hypertension with updated guidelines from aafp & jnc vii
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Hypertension With updated guidelines from AAFP & JNC VII. Omar A. Khan, MD MHS January 2006. Objectives. Review the AAFP/JNC VII diagnostic criteria for hypertension Review various treatment options, indications and side effects. Fast Facts about Hypertension in the US:. - PowerPoint PPT PresentationTRANSCRIPT
HypertensionHypertension
With updated guidelines With updated guidelines from AAFP & JNC VIIfrom AAFP & JNC VII
Omar A. Khan, MD MHSOmar A. Khan, MD MHS
January 2006January 2006
ObjectivesObjectives
• Review the AAFP/JNC VII Review the AAFP/JNC VII diagnostic criteria for diagnostic criteria for hypertensionhypertension
• Review various treatment options, Review various treatment options, indications and side effects indications and side effects
Fast Facts about Fast Facts about Hypertension in the Hypertension in the
US:US:• Hypertensive population: Hypertensive population:
42,000,00042,000,000• Controlled hypertensives: Controlled hypertensives: 27%27%• Those unaware of Dx: Those unaware of Dx:
13,000,00013,000,000• Aware but untreated:Aware but untreated:
7,000,0007,000,000• Of those treated: Of those treated: 58% 58%
uncontrolleduncontrolled
JNC VIIJNC VII
JNC VIIJNC VII
Initial Drug TherapyInitial Drug TherapyBP BP ClassificatiClassificationon
SBP* SBP* (mm (mm Hg)Hg)
DBP* DBP* (mm (mm Hg)Hg)
Lifestyle Lifestyle ModificatModificat
ionion
Without Without Compelling Compelling IndicationsIndications
With With Compelling Compelling IndicationsIndications
NormalNormal <120<120 and and <80<80 EncourageEncourage
No No antihypertensive antihypertensive drug indicated.drug indicated.
Drug(s) for Drug(s) for compelling compelling indications.indications.
PrehypertenPrehypertensionsion
120–120–139139
or 80–or 80–8989 YesYes
Stage 1 Stage 1 hypertensiohypertensionn
140–140–159159
or 90–or 90–9999 YesYes
Thiazide-type Thiazide-type diuretic diuretic for most. May for most. May consider ACEI, consider ACEI, ARB, BB, CCB, ARB, BB, CCB, or combination.or combination.
Drug(s) for Drug(s) for compelling compelling indications.indications.
Other Other antihypertensive antihypertensive drugs (diuretic, drugs (diuretic, ACEI, ARB, BB, ACEI, ARB, BB, CCB) as needed.CCB) as needed.
Stage 2 Stage 2 hypertensiohypertensionn
160160 or or 100100 YesYes
Two-drug Two-drug combination combination for most (usuallyfor most (usuallythiazide-type thiazide-type diuretic diuretic and ACEI or ARB and ACEI or ARB or or BB or CCB).BB or CCB).
JNC 7: Classification and Management of Blood Pressure for Adults
JNC 7. May 2003. NIH publication 03-5233.
Diagnostic WorkupDiagnostic Workup
CVD Risk FactorsCVD Risk Factors
• HTNHTN• ObesityObesity• HyperlipidemiHyperlipidemi
aa• DiabetesDiabetes• Cigarette Cigarette
SmokingSmoking
• InactivityInactivity• Age:Age:
>55 in men>55 in men
>65 in women>65 in women
• Fam history of Fam history of premature premature CVDCVD
JNC 7: Treatment Algorithm for JNC 7: Treatment Algorithm for HypertensionHypertension
SBP=systolic blood pressure; DBP=diastolic blood pressure; ACEI=angiotensin- converting enzyme inhibitor; ARB=angiotensin receptor blocker; BB=-blocker; CCB=calcium channel blocker
JNC 7. May 2003. NIH publication 03-5233.
Optimize dosages or add additional drugs until goal blood pressure is achieved.Consider consultation with hypertension specialist.
Not at goal blood pressure
Without compelling indications
Stage 1 hypertension(SBP 140–159 or DBP 90–99 mm Hg)Thiazide-type diuretic 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).
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
With compelling indications
Drugs for compelling indicationsOther antihypertensive drugs (diuretic, ACEI, ARB, BB, CCB) as needed.
Compelling IndicationsCompelling Indications• Heart Failure:Heart Failure:
• Post- MI:Post- MI:• High CVD risk:High CVD risk:• DM:DM:
• CRFCRF– Cr > 1.5 in menCr > 1.5 in men– Cr > 1.3 in womenCr > 1.3 in women
• S/P CVAS/P CVA
Thiazide/loop, BB, ACEi, ARB, Thiazide/loop, BB, ACEi, ARB, Aldosterone antagonistAldosterone antagonist
BB, ACE, Aldosterone antagonistBB, ACE, Aldosterone antagonist Thiazide, BB, ACE, Ca channel Thiazide, BB, ACE, Ca channel
blockerblocker Thiazide, BB, ACE, ARB, CCBThiazide, BB, ACE, ARB, CCB
ACE, ARB. For creatinine 2-3 try ACE, ARB. For creatinine 2-3 try loop diureticloop diuretic
Thiazide, ACE inhibitorThiazide, ACE inhibitor
Lifestyle Modifications to Manage Lifestyle Modifications to Manage HTNHTN
ModificationModification RecommendationsRecommendations Approximate Systolic Approximate Systolic
Blood Pressure Blood Pressure ReductionReduction
Weight ReductionWeight Reduction Maintain normal body Maintain normal body weight (BMI 18.5-24.9)weight (BMI 18.5-24.9)
5-20 mm Hg for each 5-20 mm Hg for each 10 kg weight loss10 kg weight loss
Adapt Adapt DASHDASH eating plan eating plan Consume diets rich in Consume diets rich in fruits, vegetables, low fruits, vegetables, low fat dairy and low fat dairy and low saturated fatsaturated fat
8-14 mm Hg8-14 mm Hg
Dietary sodium reductionDietary sodium reduction Reduce sodium to no Reduce sodium to no more than 2.4 g/day more than 2.4 g/day sodium or sodium or 6 g/day NaCl6 g/day NaCl
2-8 mm Hg2-8 mm Hg
Increase physical activityIncrease physical activity Engage in regular Engage in regular aerobic activity such as aerobic activity such as walking walking (30 min/day on most (30 min/day on most days)days)
4-9 mm Hg4-9 mm Hg
Moderate alcohol Moderate alcohol consumptionconsumption
Limit alcohol to no more Limit alcohol to no more than 2 drinks/d for men than 2 drinks/d for men and 1 drinks/day for and 1 drinks/day for women.women.
2-4 mm Hg2-4 mm HgSource: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure JNCVII. JAMA. 2003;289:2560-2572.
Failures of Patient Failures of Patient EducationEducation
• 50% of patients discontinue their anti-50% of patients discontinue their anti-hypertensive within 1 year of hypertensive within 1 year of initiating treatment.initiating treatment.
• DASH diet for hypertension: DASH diet for hypertension: – limit sodiumlimit sodium– Increase fruits and vegetables (8-10/d)Increase fruits and vegetables (8-10/d)– Increase low fat dairy (3-4/d)Increase low fat dairy (3-4/d)
• Focus on diet history for hypertensive Focus on diet history for hypertensive patientspatients
Key Diet History Questions Key Diet History Questions for Patients with HTNfor Patients with HTN
• Do you use a salt shaker?Do you use a salt shaker?
• Do you taste your food before you add salt?Do you taste your food before you add salt?
• How often do you eat salty foods, such as chips, pretzels, How often do you eat salty foods, such as chips, pretzels, salted nuts, canned and smoked foods?salted nuts, canned and smoked foods?
• Do you read labels for sodium content?Do you read labels for sodium content?
• How many servings of fruits and vegetables do you eat How many servings of fruits and vegetables do you eat everyday?everyday?
• How often do you eat or drink dairy products? What kind?How often do you eat or drink dairy products? What kind?
• How often do you eat out? What kinds of restaurants?How often do you eat out? What kinds of restaurants?
• Do you like to drink alcohol? How much?Do you like to drink alcohol? How much?
• How often do you exercise, including walking?How often do you exercise, including walking?
TIPS on drugs for HTTIPS on drugs for HT
• CCB OK for isolated systolic CCB OK for isolated systolic hypertension (ISH)hypertension (ISH)
• For DM: ACEi or ARB with or without For DM: ACEi or ARB with or without diuretic, then add BB or CCBdiuretic, then add BB or CCB
• When ACEi causes cough, substitute When ACEi causes cough, substitute ARBARB
• Don’t use short acting CCB (increases Don’t use short acting CCB (increases deaths due to arrhythmias).deaths due to arrhythmias).
• Alpha blockers (e.g. clonidine) only as Alpha blockers (e.g. clonidine) only as second line (more side effects).second line (more side effects).
• Most patients should start with a Most patients should start with a diuretic as they enhance the diuretic as they enhance the effectiveness of other agents.effectiveness of other agents.
• Most patients will require more than Most patients will require more than one agent.one agent.
• Add a baby aspirin to improve Add a baby aspirin to improve cardiovascular outcomes.cardiovascular outcomes.
Special PopulationsSpecial Populations• Minorities:Minorities:
• Women:Women:
• Aged:Aged:
• Blacks have greater prevalence, Blacks have greater prevalence, severity, and impact and poorer severity, and impact and poorer response to monotherapy. ACE response to monotherapy. ACE induced angioedema is more induced angioedema is more commoncommon
• Estrogen containing oral Estrogen containing oral contraceptives elevate BP. Aldomet, contraceptives elevate BP. Aldomet, BB, and vasodilators OK in BB, and vasodilators OK in pregnancypregnancy
• Higher prevalence, ISH more Higher prevalence, ISH more common, more frequent common, more frequent complications from ACE, CCBcomplications from ACE, CCB
ThiazidesThiazides
• ChlorothiazideChlorothiazide (Diuril)(Diuril)• ChlorthalidoneChlorthalidone• HydrochlorthiazideHydrochlorthiazide(Microzide, (Microzide,
Hydrodiuril)Hydrodiuril)• PolythiazidePolythiazide (Renese)(Renese)• IndapamideIndapamide (Lozol)(Lozol)• MetolazoneMetolazone (Mykrox, (Mykrox,
Zaroxolyn)Zaroxolyn)
*All trade / brand / generic names are *All trade / brand / generic names are specific to the USAspecific to the USA
Benefits of Thiazide Benefits of Thiazide DiureticsDiuretics
• Evidence-based support for end Evidence-based support for end points that matter (prevention of CV points that matter (prevention of CV and all-cause mortality).and all-cause mortality).
• Reduced calcium excretion is a Reduced calcium excretion is a potential benefit for osteoporosis potential benefit for osteoporosis prevention.prevention.
Loop DiureticsLoop Diuretics
• BumetanideBumetanide (Bumex)(Bumex)• FurosemideFurosemide (Lasix)(Lasix)• TorsemideTorsemide (Demadex)(Demadex)
Potassium-sparing Diuretics•Amiloride (Midamor)•Triamterene (Dyrenium)*All trade / brand / generic names are *All trade / brand / generic names are specific to the USAspecific to the USA
Aldosterone Receptor Aldosterone Receptor BlockersBlockers
• Eplerone (Inspra)Eplerone (Inspra)• Spironolactone (Aldactone)Spironolactone (Aldactone)
Combined alpha- and beta- blockers•Carvedilol (Coreg)•Labetalol (Normodyne, Trandate)
*All trade / brand / generic names are *All trade / brand / generic names are specific to the USAspecific to the USA
Beta-blockersBeta-blockers
• AtenololAtenolol (Tenormin)(Tenormin)• BetaxololBetaxolol (Kerlone)(Kerlone)• BisoprololBisoprolol (Zebeta)(Zebeta)• MetoprololMetoprolol (Lopressor, (Lopressor,
Toprol XL)Toprol XL)• NadololNadolol (Corgard)(Corgard)• PropranololPropranolol (Inderal/XL)(Inderal/XL)• TimololTimolol (Blocadren)(Blocadren)
*All trade / brand / generic names are *All trade / brand / generic names are specific to the USAspecific to the USA
ACE inhibitorsACE inhibitors
• BenzaprilBenzapril (Lotensin)(Lotensin)• CaptoprilCaptopril (Capoten)(Capoten)• EnalprilEnalpril (Vasotec)(Vasotec)• FosinoprilFosinopril (Monopril)(Monopril)• LisinoprilLisinopril (Prinivil, Zestril)(Prinivil, Zestril)• MoexiprilMoexipril (Univasc)(Univasc)• PerindoprilPerindopril (Aceon)(Aceon)• QuinaprilQuinapril (Accupril)(Accupril)• Ramipril Ramipril (Altace)(Altace)• TrandolaprilTrandolapril (Mavik)(Mavik)
*All trade / brand / generic names are *All trade / brand / generic names are specific to the USAspecific to the USA
Angiotensin II Receptor Angiotensin II Receptor BlockersBlockers
• Candesartan Candesartan (Atacand)(Atacand)• Eprosartan Eprosartan (Tevetan)(Tevetan)• Irbesartan Irbesartan (Avapro)(Avapro)• Losartan Losartan (Cozaar)(Cozaar)• Olmesartan Olmesartan (Benicar)(Benicar)• Telmisartan Telmisartan (Micardis)(Micardis)• Valsartan Valsartan (Diovan)(Diovan)
*All trade / brand / generic names are *All trade / brand / generic names are specific to the USAspecific to the USA
Calcium channel Calcium channel blockersblockers
• DihydropyridinesDihydropyridines– Amlodipine (Norvasc)Amlodipine (Norvasc)– FelodipineFelodipine (Plendil) (Plendil)– IsradipineIsradipine
(Dynacirc CR)(Dynacirc CR)– Nicardipine (Cardene Nicardipine (Cardene
SR) SR)– Nifedipine (Adalat Nifedipine (Adalat
CC, Procardia CC, Procardia XL)XL)
– Nisoldipine (Sular)Nisoldipine (Sular)
• DHPs can have negative inotropic effects, unlike non-DHPs, DHPs can have negative inotropic effects, unlike non-DHPs, so use with caution in pts with impaired cardiac functionso use with caution in pts with impaired cardiac function
Calcium channel Calcium channel blockersblockers
• non-Dihydropyridines:non-Dihydropyridines:– Diltiazem Diltiazem
(Cardizem CD, (Cardizem CD, Dilacor XR, Tiazac, Dilacor XR, Tiazac, Cardizem LA)Cardizem LA)
– Verapamil (Calan Verapamil (Calan SR, Isoptin SR)SR, Isoptin SR)
• DHPs can have negative inotropic effects, unlike non-DHPs, DHPs can have negative inotropic effects, unlike non-DHPs, so use with caution in pts with impaired cardiac functionso use with caution in pts with impaired cardiac function
*All trade / brand / generic names are *All trade / brand / generic names are specific to the USAspecific to the USA
AlphaAlpha11 blockers blockers
• Doxazosin Doxazosin (Cardura)(Cardura)• PrazosinPrazosin (Minipress)(Minipress)• TerazosinTerazosin (Hytrin)(Hytrin)
*All trade / brand / generic names are *All trade / brand / generic names are specific to the USAspecific to the USA
Direct Vasodilators
• Hydralazine (Apresoline)• Minoxidil (Loniten)
*All trade / brand / generic names are *All trade / brand / generic names are specific to the USAspecific to the USA
Centrally acting drugsCentrally acting drugs
• ClonidineClonidine (Catapres)(Catapres)• MethyldopaMethyldopa (Aldomet)(Aldomet)• ReserpineReserpine (generic)(generic)• GuanfacineGuanfacine (generic)(generic)
*All trade / brand / generic names are *All trade / brand / generic names are specific to the USAspecific to the USA
Again: Treatment Again: Treatment AlgorithmAlgorithm
Lifestyle Modification
Not at goal BP
Initial Drug Choices
W/O Compelling Indications
Stage 1 Stage 2
With Compelling Indications
Drug for Indication
Thiaz, ACE, ARB, BB, CCB 2 Drug Combo Not at Goal BP
Adjust Dose or add additional agents
ReferencesReferences
• JNC 7 report: available via NIH JNC 7 report: available via NIH ((Publication 03-5233)
• JAMA 289 (19), May 21 2003 (online)
• AAFP monograph: #305AAFP monograph: #305
HTN True or FalseHTN True or False
• ACE Inhibitors should be initial drug therapy ACE Inhibitors should be initial drug therapy for most, either alone or combined with for most, either alone or combined with other drug classes.other drug classes.
• ACE InhibitorsACE Inhibitors ThiazidesThiazides should be initial should be initial drug therapy for most, either alone or drug therapy for most, either alone or combined with other drug classes.combined with other drug classes.
FalseFalse
• For persons over age 50, DBP is more important than SBP as CVD risk factor.
True or FalseTrue or False
• For persons over age 50, SBP is a more important than DBP as CVD risk factor.
FalseFalse
• Normal blood pressure is defined as SBP < 135 and DBP < 90.
True or FalseTrue or False
• Normal blood pressure is defined as SBP < 120 and DBP < 80. People with SBP 120 – 139 OR DBP 80 – 89 should be considered prehypertensive.
FalseFalse
• Those people whose BP is classified as prehypertensive should be initially treated with lifestyle modification from the time they are identified.
True or FalseTrue or False
• Those people whose BP is classified as prehypertensive should be initially treated with lifestyle modification from the time they are identified.
TrueTrue
• Key lifestyle modification measures that, if initiated in all prehypertensive and hypertensive individuals, are likely to lower BP, include all except…..• a) Weight reduction
• b) DASH Eating Plan
• c) Smoking cessation
• d) Dietary sodium reduction
• e) Physical activity
• f) Moderation of alcohol intake
• Key lifestyle modification measures that should be initiated in all prehypertensive and hypertensive individuals in order to lower BP include all except…..• a) Weight reduction
• b) DASH Eating Plan
• c) Smoking cessation
• d) Dietary sodium reduction
• e) Physical activity
• f) Moderation of alcohol intake
• If BP is >20/10 mmHg above goal, initiate therapy with a single agent and lifestyle modification.
True or FalseTrue or False
• False. If BP is >20/10 mmHg above goal, initiate therapy with two agents, one usually should be a thiazide-type diuretic.
FalseFalse
• Self measurement can help assess “white-coat” HTN.
True or FalseTrue or False
• Self measurement can help improve adherence with therapy, provide helpful information on response to therapy and assist in assessing “white-coat” HTN.
TrueTrue
• Most patients will only require one antihypertensive drug to achieve goal BP.
True or FalseTrue or False
• Most patients will require 2 or more antihypertensive drugs to achieve goal BP
FalseFalse