Treatment of Hypertension

1. Treatment of Hypertension Based on the Seventh Report of the Joint National Committee on Prevention, Detection ,Evaluation and Treatment of High Blood Pressure (JNC-7) Jai Radhakrishnan, M.D. Division of Nephrology

2. Objectives • Define hypertension • Principles of treatment • Special groups

4. Blood Pressure Classification

5. Why Treat Hypertension ? • To decrease: • Cerebrovascular Accidents 35-40% • Coronary events20-25% • Heart failure50% • Progression of renal disease • Progression to severe hypertension • All cause mortality

6. Awareness, Treatment and Control of Blood Pressure 1976-2000 (NHANES)

7. Factors to Consider in Treating Hypertension • Repeat readings • r/o secondary causes • Estimate CV risk status • Co-morbid conditions • Lifestyle changes • Drugs

8. “Secondary” Hypertension • Difficult to control • Sudden onset of HTN • Well controlled-> difficult to control • Severe hypertension • History/physical/labs

9. Initial Workup of Secondary HTN • Renal parenchymal disease • UA, spot urine protein/creatinine, serum creatinine, USG. • Renovascular • Captopril scan • Coarctation • Lower Extremity BP • Primary aldosteronism • Serum and urinary K • Plasma renin and aldosterone ratio • Pheochromocytoma • Spot urine for metanephrine/creatinine

10. Laboratory Tests in Uncomplicated HTN • ECG • Urine analysis • Blood glucose, hematocrit • Basic metabolic panel • Lipid profile after 9-12 hour fast • Urine microalbumin

11. Hypertension Smoking Obesity (BMI > 30kg/m2) Dyslipidemia Diabetes Microalbuminuria or GFR <60ml/min Age > 55 (men), 65 (women) Family history of CVD (Men< 55, Women <65) Estimate Risk Status • Metabolic Syndrome

12. Heart Disease CAD (Angina, myocardial infarction, coronary revascularization Left Ventricular Hypertrophy Heart Failure Stroke/TIA Chronic kidney disease Peripheral arterial disease Retinopathy Target Organ Damage

13. Goals of Therapy • BP <140/90 mmHg • BP <130/80 mmHg in patients with diabetes or chronic kidney disease. • Achieve SBP goal especially in persons >50 years of age.

14. Lifestyle Modification

15. Diuretics Thiazide Loop diuretics Aldosterone antagonists K-sparing Adrenergic inhibitors Peripheral agents Central (α-agonists) alpha -blockers* beta-blockers Alpha+beta-blockers Direct Vasodilators * Calcium channel blockers Dihydropyridine Non dihydropyridine ACE-inhibitors Angiotensin-II blockers Drugs for Hypertension * Usually not monotherapy

17. Without Compelling Indications With Compelling Indications Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Stage 1 Hypertension(SBP 140–159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Stage 2 Hypertension(SBP >160 or DBP >100 mmHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved.Consider consultation with hypertension specialist. Algorithm for Treatment of Hypertension Lifestyle Modifications Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices

18. Classification and Management of BP for adults *Treatment determined by highest BP category. †Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension. ‡Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.

19. Special Considerations Compelling Indications Special populations

20. HTN with COPD and MI A 55 year old patient with COPD and HTN (controlled with nifedipine) is admitted with severe chest pain x24 hrs. BP is 170/100 and she has a soft S3 gallop. ECG shows an anterior wall MI. She is not a candidate for thrombolysis. ECHO shows an ejection fraction of 35%. How will you manage her hypertension?

21. Compelling Indications for Certain Drug Classes

22. HTN with CAD • Beta blockers: cardioprotective (reinfarction, arrhythmias and sudden death) • ACE inhibitors: MI with systolic dysfunction- heart failure and mortality improved

23. Renal Insufficiency • A 30 year old patient with IDDM is referred with difficult-to-control HTN on diltiazem and clonidine. • Exam reveals BP=190/100 and 3+ edema. • Labs: Creatinine= 2.2 mg/dL Serum K= 5.1 meq/L 24 hour protein= 5 g

24. Hypertension with Renal Insufficiency • Goal BP <130/80 • ACE-inhibitors/angiotensin receptor blockers should be used if no contraindications • Most patients have volume overload: • Diuretics should be included in the regimen. • Thiazides ineffective if S Creat>2.5

25. A 40 year old previously healthy male is brought to the E.R. with 3 days of progressive shortness of breath and has experienced blurred vision in both eyes. Physical exam: Blood pressure 230/140. Lethargic. Eye exam: PapilledemaChest: Bibasilar cracklesCardiac: S1S2S4Neuro: Bilateral upgoing plantars:Extr: 2+ edema Labs:K=3.4, BUN=35, Creatinine: 2.2 CXR: Pulmonary edema Urine: 10-15 red cells, 2+ albumin.

26. Hypertensive Urgencies and Emergencies • HYPERTENSIVE EMERGENCIES • Require immediate blood pressure reduction (not necessarily to normal range) to prevent or limit target organ damage. • HYPERTENSIVE URGENCIES • Require reduction of blood pressure within a few hours

27. Emergencies & Urgencies • HYPERTENSIVE EMERGENCIES • Require immediate blood pressure reduction (not necessarily to normal range) to prevent or limit target organ damage. • HYPERTENSIVE URGENCIES • Require reduction of blood pressure within a few hours

28. VASODILATORS Nitroprusside Fenoldopam Nitroglycerine Enalaprilat Nicardipine Hydralazine ADRENERGIC INHIBITORS Labetalol Esmolol Phentolamine Parenteral Drugs For Treatment of Hypertensive Emergencies

29. Pregnancy and Hypertension A 24 year old primiparous woman is seen in the obstetric clinic at 30 weeks gestation. BP: 160/100, 2 + pedal edema Otherwise unremarkable physical exam. Urine shows 1000 mg of protein. Other labs: N After 2 days of bed rest BP remains 160-170/100

30. Drug Therapy of the Hypertensive Pregnant Patient • Methyldopa: Drug of choice. • Beta blockers (not early pregnancy). • Hydralazine is the parenteral drug of choice. • Most agents if used prior to pregnancy may be continued • (except ACE-I OR A-II BLOCKERS)

31. Resistant Hypertension • Improper BP measurement • Excess sodium intake • Inadequate diuretic therapy • Medication • Inadequate doses • Drug actions and interactions (e.g., nonsteroidal anti-inflammatory drugs (NSAIDs), illicit drugs, sympathomimetics, oral contraceptives) • Over-the-counter (OTC) drugs and herbal supplements • Excess alcohol intake • Identifiable causes of HTN

32. Conclusions • The initial approach to hypertension should start with ruling out secondary causes, detecting and treating other cardiovascular risk factors, and looking for target organ damage. • Treatment should always include lifestyle changes. • Medication use should be guided by the severity of HTN and the presence of “compelling” indications. • Thiazide-type diuretics should be initial drug therapy for most, either alone or combined with other drug classes. • Most patients will require two or more antihypertensive drugs

33. Conclusions • HTN is a risk factor for mortality and cardiovascular and renal disease • HTN is common but not controlled. • Target BP 140/90 (130/80 in DM, CKD) • Remember Compelling Indications

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