Diagnosis and Management of Hypertension

Davin Haraway DO,FACOI,CWSAssociate Professor of Medicine – OSU

Center for Health Sciences

Why talk about the Same Old Thing?● Those age 55 with normal blood pressure will have a 90 percent

lifetime risk of developing hypertension● Hypertension control reduces excess morbidity and mortality.● Beginning with 115/75 – CVD risk doubles for each increment of

20/10mmHg● >50million americans have High Blood Pressure warranting some

form of treatment● 30% adults are still unaware of their hypertension● >40% of individuals with hypertension are not on treatment● 2/3 of patients on treatment are not controlled to BP levels of less

than 140/90● Hypertensive patients are 2.5 times more likely to develop

diabetes within 5 years

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Residual lifetime risk of developing hypertension among people with blood pressure <140/90 mmHg

Years

Lifetime Risk of Developing Hypertension Beginning at Age 65

Men Women

Vasan RS, et al. JAMA. 2002; 287:1003-1010.Copyright 2002, American Medical Association.

www.hypertensiononline.org

                                                                                                                                                                                                                  

Table 1. Classification and Management of Blood Pressure for Adults Aged 18 Years or Older

HTN Classification

?Prehypertension

● NOT a DISEASE category– Should encourage Lifestyle modification as this group

has an increased risk of becoming hypertensive

● NOT candidates for drug therapy (unless compelling indications ie DM etc goal <130/80)

                                                                                                                                  

        

Table 3. Lifestyle Modifications to Manage Hypertension*

Physician Practices in Treating HTN With and Without Diabetes

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80-84 85-89 90-94 95-99 100-110

40-60y/no DM >70y/no DM40-60y/with DM >70y/with DM

Hyman DJ, Pavlik VN. Arch Intern Med. 2000;160(15):2281-2286.Reprinted by permission, American Medical Association.

DBP (mmHg) to Start Treatment

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www.hypertensiononline.org

Accurate BP measurement

● Who checks your patients BP?– You or Staff

● IF Staff – Do they know what to listen for or do they use automated equipment

– Seated quietly for 5 minutes– Appropriate size cuff– Inflate 20-30 mmHg above loss of radial pulse– Deflate at 2mmHg per second– 1st sound SBP ; Disappearance of Korotkoff sound (phase 5) is

DBP– Confirm Elevated blood pressure within 2months(stage 1) –

shorter for stage 2 if new onset

If HTN diagnosed

Evaluate for Cardiovascular Risk Factors

Age,Fm Hx, Lipids, Obesity, microalbuminuria, Inactivity,Smoking

Evaluate for Target Organ Damage

LVH or reduced EF, Angina,stroke,dementia,Kidney disease, PAD,retinopathy

Think about Secondary Hypertension with any new onset Hypertension or uncontrolled hypertension

Identifiable causes of hypertension● Chronic kidney disease\● Coarctation of the Aorta● Cushing’s Syndrome● Drug induced● Obstructive uropathy● Pheochromocytoma● Primary aldosteronism and other mineralocorticoid

excess states● Renovascular HTN – stenosis and fibromuscular

dysplasia● Sleep Apnea● Thyroid (either HYPER or HYPO) or parathyroid

disease

Box 3. Causes of Resistant Hypertension Improper blood pressure measurement Volume overload and pseudotolerance Excess sodium intake Volume retention from kidney disease Inadequate diuretic therapy) Drug-induced or other causes Nonadherence Inadequate doses Inappropriate combinations Nonsteroidal anti-inflammatory drugs; cyclooxygenase 2 inhibitors Cocaine, amphetamines, other illicit drugs Sympathomimetics (decongestants, anorectics)

Oral contraceptives Adrenal steroids Cyclosporine and tacrolimus

Erythropoietin Licorice (including some chewing tobacco) Selected over-the-counter dietary supplements and medicines (eg, ephedra, ma haung, bitter orange) Associated conditions Obesity Excess alcohol intake Identifiable causes of hypertension (see Box 2)

Which Drugs do you use?

● Stage 1 – Thiazide 1st unless compelling indication

● Stage 2 – Two drugs (one of the two should be a diuretic or ACE/ARB)

● Compelling Indications for certain disease modifying meds should be considered

                                                                                                                                                                                                             

     

Table 6. Clinical Trial and Guideline Basis for Compelling Indications for Individual Drug Classes

                                                                                                  

                                        

                                                                                                      

                                    

Table 4. Oral Antihypertensive Drugs*

                                                                                          

                                                

Table 5. Combination Drugs for Hypertension

OK Now what?

● 2/3 of patients with hypertension will need at least two medicines for BP control

Pearls

● For resistant HTN – sit down and take a good history – How much water,pop, coffee,milk,juice,tea,ice –

anything liquid do you drink daily.– Food preferences and salt intake– Drugs/Alcohol– Compliance

Pearls cont.

● The only thiazide that will work with an elevated creat. Is metolazone(zaroxolyn)

● If elevated creat. Than will need to use a loop diuretic● If potassium is elevated – evaluate current meds and use

a diuretic● If potassium is low – ask why● Check for edema – and ask why● Elderly patients benefit from blood pressure management● Black patients benefit from ACE/ARB – may need to use

larger doses to obtain BP lowering effect

Pearls Cont.

● Metabolic acidosis and hyperkalemai? – use diuretic – loop if creat. Elevated

● Take blood pressure periodically lying and standing so as not to miss supine hypertension associated with autonomic insufficiency – this is treated differently

Escape of Angiotensin II Despite ACE Inhibition

Biollaz J, et al. J Cardiovasc Pharmacol. 1982;4(6):966-972.

Plasma Ang II(pg/mL)

Plasma ACE(nmoL/mL/min)

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Placebo 4 h 24 h 1 2 3 4 5 6

Hospital Months

020406080

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*P <.001 vs placebo

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Osterberg, L. et al. N Engl J Med 2005;353:487-497

Adherence to Medication According to Frequency of Doses

Osterberg, L. et al. N Engl J Med 2005;353:487-497

Barriers to Adherence

                                                                                                                                                                

             

Figure. Algorithm for Treatment of Hypertension