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Review Of Management Of HypertensionReview Of Management Of Hypertension

ByProfessor

Dr Intekhab AlamDepartment of MedicineLady Reading Hospital, Peshawar

44

Management of Hypertension Management of Hypertension Lecture Objectives

• Define Hypertension (HTN)• Learn how to measure blood pressure• Understand initial clinical evaluation• Identify causes of secondary HTN• Describe lifestyle modifications that lower blood

pressure• Select appropriate anti-HTN medications• Provide appropriate follow-up care

55

What is Blood Pressure?What is Blood Pressure?

The primary reason most of us are awake The primary reason most of us are awake and breathing at this very moment in this and breathing at this very moment in this

lecture! lecture!

BP = CO x TPR BP = CO x TPR (CO = HR x SV)(CO = HR x SV)

– Stroke volume – Stroke volume – affected by contractility and venous returnaffected by contractility and venous return

– TPR is regulated byTPR is regulated byNorepinephrine, Epinephrine, Angiotensin II.Norepinephrine, Epinephrine, Angiotensin II.

66

““Hypertension (HTN)Hypertension (HTN) is defined as is defined as sustained abnormal sustained abnormal elevation of the elevation of the arterial blood arterial blood pressure.”pressure.”

(Brashers, 2006, (Brashers, 2006, p.1).p.1).

Hypertension DefinedHypertension Defined

77

HypertensionHypertension

“It is an abnormal and persistent elevation of BP.”

BP limits are different in children and pregnancy.BP goal is different if you have diabetes or chronic kidney disease.Primary (“essential”) 95% of cases.Secondary 5% of cases.Starting at 115/75 mmHg, CVD risk doubles with Starting at 115/75 mmHg, CVD risk doubles with each increment of 20/10 mmHg throughout the BP each increment of 20/10 mmHg throughout the BP range.range.

88

JNC-7 ClassificationJNC-7 Classification

NormalNormal

PrehypertensionPrehypertension

Stage I hypertensionStage I hypertension

Stage II hypertensionStage II hypertension

SBP (mmHg)SBP (mmHg) DBP (mmHg)DBP (mmHg)BP ClassificationBP Classification

< 120< 120

120-139120-139

140-159140-159

>> 160 160

< 80< 80

80-8980-89

90-9990-99

>> 100 100

andand

oror

oror

oror

http://hin.nhlbi.nih.gov/nhbpep_slds/menu.htmhttp://hin.nhlbi.nih.gov/nhbpep_slds/menu.htm

99

Diagnosis of HTNDiagnosis of HTN

Repeated abnormal elevation of BP usingproper technique/cuff on 3 separate occasions over at least 6 weeks

A single blood pressure >200/120

Keep in mind:– Risk factors– Evidence of end-organ disease

1010

Epidemiology !Epidemiology !

The most common primary diagnosis in the United States, 50 million The most common primary diagnosis in the United States, 50 million American affected.American affected.Only 70% are aware they have HTNOnly 70% are aware they have HTNOf those aware of their HTN, only 50% are being treated.Of those aware of their HTN, only 50% are being treated.Only 25% of all hypertensive patients have their BP under controlOnly 25% of all hypertensive patients have their BP under control

In the year 2000, 16·7 million people died from cardiovascular In the year 2000, 16·7 million people died from cardiovascular disease, accounting for 30·3% of all deaths worldwidedisease, accounting for 30·3% of all deaths worldwideHTN is a risk factor for coronary artery disease (CAD), congestive HTN is a risk factor for coronary artery disease (CAD), congestive heart failure (CHF), stroke, and renal failure heart failure (CHF), stroke, and renal failure

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Prevalence of Hypertension in South AsiaPrevalence of Hypertension in South Asia

More than half of the cardiovascular deaths take place in More than half of the cardiovascular deaths take place in developing countries.developing countries.

South Asia (Pakistan, India, Bangladesh, Nepal, and Sri South Asia (Pakistan, India, Bangladesh, Nepal, and Sri Lanka) represents more than a quarter of the developing Lanka) represents more than a quarter of the developing world, and is likely to be strongly affected by the world, and is likely to be strongly affected by the increase in cardiovascular disease, for several reasons. increase in cardiovascular disease, for several reasons.

First, people from south Asia are known to have a high First, people from south Asia are known to have a high coronary risk; this tendency has been well recorded in coronary risk; this tendency has been well recorded in studies of expatriate south Asians and has also been studies of expatriate south Asians and has also been shown in native settings.shown in native settings.

1212

Prevalence of Hypertension in South AsiaPrevalence of Hypertension in South Asia

SexSex PakistanPakistan 1 1 India India 2,32,3 Bangladesh Bangladesh 44 NepalNepal 6 6 Sri Lanka Sri Lanka 55

MenMen15-30 Years15-30 Years

17%17% 36.4%36.4% 9.89.8 .... 17%17%

WomenWomen15-30 Years15-30 Years

…… 37.5%37.5% 15.6%15.6% .... ....

• Hypertension classified according to WHO Criteria

References: 1. Pakistan Medical Research Council. National Health Survey of Pakistan 1990-94: health profile of the people of Pakistan. Islamabad: Network publication service, 1998. 2. Gupta R, Gupta VP, Sarna M, et al. Prevalence of coronary heart disease and risk factors in an urban Indian population: Jaipur Heart Watch-2.  Indian Heart J  2002; 54: 59-66.  3.Fernandes VL, Kottke TE, Nicholas JJ. Tobacco consumption and coronary artery disease. In: Rao GHR, Kakkar VV, eds. Coronary artery disease in South Asians., New Dehli: Jaypee Brothers, 2001: 147-64. 4. Zaman MM, Yoshiike N, Rouf MA, et al. Cardiovascular risk factors: distribution and prevalence in a rural population of Bangladesh.  J Cardiovasc Risk  2001; 5. 103-08. 5.Mendis S, Ekanayake EM. Prevalence of coronary heart disease and its risk factors in middle aged males in a defined population in central Sri Lanka.  Int J Cardiol  1994; 46: 135-42. 6.Pandey MR, Neupane RP, Gautam A. Epidemiological study of tobacco smoking among adults in a rural community of the hill region of Nepal with special reference to attitudes and beliefs.  Int J Cardiol  1988; 17: 535-41.

1313

The CVD Situation in PakistanThe CVD Situation in Pakistan

Pakistan's Hypertension Statistics (NHS)Pakistan's Hypertension Statistics (NHS)

Hypertension is the most common cardiovascular disease in Pakistan.Hypertension is the most common cardiovascular disease in Pakistan.

There are an estimated 12 million hypertensives in the country.There are an estimated 12 million hypertensives in the country.

Hypertension affects one in three individuals over the age of 45 years in Hypertension affects one in three individuals over the age of 45 years in Pakistan. Pakistan.

Only 3% of the hypertensive population in Pakistan is adequately Only 3% of the hypertensive population in Pakistan is adequately controlled.controlled.

(The National Health Survey of Pakistan, jointly conducted by the Pakistan Medical Research Council in collaboration with the Federal Bureau of statistics, (The National Health Survey of Pakistan, jointly conducted by the Pakistan Medical Research Council in collaboration with the Federal Bureau of statistics, Pakistan and the Department of Health ad Human Services, Washington, USA )Pakistan and the Department of Health ad Human Services, Washington, USA )

1414

Historical Trends in HTNHistorical Trends in HTNNational Health and Nutrition Examination SurveyNational Health and Nutrition Examination Survey

AwarenessAwareness

TreatmentTreatment

ControlControl

1991-19941991-1994

68%68%

54%54%

27%27%

1976-19801976-1980

51%51%

31%31%

10%10%

1988-19911988-1991

73%73%

55%55%

29%29%

1994-20001994-2000

70%70%

59%59%

34%34%

SBP < 140 mmHg and DBP < 90 mmHgSBP < 140 mmHg and DBP < 90 mmHg

Trends in awareness, treatment, and control of high blood Trends in awareness, treatment, and control of high blood pressure in adults ages 18-74pressure in adults ages 18-74

http://hin.nhlbi.nih.gov/nhbpep_slds/menu.htmhttp://hin.nhlbi.nih.gov/nhbpep_slds/menu.htm

1515

Benefits of Lowering BPBenefits of Lowering BP

Sustaining a 12 mmHg reduction in SBP over 10 years Sustaining a 12 mmHg reduction in SBP over 10 years will prevent one death for every 11 patients treated with will prevent one death for every 11 patients treated with Stage I HTN with additional CVD risk factorsStage I HTN with additional CVD risk factors

Why to treat HTN? Why to treat HTN? “The relationship between BP and CVD is positive and continuous.”

– 35-40% 35-40% in stroke morbidity and mortality in stroke morbidity and mortality – 20-25% 20-25% CAD events CAD events– 21% 21% vascular mortality vascular mortality– 52% 52% in CHF in CHF– 35% 35% in LVH in LVH

1616

BP Measurement TechniquesBP Measurement Techniques

MethodMethod Brief DescriptionBrief Description

In-officeIn-office Two readings, 5 minutes apart, sitting in Two readings, 5 minutes apart, sitting in chair. Confirm elevated reading in contra chair. Confirm elevated reading in contra

lateral arm.lateral arm. Ambulatory BP Ambulatory BP monitoringmonitoring

Indicated for evaluation of “white-coat” Indicated for evaluation of “white-coat” HTN. HTN. Absence of 10–20% BP decrease Absence of 10–20% BP decrease during sleep may indicate increased CVD during sleep may indicate increased CVD

risk.risk. Self-measurementSelf-measurement Provides information on response to Provides information on response to

therapy. May help improve adherence to therapy. May help improve adherence to

therapy and evaluate “white-coat” HTN.therapy and evaluate “white-coat” HTN.

1717

Patient EvaluationPatient Evaluation

Evaluation of patients with documented HTN has three objectives:

1. Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guides treatment.

2. Reveal identifiable causes of high BP.

3. Assess the presence or absence of target organ damage and CVD.

1818

Patient EvaluationPatient Evaluation

HypertensionHypertension

SmokingSmoking

Obesity Obesity

Physical inactivityPhysical inactivity

DyslipidemiaDyslipidemia

DiabetesDiabetes

Microalbuminuria or est Microalbuminuria or est GFR < 60 ml/minGFR < 60 ml/min

AgeAge– Males > 55 yrsMales > 55 yrs– Females > 65 yrsFemales > 65 yrs

Family history of CVDFamily history of CVD– Males < 55 yrsMales < 55 yrs– Females < 65 yrsFemales < 65 yrs

Assess lifestyle and identify other CV risk factors or Assess lifestyle and identify other CV risk factors or concomitant disordersconcomitant disorders

1919

Identifiable Causes of HypertensionIdentifiable Causes of Hypertension

Sleep apnea Drug-induced or related causes Chronic kidney disease Primary aldosteronism Renovascular disease Chronic steroid therapy and Cushing’s

syndrome Pheochromocytoma Coarctation of the aorta Thyroid or parathyroid disease

2020

Target Organ DamageTarget Organ Damage Heart

• Left ventricular hypertrophy• Angina or prior myocardial infarction• Prior coronary revascularization• Heart failure

Brain• Stroke or transient ischemic attack

Chronic kidney disease

Peripheral arterial disease Retinopathy

2121

Laboratory TestsLaboratory Tests Routine Tests Electrocardiogram (Look for LVH, CAD, arrhythmia) Urinalysis (Look for protein/blood) Blood glucose, and hematocrit Serum potassium, creatinine, or the corresponding

estimated GFR, and calcium Lipid profile, after 9- to 12-hour fast, that includes

high-density and low-density lipoprotein cholesterol, and triglycerides.

Alb:Cr ratio: Look for microscopic albuminuria.

Optional tests • Measurement of urinary albumin excretion or albumin/creatinine ratio

Specialized investigations: for secondary hypertension not generally indicated unless BP control is not achieved or clinically indicated.

2222

Treatment OutlineTreatment Outline

Goals of TherapyGoals of TherapyLifestyle modificationLifestyle modificationClassification and management of BP for Classification and management of BP for adultsadultsPharmacologic treatmentPharmacologic treatmentCompelling indications for individual drug Compelling indications for individual drug classesclassesFollow-up and monitoringFollow-up and monitoring

2323

Goals of TherapyGoals of Therapy

Reduce CVD and renal morbidity and mortality.

Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients with diabetes or chronic kidney disease.

Achieve SBP goal especially in persons >50 years of age.

• Maintain QOL and Minimize side effects.

2424

Works best in motivated individualsWorks best in motivated individualsInitiate at prehypertension classificationInitiate at prehypertension classificationObesity Obesity risk for HTN and DM risk for HTN and DM

Sodium “Sodium “restriction”restriction” and other diet aids: and other diet aids:– Usual salt intake 10 gm/d = 4 gm Na+Usual salt intake 10 gm/d = 4 gm Na+– Reduce to 2.4 gm Na+/dayReduce to 2.4 gm Na+/day– Caution – salt substitutes contain K+Caution – salt substitutes contain K+

Discourage excessive consumption of coffee and other caffeine-rich Discourage excessive consumption of coffee and other caffeine-rich products. products.

Stop smoking and Alcohol consumption.Stop smoking and Alcohol consumption.Exercise/Activity:Exercise/Activity:– 30-40 minutes 3-4x/wk, optimal 5x/wk30-40 minutes 3-4x/wk, optimal 5x/wk– Stress reductionStress reduction

Lifestyle ModificationLifestyle Modification

2525

Lifestyle ModificationLifestyle Modification

ModificationModification Approximate SBP reductionApproximate SBP reduction(range)(range)

Weight reductionWeight reduction 55––2020  mmHg/10 kg weight lossmmHg/10 kg weight loss

Adopt DASH eating planAdopt DASH eating plan 88––14 mmHg14 mmHg

Dietary sodium reductionDietary sodium reduction 22––8 mmHg8 mmHg

Physical activity Physical activity 44––9 mmHg9 mmHg

Stopping alcohol Stopping alcohol consumptionconsumption

22––4 mmHg4 mmHg

2626

Pharmacologic TreatmentPharmacologic Treatment

Antihypertensive Drug ClassesAntihypertensive Drug Classes– DiureticsDiuretics– Angiotensin Converting Enzyme Inhibitors Angiotensin Converting Enzyme Inhibitors

(ACEI)(ACEI)– Angiotensin II Receptor Blockers (ARB)Angiotensin II Receptor Blockers (ARB)– Beta blockersBeta blockers– Calcium Channel Blockers (CCB)Calcium Channel Blockers (CCB)– Direct VasodilatorsDirect Vasodilators

2727

JNC-7 Management of BP for AdultsJNC-7 Management of BP for Adults

BP classificationBP classification

NormalNormal

PrehypertensionPrehypertension

Stage I HTNStage I HTN

Stage II HTNStage II HTN

Lifestyle Lifestyle

EncourageEncourage

YesYes

YesYes

YesYes

No compelling No compelling indication indication

No drug txNo drug tx

Thiazide for mostThiazide for most

2 drugs combination 2 drugs combination including thiazideincluding thiazide

Compelling indication Compelling indication

Drugs targeted for the Drugs targeted for the compelling indicationscompelling indications

Drugs targeted for the Drugs targeted for the compelling indicationscompelling indications

Drugs targeted for the Drugs targeted for the compelling indicationscompelling indications

< 120/80< 120/80

120-139 / 80-89120-139 / 80-89

140-159 / 90-99140-159 / 90-99

>> 160 / 160 / >> 100 100

2828

National Institute for Health and Clinical National Institute for Health and Clinical Excellence (NICE) Excellence (NICE)

NICE NICE is an independent UK is an independent UK based organisation based organisation

responsible for providing responsible for providing national guidance on the national guidance on the

promotion of good health and promotion of good health and the prevention and treatment the prevention and treatment

of ill health.of ill health.

2929

Pharmacological interventions:Pharmacological interventions:

In hypertensive patients aged 55 or older or black In hypertensive patients aged 55 or older or black patients of any age, the first choice for initial therapy patients of any age, the first choice for initial therapy should either be a calcium-channel blocker or a thiazide-should either be a calcium-channel blocker or a thiazide-type diuretic. For this recommendation, type diuretic. For this recommendation, black patients black patients are considered to be those of African or Caribbean are considered to be those of African or Caribbean descent, not mixed-race, Asian or Chinese. descent, not mixed-race, Asian or Chinese.

In hypertensive patients younger than 55, the first choice In hypertensive patients younger than 55, the first choice for initial therapy should be an angiotensin-converting for initial therapy should be an angiotensin-converting enzyme (ACE) inhibitor (or an angiotensin-II receptor enzyme (ACE) inhibitor (or an angiotensin-II receptor antagonist if an ACE inhibitor is not tolerated). antagonist if an ACE inhibitor is not tolerated).

3030

Pharmacological interventions:Pharmacological interventions:

If initial therapy was with a calcium-channel blocker or a If initial therapy was with a calcium-channel blocker or a thiazide-type diuretic and a second drug is required, add an thiazide-type diuretic and a second drug is required, add an ACE inhibitor (or an angiotensin-II receptor antagonist if an ACE inhibitor (or an angiotensin-II receptor antagonist if an ACE inhibitor is not tolerated). If therapy was initiated with ACE inhibitor is not tolerated). If therapy was initiated with an ACE inhibitor (or angiotensin-II receptor antagonist), an ACE inhibitor (or angiotensin-II receptor antagonist), add a calcium-channel blocker or a thiazide-type diuretic. add a calcium-channel blocker or a thiazide-type diuretic.

If treatment with three drugs is required, the combination of If treatment with three drugs is required, the combination of ACE inhibitor (or angiotensin-II receptor antagonist), ACE inhibitor (or angiotensin-II receptor antagonist), calcium-channel blocker and thiazide-type diuretic should calcium-channel blocker and thiazide-type diuretic should be used. be used.

3131

Pharmacological interventions:Pharmacological interventions:

If blood pressure remains uncontrolled on adequate If blood pressure remains uncontrolled on adequate doses of three drugs, consider adding a fourth doses of three drugs, consider adding a fourth and/or seeking expert advice. and/or seeking expert advice.

If a fourth drug is required, one of the following If a fourth drug is required, one of the following should be considered: should be considered:

– a higher dose of a thiazide-type diuretic or the a higher dose of a thiazide-type diuretic or the addition of another diuretic (careful monitoring is addition of another diuretic (careful monitoring is recommended) or recommended) or

– beta-blockers or beta-blockers or

– selective alpha-blockers. selective alpha-blockers.

3232

Pharmacological interventions:Pharmacological interventions:

If blood pressure remains uncontrolled on adequate doses of four If blood pressure remains uncontrolled on adequate doses of four drugs, and expert advice has not yet been obtained, this should drugs, and expert advice has not yet been obtained, this should now be sought. now be sought.

““Beta-blockers are not a preferred initial therapy for hypertension.”Beta-blockers are not a preferred initial therapy for hypertension.”

However, beta-blockers may be considered in younger people, However, beta-blockers may be considered in younger people, particularly: particularly: – those with an intolerance or contraindication to ACE inhibitors those with an intolerance or contraindication to ACE inhibitors

and angiotensin-II receptor antagonists or and angiotensin-II receptor antagonists or – women of child-bearing potential or women of child-bearing potential or – people with evidence of increased sympathetic drive.people with evidence of increased sympathetic drive. In these circumstances, if therapy is initiated with a beta-blocker and a In these circumstances, if therapy is initiated with a beta-blocker and a

second drug is required, add a calcium-channel blocker rather than a second drug is required, add a calcium-channel blocker rather than a thiazide-type diuretic to reduce the patient’s risk of developing diabetes. thiazide-type diuretic to reduce the patient’s risk of developing diabetes.

3333

Pharmacological interventions:Pharmacological interventions:When a beta-blocker is withdrawn, the dose should be When a beta-blocker is withdrawn, the dose should be stepped down gradually. Beta-blockers should not be stepped down gradually. Beta-blockers should not be withdrawn in patients who have compelling indications withdrawn in patients who have compelling indications for beta-blockade, for example those who have for beta-blockade, for example those who have symptomatic angina or who have had a myocardial symptomatic angina or who have had a myocardial infarction. infarction.

Offer patients with isolated systolic hypertension (systolic Offer patients with isolated systolic hypertension (systolic BP 160 mmHg or more) the same treatment as patients BP 160 mmHg or more) the same treatment as patients with both raised systolic and diastolic blood pressure. with both raised systolic and diastolic blood pressure.

Offer patients over 80 years of age the same treatment Offer patients over 80 years of age the same treatment as other patients over 55, taking account of any as other patients over 55, taking account of any comorbidity and their existing burden of drug use. comorbidity and their existing burden of drug use.

3434

The Atenolol DebateThe Atenolol Debate

Meta-analysis of 8 randomized, controlled, Meta-analysis of 8 randomized, controlled, clinical studies involving atenololclinical studies involving atenolol

Atenolol vs. placebo (6825)Atenolol vs. placebo (6825)– No outcome difference for all-cause mortality, CV No outcome difference for all-cause mortality, CV

mortality, or MImortality, or MI– Trend for lower risk of stroke (outlier HEP?)Trend for lower risk of stroke (outlier HEP?)

Atenolol vs. other antihypertensive (17,671)Atenolol vs. other antihypertensive (17,671)– No major differences with respect to BP controlNo major differences with respect to BP control mortality, mortality, trend CV mortality, trend CV mortality, risk of stroke risk of stroke

3535

The Atenolol DebateThe Atenolol Debate

Authors suggestion for findingsAuthors suggestion for findings– Perhaps all B-blockers are not created equal?Perhaps all B-blockers are not created equal?

Atenolol – hydrophilic, lacks penetration into CNSAtenolol – hydrophilic, lacks penetration into CNSAtenolol – no benefit in remodeling, endothelial Atenolol – no benefit in remodeling, endothelial dysfunction dysfunction

More doom for Atenolol?More doom for Atenolol?– ASCOT Trial was halted earlyASCOT Trial was halted early

> 19,000 patients> 19,000 patientsAtenolol + Thiazide vs. Amlodipine + PerindoprilAtenolol + Thiazide vs. Amlodipine + PerindoprilResults due in March – implication thus far for greater Results due in March – implication thus far for greater CV mortality and strokeCV mortality and stroke

3636

Pharmacological interventions:Pharmacological interventions:

Where possible, recommend treatment with drugs Where possible, recommend treatment with drugs taken only once a day.taken only once a day.

Prescribe non-proprietary drugs where these are Prescribe non-proprietary drugs where these are appropriate and minimise cost. appropriate and minimise cost.

3737

Special ConsiderationsSpecial Considerations

Compelling Indications

•Compelling Populations

•BlacksBlacks• DiabeticsDiabetics• ElderlyElderly

• Renovascular diseaseRenovascular disease• PregnancyPregnancy

3838

Compelling IndicationsCompelling Indications

Compelling IndicationCompelling Indication Initial Therapy OptionsInitial Therapy Options Clinical Trial Basis Clinical Trial Basis

Heart failureHeart failure Thiazide, BB, ACEI, Thiazide, BB, ACEI, ARB, ALDO-AntARB, ALDO-Ant

ACC/AHA HF Guidelines, Merit-ACC/AHA HF Guidelines, Merit-HF, Copernicus, CIBIS, SOLVD, HF, Copernicus, CIBIS, SOLVD, AIRE, TRACE, ValHeft, RalesAIRE, TRACE, ValHeft, Rales

MIMI ACC/AHA Guidelines, BHAT, ACC/AHA Guidelines, BHAT, SAVE, Capricorn, EphesusSAVE, Capricorn, Ephesus

BB, ACEI, ALDO-AntBB, ACEI, ALDO-Ant

High CAD riskHigh CAD risk

DiabetesDiabetes

Recurrent Stroke Recurrent Stroke PreventionPrevention

CRFCRF

Thiazide, BB, ACEI, CCBThiazide, BB, ACEI, CCB

BB, ACE, ARB, CCBBB, ACE, ARB, CCB

ACE, ARBACE, ARB

ALLHAT, HOPE, LIFE, ConvinceALLHAT, HOPE, LIFE, Convince

NKF-ADA Guideline, UKPDS, NKF-ADA Guideline, UKPDS, ALLHATALLHAT

NKF Guideline, Captopril NKF Guideline, Captopril trial, RENAAL, IDNT, REIN, trial, RENAAL, IDNT, REIN, AASKAASK

Thaizide, ACEIThaizide, ACEI PROGRESSPROGRESS

3939

Compelling PopulationsCompelling Populations

High-Risk Hypertensives:High-Risk Hypertensives:– BlacksBlacks– DiabeticsDiabetics– ElderlyElderly– Renovascular diseaseRenovascular disease– PregnancyPregnancy

4040

BlacksBlacks

The single most at risk population with HTNThe single most at risk population with HTN– Disproportionately higher rate and more severeDisproportionately higher rate and more severe

Lower plasma renin activity, more Na+ and Lower plasma renin activity, more Na+ and volume-dependent hypertensionvolume-dependent hypertension

Initial tx – DIURETICS Initial tx – DIURETICS – Second line CCB > ACEI =ARB, B-blockersSecond line CCB > ACEI =ARB, B-blockers

4141

DiabeticsDiabetics

Direct correlation between systolic BP and Direct correlation between systolic BP and decline in GFRdecline in GFR

As little as a 2 mmHg As little as a 2 mmHg BP results in significant BP results in significant reductions in CVD (HOT study)reductions in CVD (HOT study)

Preferred agents – ACEI or ARBsPreferred agents – ACEI or ARBs

4242

ElderlyElderlyPopulation with the lowest BP control, yet the most to Population with the lowest BP control, yet the most to gain! gain! ””Isolated systolic hypertension is common”Isolated systolic hypertension is common”IssuesIssues – polypharmacy, altered drug metabolism, – polypharmacy, altered drug metabolism, physiological changesphysiological changes> 50% of these patients will require combination therapy > 50% of these patients will require combination therapy to achieve goal BPto achieve goal BPSusceptible to volume depletion – orthostatic hypotensionSusceptible to volume depletion – orthostatic hypotensionCognitive impairmentCognitive impairmentFixed incomesFixed incomesLow-dose thiazide is drug of choiceLow-dose thiazide is drug of choice– Additional agent should include – CCB or B-blockerAdditional agent should include – CCB or B-blocker

““Start low and go slow”Start low and go slow”

4343

Renal vascular DiseaseRenal vascular Disease

ACEI and ARBsACEI and ARBs

In patients with RAS or RA hyperplasiaIn patients with RAS or RA hyperplasia– ACEI and ARBs – particularly advantageousACEI and ARBs – particularly advantageous plasma renin and angiotensin activity plasma renin and angiotensin activity

CautionCaution – Rapid and profound drop in BP as – Rapid and profound drop in BP as well as renal failurewell as renal failure

Avoid in bilateral RASAvoid in bilateral RAS

4444

PregnancyPregnancyAlmost all cardiovascular drugs are either risk Almost all cardiovascular drugs are either risk category C or D.category C or D.Chronic/transient hypertension vs. Chronic/transient hypertension vs. preeclampsiapreeclampsiaTreatment warranted with DBP > 100mmHgTreatment warranted with DBP > 100mmHgProblem – not much data from controlled Problem – not much data from controlled clinical studiesclinical studiesMethyldopa, Hydralazine, DiureticsMethyldopa, Hydralazine, DiureticsCaution?Caution?– BB, CCBBB, CCB

AvoidAvoid– ACEI, ARBACEI, ARB

4545

Causes of Resistant HTNCauses of Resistant HTN

Improper BP measurementImproper BP measurement

Excess sodium intakeExcess sodium intake

Inadequate diuretic therapyInadequate diuretic therapy

MedicationMedication– Inadequate dosesInadequate doses– ComplianceCompliance– Drug interactionsDrug interactions– OTC/herbals/dietary supplementsOTC/herbals/dietary supplements

Excess alcohol intakeExcess alcohol intake

Identifiable causes of HTNIdentifiable causes of HTN

4646

Public Health Challenges Public Health Challenges and Community Programsand Community Programs

Public health approaches (e.g. reducing calories, saturated fat, and salt in processed foods and increasing community/school opportunities for physical activity) can achieve a downward shift in the distribution of a population’s BP, thus potentially reducing morbidity, mortality, and the lifetime risk of an individual’s becoming hypertensive.

These public health approaches can provide an attractive opportunity to interrupt and prevent the continuing costly cycle of managing HTN and its complications.

4747

Population-Based Strategy Population-Based Strategy SBP Distributions

BeforeIntervention

AfterIntervention

Reduction in SBPmmHg

235

Reduction in BP

% Reduction in MortalityStroke CHD Total

–6 –4 –3–8 –5 –4–14  –9 –7

4848

Which is the Best StrategyWhich is the Best StrategyPolypill vs. PolymealPolypill vs. Polymeal

CVD Reduction by 80%. CVD Reduction by 80%.

Wald et al. BMJ 2003Wald et al. BMJ 2003

Enalapril 10 mgEnalapril 10 mg

Thiazide 25 mgThiazide 25 mg

Atenolol 25 mgAtenolol 25 mg

Aspirin 75 mgAspirin 75 mg

Atorvastatin 10 mgAtorvastatin 10 mg

Folic acid 5 mgFolic acid 5 mg

CVD Reduction by 75%. CVD Reduction by 75%.

Franco et al. BMJ 2004Franco et al. BMJ 2004

Fish 114 g. Fish 114 g.

Walk, 4 times/weekWalk, 4 times/week

Dark chocolate 100 gDark chocolate 100 g

Fruits and vegetables Fruits and vegetables 400 g400 g

Garlic 2.7 gGarlic 2.7 g

Almonds 68 gAlmonds 68 g

4949

Follow-up and MonitoringFollow-up and Monitoring– Patients should return for follow-up and adjustment

of medications until the BP goal is reached.

– More frequent visits for stage 2 HTN or with complicating comorbid conditions.

– Serum potassium and creatinine monitored 1–2 times per year.

– After BP at goal and stable, follow-up visits at 3- to 6-month.

– Comorbidities, such as heart failure, associated diseases, such as diabetes, and the need for laboratory tests influence the frequency of visits.

5050

Continuing treatmentContinuing treatmentThe aim of medication is to reduce blood pressure to The aim of medication is to reduce blood pressure to 140/90 mmHg or below. However, patients not achieving 140/90 mmHg or below. However, patients not achieving this target, or for whom further treatment is inappropriate or this target, or for whom further treatment is inappropriate or declined, will still receive worthwhile benefit from the declined, will still receive worthwhile benefit from the drug(s) if these lower blood pressure. drug(s) if these lower blood pressure.

Patients may become motivated to make lifestyle changes Patients may become motivated to make lifestyle changes and want to reduce or stop using antihypertensive drugs. If and want to reduce or stop using antihypertensive drugs. If at low cardiovascular risk and with well controlled blood at low cardiovascular risk and with well controlled blood pressure, these patients should be offered a trial reduction pressure, these patients should be offered a trial reduction or withdrawal of therapy with appropriate lifestyle guidance or withdrawal of therapy with appropriate lifestyle guidance and ongoing review. and ongoing review.

Questions?