Hypertension: A Didactic in 3 Acts

1. Hypertension: A Didactic in 3 Acts Carla Ainsworth, MD, MPH Swedish Family Medicine August 17, 2010

2. Hypertension, hypertension and more hypertension • Outpatient diagnosis and medical management of HTN (1 hr) • Lifestyle modifications (25 min) • Ruling out secondary HTN (20 min)

3. Outpatient diagnosis and management of HTN • (Is there any other kind?)

4. Begin With the End in Mind • Why should your patients want to treat their hypertension? • What classes of meds should you focus on when initiating treatment? • What labs should you follow for surveillance?

5. Why Do We Care?

6. HTN is VERY prevalent • An estimated 27% of Americans • 65% of people over age 60 • Only 1 in 4 of these individuals are taking adequate medication • Single most common diagnosis made by family physicians; 11% of visits

7. Why Do We Care? • Significant morbidity and mortality • CAD including MI and CHF • Stroke and TIAs • Chronic kidney disease and ESRD • Even pre-hypertension is associated with increased cardiovascular risk

8. We Care Because Treatment Works! • In patients with Stage I hypertension, a 12 mm Hg decrease in SBP for 10 yrs will prevent 1 death for every 11 patients treated • In patients with CVD or other end-organ damage, NNT is 9 to prevent a death

10. Classification of Blood Pressure for Adults

11. To Make the Diagnosis • BP must be measured correctly • Feet on floor • Both arms if elevated • Cuff bladder must circle at least 80% of the arm • Arm supported at level of heart • Back supported

12. How Much is Enough? • JNC -- 3 measurements to make dx • ICSI -- reconfirm in 1-2 months • GHC -- initial visit plus 2 additional visits • Who gets held to the tougher standard (130/80)? • Diabetics • Patients with Chronic Kidney Disease

13. Initial Labs • electrocardiogram (ECG) • Urinalysis • blood glucose • serum potassium, creatinine, and calcium • Hematocrit • lipid profile - HDL cholesterol, LDL cholesterol, triglycerides

14. Time to Treat … Where to Start? • Thiazide diuretics • ACE inhibitors and ARBs • Calcium channel blockers • Beta blockers?

15. Thiazide-type diuretics • Where to start? • Hydrochlorothiazide 12.5 mg • Chlorthalidone 12.5 mg • How much room? • Up to 25 mg, unclear benefit beyond that • Cost? Cheap! • Side effects -- hypokalemia, glucose intolerance

16. ACE Inhibitors • Where to start? • Lisinopril 10 mg QD • Benazapril 10 mg QD • Enalapril 5 mg QD • How much room? • Up to 80 mg (only 40 mg for enalapril) • Cost -- cheap! • Side effects -- cough

17. Better together? • GHC protocol considers starting patients on combo ACEI + diuretic as initial therapy • How many patients will reach goal on single drug therapy? • Less than 50% • Especially consider for Stage II HTN patients who need significant drop • What about ACE + CCB?

18. Where to start? Amlodipine 5 mg QD Diltiazem ER 120 mg QD Nifedipine ER 30 mg QD How much room? Amlodipine 10 mg QD Diltiazem ER 540 mg QD Nifedipine ER 120 mg QD Cost Amlodipine is generic, but not available on $4 formulary Diltiazem=cheap! Nifedipine-less cheap Side effects edema constipation Calcium Channel Blockers

19. Beta-Blockers • Where to start? • Not with beta blockers • Why not? • Possible increase in stroke risk, particularly in elderly patients • But aren’t beta-blockers good for CAD? • Think about “compelling indications”

20. “Compelling Indications”

21. Beta-Blockers • Where to start? • Metoprolol 25 mg BID • Atenolol 25 mg QD • How much room? • Up to 100 mg • Cost -- cheap! • Side effects -- bradycardia, fatigue, depression

22. Too many choices, just tell me what to do! • Some general rules • You get your greatest gain out of adding a new class, may not benefit from more than 1 increase (though will see increase in side effects) • If patient has almost no change with med 1, switch to med 2 instead of adding. Increases chance of single agent treatment

23. Even more meds • ARBs (losartan is generic but still pricey) • Alpha blockers • Aldosterone antagonists

24. Uncontrolled on 3 meds Progressive CKD despite meds New evidence of CVD Who? Cardiology Renal Endocrine When to Ask for Help

25. Isolated Systolic Hypertension • More prevalent in older population • We should still treat SBP to goal, though watch to not decrease diastolic BP below 65 mm Hg • Pulse pressure may be independent predictor of risk, esp in older patients

26. What about race? • ACE inhibitors and ARBs not as effective in African-Americans • Balance this with comorbidities and “compelling indications” • Think about primary hyperaldosteronism

27. Follow up Labs: Potassium and Creatinine, maybe sodium • at initiation of treatment • 2-4 weeks after starting • Again after every dose adjustment • Annually

28. Act I Finale • Why should your patients want to treat their hypertension? • What classes of meds should you focus on when initiating treatment? • What labs should you follow for surveillance?

29. Lifestyle Modifications

30. Begin with the End in Mind • What is a good resource about dietary modification for your patients? • Which lifestyle modifications yield the greatest improvement in BP?

31. Lifestyle Changes • Weight loss • Dietary changes • Exercise

32. A case: • 65 year old woman in for annual exam • Working on weight loss, it’s “hard” • Meds: maxzide 37.5/25 and atenolol 50 mg • Vitals: 136/80, weight 297 lbs • Labs: Tchol 259/Trig 332/HDL 45/LDL 148 • Potassium 3.8, Cr 0.99 • Glucose 88 • What’s your plan?

33. A year later • 66 yo woman for annual exam • Didn’t want to go on cholesterol meds • Eating better, going to the gym almost every day • Vitals: 128/78, Weight 260 lb! • Labs: Tchol 222/Trig 271/HDL 44/LDL 124 • Potassium 4.6, Cr 1.04 • Glucose 88

34. Weight Loss • Calories in < calories out • You need to be net negative 500 cal every day to lose 1-2 pounds per week • Average active woman needs: • 1800-2000 cal/day • Average active man needs: • 2200-2400 cal/day

35. Weight Loss Resources • Overeaters Anonymous • Weight Watchers • www.thedailyplate.com • www.MyPyramid.gov

36. Dietary Changes • Will impact blood pressure independent of weight loss • Patients need concrete ideas on how to change their diet -- a diet prescription?

37. D-A-S-H • Dietary Approaches to Stop Hypertension • Not only reduces sodium • Offers increased potassium, calcium and magnesium • Proven to lower BP 8-14 mm Hg • Not a diet for losing weight • 2000 calories per day • 2300 mg of sodium or lower at 1500 mg

38. How much will this help me?

39. Act II Finale • What is a good resource about dietary modification for your patients? • Which lifestyle modifications yield the greatest improvement in BP?

40. Secondary Hypertension • “None of those causes are really that common anyway”

41. Begin With the End in Mind • Which patients need evaluation for secondary hypertension? • What is an appropriate evaluation? • What is an over-the-counter medicine that makes blood pressure worse?

42. JNC 7 on “Identifiable Causes” • More extensive testing for identifiable causes is not indicated generally unless BP control is not achieved

43. Renovascular disease Chronic kidney dz Thyroid disease Parathyroid disease OTC medications Sleep apnea Obesity Illicit drugs Excessive alcohol use Primary aldosteronism Pheochromocytoma Cushing’s syndrome Coarctation Name some identifiable causes

44. Medications • NSAIDs • Decongestants • Anorectics • Ephedra • Ma huang • Steroids • OCPs