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HYPERTENSION

HYPERTENSION. The basics. What?. JNC7 defines hypertension as BP 140/90 prehypertension is a new term used to describe BP 120-139/80-89 ( Europe disagrees ) optimal BP for patients with comorbid conditions (DM or renal dx) <130/80

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HYPERTENSION

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  1. HYPERTENSION The basics

  2. What? • JNC7 defines hypertension as BP 140/90 • prehypertension is a new term used to describe BP 120-139/80-89(Europe disagrees) • optimal BP for patients with comorbid conditions (DM or renal dx) <130/80 Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. www.nhlbi.nih.gov (may 2003)

  3. Why? • HTN is the most common primary diagnosis in the US • Less than 60% of an estimated 50 Million patients are on antihypertensive treatment • Of those patients receiving treatment only 34% have their pressure controlled • 30% of hypertensives are unaware they have a problem • CV damage can begin at levels as low as 115/75 (Framingham)

  4. Cardiovascular disease • The blood pressure relationship to CVD risk is continuous, consistent and independent of other risk factors • Each increment of 20/10 mmHg doublesthe risk of CVD beginning at 115/75

  5. Goal • To reduce cardiovascular and renal morbidity and mortality through appropriate treatment of hypertension • To achieve SBP goals in all hypertensive patients and especially in those >50 yrs old

  6. DATA • ALLHAT(JAMA 2002;288:2981-3007) • Largest hypertension clinical trial • 42,418 patients • TAKE HOME: • new antihypertensives are “as good as” diuretics for prevention of ischemic coronary events. • More than 2/3 of patients in trial required 2 or more agents to achieve their target BP • Antihypertensive and Lipid Lowering to protect against Heart Attacks Trial

  7. MO DATA • LIFE(Lancet2002;359:995-1003) • compared Losartan and Atenolol (+HCTZ) for prevention of cardiovascular morbidity and death. • 9193 patients with stage II HTN >160/95 and LVH, followed 4 years for endpoint • Losartan may prevent more cardiac morbidity and death than atenolol with fewer side effects and similar BP lowering. • 25% reduction in fatal/nonfatal stroke Losartan Intervention For Endpoint reduction in hypertension study

  8. History and Physical • Assess risk factors and co-morbidities • Target Organ Damage? LVH,angina,MI,CHF,CABG,TIA,stroke,PVD,retinopathy • Symptomatic? • Is this secondary to another disease process or a medication? • LABS: UA, glucose, Hct, lipids, K, Cr, Ca, EKG

  9. Weight reduction DASH decreased NaCl Physical exercise decrease ETOH consumption 5-20 mmHG per 10kg 8-14 mmHg 2-8 mmHg 4-9 mmHg 2-4 mmHg Lifestyle, Lifestyle, Lifestyle

  10. DASH • Dietary Approaches to Stop Hypertension eating plan • grains 7-8 servings daily • vegetables 4-5 • fruits 4-5 • lowfat/fatfree dairy 2-3 • meats/poultry 2 or less • nuts, seeds, dried beans 4-5 per week • fats and oils 2-3 tbs • sweets 5 per week (sugar, jam,candy, icecream) • SALT 1500 or 2400 mg/day 2/3 tsp-1tsp daily

  11. Which Drug do I use • Thiazide diuretics should be first line for most patients.Forget “sequential monotherapy” Consider ACEI, ARB, BB, CCB for additional therapy • MOST patients will need at least 2 drugs • Certain conditions are “compelling” for the use of other classes • if BP >20/10 above goal…start 2 agents • CCB are less effective in preventing CAD/CHF but may decrease stroke

  12. CHF post MI CVD high risk/LVH Diabetes Chronic renal disease recurrent stroke prevention THIAZ, BB,ACEI, ARB, ALDOANT BB, ACEI,ALDANT THIAZ,BB,ACEI, CCB ACEI, ARB THIAZ, ACEI Compelling indications

  13. Special situations Minority population • socioeconomic factors/lifestyle barriers • prevalence and severity of HTN is highest in AA population • AA have reduced responses to monotherapy with BB, ACEI, ARB than Caucasians • Thiazide diuretics are first line with CCB as backup • combos proven to be effective:BB/diuretic, ACEI/diuretic, ACEI/CCB, ARB/diuretic

  14. DATA • Management of High Blood Pressure in African Americans ARCH INTERN MED/VOL 163, MAR 10, 2003 • TAKE HOME: • BP goals <130/80 in patients with DM or nondiabetic renal disease (proteinuria <1g/d) • Combination therapy is FIRST LINE in patients with a BP >15/10 above target • Assess for increased risk based also on low birth weight, fmhx,DM • albumin/CR ratio

  15. LVH • LVH is an independent risk factor for CVD • Patients with LVH have a 5Fold increase in risk for sudden death and a 3Fold increase in CAD • regression has been shown to occur with aggressive BP management and all drugsEXCEPThydralazine and minoxidil • treatment includes NaCl restriction and weight reduction

  16. >65 • >2/3 of people >65 have HTN • lowest rate of control • BP control (specifically SBP) can help decrease progression of dementia • start low and go slow with dosing

  17. Women • Oral contraceptives may increase BPs • HRT does not • pregnancy and essential HTN=methyldopa

  18. Resistance to treatment • Are you measuring correctly? • NaCl? • inadequate diuretic doses? • NSAIDS? • illicit drug use? • OTCs? • ETOH? • secondary hypertension?

  19. Pearls • Osteoporosis- thiazides help slow demineralization • Atrial arrhythmia, migraines, hyperthyroidism, tremor,peri-op HTN- use a BB • prostatism- use an alpha blocker • Gout- avoid HCTZ

  20. Pearls • Hyponatremia- avoid HCTZ • combo ARB/spironolactone = high K+ • pregnant- no ACEI, no ARB • asthma, RAD, heart block - no BB

  21. Common sense • Patients with HTN should be followed regularly and frequently when not at goal • check K+ and CR at least 2X/yr in HTN • Predict, assess and treat co-morbidities • when BP at goal F/U q3-6 months

  22. HTN Obesity (BMI>30kg/m2) Dyslipidemia Diabetes Tobacco inactivity Microalbuminuria or GFR <60 mL/min Age >55 men >65 women Family history of premature CVD Cardiovascular Disease Risk Factors

  23. Sleep apnea drugs renal disease primary aldosteronism renovascular disease (RAS) Cushings steroid therapy pheochromocytoma coarctation of the aorta thyroid disease parathyroid disease Assess for Identifiable Causes of Hypertension

  24. Mr. B Mr B. is a 55 yo SSO, obese patient that you have been seeing for years. He has diabetes which is well controlled on oral medicines. His most recent Cr was 1.4 and he has had mild proteinuria for years and is on a low dose ACEI. He is in today for his yearly exam and DM follow-up. You note that his BP is 148/90.

  25. What now? • What are his risk factors? • Co-morbidities? • Goal BP? • Do you need labs?

  26. Mr. G Mr. G is a 40yo AA who is in your office for a job physical. He has occasional headaches and a family history of early MI. He has no other issues or significant history. His exam is benign but BP is 156/95 and is 160/95 on repeat. Pt tells you, “yeah, they told me it was high last year but I’m young so, not to worry about it”. What now? What follow-up? Labs?

  27. Little miss S. 35 yo white,female with depression. You are treating the patient with Zoloft and trazadone and she takes NSAIDs intermittently for menstrual pain. During a follow-up visit you note that her BP is 135/88. As you look back she is consistently 130-139/85-89. She is still smoking. What now?

  28. Mr. IB • 54 yo Hispanic multiple visits for hypertension. Pt consistently comes in with BPs 160s/100. You have initiated a work-up and found that he has LVH on EKG, a cholesterol of 250 with a poor ratio and a Cr of 3 and K+ 2.1. His current meds are HCTZ 25mg, lisinopril 40 mg and atenolol 50 mg BID. No matter what you do it seems his blood pressure does not budge. • What now?

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