HypertensionHypertension

Jared Helms D.O. OGME-2Jared Helms D.O. OGME-2

22 August 200722 August 2007

HypertensionHypertension

The treatment of hypertension is the The treatment of hypertension is the most common reason for office visits most common reason for office visits of non-pregnant adults to physicians of non-pregnant adults to physicians in the United States and for use of in the United States and for use of prescription drugs. prescription drugs.

Cherry, DK, Burt, CW, Woodwell, DA. Advance data from vital and health statistics. No 337. Hyattsville, MD. National Center for Health Statistics, 2003.

DefinitionsDefinitions

NormotensiveNormotensive: systolic <120 mmHg : systolic <120 mmHg and diastolic <80 and diastolic <80

PrehypertensionPrehypertension: systolic 120-139 : systolic 120-139 oror diastolic 80-89 diastolic 80-89

HypertensionHypertension Stage 1Stage 1: systolic 140-159 or diastolic : systolic 140-159 or diastolic

90-99 90-99 Stage 2Stage 2: systolic 160 or diastolic : systolic 160 or diastolic

100 100 The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. Chobanian AV; et al.

JAMA 2003 May 21;289(19):2560-72. Epub 2003 May 14.

DefinitionsDefinitions

Hypertensive urgency: Hypertensive urgency: Severe Severe hypertension (as defined by a diastolic hypertension (as defined by a diastolic blood pressure above 120 mmHg) in blood pressure above 120 mmHg) in asymptomatic patients asymptomatic patients

Malignant hypertension: Malignant hypertension: marked marked hypertension with retinal hemorrhages, hypertension with retinal hemorrhages, exudates, or papilledema; usually exudates, or papilledema; usually associated with a diastolic pressure above associated with a diastolic pressure above 120 mmHg120 mmHg

CausesCauses

Essential HypertensionEssential Hypertension Secondary HypertensionSecondary Hypertension

Primary renal disease Primary renal disease Renovascular disease Renovascular disease Oral contraceptives Oral contraceptives Pheochromocytoma Pheochromocytoma Primary hyperaldosteronism Primary hyperaldosteronism endocrine disordersendocrine disorders Sleep apnea syndrome Sleep apnea syndrome Coarctation of the aortaCoarctation of the aorta

Essential vs. SecondaryEssential vs. Secondary

There are four major general clinical clues that There are four major general clinical clues that are suggestive of secondary hypertensionare suggestive of secondary hypertension

Severe or refractory hypertension. Severe or refractory hypertension. An acute rise in blood pressure over a An acute rise in blood pressure over a

previously stable value. previously stable value. Proven age of onset before puberty or above Proven age of onset before puberty or above

the age of 50 to 55 yearsthe age of 50 to 55 years Age less than 30 years in non-obese, non-black Age less than 30 years in non-obese, non-black

patients with a confirmed negative family patients with a confirmed negative family history of hypertension. history of hypertension.

Essential HypertensionEssential Hypertension

pathogenesis of essential pathogenesis of essential hypertension is poorly understoodhypertension is poorly understood Increased sympathetic neural activity, Increased sympathetic neural activity,

with enhanced beta-adrenergic with enhanced beta-adrenergic responsivenessresponsiveness

Increased angiotensin II activity and Increased angiotensin II activity and mineralocorticoid excessmineralocorticoid excess

genetic factors genetic factors Reduced adult nephron mass may Reduced adult nephron mass may

predispose to hypertensionpredispose to hypertension

Risk FactorsRisk Factors

A variety of risk factors have been associated A variety of risk factors have been associated with essential hypertension:with essential hypertension: tends to be both more common and more tends to be both more common and more

severe in blackssevere in blacks Increased salt intakeIncreased salt intake excess alcohol intakeexcess alcohol intake weight gainweight gain DyslipidemiaDyslipidemia

Risk factors for arterial hypertension in adults with initial optimal blood pressure: the Strong Heart StudyHypertension. 2006 Feb Dyslipidemia and the risk of incident hypertension in men. Hypertension. 2006 Jan

ComplicationsComplications

Increase in risk begins as the blood Increase in risk begins as the blood pressure rises above 110/75 mmHgpressure rises above 110/75 mmHg

At any blood pressure, is importantly At any blood pressure, is importantly affected by the presence or absence affected by the presence or absence of other risk factors of other risk factors

Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002 Dec

Complications- CVComplications- CV

premature cardiovascular premature cardiovascular diseasedisease

heart failureheart failure Left ventricular Left ventricular

hypertrophyhypertrophy

Complications- NeurologicalComplications- Neurological

StrokeStroke Intracerebral Intracerebral

hemorrhagehemorrhage Hypertensive Hypertensive

encephalopathyencephalopathy

Complications- RenalComplications- Renal

Chronic renal Chronic renal insufficiencyinsufficiency

End-stage renal diseaseEnd-stage renal disease AnemiaAnemia Electrolyte disordersElectrolyte disorders

DiagnosisDiagnosis 3-6 visits over the space of weeks to months3-6 visits over the space of weeks to months

No evidence of end organ damageNo evidence of end organ damage Cuff SizeCuff Size

Too small can overestimate by 10-50 mmHgToo small can overestimate by 10-50 mmHg Arm circumference 22 to 26 cm, 'small adult' cuff, 12 x Arm circumference 22 to 26 cm, 'small adult' cuff, 12 x

22 cm 22 cm Arm circumference 27 to 34 cm, 'adult' cuff: 16 x 30 cm Arm circumference 27 to 34 cm, 'adult' cuff: 16 x 30 cm Arm circumference 35 to 44 cm, 'large adult' cuff: 16 x Arm circumference 35 to 44 cm, 'large adult' cuff: 16 x

36 cm 36 cm Arm circumference 45 to 52 cm, 'adult thigh' cuff; 16 x Arm circumference 45 to 52 cm, 'adult thigh' cuff; 16 x

42 42

Confirming the diagnosis of mild hypertension. Br Med J (Clin Res Ed) 1983 Jan 22;286(6361):287-9.

Variation in cuff blood pressure in untreated outpatients with mild hypertension--implications for initiating antihypertensive treatment. J Hypertens 1987 Apr;5(2):207-11.

DiagnosisDiagnosis

White Coat HypertensionWhite Coat Hypertension Ambulatory monitoringAmbulatory monitoring

Masked HypertensionMasked Hypertension

How common is white coat hypertension? JAMA 1988 Jan 8;259(2):225-8.

Prevalence, persistence, and clinical significance of masked hypertension in youth. Hypertension 2005 Apr;45(4):493-8.

Work up-HistoryWork up-History

““When was the last time you were told your When was the last time you were told your blood pressure was normal”blood pressure was normal”

Family HistoryFamily History NoncomplianceNoncompliance Symptoms of target organ damageSymptoms of target organ damage

HeadachesHeadaches Visual changesVisual changes Chest painChest pain ClaudicationClaudication DyspneaDyspnea

Work up-HistoryWork up-History

Presence of other risk factors for Presence of other risk factors for cardiovascular diseasecardiovascular disease SmokingSmoking DiabetesDiabetes DyslipidemiaDyslipidemia Physical inactivityPhysical inactivity

Work up-HistoryWork up-History

Signs and symptoms that suggest an Signs and symptoms that suggest an identifiable cause of hypertensionidentifiable cause of hypertension Muscle weaknessMuscle weakness Thinning of the skinThinning of the skin Flank painFlank pain

Symptoms suggestive of Symptoms suggestive of pheochromocytomapheochromocytoma Spells of tachycardia, sweating, tremorSpells of tachycardia, sweating, tremor

Work up-PEWork up-PE

Evaluate for signs of end-organ Evaluate for signs of end-organ damagedamage Retinopathy Retinopathy ((Hemorrhage, Papilledema, Cotton wool Hemorrhage, Papilledema, Cotton wool

spots)spots)

PulsesPulses Cardiac Cardiac (rhythm, murmurs)(rhythm, murmurs)

Abdominal bruitsAbdominal bruits EdemaEdema Neurologic AssessmentNeurologic Assessment

Work up- LabWork up- Lab

CBC, CMPCBC, CMP TSHTSH Lipid ProfileLipid Profile UAUA EKGEKG +/- CXR+/- CXR

Lifestyle ModificationsLifestyle ModificationsModificationModification RecommendationRecommendation Approximate systolic Approximate systolic

BP reduction, range*BP reduction, range*

Weight reductionWeight reduction Maintain normal body weight (BMI, 18.5 to 24.9 Maintain normal body weight (BMI, 18.5 to 24.9 kg/m2)kg/m2)

5-20 mmHg per 10-kg 5-20 mmHg per 10-kg weight lossweight loss

Adopt DASH eating planAdopt DASH eating plan Consume a diet rich in fruits, vegetables, and low-Consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of fat dairy products with a reduced content of saturated and total fatsaturated and total fat

8 to 14 mmHg8 to 14 mmHg

Dietary sodium reductionDietary sodium reduction Reduce dietary sodium intake to no more than 100 Reduce dietary sodium intake to no more than 100 meq/day (2.4 g sodium or 6 g sodium chloride)meq/day (2.4 g sodium or 6 g sodium chloride)

2 to 8 mmHg2 to 8 mmHg

Physical activityPhysical activity Engage in regular aerobic physical activity such as Engage in regular aerobic physical activity such as brisk walking (at least 30 minutes per day, most brisk walking (at least 30 minutes per day, most days of the week)days of the week)

4 to 9 mmHg4 to 9 mmHg

Moderation of alcohol Moderation of alcohol consumptionconsumption

Limit consumption to no more than 2 drinks per day Limit consumption to no more than 2 drinks per day in most men and no more than 1 drink per day in in most men and no more than 1 drink per day in women and lighter-weight personswomen and lighter-weight persons

2 to 4 mmHg2 to 4 mmHg

TherapeuticsTherapeuticsBP BP Systolic Systolic

BP BP mmHg*mmHg*

DiastoliDiastolic BP c BP

mmHg*mmHg*

Lifestyle Lifestyle ModificatioModificatio

nn

Initial Drug Initial Drug therapytherapy

WITHOUT WITHOUT compeling compeling indicationindication

Initial Drug Initial Drug therapytherapy

WITH compeling WITH compeling indicationindication

NormalNormal <120<120 AndAnd <80<80 EncourageEncourage

PrehypertensioPrehypertensionn

120-139120-139 OROR 80-8980-89 YESYES No No antihypertensive antihypertensive drug indicateddrug indicated

Drug(s) for the Drug(s) for the compelling compelling indications indications

Stage 1 Stage 1 140-159140-159 OROR 90-9990-99 YESYES Thiazide-type Thiazide-type diuretics for most; diuretics for most; may consider ACE may consider ACE

inhibitor, ARB, inhibitor, ARB, beta blocker, CCB, beta blocker, CCB,

or combinationor combination

Drug(s) for the Drug(s) for the compelling compelling

indications; other indications; other anti-hypertensive anti-hypertensive drugs (diuretics, drugs (diuretics,

ACE inhibitor, ARB, ACE inhibitor, ARB, beta blocker, CCB) beta blocker, CCB)

as neededas needed

Stage 2 Stage 2 >160>160 OROR >100>100 YESYES 2-drug 2-drug combination for combination for most (usually most (usually thiazide-type thiazide-type

diuretic and ACE diuretic and ACE inhibitor or ARB or inhibitor or ARB or

beta blocker or beta blocker or CCB) CCB)

Drug(s) for the Drug(s) for the compelling compelling

indications; other indications; other antihypertensive antihypertensive drugs (diuretics, drugs (diuretics,

ACE inhibitor, ARB, ACE inhibitor, ARB, beta blocker, CCB) beta blocker, CCB)

as neededas needed

Getting to GoalGetting to Goal

Uncomplicated HTN: < 140/90 mmHgUncomplicated HTN: < 140/90 mmHg If older than 65 keep Diastolic above 65 If older than 65 keep Diastolic above 65

mmHgmmHg Chronic Renal Disease: < 130/80 Chronic Renal Disease: < 130/80

mmHgmmHg Diabetes Mellitus: < 130/80 mmHgDiabetes Mellitus: < 130/80 mmHg Cardiovascular Disease: < 130/80 Cardiovascular Disease: < 130/80

mmHgmmHg The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. Chobanian AV; et al.

JAMA 2003 May 21;289(19):2560-72. Epub 2003 May 14.

Initial Drug TherapyInitial Drug Therapy

Uncomplicated HTN: Low dose Uncomplicated HTN: Low dose diureticdiuretic

Heart Failure: ACEIHeart Failure: ACEI Asymptomatic LV dysfunction: ACEIAsymptomatic LV dysfunction: ACEI MI: ACEIMI: ACEI Diabetes: ACEIDiabetes: ACEI Renal Failure: ACEIRenal Failure: ACEI

Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002 Dec 18

Initial Drug TherapyInitial Drug Therapy

Severe HTN with EKG evidence of LVH: Severe HTN with EKG evidence of LVH: ARBARB

S/p AMI with heart failure or S/p AMI with heart failure or asymptomatic LV dysfunction: Beta asymptomatic LV dysfunction: Beta blockers w/o ISAblockers w/o ISA

There are no absolute indications for There are no absolute indications for calcium channel blockers in calcium channel blockers in hypertensive patientshypertensive patients

Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). ALLHAT Collaborative Research Group. JAMA 2000 Apr 19;283(15):1967-75. Should beta blockers remain first choice in the treatment of primary hypertension? A meta-analysis. Lancet 2005 Oct 29-Nov 4;366(9496):1545-53.

Initial Drug TherapyInitial Drug Therapy

Switching vs. Additive therapySwitching vs. Additive therapy Age & Race PredictorsAge & Race Predictors

Younger patients: beta blockers and Younger patients: beta blockers and ACEI & ARBs ACEI & ARBs

Older patients: diuretics and CCBs Older patients: diuretics and CCBs Black patients: diuretics and CCBs Black patients: diuretics and CCBs

1. Optimisation of antihypertensive treatment by crossover rotation of four major classes. Lancet 1999 Jun 122. ACE inhibitors, beta-blockers, calcium blockers, and diuretics for the control of systolic hypertension. Am J Hypertens 2001 Mar3. Response to a second single antihypertensive agent used as monotherapy for hypertension after failure of the initial drug. Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents. Arch Intern Med 1995 Sep 114. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. Chobanian AV; et al. JAMA 2003 May 21;289(19):2560-72. Epub 2003 May 14.

Questions?Questions?

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