Clinical Aspects of Hypertension

1. Clinical Aspects of Hypertension Anna Maio, M.D.

2. Incidence and Prevalence 58-65 million Americans 30% incidence in the 18 and older age group 1/2 of people over 65 are hypertensive • 15% of whites and 25% of African Americans--reason unknown • More common in men than in women up to the age of 50.

3. JNC 7 Report-JAMA-May, 2003 Classification of BP

4. Definition of Isolated Systolic Hypertension • Systolic blood pressure>160 mmHg • Diastolic blood pressure< or = 90 mmHg • Prevalence increases with age • 11.7% of individuals >80 years of age • 50% higher prevalence in women and African Americans

5. Emergent/Urgent Hypertension • DBP>120 mmHg and papilledema (malignant) • Usually renal failure or stroke or chest pain or confusion or hemolytic anemia is present • Requires admission to an ICU, arterial line and parenteral treatment

6. Risk Factors for Essential HTN • More common and more severe in blacks • Relationship between sodium intake and hypertension • Association between excess alcohol and HTN • Increased prevalence of obesity • More common among those with hostile attitudes

7. Identifiable Causes of Hypertension • Chronic kidney disease and renovascular disease (5-10%) • Sleep apnea • Chronic steroid therapy/Cushing syndrome • Primary aldosteronism • Pheochromocytoma • Coarctation of the aorta • Thyroid or parathyroid disease

8. Identifiable CausesDrug-Induced or Drug-Related • NSAIDS/COX-2 inhibitors • Cocaine, amphetamines, other illicit drugs • Sympathomimetics • OCPs • Adrenal steroids • Cyclosporine and tacrolimus • Erythropoietin • Licorice

9. History • Duration of disease • Prior treatment including drugs, doses, side effects • Use of estrogens, steroids, sympathomimetics, etc. (drugs taken are essential) • Family history of HTN, early cardiac death, pheo, renal disease • ROS focuses on the target organs

10. Physical Exam • Measurement of BP in both arms, BMI • Fundi • Auscultation for carotid, abdominal, and femoral bruits • Palpation of the thyroid • Heart, lungs, abdomen • Edema and pulses • Neuro assessment

11. Laboratory and Other Studies • Urinalysis • Glucose, serum potassium, creatinine, calcium • Hematocrit? • TSH? • Pregnancy test? • EKG? • Lipids?

12. Essential vs.. Secondary Causes • Use clues in the history and physical to order other testing • Acute BP rise over stable baseline • Age<20 or >50 years of age • Severe HTN with retinal involvement • Unexplained hypokalemia • No family history • Abdominal bruit

13. Complication Associated With Untreated Hypertension • Coronary Artery Disease • Cerebrovascular Disease • Left ventricular hypertrophy with congestive heart failure • Renal failure • Aortic dissection • Retinal hemorrhages/papilledema

14. Cardiovascular Disease Risk • Relationship is independent of other risk factors • The higher the BP the greater the chance of MI, HF, stroke, and kidney disease • Stage 1 and risk factors--12 mmHg decrease in systolic BP for 10 years will prevent 1 death for every 11 treated patients

15. Benefits of Treatment • 35-40% mean reduction in stroke • 20-25% in myocardial infarction • 50% reduction in heart failure

16. Initial Drug Therapy

17. Treatment • Lifestyle changes • Treatment of hypertension with and without CI • Initiating therapy with 2 drugs if > 20/10 mmHg over goal/side effect problems • Use thiazide diuretics

18. Lifestyle Modifications • Weight reduction BMI=18.5-24.9 • Adopt DASH eating plan Consume diet rich in fruits, veggies, and low-fat dairy • Dietary sodium reduction • Physical activity Regular aerobic activity at least 30 minutes/day most days/week • Moderation of alcohol consumption No more than 2/day

19. Compelling Indications • HF-diuretic, beta-blocker, ACEI, ARB, aldosterone antagonist • Post-MI-beta-blocker, ACEI, aldosterone antagonist • High coronary disease risk-diuretic, beta-blocker, ACEI, CCB • Diabetes-diuretic, beta-blocker, ACEI, ARB, CCB

20. Compelling Indications • Chronic kidney disease-ACEI, ARB • Recurrent stroke prevention-diuretic, ACEI

21. Favorable Drug Effects • Thiazides are useful in slowing the demineralization in osteoporosis • Beta-blockers can be used to treat arrhythmias, migraine, thyrotoxicosis, tremor, or stage fright • CCBs can be used in Raynaud’s and some arrhythmias • Alpha-blockers may be useful in prostatic hypertrophy

22. Unfavorable Drug Effects • Pregnancy--methyldopa, beta-blockers, and vasodilators; ACEI and ARBs are contraindicated because of fetal defects and should be avoided in women who are likely to get pregnant • Thiazides should be used with caution in gout or a history of hyponatremia • Avoid beta-blockers in reactive airway disease or heart block

23. Creating a Drug Regimen • Choose first drug very carefully; often a thiazide • Bring patient back in 1-2 weeks • Add second drug if needed; if first drug is not a diuretic the second one should be • Third drug is often a CCB or an alpha2 agonist • If the patient requires a 4th drug it is usually a potent vasodilator

24. Drug Regimen for Isolated Systolic Hypertension • Drugs shown to be of benefit (>33% reduction in stroke) are thiazide diuretics and beta-blockers • Always check orthostatic blood pressure since this can effect quality of life

25. Drug Regimens for Accelerated Hypertension • All drugs should be given in a monitered setting-CCU or ICU; consider an arterial line • Drugs should be given parenterally • Volume overload is common; assess need for loop diuretic • Nitroprusside, Enalapril, Esmolol, Cardizem are just a few of the drugs available IV now

26. Physicians’ Role • Strive for optimal blood pressure control • Look for identifiable causes and treat/eliminate when possible • Partner with the patient to choose the best drug regimen considering cost, convenience, side effects • Follow-up and education

27. Improving Hypertension Control • Clinical inertia

28. Questions?????