Transcript Diagnosis and Management of Hypertension - Copyright OSU-CHS

Diagnosis and Management of
Hypertension
Davin Haraway DO,FACOI,CWS
Associate Professor of Medicine – OSU
Center for Health Sciences
Why talk about the Same Old Thing?
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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
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30% adults are still unaware of their hypertension
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>40% of individuals with hypertension are not on treatment
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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
Lifetime Risk of Developing
Hypertension Beginning at Age 65
Risk of hypertension (%)
100
80
Men
Women
60
40
20
0
0
2
4
6
8
10
Years
12
14
16 18
20
Residual lifetime risk of developing hypertension
among people with blood pressure <140/90 mmHg
Vasan RS, et al. JAMA. 2002; 287:1003-1010.
Copyright 2002, American Medical Association.
www.hypertensiononline.or
g
HTN Classification
Table 1. Classification and Management of Blood Pressure for Adults Aged 18 Years or Older
?Prehypertension
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NOT a DISEASE category
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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
40-60y/no DM
40-60y/with DM
>70y/no DM
>70y/with DM
% of respondents
60
50
40
30
20
10
DBP (mmHg) to Start Treatment
0
Hyman DJ, Pavlik VN. Arch Intern Med. 2000;160(15):2281-2286.
85-89Medical 90-94
95-99
100-110
www.hypertensiononline.org
Reprinted 80-84
by permission, American
Association.
Accurate BP measurement
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Who checks your patients BP?
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You or Staff
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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
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Chronic kidney disease\
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Coarctation of the Aorta
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Cushing’s Syndrome
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Drug induced
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Obstructive uropathy
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Pheochromocytoma
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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?
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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
OK Now what?
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2/3 of patients with hypertension will need at
least two medicines for BP control
Pearls
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For resistant HTN – sit down and take a good
history
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How much water,pop, coffee,milk,juice,tea,ice –
anything liquid do you drink daily.
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Food preferences and salt intake
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Drugs/Alcohol
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Compliance
Pearls cont.
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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
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If potassium is low – ask why
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Check for edema – and ask why
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Elderly patients benefit from blood pressure management
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Black patients benefit from ACE/ARB – may need to use
larger doses to obtain BP lowering effect
Pearls Cont.
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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
100
80
Plasma ACE 60
(nmoL/mL/min) 40
20
0
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24 h
1
2
3
4
5
6
30
Plasma Ang II
(pg/mL)
20
10
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0
Placebo
4h
Hospital
Months
*P <.001 vs placebo
Biollaz J, et al. J Cardiovasc Pharmacol. 1982;4(6):966-972.
www.hypertensiononline.org
Adherence to Medication According to Frequency of Doses
Osterberg, L. et al. N Engl J Med 2005;353:487-497
Barriers to Adherence
Osterberg, L. et al. N Engl J Med 2005;353:487-497
Figure. Algorithm for Treatment of Hypertension