Transcript Hypertension

Treatment of Hypertension
Based on the Seventh Report of the
Joint National Committee on
Prevention, Detection ,Evaluation and Treatment
of High Blood Pressure (JNC-7)
Jai Radhakrishnan, M.D.
Division of Nephrology
Objectives



Define hypertension
Principles of treatment
Special groups
Blood Pressure Classification
BP
CLASSIFICATION
SBP
DBP
<120 and
<80
Prehypertension
120-139 or
80-89
Stage 1 HTN
140-159 or
90-99
Stage 2 HTN
>160
>100
Normal
Why Treat Hypertension ?

To decrease:






Cerebrovascular Accidents
35-40%
Coronary events
20-25%
Heart failure
50%
Progression of renal disease
Progression to severe hypertension
All cause mortality
Awareness, Treatment and Control of
Blood Pressure 1976-2000 (NHANES)
80
70
60
50
Awareness
Treatment
Control
40
30
20
10
0
1976-1980 1988-1991 1991-1994 1999-2000
Factors to Consider in Treating
Hypertension






Repeat readings
r/o secondary causes
Estimate CV risk status
Co-morbid conditions
Lifestyle changes
Drugs
“Secondary” Hypertension





Difficult to control
Sudden onset of HTN
Well controlled-> difficult to
control
Severe hypertension
History/physical/labs
Initial Workup of
Secondary HTN

Renal parenchymal disease


Renovascular


Lower Extremity BP
Primary aldosteronism



Captopril scan
Coarctation


UA, spot urine protein/creatinine, serum creatinine, USG.
Serum and urinary K
Plasma renin and aldosterone ratio
Pheochromocytoma

Spot urine for metanephrine/creatinine
Laboratory Tests in
Uncomplicated HTN






ECG
Urine analysis
Blood glucose, hematocrit
Basic metabolic panel
Lipid profile after 9-12 hour fast
Urine microalbumin
Estimate Risk Status








Hypertension
Smoking
Obesity (BMI > 30kg/m2)
Dyslipidemia
Diabetes
Microalbuminuria or GFR <60ml/min
Age > 55 (men), 65 (women)
Family history of CVD
(Men< 55, Women <65)
Metabolic Syndrome
Target Organ Damage

Heart Disease

CAD (Angina, myocardial infarction, coronary
revascularization
Left Ventricular Hypertrophy

Heart Failure





Stroke/TIA
Chronic kidney disease
Peripheral arterial disease
Retinopathy
Goals of Therapy
BP <140/90 mmHg
BP <130/80 mmHg in patients
with diabetes or chronic kidney disease.
Achieve SBP goal especially in persons
>50 years of age.
Lifestyle Modification
Modification
Weight reduction
Approximate SBP reduction
(range)
5–20 mmHg/10 kg weight loss
Adopt DASH eating plan
8–14 mmHg
Dietary sodium reduction
2–8 mmHg
Physical activity
4–9 mmHg
Moderation of alcohol
consumption
2–4 mmHg
Drugs for Hypertension

Diuretics





Thiazide
Loop diuretics
Aldosterone antagonists
K-sparing




alpha -blockers*
beta-blockers
Alpha+beta-blockers
Calcium channel
blockers

Adrenergic inhibitors
 Peripheral agents
 Central (α-agonists)

Direct Vasodilators *

Dihydropyridine
Non dihydropyridine

ACE-inhibitors

Angiotensin-II blockers
* Usually not monotherapy
Algorithm for Treatment of Hypertension
Lifestyle Modifications
Not at Goal Blood Pressure (<140/90 mmHg)
(<130/80 mmHg for those with diabetes or chronic kidney disease)
Initial Drug Choices
Without Compelling
Indications
With Compelling
Indications
Stage 1 Hypertension
Stage 2 Hypertension
(SBP 140–159 or DBP 90–99 mmHg)
Thiazide-type diuretics for most.
May consider ACEI, ARB, BB, CCB,
or combination.
(SBP >160 or DBP >100 mmHg)
2-drug combination for most (usually
thiazide-type diuretic and
ACEI, or ARB, or BB, or CCB)
Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
Drug(s) for the compelling
indications
Other antihypertensive drugs
(diuretics, ACEI, ARB, BB, CCB)
as needed.
Classification and Management
of BP for adults
Initial drug therapy
BP Class
SBP
DBP Lifestyle
Normal
<120
<80
Prehypertension
120–
139
or 80–
89
Yes
No antihypertensive drug Drug(s)
indicated.
Stage 1
Hypertension
140–
159
or 90–
99
Yes
Thiazide-type diuretics
for most. May consider
ACEI, ARB, BB, CCB, or
combination.
Stage 2
Hypertension
>160
or
>100
Yes
Without compelling
indication
Encourage None
Two-drug combination
(usually thiazide and
ACEI or ARB or BB or
CCB).
*Treatment determined by highest BP category.
†Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.
‡Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.
Compelling
indications
None
Other
antihypertensive
drugs (diuretics,
ACEI, ARB, BB,
CCB) as needed.
Special Considerations
Compelling Indications
Special populations
HTN with COPD and MI
A 55 year old patient with COPD and HTN (controlled
with nifedipine) is admitted with severe chest pain
x24 hrs.
BP is 170/100 and she has a soft S3 gallop.
ECG shows an anterior wall MI.
She is not a candidate for thrombolysis. ECHO shows an
ejection fraction of 35%.
How will you manage her hypertension?
Compelling Indications for
Certain Drug Classes
HTN with CAD


Beta blockers: cardioprotective
(reinfarction, arrhythmias and sudden
death)
ACE inhibitors: MI with systolic
dysfunction- heart failure and mortality
improved
Renal Insufficiency

A 30 year old patient with IDDM is referred
with difficult-to-control HTN on diltiazem and
clonidine.

Exam reveals BP=190/100 and 3+ edema.

Labs:
Creatinine
Serum K
24 hour protein
= 2.2 mg/dL
= 5.1 meq/L
=5g
Hypertension with Renal Insufficiency



Goal BP <130/80
ACE-inhibitors/angiotensin receptor blockers
should be used if no contraindications
Most patients have volume overload:


Diuretics should be included in the regimen.
Thiazides ineffective if S Creat>2.5
A 40 year old previously healthy male is brought to the E.R. with 3
days of progressive shortness of breath and has experienced
blurred vision in both eyes.
Physical exam:
Blood pressure 230/140. Lethargic.
Eye exam: Papilledema
Chest: Bibasilar crackles
Cardiac: S1S2S4
Neuro: Bilateral upgoing plantars:
Extr: 2+ edema
Labs: K=3.4, BUN=35, Creatinine: 2.2
CXR: Pulmonary edema
Urine: 10-15 red cells, 2+ albumin.
Hypertensive Urgencies and
Emergencies

HYPERTENSIVE EMERGENCIES


Require immediate blood pressure reduction (not necessarily
to normal range) to prevent or limit target organ damage.
HYPERTENSIVE URGENCIES

Require reduction of blood pressure within a few hours
Emergencies
& Urgencies

HYPERTENSIVE
EMERGENCIES


Require immediate
blood pressure
reduction (not
necessarily to normal
range) to prevent or
limit target organ
damage.
HYPERTENSIVE
URGENCIES

Require reduction of
blood pressure within a
few hours
Parenteral Drugs For Treatment of
Hypertensive Emergencies
VASODILATORS
 Nitroprusside
 Fenoldopam
 Nitroglycerine
 Enalaprilat
 Nicardipine
 Hydralazine
ADRENERGIC
INHIBITORS
 Labetalol
 Esmolol
 Phentolamine
Pregnancy and Hypertension
A 24 year old primiparous woman is seen in the
obstetric clinic at 30 weeks gestation.
BP: 160/100, 2 + pedal edema
Otherwise unremarkable physical exam.
Urine shows 1000 mg of protein. Other labs: N
After 2 days of bed rest BP remains 160-170/100
Drug Therapy of the Hypertensive
Pregnant Patient




Methyldopa: Drug of choice.
Beta blockers (not early pregnancy).
Hydralazine is the parenteral drug of
choice.
Most agents if used prior to pregnancy
may be continued

(except ACE-I OR A-II BLOCKERS)
Resistant Hypertension
 Improper BP measurement
 Excess sodium intake
 Inadequate diuretic therapy
 Medication
• Inadequate doses
• Drug actions and interactions (e.g., nonsteroidal anti-inflammatory
drugs (NSAIDs), illicit drugs, sympathomimetics, oral contraceptives)
• Over-the-counter (OTC) drugs and herbal supplements
 Excess alcohol intake
 Identifiable causes of HTN
Conclusions
 The initial approach to hypertension should start with ruling out
secondary causes, detecting and treating other cardiovascular risk
factors, and looking for target organ damage.
 Treatment should always include lifestyle changes.
 Medication use should be guided by the severity of HTN and the
presence of “compelling” indications.
 Thiazide-type diuretics should be initial drug therapy for most, either
alone or combined with other drug classes.
 Most patients will require two or more antihypertensive drugs
Conclusions




HTN is a risk factor for mortality and
cardiovascular and renal disease
HTN is common but not controlled.
Target BP 140/90 (130/80 in DM, CKD)
Remember Compelling Indications
www.nhlbi.nih.gov/