Jared Helms D.O. OGME-2 22 August 2007. Hypertension. The treatment of hypertension is the most common reason for office visits of non-pregnant adults to physicians in the United States and for use of prescription drugs.

leandra-shepard
Download Presentation

Hypertension

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Hypertension Jared Helms D.O. OGME-2 22 August 2007

  2. Hypertension The treatment of hypertension is the most common reason for office visits of non-pregnant adults to physicians in the United States and for use of prescription drugs. Cherry, DK, Burt, CW, Woodwell, DA. Advance data from vital and health statistics. No 337. Hyattsville, MD. National Center for Health Statistics, 2003.

  3. Definitions • Normotensive: systolic <120 mmHg and diastolic <80 • Prehypertension: systolic 120-139 or diastolic 80-89 • Hypertension • Stage 1: systolic 140-159 or diastolic 90-99 • Stage 2: systolic 160 or diastolic 100 The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. Chobanian AV; et al. JAMA 2003 May 21;289(19):2560-72. Epub 2003 May 14.

  4. Definitions • Hypertensive urgency: Severe hypertension (as defined by a diastolic blood pressure above 120 mmHg) in asymptomatic patients • Malignant hypertension: marked hypertension with retinal hemorrhages, exudates, or papilledema; usually associated with a diastolic pressure above 120 mmHg

  5. Causes • Essential Hypertension • Secondary Hypertension • Primary renal disease • Renovascular disease • Oral contraceptives • Pheochromocytoma • Primary hyperaldosteronism • endocrine disorders • Sleep apnea syndrome • Coarctation of the aorta

  6. Essential vs. Secondary There are four major general clinical clues that are suggestive of secondary hypertension • Severe or refractory hypertension. • An acute rise in blood pressure over a previously stable value. • Proven age of onset before puberty or above the age of 50 to 55 years • Age less than 30 years in non-obese, non-black patients with a confirmed negative family history of hypertension.

  7. Essential Hypertension • pathogenesis of essential hypertension is poorly understood • Increased sympathetic neural activity, with enhanced beta-adrenergic responsiveness • Increased angiotensin II activity and mineralocorticoid excess • genetic factors • Reduced adult nephron mass may predispose to hypertension

  8. Risk Factors • A variety of risk factors have been associated with essential hypertension: • tends to be both more common and more severe in blacks • Increased salt intake • excess alcohol intake • weight gain • Dyslipidemia Risk factors for arterial hypertension in adults with initial optimal blood pressure: the Strong Heart Study Hypertension. 2006 Feb Dyslipidemia and the risk of incident hypertension in men. Hypertension. 2006 Jan

  9. Complications • Increase in risk begins as the blood pressure rises above 110/75 mmHg • At any blood pressure, is importantly affected by the presence or absence of other risk factors Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002 Dec

  10. Complications- CV • premature cardiovascular disease • heart failure • Left ventricular hypertrophy

  11. Complications- Neurological • Stroke • Intracerebral hemorrhage • Hypertensive encephalopathy

  12. Complications- Renal • Chronic renal insufficiency • End-stage renal disease • Anemia • Electrolyte disorders

  13. Diagnosis • 3-6 visits over the space of weeks to months • No evidence of end organ damage • Cuff Size • Too small can overestimate by 10-50 mmHg • Arm circumference 22 to 26 cm, 'small adult' cuff, 12 x 22 cm • Arm circumference 27 to 34 cm, 'adult' cuff: 16 x 30 cm • Arm circumference 35 to 44 cm, 'large adult' cuff: 16 x 36 cm • Arm circumference 45 to 52 cm, 'adult thigh' cuff; 16 x 42 Confirming the diagnosis of mild hypertension. Br Med J (Clin Res Ed) 1983 Jan 22;286(6361):287-9. Variation in cuff blood pressure in untreated outpatients with mild hypertension--implications for initiating antihypertensive treatment. J Hypertens 1987 Apr;5(2):207-11.

  14. Diagnosis • White Coat Hypertension • Ambulatory monitoring • Masked Hypertension How common is white coat hypertension? JAMA 1988 Jan 8;259(2):225-8. Prevalence, persistence, and clinical significance of masked hypertension in youth. Hypertension 2005 Apr;45(4):493-8.

  15. Work up-History • “When was the last time you were told your blood pressure was normal” • Family History • Noncompliance • Symptoms of target organ damage • Headaches • Visual changes • Chest pain • Claudication • Dyspnea

  16. Work up-History • Presence of other risk factors for cardiovascular disease • Smoking • Diabetes • Dyslipidemia • Physical inactivity

  17. Work up-History • Signs and symptoms that suggest an identifiable cause of hypertension • Muscle weakness • Thinning of the skin • Flank pain • Symptoms suggestive of pheochromocytoma • Spells of tachycardia, sweating, tremor

  18. Work up-PE • Evaluate for signs of end-organ damage • Retinopathy (Hemorrhage, Papilledema, Cotton wool spots) • Pulses • Cardiac (rhythm, murmurs) • Abdominal bruits • Edema • Neurologic Assessment

  19. Work up- Lab • CBC, CMP • TSH • Lipid Profile • UA • EKG • +/- CXR

  20. Lifestyle Modifications

  21. Therapeutics

  22. Getting to Goal • Uncomplicated HTN: < 140/90 mmHg • If older than 65 keep Diastolic above 65 mmHg • Chronic Renal Disease: < 130/80 mmHg • Diabetes Mellitus: < 130/80 mmHg • Cardiovascular Disease: < 130/80 mmHg The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. Chobanian AV; et al. JAMA 2003 May 21;289(19):2560-72. Epub 2003 May 14.

  23. Initial Drug Therapy • Uncomplicated HTN: Low dose diuretic • Heart Failure: ACEI • Asymptomatic LV dysfunction: ACEI • MI: ACEI • Diabetes: ACEI • Renal Failure: ACEI 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 Dec 18

  24. Initial Drug Therapy • Severe HTN with EKG evidence of LVH: ARB • S/p AMI with heart failure or asymptomatic LV dysfunction: Beta blockers w/o ISA • There are no absolute indications for calcium channel blockers in hypertensive patients Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). ALLHAT Collaborative Research Group. JAMA 2000 Apr 19;283(15):1967-75. Should beta blockers remain first choice in the treatment of primary hypertension? A meta-analysis. Lancet 2005 Oct 29-Nov 4;366(9496):1545-53.

  25. Initial Drug Therapy • Switching vs. Additive therapy • Age & Race Predictors • Younger patients: beta blockers and ACEI & ARBs • Older patients: diuretics and CCBs • Black patients: diuretics and CCBs 1. Optimisation of antihypertensive treatment by crossover rotation of four major classes. Lancet 1999 Jun 12 2. ACE inhibitors, beta-blockers, calcium blockers, and diuretics for the control of systolic hypertension. Am J Hypertens 2001 Mar 3. Response to a second single antihypertensive agent used as monotherapy for hypertension after failure of the initial drug. Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents. Arch Intern Med 1995 Sep 11 4. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. Chobanian AV; et al. JAMA 2003 May 21;289(19):2560-72. Epub 2003 May 14.

  26. Questions?

  27. fin

More Related