Transcript Hypertension - UNC School of Medicine

Hypertension
Robin Felker
Bloomer Hill-NCSRHC
September 16, 2009
Outline
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Epidemiology of HTN
Clinical Presentation
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Interventions
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Symptoms
BP measurement and interpretation
Behavior Modification
Drugs
Comorbitities and Complications
HTN at Bloomer Hill
Epidemiology
Epidemiology
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Hypertension is the most common primary diagnosis
in US (PDx in 35 million office visits)
Framingham Heart Study suggests that individuals
who are normotensive at age 55 have a 90 percent
lifetime risk for developing hypertension
In Stage I HTN, achieving a sustained 12 mmHg
reduction in SBP over 10 years will prevent 1 death
for every 11 patients treated
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If CVD or organ damage, only 9 patients would require such
BP reduction to prevent a death
Epidemiology
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Age-adjusted prevalence of hypertension is
significantly higher among blacks (39%) than
among whites (29%)
Racial disparity in SBP control contributes to
nearly 8,000 excess deaths annually from
heart disease and stroke among blacks
Hypertension is the single largest contributor,
of any medical condition, to racial disparity in
adult mortality
Identifying HTN in the Clinic
Clinical Symptoms
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Commonly ASYMPTOMATIC!
“Classic Sx”: Headache, epistaxis, dizziness
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No more frequent in HT than non-HT patients
Flushing, sweating, blurred vision
Family history (first degree relatives)
Manifestations of organ damage
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Will discuss later
Natural History
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Essential Hypertension (95% of cases)
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Chronic Renal Disease (2-4%)
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Age of onset: 20-50 years
Family history of hypertension (1st degree relatives)
Gradual onset, mild-to-moderate BP
Normal serum K+, urinalysis
Increased creatinine, abnormal urinalysis
Primary aldosteronism (1-2%)
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Decreased serum K+
Proper BP measurement
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Persons should be seated quietly for at least
5 minutes in a chair (rather than on an exam
table), with feet on the floor, and arm
supported at heart level
Need an appropriate-sized cuff (cuff bladder
encircling at least 80 percent of the arm)
Release air so needle falls 2-3 mmHg/sec
Be wary of stress, discomfort, and other
evidence of “White Coat HTN”
Need elevated HTN on 2 separate occasions
Things to think about
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Ideal PE should include
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BP confirmation, with verification in the contralateral arm
Examination of the optic fundi
Body mass index(BMI)/waist circumference
Auscultation for carotid, abdominal, and femoral bruits
Palpation of the thyroid gland
Thorough examination of the heart and lungs
Examination of the abdomen for enlarged kidneys, masses,
and abnormal aortic pulsation
Palpation of the lower extremities for edema and pulses
Neurological assessment
Things to think about
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Laboratory tests
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Urinalysis and serum Cr/BUN (rule out renal disease)
Serum potassium (aldosteronism)
Blood glucose level (diabetes strongly linked to HTN and
renal disease)
Serum Cholesterol (global vascular screen)
ECG (to monitor for LVH)
Interpreting Blood Pressure
HTN Interventions
Interventions
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Goal of treatment is to reduce cardiovascular
and renal morbidity and mortality
A combination of lifestyle modifications and
drug therapy are recommended
REMEMBER: The most effective therapy
prescribed by the most careful clinician will
control hypertension only if patients are
motivated
Behavior Modifications
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Lifestyle modifications are recommended even for
those with near normal BP: ≥ 120/80
Eight modifications are recommended by the AHA:
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Eat a better diet, which may include reducing salt
Enjoy regular physical activity
Maintain a healthy weight
Manage stress
Avoid tobacco smoke
Understand hot tub safety
Comply with medication prescriptions
If you drink, limit alcohol
= Cardiac disease,
renal &
diabetes
Drugs (on the $4 list…)
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Diuretics
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ACEI
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Atenolol, Bisoprolol, Carvedilol, Metoprolol, Naldolol, Pindolol,
Propranolol, Sotalol
CCB
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Lisinopril, Enalapril, Captopril, Benazepril
ARB
BB
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Hydrochlorothiazide (HCTZ) and Chlorthalidone
Thiazide-like diuretics have been shown to be best first-line treatment
Diltiazem, verapamil
Most patients will need at least 2 drugs to achieve BP goals
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Combos: Lisinopril-HCTZ, Enalopril-HCTZ, Atenolol-Chlorthalidone,
Comorbidities and
Complications
Comorbidities: Obesity
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BMI >30 is an increasingly prevalent risk
factor for the development of hypertension
and CVD
Intensive lifestyle modification should be
pursued in these individuals
Consider drug treatment for components of
metabolic syndrome
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Obesity, glucose intolerance, high BP, high TGs,
low HDL
Comorbidities : Diabetes
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Target of <130/80 mmHg
Thiazide diuretics, BBs, ACEIs, ARBs, and
CCBs are beneficial in reducing CVD and
stroke incidence in diabetics
ACEI- or ARB-based treatments favorably
affect the progression of diabetic
nephropathy and reduce albuminuria
Old Age
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Hypertension occurs in more than two-thirds
of individuals after age 65
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However, this group has worst BP control
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Lower initial drug doses may be indicated to
avoid symptoms
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But, standard recommendations should apply
Tx in Women
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Oral contraceptives may increase BP
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Risk of hypertension increases with duration
of use
Women taking oral contraceptives should
have their BP checked regularly
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Development of hypertension is a reason to
consider other forms of contraception
Tx in Minorities
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Impact of hypertension are increased in African
Americans
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African-Americans develop high blood pressure at younger ages
than other groups in the U.S.
Complications are more likely to develop with high blood
pressure, including stroke, kidney disease, blindness, dementia,
and heart disease
Reduced BP responses to monotherapy with BBs, ACEIs, or
ARBs; want to include diuretic in treatment!
Differences in adherence by race may be due to
affordability of medicines, personal beliefs, anticipated
adverse effects, and health
BP control is lowest in Mexican American and Native
American populations
Target organ damage
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Heart
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Heart failure
Brain
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Left ventricular hypertrophy
Angina or prior myocardial infarction
Prior coronary revascularization
Stroke or transient ischemic attack
Chronic kidney disease
Peripheral arterial disease
Retinopathy
Take Home Points
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Hypertension is a VERY common medical condition
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Lifestyle modifications should start even in persons
with near-normal BP (≥120/80)
Proper BP interventions include lifestyle
modifications and drug interventions
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Proper identification and treatment is essential to
preventing CHF and target organ damage
Two-drug therapy may be necessary for control
First line control is usually thiazide-like diuretic
Tx of BP with comorbidities must take into account
concurrent treatment of comorbid conditions
HTN at Bloomer Hill
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It is essential to follow BP trends and address HTN
in our patients
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If someone has a high reading, ask about
caffeine/smoking, have them sit for 5 mins and recheck
BP in the exam room
Try for repeat visit in anyone with high BP, especially
>140/90
Follow-up: every 6 months for well-controlled, monthly/bimonthly if uncontrolled, monthly with med changes
Counseling on lifestyle modifications for almost every
patient is warranted! Try for discrete goals that the
patient is on-board with and document them for follow-up
References
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Seventh Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure (JNC 7 Express).
Drugs for hypertension. Treatment Guidelines from the
Medical Letter 2009; 7(77). http://medletbest.securesites.com.libproxy.lib.unc.edu/restrictedtg/t77.html
Fiscella K, Holt K. Racial disparity in hypertension control:
tallying the death toll. Ann Fam Med 2008;6:497-502.
Lilly. Pathophysiology of Heart Disease, ed 4.
http://www.webmd.com/hypertension-high-bloodpressure/hypertension-in-african-americans