Hypertension

1. Hypertension Howard L. Sacher, D.O. Long Island Cardiology and Internal Medicine

2. Learning Objectives • To know how to detect and diagnose hypertension and its secondary causes. • To become familiar with updated recommendations for classifying hypertensive patients. • To understand the pharmacologic options for treating hypertension and their appropriate use. • To grasp the importance of counseling patients on lifestyle modification to help control hypertension

3. Hypertension • Hypertension is the most well established and important risk factor for • 1 Cardiovascular disease • 2 Cerebrovascular events • 3 Congestive Heart Failure (CHF) • 4 End stage renal disease (ESRD)

4. Hypertension (cont) • There have been enormous advances in our understanding of the value of treating hypertension over the past three decades, yet the most recent surveys show that hypertension remains largely untreated and uncontrolled

5. Hypertension (cont) • The relationship between systolic and diastolic blood pressure is strong, graded and continuous • The higher the BP, the higher the risk • Systolic BP is a better predictor of cardiovascular disease at all ages but particularly in the older age group • Diastolic BP does not rise with age after the fifth decade, a time when isolated systolic BP begins to increase sharply in prevalence

6. “The objective of antihypertensive therapy should be to not only lower the blood pressure but to prevent the lethal and disabling cardiovascular sequelae.” Kannel WB. Eur Heart J. 1992;13(suppl G):34–42.

7. JNC 7: Low Control Rates Require More Aggressive Treatment 73% 68% 70% Awareness 59% 55% 54% Treatment 51% Adults(%) 34% 31% 29% 27% Control 10% NHANES II 1976-1980 NHANES III (Phase 2) 1991-1994 NHANES 1999-2000 NHANES III (Phase 1) 1988-1991 JNC 7. JAMA. 2003.

8. JNC 7 - Algorithm for the Treatment of Hypertension Lifestyle Modifications 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 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 mm Hg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Stage 2 Hypertension(SBP >160 or DBP >100 mm Hg) two-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) Not at Goal Blood Pressure *Compeling Indications Heart failure Post-MI High coronary artery disease risk Diabetes Chronic kidney disease Recurrent stroke prevention Optimize dosages or add additional drugs until goal blood pressure is achieved.Consider consultation with hypertension specialist. Reprinted with permission from Chobanian AV et al. JAMA. 2003;289:2560-2572.

9. JNC – 7

10. JNC 7 Compelling Indications BB ACEI ARB CCB AA Diuretic CHF Post MI CAD risk Diabetes Mellitus Renal disease Recurrent strokeprevention                      BB, beta blocker; ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker;CCB, calcium channel blocker; AA, aldosterone antagonist; CHF, chronic heart failure;MI, myocardial infarction; CAD, coronary artery disease; DM, diabetes mellitus JNC 7. JAMA. 2003.

11. JNC 7 – Key Messages • 2 out of 3 patients remain uncontrolled or not optimally treated • For persons over age 50, SBP is a more important than DBP as CVD risk factor. • Most patients will require two or more antihypertensive drugs to achieve goal BP. • If BP is >20/10 mmHg above goal, consider initiating therapy with two agents, one usually should be a thiazide-type diuretic. • Starting at 115/75 mmHg, CVD risk doubles with each increment of 20/10 mmHg throughout the BP range. • Tolerability: Adherence to medication regime critical to improving HTN control The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)

12. Patient Evaluation • Repeat BP’s • Teach Patients to take BP’s • Promotes participation by patient • May reduce costs by reducing visits • Ambulatory BP monitoring • BP – • Evaluate diurnal variations • Patient at a greater risk for end organ disease

13. Patient Evaluation (cont) • History – medication , lifestyle habits such as diet, exercise, smoking history, family history and review of symptoms that may reflect secondary hypertension, target organ disease or co-morbid conditions

14. Patient Evaluation (cont) • Physical Exam – • BP – standing and sitting in both arms and legs • Looking for patients with orthostatic hypotension over 60 • Coarctation of the aorta in younger patients • Peripheral vascular disease • Fundoscopic exam – looking for evidence of hypertensive retinopathy

15. Patient Evaluation (cont) • Evaluation of the Heart • S4 – decreased LV function compliance precedes systolic dysfunction or S3 gallop • Evidence of CHF • Rales (Crackles) • Hepatomegaly • Peripheral Edema • Neurological exam for evidence of Cerebrovascular disease

16. Patient Evaluation (cont) • Laboratory Evidence • Complete blood count (CBC) • Renal failure and polycythemia • Chemistries – Na+, K+, creatinine, fasting glucose and lipid profile • K+ - low in hyperaldosteronism, high in renal failure • Urinalysis • 12 lead EKG • LVH, Ischemia

20. Pheochromocytoma • Pheochromocytoma • Catacholamine producing tumors can occur in the adrenal gland or anywhere along the neuroectodermal crest; 10% of adults have multiple tumors • Triad • Episodic Headaches • Tachycardia • Diaphoresis with labile hypertension • Associated with multiple endocrine neoplastic (MEN) syndromes, neurofibromatosis, and Van Hipple Landau syndrome

21. Pheochromocytoma • Diagnosis • Postural hypertension • Resting tachycardia • Café au lait spots • Resting supine catacholamine levels > 2000 pg/ml (nep, ep) • Clonidine suppression test • Lowers catacholamine levels in essential HTN but not pheochromocytoma • Glucagon (2mg IV) increases plasma catecholamines at least three fold or >2000 1 to 3 minutes after administration in patients with pheochromocytoma

22. Pheochromocytoma • Tumor Localization accomplished by • CT scan • MRI • Radioisotope uptake studies • Treatment • Surgical removal of tumor • Alpha and beta adrenergic blockers are useful for chronic management or non-surgical cases (alpha blockers commonly used)

23. Hyperaldosteronism • Spontaneous hypokalemia while on diuretics and potassium supplements • Primary Hyperaldosteronism • Small unilateral adenoma (<1cm) is more common in women • Bilateral adrenal hyperplasia is more common in men • Diagnosis • Measure 24 hour urinary aldosterone measurements for two days on high sodium diet (>!4g/ 24 hours) • Increased aldosterone with low levels of plasma renin activity • Adenomas detected by MRI

24. Hyperaldosteronism (cont) • Treatment • Surgery for small solitary adenomas • Medical treatment for adrenal hyperplasia • Diuretics and vasodilators • Aldosterone antagonists do not reduce BP adequately but may be needed to correct hypokalemia

25. Renal Artery Stenosis • More commonly found stage 3 or resistant hypertension • When bilateral can have reduced kidney function • Clinical clues to renovascular disease • Onset before age 30 or recent onset of significant high BP after age 55 • Abdominal bruit if diastolic and lateralized • Accelerated or resistant high blood pressure • Recurrent flash pulmonary edema • Renal failure with normal sediment • Co-exiting ASVD especially in long smokers • Acute renal failure – particularly after ACE I or Angiotensin receptors blockers

26. Renal Artery Stenosis (cont) • Diagnosis • Captopril enhances radionuclide renal scan • Duplex doppler flow studies • MRI and MRA • Definitive diagnosis – angiography • Treatment • Revascularization • Fibromuscular dysplasia – Percutaneous transluminal renal angioplasty (PTRA) is comparable to surgery • Atherosclerotic renal artery stenosis – ideal for PTCA with stenting if renal function normal • Surgery or PTCA with stenting to preserve renal function

27. LVH with left atrial enlargement

28. HTN 2nd to RAS

29. HTN 2nd to Fibromuscular Dysplasia

30. 10-Minute Break

31. JNC - 7 • Joint National Committee (JNC) on the Detection, Evaluation and Control of High Blood Pressure • Emphasis: risk stratification for cardiovascular disease • Smoking • Dyslipidemia • Diabetes Mellitus • Old age • Male sex • Post-Menopausal • Family History of cardiovascular disease

32. At any given level of SBP the absolute risk of a coronary event increases dramatically as compared to those with no risks

33. Lifestyle Modifications • Weight redistribution – lowers BP but also has effect on lipids and glucose metabolism • There is a Metabolic Syndrome • Obesity • High BP • Hyperlipidemia • Insulin resistance or Diabetes • Reduction of dietary sodium • Correlation between dietary sodium and blood pressure– most patients benefit from reducing intake to below 2400mg/day, 6 g salt. Also enhances the efficacy of anti-hypertensive agents and may reduce potassium effect of diuretic agents and minimize hypokalemia. (i.e. processed foods)

34. Lifestyle Modifications (cont) • Alcohol • 1 ounce of ethanol • 24 ounces of beer • 10 ounces of wine • 2 ounce of 100 proof whisky • Tobacco • Aerobic Exercise

35. Diabetic Hypertensive patients • Blood glucose controlled • Weight loss • Aerobic exercise • Angiotensin Converting Enzyme (ACE) Inhibitors or Angiotensis Receptor Blockers (ARB) • Treatment to lower BP using ACE-I and ARB • Microvascular – retinopathy, nephropathy • Macrovascular – CAD, angina, AAA, CVA • BP goals < or = to 120 / 80

36. Congestive Heart Failure • Treatment • ACE I • ARB • Diuretics • B-Blockers • Digitalis • Monitor for • Orthostatic hypotension • Renal function • K+ levels

37. Post-Myocardial Infarction • Treatment • ß-Blockers • ACE- I in patients with systolic dysfunction • Diltiazem or Verapamil in patients with non Q-wave infarction may be used if B-blocker ineffective or contraindicated

38. Isolated Systolic Hypertension (ISH) and Hypertension in older patients • Higher risk for cardiovascular disease • Lifestyle modifications • Decreased vascular compliance due to loss of arterial elasticity associated with aging • Drug of choice • Low dose thiazide diuretics • Be concerned about postural hypotension or cognitive dysfunction (central alpha 2 agonists)

39. Ischemic Heart Disease • Treatment • B-Blockers • Calcium channel blockers as a second choice if beta blockers are contraindicated; or both drugs can be used together to achieve BP goals • Treat risk factors • High lipids • Diabetes or Insulin resistance • Weight loss • ACE-Inhibitors

40. Renal Disease • Aggressive treatment to lower BP • < or = 130/85 • Goal will slow rate of disease progression • ACE inhibitors are drugs of choice but must be used with caution if creatinine >3 mg/dl and are not used when renovascular hypertension is suspected • Thiazide diuretics are not effective if serum creatinine is > 2.5 mg/dl and loop diuretics are required

41. African-Americans and HTN • High prevalence • Occurs earlier, more severe and is associated with higher risks of cardiovascular disease • Stroke and heart disease mortality rates 80% and 50% higher respectively • End stage renal disease 320% higher • Lifestyle modifications • Diuretics are drugs of choice for uncomplicated hypertension • Ca channel blockers and alpha blockers are also effective • All other drugs can be used to achieve BP goals

42. Women and HTN • Same therapy as men • If on OCP stop and monitor BP • During pregnancy ACE-I and ARB should be stopped • Alpha-Methyldopa during pregnancy

43. Patients Undergoing Surgery • If BP is > 180/110, patient must be treated to reduce the risk of perioperative ischemic events • Cardio-selective beta-blockers, unless contraindicated, are drugs of choice • Hypertensive patients who are well controlled prior to surgery should be continued on their own regimen as soon as possible after surgery