Transcript Update on management of HYPERTENSION

Update on management of
HYPERTENSION
BMH-GT 12/03/08
Panelists : All Internists and medical
staff members are welcome to
participate in discussion
Hypertension: A Significant CV and
Renal Disease Risk Factor
CAD
CHF
LVH
Stroke
Hypertension

Morbidity
Renal
disease
Peripheral
vascular disease

Disability
National High Blood Pressure Education Program Working Group. Arch Intern Med. 1993;153:186208.
Blood Pressure Classification
JNC VII
BP
Classification
Normal
SBP
mmHg
<120
DBP
mmHg
and
<80
Prehypertension
120–139
or
80–89
Stage 1
Hypertension
Stage 2
Hypertension
140–159
or
90–99
>160
or
>100
Compelling Indications for
Individual Drug Classes
Compelling
Indication
Initial Therapy
Options
THIAZ, BB, ACE, ARB,
CCB
Chronic kidney
disease
ACEI, ARB
Diabetes
Recurrent stroke THIAZ, ACEI
prevention
Clinical Trial
Basis
NKF-ADA
Guideline, UKPDS,
ALLHAT
NKF Guideline,
Captopril Trial,
RENAAL, IDNT,
REIN, AASK
PROGRESS
Compelling Indications for
Individual Drug Classes
Compelling
Indication
Heart failure
Initial Therapy
THIAZ, BB, ACEI,
ARB, ALDO ANT
reversal of LVH
Postmyocardial
infarction
High CAD risk
BB, ACEI, ALDO
ANT
THIAZ, BB, ACE,
CCB
Clinical Trial
Basis Heart Failure
ACC/AHA
Guideline, MERIT-HF,
COPERNICUS, CIBIS,
SOLVD, AIRE, TRACE,
ValHEFT, RALES
ACC/AHA Post-MI
Guideline, BHAT,
SAVE, Capricorn,
EPHESUS
ALLHAT, HOPE,
ANBP2, LIFE,
CONVINCE
JNC-VII New Features and Key
Messages (Continued)
Thiazide-type diuretics should be initial drug
therapy for most, either alone or combined with
other drug classes.
 Certain high-risk conditions are compelling
indications for other drug classes.
 Most patients will require two or more
antihypertensive drugs to achieve goal BP.
If BP is >20/10 mmHg above goal, initiate
therapy with two agents, one usually should be
a thiazide-type diuretic.
New Features and Key Messages
 For persons over age 50, SBP is a more important
than DBP as CVD risk factor
 Starting at 115/75 mmHg, CVD risk doubles with
each increment of 20/10 mmHg throughout the
BP range.
 Persons who are normotensive at age 55 have a
90% lifetime risk for developing HTN.
 Those with SBP 120–139 mmHg or DBP 80–89
mmHg should be considered prehypertensive
who require health-promoting lifestyle
modifications to prevent CVD.
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)
Drug(s) for the compelling
indications
Other antihypertensive drugs
(diuretics, ACEI, ARB, BB, CCB)
as needed.
Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
8
Guidelines on Management of
Diabetic Nephropathy
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Hypertensive Type 2 Diabetic Patients*
 ARBs are the initial agents of choice
Type 1 Diabetics with or without hypertension*
 ACEIs are the initial agents of choice
African Americans demonstrate somewhat reduced BP
responses to monotherapy with BBs, ACEIs, or ARBs
compared to diuretics or CCBs.
These differences usually eliminated by adding adequate
doses of a diuretic
LVH
Prevalent in children with obesity as well
 LVH is an independent risk factor that
increases the risk of CVD.
 Regression of LVH occurs with aggressive
BP management: weight loss, sodium
restriction, and treatment with all classes
of drugs except the direct vasodilators
hydralazine and minoxidil.

Hypertension in Elderly

Hypertension is common.

SBP is a better predictor of events than DBP.

Pseudohypertension and “white-coat
hypertension” may indicate a need for readings
outside the office.

Primary hypertension is the most common
cause, but common identifiable causes
(e.g., renovascular hypertension) should be
considered
Management in Elderly
Most prevalent and least controlled
 Lower initial drug doses may be indicated
to avoid symptoms; standard doses and
multiple drugs will be needed to reach BP
targets.
 Avoid volume depletion and excessively
rapid dose titration of drugs.

Special Situations
Pregnancy use Aldomet ;hydralazine
;Labetolol (ACEI contraindicated) Nipride
(<4hours)
 Asthma and CHF patients

Labetolol ( iV or PO)
 Carvedilol
 Nevibolol

One size doesn’t fit all
Attack sympathetic tone (clonidine max
0.6 mg patch )
 Use direct vasodilation (Hydralazine ;
minoxdil)
 Reserpine depletes catecholamines
 Diuretics in different isolated doses
 CCB or ACEI/ARB depending on special
needs

BP controls Depends on 3
Volume Status
 Autonomic reflexes ( sympathetic tone)
 Renin –angiotensin system

Sympatholytics
Alpha or Beta Blockers
 Clonidine
 Reserpine
 Phentolamine

RAS SYSTEM MEDs.
ACEI
 ARB
 DRI
 BETA BLOCKERS

2nd Tier medicines
Clonidine ( patch is still expensive)-central
 Minoxidil black box warning ; direct
peripheral vasodialtor ( edema and tachy)
 Cardura - alpha 1 blocker --CHF ; edema
(apply to all alpha blockers)
 Reserpine –preipheral adrenergic inhibitordepression
 Hydralazine ---bidil direct vasodilator

Diuretics Therapy
HCTZ is underdosed in Combination pills
 MRFIT, ALLHAT show Chlorthalidone is
superior. Chlor-clonidine combination
 Aldosterone –12 mmHg in resistant HTN,
LVH, Endothelial fn; Inspra is generic
 Stage 4 to Stage 5 CKD use demadex
which is generic now (less hypokalemia
than HCTZ and equal BP reduction)

CCB Therapy
Non-Dihydropyridines Nifedipine,Diltiazem
 Dihydropyridines DHP(Norvasc, PLendil)
 Nisoldipine most cardioselective
 Non-DHP reduce proteinuria
 Combination is more potent
 Pulm.HTN; PVD; Arrythmias; LVH
 Edema worse with DHP

Dietary Approaches to Stop
Hypertension (DASH)

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Diet high in fruits and vegetables and low-fat
dairy products lowers blood pressure (11 mmHg
SBP/ 5 mmHg DBP lower than traditional US
diet), including more than a sodium-restricted
diet
Recommends 7-8 servings/day of grain/grain
products, 4-5 vegetable, 4-5 fruit, 2-3 low- or
non-fat dairy products, 2 or less meat, poultry,
and fish.
NEJM 1997; 366: 1117-24.
www.nhlbi.nih.gov/
Causes of
Resistant Hypertension
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Improper BP measurement
Excess sodium intake
Inadequate diuretic therapy
Medication
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Inadequate doses
Drug actions and interactions (e.g., nonsteroidal antiinflammatory
drugs (NSAIDs), illicit drugs,
sympathomimetics, oral contraceptives)
Over-the-counter (OTC) drugs and herbal supplements
Excess alcohol intake
Identifiable causes of HTN
Lifestyle Modifications
For Prevention
and Management
 Lose
weight if
overweight
 Limit alcohol intake
 Increase aerobic
physical activity
 Reduce sodium intake
 Maintain adequate
intake of potassium
For Overall and
Cardiovascular
Health
 Maintain
adequate
intake of calcium
and magnesium
 Stop
smoking
 Reduce dietary
saturated fat and
cholesterol
Lifestyle Modification
Modification
Weight reduction
Adopt DASH eating
plan
Dietary sodium
reduction
Physical activity
Moderation of alcohol
consumption
Approximate SBP reduction
(range)
5–20 mmHg/10 kg weight loss
8–14 mmHg
2–8 mmHg
4–9 mmHg
2–4 mmHg
NON-PHARMACOLOGIC
MEASURES
SLEEP APNEA
 EXERCISE
 ALCOHOL
 DIET; K INTAKE; SODIUM
 AMBULATORY BP MONITORING
 RESPERATE BIOFEEDBACK
 SECONDARY HTN
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