Hypertension With updated guidelines from AAFP & JNC VII

1. HypertensionWith updated guidelines from AAFP & JNC VII Omar A. Khan, MD MHS January 2006

2. Objectives • Review the AAFP/JNC VII diagnostic criteria for hypertension • Review various treatment options, indications and side effects

3. Fast Facts about Hypertension in the US: • Hypertensive population: 42,000,000 • Controlled hypertensives: 27% • Those unaware of Dx: 13,000,000 • Aware but untreated: 7,000,000 • Of those treated: 58% uncontrolled

4. JNC VII

5. JNC VII

6. JNC 7: Classification and Management of Blood Pressure for Adults JNC 7. May 2003. NIH publication 03-5233.

7. Diagnostic Workup

8. HTN Obesity Hyperlipidemia Diabetes Cigarette Smoking Inactivity Age: >55 in men >65 in women Fam history of premature CVD CVD Risk Factors

11. Not at goal blood pressure (<140/90 mm Hg)(<130/80 mm Hg for those with diabetes or chronic kidney disease) Initial drug choices Without compelling indications With compelling indications Stage 1 hypertension (SBP 140–159 or DBP 90–99 mm Hg) Thiazide-type diuretic for most. May consider ACEI, ARB, BB, CCB, or combination. Stage 2 hypertension (SBP ³160 or DBP ³100 mm Hg) Two-drug combination for most (usually thiazide-type diuretic and ACEI or ARB or BB or CCB). Drugs for compelling indications Other antihypertensive drugs (diuretic, ACEI, ARB, BB, CCB) as needed. Not at goal blood pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist. JNC 7: Treatment Algorithm for Hypertension Lifestyle modifications SBP=systolic blood pressure; DBP=diastolic blood pressure; ACEI=angiotensin- converting enzyme inhibitor; ARB=angiotensin receptor blocker; BB=b-blocker; CCB=calcium channel blocker JNC 7. May 2003. NIH publication 03-5233.

12. Heart Failure: Post- MI: High CVD risk: DM: CRF Cr > 1.5 in men Cr > 1.3 in women S/P CVA Thiazide/loop, BB, ACEi, ARB, Aldosterone antagonist BB, ACE, Aldosterone antagonist Thiazide, BB, ACE, Ca channel blocker Thiazide, BB, ACE, ARB, CCB ACE, ARB. For creatinine 2-3 try loop diuretic Thiazide, ACE inhibitor Compelling Indications

13. Lifestyle Modifications to Manage HTN Source: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure JNCVII. JAMA. 2003;289:2560-2572.

14. Failures of Patient Education • 50% of patients discontinue their anti-hypertensive within 1 year of initiating treatment. • DASH diet for hypertension: • limit sodium • Increase fruits and vegetables (8-10/d) • Increase low fat dairy (3-4/d) • Focus on diet history for hypertensive patients

15. Key Diet History Questions for Patients with HTN • Do you use a salt shaker? • Do you taste your food before you add salt? • How often do you eat salty foods, such as chips, pretzels, salted nuts, canned and smoked foods? • Do you read labels for sodium content? • How many servings of fruits and vegetables do you eat everyday? • How often do you eat or drink dairy products? What kind? • How often do you eat out? What kinds of restaurants? • Do you like to drink alcohol? How much? • How often do you exercise, including walking?

16. TIPS on drugs for HT • CCB OK for isolated systolic hypertension (ISH) • For DM: ACEi or ARB with or without diuretic, then add BB or CCB • When ACEi causes cough, substitute ARB • Don’t use short acting CCB (increases deaths due to arrhythmias). • Alpha blockers (e.g. clonidine) only as second line (more side effects).

17. Most patients should start with a diuretic as they enhance the effectiveness of other agents. • Most patients will require more than one agent. • Add a baby aspirin to improve cardiovascular outcomes.

18. Minorities: Women: Aged: Blacks have greater prevalence, severity, and impact and poorer response to monotherapy. ACE induced angioedema is more common Estrogen containing oral contraceptives elevate BP. Aldomet, BB, and vasodilators OK in pregnancy Higher prevalence, ISH more common, more frequent complications from ACE, CCB Special Populations

19. Thiazides • Chlorothiazide (Diuril) • Chlorthalidone • Hydrochlorthiazide(Microzide, Hydrodiuril) • Polythiazide (Renese) • Indapamide (Lozol) • Metolazone (Mykrox, Zaroxolyn) *All trade / brand / generic names are specific to the USA

20. Benefits of Thiazide Diuretics • Evidence-based support for end points that matter (prevention of CV and all-cause mortality). • Reduced calcium excretion is a potential benefit for osteoporosis prevention.

21. Loop Diuretics • Bumetanide (Bumex) • Furosemide (Lasix) • Torsemide (Demadex) Potassium-sparing Diuretics • Amiloride (Midamor) • Triamterene (Dyrenium) *All trade / brand / generic names are specific to the USA

22. Aldosterone Receptor Blockers • Eplerone (Inspra) • Spironolactone (Aldactone) Combined alpha- and beta- blockers • Carvedilol (Coreg) • Labetalol (Normodyne, Trandate) *All trade / brand / generic names are specific to the USA

23. Beta-blockers • Atenolol (Tenormin) • Betaxolol (Kerlone) • Bisoprolol (Zebeta) • Metoprolol (Lopressor, Toprol XL) • Nadolol (Corgard) • Propranolol (Inderal/XL) • Timolol (Blocadren) *All trade / brand / generic names are specific to the USA

24. ACE inhibitors • Benzapril (Lotensin) • Captopril (Capoten) • Enalpril (Vasotec) • Fosinopril (Monopril) • Lisinopril (Prinivil, Zestril) • Moexipril (Univasc) • Perindopril (Aceon) • Quinapril (Accupril) • Ramipril (Altace) • Trandolapril (Mavik) *All trade / brand / generic names are specific to the USA

25. Angiotensin II Receptor Blockers • Candesartan (Atacand) • Eprosartan (Tevetan) • Irbesartan (Avapro) • Losartan (Cozaar) • Olmesartan (Benicar) • Telmisartan (Micardis) • Valsartan (Diovan) *All trade / brand / generic names are specific to the USA

26. Dihydropyridines Amlodipine (Norvasc) Felodipine (Plendil) Isradipine (Dynacirc CR) Nicardipine (Cardene SR) Nifedipine (Adalat CC, Procardia XL) Nisoldipine (Sular) Calcium channel blockers • DHPs can have negative inotropic effects, unlike non-DHPs, so use with caution in pts with impaired cardiac function

27. non-Dihydropyridines: Diltiazem (Cardizem CD, Dilacor XR, Tiazac, Cardizem LA) Verapamil (Calan SR, Isoptin SR) Calcium channel blockers *All trade / brand / generic names are specific to the USA • DHPs can have negative inotropic effects, unlike non-DHPs, so use with caution in pts with impaired cardiac function

28. Alpha1 blockers • Doxazosin (Cardura) • Prazosin (Minipress) • Terazosin (Hytrin) *All trade / brand / generic names are specific to the USA

29. Direct Vasodilators • Hydralazine (Apresoline) • Minoxidil (Loniten) *All trade / brand / generic names are specific to the USA

30. Centrally acting drugs • Clonidine (Catapres) • Methyldopa (Aldomet) • Reserpine (generic) • Guanfacine (generic) *All trade / brand / generic names are specific to the USA

31. Again: Treatment Algorithm

32. References • JNC 7 report: available via NIH (Publication 03-5233) • JAMA 289 (19), May 21 2003 (online) • AAFP monograph: #305

33. HTN True or False • ACE Inhibitors should be initial drug therapy for most, either alone or combined with other drug classes.

34. False • ACE InhibitorsThiazides should be initial drug therapy for most, either alone or combined with other drug classes.

35. True or False • For persons over age 50, DBP is more important than SBP as CVD risk factor.

36. False • For persons over age 50, SBP is a more important than DBP as CVD risk factor.

37. True or False • Normal blood pressure is defined as SBP < 135 and DBP < 90.

38. False • Normal blood pressure is defined as SBP < 120 and DBP < 80. People with SBP 120 – 139 OR DBP 80 – 89 should be considered prehypertensive.

39. True or False • Those people whose BP is classified as prehypertensive should be initially treated with lifestyle modification from the time they are identified.

40. True • Those people whose BP is classified as prehypertensive should be initially treated with lifestyle modification from the time they are identified.

41. Key lifestyle modification measures that, if initiated in all prehypertensive andhypertensive individuals, are likely to lower BP, include all except….. • a) Weight reduction • b) DASH Eating Plan • c) Smoking cessation • d) Dietary sodium reduction • e) Physical activity • f) Moderation of alcohol intake

42. Key lifestyle modification measures that should be initiated in all prehypertensive andhypertensive individuals in order to lower BP include all except….. • a) Weight reduction • b) DASH Eating Plan • c) Smoking cessation • d) Dietary sodium reduction • e) Physical activity • f) Moderation of alcohol intake

43. True or False • If BP is >20/10 mmHg above goal, initiate therapy with a single agent and lifestyle modification.

44. False • False. If BP is >20/10 mmHg above goal, initiate therapy with two agents, one usually should be a thiazide-type diuretic.

45. True or False • Self measurement can help assess “white-coat” HTN.

46. True • Self measurement can help improve adherence with therapy, provide helpful information on response to therapy and assist in assessing “white-coat” HTN.

47. True or False • Most patients will only require one antihypertensive drug to achieve goal BP.

48. False • Most patients will require 2 or more antihypertensive drugs to achieve goal BP