Transcript HTN- AAFP- Ed Sess

Hypertension
With updated guidelines from
AAFP & JNC VII
Omar A. Khan, MD MHS
January 2006
Objectives
• Review the AAFP/JNC VII diagnostic
criteria for hypertension
• Review various treatment options,
indications and side effects
Fast Facts about
Hypertension in the US:
•
•
•
•
•
Hypertensive population:
Controlled hypertensives:
Those unaware of Dx:
Aware but untreated:
Of those treated:
42,000,000
27%
13,000,000
7,000,000
58% uncontrolled
JNC VII
JNC VII
JNC 7: Classification and Management
of Blood Pressure for Adults
Initial Drug Therapy
BP
Classification
SBP*
(mm
Hg)
DBP*
(mm
Hg)
Lifestyle
Modification
Normal
<120
and <80
Encourage
120–139
or 80–89
Yes
No antihypertensive
drug indicated.
Yes
Thiazide-type diuretic
for most. May consider
ACEI, ARB, BB, CCB,
or combination.
Yes
Two-drug combination
for most (usually
thiazide-type diuretic
and ACEI or ARB or
BB or CCB).
Prehypertension
Stage 1
hypertension
Stage 2
hypertension
140–159
160
or 90–99
or 100
JNC 7. May 2003. NIH publication 03-5233.
Without
Compelling
Indications
With
Compelling
Indications
Drug(s) for
compelling
indications.
Drug(s) for
compelling
indications.
Other
antihypertensive drugs
(diuretic, ACEI, ARB,
BB, CCB) as needed.
Diagnostic Workup
CVD Risk Factors
•
•
•
•
•
HTN
Obesity
Hyperlipidemia
Diabetes
Cigarette Smoking
• Inactivity
• Age:
>55 in men
>65 in women
• Fam history of
premature CVD
JNC 7: Treatment Algorithm for Hypertension
Lifestyle modifications
Not at goal blood pressure (<140/90 mm Hg)
(<130/80 mm Hg for those with diabetes or chronic kidney disease)
Initial drug choices
Without compelling indications
Stage 1 hypertension
(SBP 140–159 or DBP 90–99 mm Hg)
Thiazide-type diuretic for most.
May consider ACEI, ARB, BB, CCB,
or combination.
Stage 2 hypertension
(SBP 160 or DBP 100 mm Hg)
Two-drug combination for most
(usually thiazide-type diuretic and
ACEI or ARB or BB or CCB).
With compelling indications
Drugs for compelling indications
Other antihypertensive drugs
(diuretic, 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.
SBP=systolic blood pressure; DBP=diastolic blood pressure; ACEI=angiotensinconverting enzyme inhibitor; ARB=angiotensin receptor blocker; BB=b-blocker;
CCB=calcium channel blocker
JNC 7. May 2003. NIH publication 03-5233.
Compelling Indications
• Heart Failure:
• Post- MI:
• High CVD risk:
• DM:
• CRF
– Cr > 1.5 in men
– Cr > 1.3 in women
• S/P CVA
 Thiazide/loop, BB, ACEi, ARB,
Aldosterone antagonist
 BB, ACE, Aldosterone antagonist
 Thiazide, BB, ACE, Ca channel blocker
 Thiazide, BB, ACE, ARB, CCB
 ACE, ARB. For creatinine 2-3 try loop
diuretic
 Thiazide, ACE inhibitor
Lifestyle Modifications to Manage HTN
Modification
Recommendations
Approximate Systolic
Blood Pressure Reduction
Weight Reduction
Maintain normal body weight
(BMI 18.5-24.9)
5-20 mm Hg for each
10 kg weight loss
Adapt DASH eating plan
Consume diets rich in fruits,
vegetables, low fat dairy and low
saturated fat
8-14 mm Hg
Dietary sodium reduction
Reduce sodium to no more than
2.4 g/day sodium or
6 g/day NaCl
2-8 mm Hg
Increase physical activity
Engage in regular aerobic
activity such as walking
(30 min/day on most days)
4-9 mm Hg
Moderate alcohol consumption
Limit alcohol to no more than 2
drinks/d for men and 1
drinks/day for women.
2-4 mm Hg
Source: The Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure JNCVII. JAMA. 2003;289:2560-2572.
Failures of Patient Education
• 50% of patients discontinue their antihypertensive within 1 year of initiating
treatment.
• DASH diet for hypertension:
– limit sodium
– Increase fruits and vegetables (8-10/d)
– Increase low fat dairy (3-4/d)
• Focus on diet history for hypertensive patients
Key Diet History Questions
for Patients with HTN
• Do you use a salt shaker?
• Do you taste your food before you add salt?
• How often do you eat salty foods, such as chips, pretzels,
salted nuts, canned and smoked foods?
• Do you read labels for sodium content?
• How many servings of fruits and vegetables do you eat everyday?
• How often do you eat or drink dairy products? What kind?
• How often do you eat out? What kinds of restaurants?
• Do you like to drink alcohol? How much?
• How often do you exercise, including walking?
TIPS on drugs for HT
• CCB OK for isolated systolic hypertension
(ISH)
• For DM: ACEi or ARB with or without diuretic,
then add BB or CCB
• When ACEi causes cough, substitute ARB
• Don’t use short acting CCB (increases deaths
due to arrhythmias).
• Alpha blockers (e.g. clonidine) only as second
line (more side effects).
• Most patients should start with a diuretic as they
enhance the effectiveness of other agents.
• Most patients will require more than one agent.
• Add a baby aspirin to improve cardiovascular
outcomes.
Special Populations
• Minorities:
• Blacks have greater prevalence, severity, and
impact and poorer response to
monotherapy. ACE induced angioedema is
more common
• Women:
• Estrogen containing oral contraceptives
elevate BP. Aldomet, BB, and vasodilators
OK in pregnancy
• Aged:
• Higher prevalence, ISH more common,
more frequent complications from ACE,
CCB
Thiazides
• Chlorothiazide (Diuril)
• Chlorthalidone
• Hydrochlorthiazide(Microzide,
Hydrodiuril)
• Polythiazide
(Renese)
• Indapamide
(Lozol)
• Metolazone
(Mykrox, Zaroxolyn)
*All trade / brand / generic names are specific to the USA
Benefits of Thiazide Diuretics
• Evidence-based support for end points that
matter (prevention of CV and all-cause
mortality).
• Reduced calcium excretion is a potential benefit
for osteoporosis prevention.
Loop Diuretics
• Bumetanide
• Furosemide
• Torsemide
(Bumex)
(Lasix)
(Demadex)
Potassium-sparing Diuretics
•Amiloride
•Triamterene
(Midamor)
(Dyrenium)
*All trade / brand / generic names are specific to the USA
Aldosterone Receptor Blockers
• Eplerone (Inspra)
• Spironolactone (Aldactone)
Combined alpha- and beta- blockers
•Carvedilol (Coreg)
•Labetalol (Normodyne, Trandate)
*All trade / brand / generic names are specific to the USA
Beta-blockers
•
•
•
•
Atenolol
(Tenormin)
Betaxolol(Kerlone)
Bisoprolol
(Zebeta)
Metoprolol
(Lopressor,
Toprol
XL)
• Nadolol
(Corgard)
• Propranolol (Inderal/XL)
• Timolol
(Blocadren)
*All trade / brand / generic names are specific to the USA
ACE inhibitors
•
•
•
•
•
•
•
•
•
•
Benzapril
Captopril
Enalpril
Fosinopril
Lisinopril
Moexipril
Perindopril
Quinapril
Ramipril
Trandolapril
(Lotensin)
(Capoten)
(Vasotec)
(Monopril)
(Prinivil, Zestril)
(Univasc)
(Aceon)
(Accupril)
(Altace)
(Mavik)
*All trade / brand / generic names are specific to the USA
Angiotensin II Receptor Blockers
•
•
•
•
•
•
•
Candesartan
Eprosartan
Irbesartan
Losartan
Olmesartan
Telmisartan
Valsartan
(Atacand)
(Tevetan)
(Avapro)
(Cozaar)
(Benicar)
(Micardis)
(Diovan)
*All trade / brand / generic names are specific to the USA
Calcium channel blockers
• Dihydropyridines
– Amlodipine (Norvasc)
– Felodipine
(Plendil)
– Isradipine
(Dynacirc CR)
– Nicardipine (Cardene SR)
– Nifedipine (Adalat
CC, Procardia XL)
– Nisoldipine (Sular)
• DHPs can have negative inotropic effects, unlike non-DHPs,
so use with caution in pts with impaired cardiac function
Calcium channel blockers
• non-Dihydropyridines:
– Diltiazem (Cardizem CD,
Dilacor XR, Tiazac,
Cardizem LA)
– Verapamil (Calan SR,
Isoptin SR)
*All trade / brand / generic names are specific to the USA
• DHPs can have negative inotropic effects, unlike non-DHPs,
so use with caution in pts with impaired cardiac function
Alpha1 blockers
• Doxazosin
• Prazosin
• Terazosin
(Cardura)
(Minipress)
(Hytrin)
*All trade / brand / generic names are specific to the USA
Direct Vasodilators
• Hydralazine
• Minoxidil
(Apresoline)
(Loniten)
*All trade / brand / generic names are specific to the USA
Centrally acting drugs
•
•
•
•
Clonidine
Methyldopa
Reserpine
Guanfacine
(Catapres)
(Aldomet)
(generic)
(generic)
*All trade / brand / generic names are specific to the USA
Again: Treatment Algorithm
Lifestyle Modification
Not at goal BP
Initial Drug Choices
W/O Compelling Indications
Stage 1
With Compelling Indications
Stage 2
Thiaz, ACE, ARB, BB, CCB
Drug for Indication
2 Drug Combo
Not at Goal BP
Adjust Dose or add additional agents
References
• JNC 7 report: available via NIH (Publication
03-5233)
• JAMA 289 (19), May 21 2003 (online)
• AAFP monograph: #305
HTN True or False
• ACE Inhibitors should be initial drug therapy
for most, either alone or combined with other
drug classes.
False
• ACE Inhibitors Thiazides should be initial
drug therapy for most, either alone or
combined with other drug classes.
True or False
• For persons over age 50, DBP is more
important than SBP as CVD risk factor.
False
• For persons over age 50, SBP is a more
important than DBP as CVD risk factor.
True or False
• Normal blood pressure is defined as SBP <
135 and DBP < 90.
False
• Normal blood pressure is defined as SBP <
120 and DBP < 80. People with SBP 120 –
139 OR DBP 80 – 89 should be considered
prehypertensive.
True or False
• Those people whose BP is classified as
prehypertensive should be initially treated
with lifestyle modification from the time
they are identified.
True
• Those people whose BP is classified as
prehypertensive should be initially treated
with lifestyle modification from the time
they are identified.
• Key lifestyle modification measures that, if
initiated in all prehypertensive and
hypertensive individuals, are likely to lower
BP, include all except…..
•
•
•
•
•
•
a) Weight reduction
b) DASH Eating Plan
c) Smoking cessation
d) Dietary sodium reduction
e) Physical activity
f) Moderation of alcohol intake
• Key lifestyle modification measures that
should be initiated in all prehypertensive and
hypertensive individuals in order to lower BP
include all except…..
•
•
•
•
•
•
a) Weight reduction
b) DASH Eating Plan
c) Smoking cessation
d) Dietary sodium reduction
e) Physical activity
f) Moderation of alcohol intake
True or False
• If BP is >20/10 mmHg above goal, initiate
therapy with a single agent and lifestyle
modification.
False
• False. If BP is >20/10 mmHg above goal,
initiate therapy with two agents, one usually
should be a thiazide-type diuretic.
True or False
• Self measurement can help assess “whitecoat” HTN.
True
• Self measurement can help improve
adherence with therapy, provide helpful
information on response to therapy and assist
in assessing “white-coat” HTN.
True or False
• Most patients will only require one
antihypertensive drug to achieve goal BP.
False
• Most patients will require 2 or more
antihypertensive drugs to achieve goal BP