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HYPERTENSION and the use of ANTI-HYPERTENSIVES Joshua M.Crasner, DO,FACC,FACOI

HYPERTENSION and the use of ANTI-HYPERTENSIVES Joshua M.Crasner, DO,FACC,FACOI. JNC-6 (old criteria). JNC-7 Definition of HTN. JAMA 289; 2560-72: 2003. TYPES OF HYPERTENSION SYSTOLIC AND DIASTOLIC. Primary(Essential, Idiopathic) Secondary Renal: Acute GN, Diabetic Nephropathy

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HYPERTENSION and the use of ANTI-HYPERTENSIVES Joshua M.Crasner, DO,FACC,FACOI

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  1. HYPERTENSION and the use of ANTI-HYPERTENSIVESJoshua M.Crasner, DO,FACC,FACOI hypertension

  2. JNC-6 (old criteria) hypertension

  3. JNC-7 Definition of HTN JAMA 289; 2560-72: 2003 hypertension

  4. hypertension

  5. TYPES OF HYPERTENSIONSYSTOLIC AND DIASTOLIC • Primary(Essential, Idiopathic) • Secondary • Renal: Acute GN, Diabetic Nephropathy • Endocrine: TSH, cortisol, calcium • aortic coarctation • pregnancy-induced • neurologic: tumor, sleep apnea • stress: surgery, burns, EtOH withdrawal,S.cell • Drugs: decongestants, antidepressants, OCP hypertension

  6. RED FLAGS FOR SECONDARYHYPERTENSION • Abdominal bruit: renal artery stenosis • Palps,HA,pallor,perspiration: pheochromocytoma • Obesity,moon face,purple striae: Cushing’s • Abd mass: polycystic kidney,hydroneph • Obesity,hypersomnolence: OSAS • Agitation, sweating: cocaine, ethanol • Hypokalemia: hyperaldosteronism • Hypercalcemia: hyperparathyroidism hypertension

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  8. TYPES OF HYPERTENSIONSYSTOLIC • Increased Cardiac Output: • aortic regurgitation, PDA/AVF, thyrotoxicosis, Paget’s disease • Aortic rigidity hypertension

  9. HYPERTENSION WITH AGE • Systolic BP rises continuously with age • Diastolic rises up to age 50, then falls • Pulse pressure then widens with age Vasan, et al.JAMA, 2002; 287(8):1003-10 hypertension

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  12. ETIOLOGY HTN • “essential” > 90 % • Genetics, environment • African descent and elderly have low renin; more sensitive to salt and volume • non-African/young pts. have high renin hypertension

  13. ESSENTIAL HYPERTENSION • Most common HBP( > 90 %)--multifactorial • increased peripheral resistance perpetuates the process of high blood pressure and all of its secondary effects • structural hypertrophy giving rise to smooth muscle hypercontractility • pressure varies throughout the day • major risk factor for coronary, renal, and cerebrovascular disease (50% of all USA deaths) • leading cause of doctor’s visit • carries prognostic value: 16X increased risk 40 y.o. smokes hypertension

  14. TARGET ORGAN DAMAGELeft Ventricular Hypertrophy • End result of hypertensive heart disease • structural adaptation to pressure overload • initially adaptive and later pathologic • mass >100-130 g/m2 hypertension

  15. TARGET ORGAN DAMAGELEFT VENTRICULAR HYPERTROPHY • Eccentric: isotonic exercise, increased volume load mass/volume ratio low • Concentric: isometric exercise, increased pressure load mass/volume ratio high • degree does not correlate with blood pressure • Prognostic value: • sudden cardiac death, ischemia/decreased coronary flow, CHF, • increased vascular tone • Who? • Increases with age • 2-3 more times likely in obese • athletes • African descent higher LV mass response hypertension

  16. TARGET ORGAN DAMAGELEFT VENTRICULAR DYSFUNCTION • Diastolic dysfunction • reduced rate rapid early filling/incr.atrial portion • correlates with degree of LVH • CHF • Systolic dysfunction • less common as BP tighter controlled • myofibril degeneration/lysis • occurs late • CHF: will predispose to other causes(CAD, valve) hypertension

  17. TARGET ORGAN DAMAGECORONARY ARTERY DISEASE • HTN accelerates progression of CAD • increased oxygen demand • increased silent MI/sudden cardiac death/infarct size(33%) • ischemia caused by diastolic dysfunction • oxygen demand is different than for epicardial occlusion hypertension

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  19. TARGET ORGAN DAMAGERENAL DISEASE • Increased intraglomerular hypertension • loss of concentrating ability • nocturia • reduced creatinine clearance • albuminuria • salt and water retention • HTN is the leading cause of ESRD • nephrosclerosis hypertension

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  21. TARGET ORGAN DAMAGECEREBRO/PERIPHERAL VASCULARDISEASE • major risk factor for CVA/TIA • similar physiology hypertension

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  24. DETECTION OF HYPERTENSIVE HEART DISEASE • PHYSICAL EXAM • ELECTROCARDIOGRAM • 2-D ECHOCARDIOGRAM • STRESS TESTING • LAB TESTING hypertension

  25. PHYSICAL EXAM • Forceful sustained apical impulse early • S4 gallop early • S3 gallop later • LV dilation: laterally displaced apical impulse hypertension

  26. BP MEASUREMENT • Patient seated/back supported/feet on floor • Should rest 5 minutes prior • Arm at heart level • No recent caffeine, tobacco, cocaine • Take medications as directed • Cuff size important • orthostatics hypertension

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  28. ELECTROCARDIOGRAM • All patients should have as baseline • no LVH on ECG does not mean no LVH in vivo • the presence of LVH suggests target end organ damage…….poorer prognosis • Left atrial enlargement? • Conduction abnormalities hypertension

  29. 2D ECHOCARDIOGRAM • Wall thickness • chamber size • systolic and diastolic function • valve pathology hypertension

  30. 2-D Echo (Parasternal Long Axis) • The parasternal long axis view is obtained from the left sternal border. • Displayed in this view: • RV • IVS • LV • Aortic Valve (AV) • Mitral Valve (MV) • Left Atrium (LA) RV LV Apex IVS LV Aortic Valve Mitral Valve Left Atrium hypertension

  31. Motion Mode (M-Mode) • In M-Mode, the motion of all cardiac structures along the sample line is displayed over time (left to right) • Systole and Diastole are evident by the decrease in LV cavity size. • The motion of the IVS and LV Posterior wall are synchronous in contraction. hypertension

  32. DIASTOLIC DYSFUNCTION hypertension

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  37. DIASTOLIC DYSFUNCTION hypertension

  38. DIASTOLIC DYSFUNCTION hypertension

  39. DIASTOLIC DYSFUNCTION hypertension

  40. STRESS TESTING • Detects patients at increased risk • silent ischemia/subclinical CAD • hypertensive response portends poor prognosis hypertension

  41. LAB TESTING • Urine analysis • Chemistry panel • Cholesterol • CBC • Endocrine • Drug screen? hypertension

  42. GOALS AT FIRST EVAL. • Diagnose secondary or remediable causes • Uncover target organ damage • Identify coexisting risk factors that could affect treatment plans hypertension

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  44. TREATMENT OF HYPERTENSION • Prevent development/progression of LVH • JNC-7: 120/80 optimal • reduction of target organ damage: brain, heart, kidney, eyes • pharmacologic • Lifestyle modifications hypertension

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  46. LIFESTYLE MODIFICATION hypertension

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  50. PHARMACOLOGIC TREATMENT OF HYPERTENSION • inhibitors of the renin-angiotensin system a must in diabetic, renal, or CAD patients • identify co-morbidities (slide 19) • ACE inhibitors/A-II blockers • Calcium channel blockers • Beta blockers • diuretics • alpha blockers • central agents • vasodilators hypertension

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