Hypertension: Evaluation and Management

1. Hypertension: Evaluation and Management Rachel Hindin, MD Washington University School of Medicine Department of Medical Education Grace Hill Murphy O’Fallon Clinic

2. In the clinic… • 45 yo woman with no past medical history presents to the clinic for the first time for a routine physical exam. She smokes 2 packs of cigarettes a day, and drinks 3 beers every day of the week. Her BMI is 32. She does not exercise and she relies heavily on canned soups for her meals. She had a brother who died from an MI at 40 yo, and her mother had an MI at age 49 yo. Her blood pressure is 150/90. How should her blood pressure be managed? What else should be done as part of her initial evaluation?

3. In the clinic… • 65 yo man with insulin-dependent diabetes, dyslipidemia, chronic kidney disease, s/p prior 4 vessel CABG, and congestive heart failure presents for routine follow-up. His medications include Lantus 30 units qhs, Metoprolol 25 mg bid, Lisinopril 10 mg qday, Amlodipine 5 mg qday, Atorvastatin 40 mg qday, Aspirin 81 mg qday, and Furosemide 40 mg qday. He does not have any complaints. His last HgbA1c was 7.8, his microalbumin was 68. His blood pressure is 138/86, as it was on his last visit. He has taken his medicine today. How should his blood pressure be managed? Is he adequately controlled?

4. In the clinic… • 55 yo man with HTN presents to the clinic after being off of his medications for 6 months. His medications included HCTZ, Losartan, Amlodipine, Metoprolol, and Clonidine. He endorses having episodic chest pain while off of his medications, as well as having some blood in his urine over the past several days prior to presentation. His blood pressure is 240/120. How should this patient be managed?

5. Epidemiology • Number of individuals affected • 50 million US; 42,000 have HTN as primary dx • 1 billion worldwide • Visits per yr in US for HTN • 38 million outpt • 3.4 million hospital ER • Cost • $55 billion • 50% of cost - medications

7. Awareness/control • 30% of those with HTN do not know it • Only 30% of those with dx’ed HTN are adequately controlled • Healthy People 2010 sets goal of 50% controlled by 2010

8. Measuring blood pressure • The numbers • Systolic pressure: arterial pressure when ventricle contracting • Diastolic pressure: arterial pressure when ventricle relaxed • Measuring BP • seated for 5 minutes, arm at heart level; cuff encircling 80% of arm • Readings on two different days • Ambulatory • At home

9. Definition/Classification

10. Etiology • Essential hypertension (95% of cases) • Secondary hypertension (5% of cases)

11. Essential hypertension • Genetics • Sodium intake • EtOH intake • Obesity • Tobacco

12. Primary aldosteronism Renovascular disease Pheochromocytoma Coarctation of aorta Thyroid disease Chronic kidney disease Sleep apnea Medication induced: NSAIDs Steroids Cocaine/ amphetamines Sympathomimetics Oral contraceptives Cyclosporine/ tacrolimus Secondary hypertension

13. Complications • Cardiac • Coronary artery disease/MI • Congestive heart failure • Neurologic • Cerebrovascular disease/stroke • Peripheral vascular • Claudication • Renal • Chronic renal insufficiency/End Stage Renal Disease • Ophthalmic

14. Evaluation • History • Physical exam • Laboratory evaluation

15. Symptoms Cardiac: chest pain, shortness of breath Neurologic: headaches, visual changes Renal: lower extremity edema, hematuria Peripheral vascular disease: claudication Past medical history MI CVA Renal insufficiency Hyperlipidemia Diabetes Social history Tobacco Alcohol Illicit drug use Psychosocial factors Family history MI CVA Diabetes History

16. Ophthalmic Cardiac Displaced PMI Murmur Elevated JVP Pulmonary Crackles Abdominal Bruits Neurologic Strength Reflexes Extremities Edema Pulses Physical

17. Laboratory evaluation • Basic metabolic panel • Assess renal function • Fasting lipid profile • Screen for hyperlipidemia • Fasting glucose • Screen for diabetes • Symptom specific testing • Chest pain: EKG, stress test • Shortness of breath: echocardiogram • Visual changes: eye referral • Renal insufficiency: urine microalbumin

18. Goals of treatment • Blood pressure control: adequately control blood pressure for pt’s specific comorbidities • No comorbidities: <140/90 • Diabetes/chronic kidney disease: <130/80 • Risk reduction for complications • Primary prevention • Secondary prevention

19. Treatment • Lifestyle • Pharmacologic

20. Weight reduction Normal BMI:18.5-24.9 Dietary modification DASH (dietary approach to stop hypertension diet) 2g sodium diet Physical activity 30 minutes of aerobic exercise x 5 days per week Alcohol modification Men: 2 drinks/day Women: 1 drink/day Treatment: lifestyle changes

22. Diuretics Decrease total body water ACEI/ARB Inhibit conversion of angiotensinogen to angiotensin/inhibit angiotensin activity at receptors Beta-blockers Decrease heart rate and cardiac contractility Calcium channel blockers Block calcium channel induced vasoconstriction and cardiac contractility Alpha-blockers Block alpha induced arterial vasoconstriction Central alpha-agonists Decrease peripheral catecholamines Treatment: medications

23. Isolated HTN diuretic Diabetes ACEI Coronary artery disease ACEI Beta-blocker Congestive heart failure ACEI Beta-blocker Chronic kidney disease ACEI Cerebrovascular disease ACEI Beta-blocker Preferred agents

24. Diagnosis: Blood pressure DBP>120, but primarily clinical diagnosis Symptoms Neurologic Cardiac Renal Etiology New diagnosis Medication nonadherence Illicit drug use Treatment Monitored blood pressure lowering Parenteral treatment Hypertensive emergency

25. Hyperlipidemia • Cholesterol/Triglycerides • Sources: diet & genetics • Types • LDL - low density lipoprotein that transports cholesterol from the liver to the tissues of the body and deposits the cholesterol in those tissues (i.e. ‘bad cholesterol’) • HDL – high density lipoprotein that transport cholesterol from tissues of the body to the liver to be degraded and excreted in the bile (i.e. ‘good cholesterol’) • Triglycerides – fat in the blood • Complications: increases risk for vascular disease (cardiovascular, cerebrovascular, peripheral arterial disease) • Measurement • Fasting lipid profile (bloodwork) following 9-12 hr fast

26. Plaque formation

27. Cardiovascular disease risk factors

28. Goals of treatment

29. Treatment: lifestyle change • Therapeutic lifestyle change • Diet • saturated fat <7% of calories • cholesterol <200 mg/day • increased fiber • Weight management • Increased physical activity

30. Treatment: medications

31. In the clinic… • 45 yo woman with no past medical history presents to the clinic for the first time for a routine physical exam. She smokes 2 packs of cigarettes a day, and drinks 3 beers every day of the week. Her BMI is 32. She does not exercise and she relies heavily on canned soups for her meals. She had a brother who died from an MI at 40 yo, and her mother had an MI at age 49 yo. Her blood pressure is 150/90. How should her blood pressure be managed? What else should be done as part of her initial evaluation?

32. In the clinic… • 65 yo man with insulin-dependent diabetes, dyslipidemia, chronic kidney disease, s/p prior 4 vessel CABG, and congestive heart failure presents for routine follow-up. His medications include Lantus 30 units qhs, Metoprolol 25 mg bid, Lisinopril 10 mg qday, Amlodipine 5 mg qday, Atorvastatin 40 mg qday, Aspirin 81 mg qday, and Furosemide 40 mg qday. He does not have any complaints. His last HgbA1c was 7.8, his microalbumin was 68. His blood pressure is 138/86, as it was on his last visit. He has taken his medicine today. How should his blood pressure be managed? Is he adequately controlled?

33. In the clinic… • 55 yo man with HTN presents to the clinic after being off of his medications for 6 months. His medications included HCTZ, Losartan, Amlodipine, Metoprolol, and Clonidine. He endorses having episodic chest pain while off of his medications, as well as having some blood in his urine over the past several days prior to presentation. His blood pressure is 240/120. How should this patient be managed?