Transcript Heart Failure

Changing Strategies
Of Treatment Of
Hypertension
Dr Sunita Dodani
Family Medicine Department
The Aga Khan University
Karachi, Pakistan
Objectives:
At the end of this presentation, we
should be able to:





Learn about recent guidelines of
hypertension management.
Define hypertension by the JNC-VI
guidelines.
Discuss the management steps
recommended by JNC VI.
Define the provider’s role in patient
compliance.
Controversies of stepped care therapy.
New Guidelines:




Joint National Committee (JNC) sixth report on
prevention, detection, evaluation and treatment
of high blood pressure (JNC-VI) - 1997.
WHO/International Society of Hypertension
(ISH), Guidelines of Hypertension Management
for Primary Care Physicians - 1999.
British Hypertension Society Guidelines for
Hypertension Management - 1999.
Local: First report of National Task Force on
Hypertension, Pakistan Hypertension League
- 1998.
JNC-VI Guidelines:
(Drawn from consensus and
evidence - based findings)

Discuss hypertension treatment in stepwise-manner.

Cover treatment strategies in special
population like Black Americans,
pregnancy and patients with co-morbid
conditions.
Definition:
 Normal pressure into 3 categories.
 Abnormal pressure into 3 stages
for adults > 18 and older.
Classification of Blood Pressure
for Adults Age 18 and Olders:
Category
Systolic
(mm Hg)
Optimal
<120
Normal
<130
High-normal 130-139
Hypertension
Stage 1
Stage 2
Stage 3
140-159
160-179
> 180
Diastolic
(mm Hg)
and <80
and <85
or 85-89
or
or
or
90-99
100-109
> 110
Changing Strategies
Of Treatment Of Hypertension (Cont’d)




Elevated BP (>140/90) on 2 or more
visits with BP taken 2 or more times on
each visit and then averaged.
Seated in a chair with arm supported at
heart level.
Must not smoke or drink caffeine for 30
minutes prior to measuring the BP.
Cuff size should encircle 80% of the
patient’s arm.
Changing Strategies
Of Treatment Of Hypertension (Cont’d)
BP measurements should be attempted
only after 5 minutes of rest.
 BP should be at least 2 minutes apart,
averaged, and then repeated if 2
measurements differ by more than 5
mmHg.
 Anxious patient may falsely give high
reading (white coat hypertension).

Changing Strategies
Of Treatment Of Hypertension(Cont’d)

BP rises in most people as they age,  BP
is not considered a normal part of aging.

Isolated systolic hypertension is
considered in patients with systolic BP
>140 mmHg and diastolic BP <90 mmHg
Management:
Three-pronged approach:

Lifestyle modifications.

Appropriate medications (based on the
patient’s demographic and medical
profile).

Professional health care support to foster
compliance.
Life Style Modification:
 Lifestyle
modifications for all
stages of hypertension and are the
initial recommendations for both
high normal and stage 1
hypertension.
Life Style Modifications (Cont’d):
 Weight
reduction
also  cholesterol and DM
 Patients
with abdominal obesity
waist size >34 cms Females
>39 cms Males
 Hypertension risk
Exercise:
 Brisk
 30-45
walking.
minutes at 40% - 60% of
maximal activity  determined by
pulse rate (220 - age x 0.4 & 0.6).
Changing Strategies
Of Treatment Of Hypertension (Cont’d)

DASH: Dietary approaches to stop
hypertension.

Like DM diet, DASH diet includes a specific
number of servings and the weight of servings.

Unlike DM Diet, DASH diet does not offer the
option of food exchanges.
Plant food sources
Only 2 - 3 animal protein servings/day
Changing Strategies
Of Treatment Of Hypertension (Cont’d)




 in Dietary sodium.

Esp. for African Americans

Elderly

DM
75 meq/day of dietary sodium or less ( 5
mmHg systolic & 2.6 mm diastolic).
Cessation of smoking.
 alcohol intake.



< 10 oz wine
< 2 oz whisky
< 24 oz beer
Initial Drug Therapy:
Step-wise approach:
1. First line - Diuretic or -blocker.
2. New agents - Ca channel blocker,
ACE inhibitor, vasodilator etc. should
be considered if patient is not
responsive to initial therapy or has
co-morbid conditions.
3. Adrenergic agents should only be
used as a last choice b/c of their side
effect profile.
Choosing the right medication for
your patient:
Choice of the treatment regimen
depends on:
Degree of BP elevation.
 Number of associated & concurrent risk
factors.
 Presence of TOD.
 Clinical CVD or associated clinical
conditions (ACC).

Risk Stratification:
Risk Factors for
Target Organ Damage Associated Clinical
Cardiovascular Diseases
1. Used for risk
stratification
:
 Levels of systolic and
diastolic BP
(Stages 1-3)
 Men > 55 years
 Women > 65 years
 Smoking
 Total Cholestrol > 6.5
mmol/L
 Diabetes
 FH of premature CVD
(TOD)
 LVH (ECG, Echo, XR)
Conditions (ACC)
Cerebrovascular
Disease
 Proteinuria & / or slight Ischemic stroke
Cerebral hemorhage
elevation of plasma
Transient ischemic attack
creatinine 1 . 2 – 2
mg/dl
(106- 177 mmol/L)
Heart Disease:
 Ultrasound or
radiological evidence
of atherosclerotic
plaques
(carotid, illiac &
f emoral arteries, aorta)
Myocardial Infarction
Angina Pectoris
Coronary
revascularization
Congestive Heart failure
Risk Stratification (Cont’d):
Risk Factors For
Cardiovascular Diseases
2. Other factors
adversely influencing
the prognosis
 Reduced HDL
 Raised LDL
Microalbuminuria in
diabetes
 Impaired GTT
 Obesity
 Sedentary life style
 Raised fibrinogen
 High risk
socioeconomic &
ethnic group
 High risk geographic
region
Target Organ
Damage
Associated Clinical
Conditions (ACC)
Renal Diseases:
(TOD)
 Generalized or focal
narrowing of the retinal
arteries ( retinopathy)
Diabetic nephropathy
Dosage & Combination Therapy

Single daily dose  interval of 4 - 6 weeks to observe
the full response, unless it is necessary to lower BP
more urgently.

If drug well tolerated but response is small,  the dose
or add drugs stepwise until BP control is attained.

Treatment can be stepped down later if BP falls
substantially below the optimal level.

Most hypertensives require a combinations of
antihypertensive therapy to achieve optimal control.
Dosage & Combination Therapy (Cont’d):
Drugs from different classes generally have
additive effect on BP.
 Submaximal doses of 2 drugs results in larger
response of BP & fewer side effects
eg: Diuretic + B-blocker
Diuretic + ACE inhibitor
Ca-channel blocker + ACE inhibitor
 Fixed dose combination may be convenient
and are acceptable when monotherapy is
ineffective

Dosage & Combination Therapy
(Cont’d)
 In
Elderly:
1. Initial drug therapy:
Diuretics
Ca channel blockers
Specific Medication Recommendations
For Concurrent Medical Problems:
Concurrent
Recommended Intermediate
Usually Not
Conditions/
Drug Therapy Drug Therapy Used or
ContraCharactersticks
indicated
Medications
Diabetes with
proteinuria
ACE Inhibitors
Ca antagonists
(both types)
ACE Inhibitors
Diuretics
Carvadilol
Losartin
Isolated Systolic Diuretics
Hypertension
Ca Antagonists
(non-DHP central
effects), long
acting forms
Heart Failure
ACE Inhibitors
Diuretics with care
Angiotensin
B Blockers
Receptor Blockers
B Blockers
Ca Antagonists
ACE Inhibitors
B Blockers
Angiotensin
Receptor Blockers
Specific Medication Recommendations For
Concurrent Medical Problems:
Concurrent
Recommended
Conditions/
Drug Therapy
Characteristics
Myocardial
Infarction
B Blockers (non-ISA)
ACE Inhibitors;
reduce mortality
after MI
Intermediate
Drug Therapy
Diuretics
ACE Inhibitors
Receptor Blockers
Non DHP,CaAntagonists, (Diltiazem,
Verapamil)
Usually Not
Contraindicated
DHP Ca
Antagonists eg
nifedipine
(immediate
release can
worsen myocardial
ischemia)
Diuretics
Angiotensin
B Blockers
African
American race Calcium Antagonists Receptor Blockers ACE Inhibitors
(both types)
Atrial
Tachycardia/
Fibrillation
B Blockers
Ca Antagonists
(Both Types)
Diuretics
ACE Inhibitors
Angiotensin.
Receptor Blockers
Specific Medication Recommendations
For Concurrent Medical Problems:
Concurrent
Conditions/
Characteristics
Recommended
Drug Therapy
Intermediate
Drug Therapy
Usually Not
Used or
Contraindicated
Medications
Angina
B Blockers
Ca Antagonists
(both types)
Diuretics
ACE Inhibitors
Angiotensin
Receptor Blockers
Diabetes
Mellitus
Low dose diuretics ACE Inhibitors
B Blockers
(careful
Receptor Blockers
monitoring)
Ca antagonists
(both types)
Dyslipidemia
Angiotensin
ACE Inhibitors
B Blockers
Receptor Blockers Ca Antagonists
(both types)
Diuretics with care
Specific Medication Recommendations For
Concurrent Medical Problems (Cont’d):
Concurrent
Conditions/
Characteristics
Recommended
Drug Therapy
Essential or
senile tremors
BBlockers
Intermediate
Drug Therapy
ACE Inhibitors
Receptor Blocker
Ca Antagonists
Diuretics
Hyperthyroidism BBlockers
Migraine
B Blockers (Non Diuretics
ISA)
ACE Inhibitors
Calcium
ReceptorBlocker
Antagonist
DHP Calcium
(non DHP)
Antagonists
Usually not
used
Contraindicated
Medications
Specific Medication Recommendations For
Concurrent Medical Problems (Cont’d):
Concurrent
Recommended Intermediate Usually Not
Conditions/
Used/
Drug Therapy
Drug
Contraindicated
Characteristics
Therapy
Medications
Osteoporosis Thiazides
Pre-operative
Hypertension
BBlockers
Diuretics
Angiotensin
ACE Inhibitors
Receptor
Blockers
( can’t be given
with severe renal
impairment)
Angiotensin
Renal
B Blockers
Receptor
Insufficiency
Blockers
Ca Antagonists
Prostatism
(both types)
WHO/ISH Guidelines for
Hypertension Management
Summary Points:
Use of Grades rather than stages, otherwise
values choosen are same as JNC-VI.
 Mild, moderate and severe are not used in the
WHO-ISH guidelines - they correspond to
grades 1,2 & 3.
 Term borderline hypertension is subgroup of
Grade 1 i.e.
Systolic 140-149
Diastolic 90-94

British Hypertension Society Guidelines
for Hypertension Management:
Summary Points:





Grades rather than stages are used to classify
hypertension.
Uses coronary heart disease risk accessors
or risk charts.
Isolated systolic hypertension defined as
systolic > 160 and diastolic < 90.
Use of aspirin (primary prevention ) in
hypertension patients.
Use of statins in patients with hypertension.
Indications for specialist referral:




Urgent treatment indicated: Malignant
hypertension, impending complications.
To investigate potential underlying causes of
hypertension when initial evaluation suggests
this possibility.
To evaluate therapeutic problems or failures.
Special circumstances: Unusually variable
blood pressure, possible white coat
hypertension, pregnancy.
Conclusion:



New guidelines like JNC-VI, unlike previous
guidelines, has introduced the concept of
aggressive blood pressure control at optimal
levels.
For elderly patients , the achievement of at
least 140/90 mm Hg or below blood pressure
is acceptable.
Life style modification alone for those
patients at relatively low overall risk for
cardiovascular diseases and with drugs for
those at higher risk.
Conclusion: (Contd…)






Diuretics or B-blockers for those as first choice with
uncomplicated hypertension.
ACE inhibitors for Diabetic patients with proteinuria.
ACE inhibitors &/ 0r diuretics for patients with heart
failure & systolic dysfunction.
Long-acting dihydropyridine Ca antagonist for systolic
hypertension in the elderly.
Follow-up during evaluation & stabilization of
treatment should be frequent to monitor BP and other
risk factors.
Follow-up is important to establish good relationship
with patient and to educate the patient.
Figure 1: Stepped Care Algorithm for
treatment of Hypertension:
Life style modification,Reduce wt
Quit smoking,Regular exc. , Decrease
sodium and alcohol
Inadequate response
Continue lifestyle modification,Initiate pharmacotherapy
Inadequate response
Increase daily dose
Substitute another
drug
Inadequate response
Add 2nd or 3rd Drug
Add 2nd drug from
diff.class
Inadeq,
response
Refer
Changing Strategies
Of Treatment Of Hypertension (Cont’d)
Goal:
 JNC-VI uses a lower goal BP
(<140/90 mmHg) for
hypertension in the elderly.
Changing Strategies
Diuretics: Of Treatment Of Hypertension (Cont’d)
  plasma volume.
 cause peripheral vasodilation.
 potentiate the effect of other anti-hypertensive drugs.
 Caution: Renal disease , Gout, DM, Dyslipidemia.
 Start low dose.
-blockers:
1 selective : start low dose & gradually-increase.
 Should not be used in COPD, CHF or  left
ventricular function.

ACE inhibitors:
DM with proteinuria.
 CHF or myocardial infarction.

Stratifying risk and quantifying prognosis:
Other risk
factors and /
or CVD
Blood Pressure (mm Hg)
Stage 1
SBP 140 - 159
DBP 90 - 99
Stage 2
SBP 160 - 179
DBP 100 - 109
Stage 3
SBP > 180
DBP > 110
Low risk
Medium risk
High risk
2. 1 - 2 risk factors Medium risk
Medium risk
v. High risk
3. 3 or more risk
factors or
diabetes or TOD
High risk
High risk
v. High risk
4. ACC
v. High risk
v. High risk
v.High risk
1. No other risk
factors
Which Drug treatment should be used?
Class of Compelling
Indications
Drug
Diuretics
Heart failure
 Elderly
 Systolic
Hypertension
Compelling Possible
Possible
ContraIndications contraindications indications

Diabetes
Gout
Dyslipidemias
 Sexually
active males

Dyslipidemia
 Athletes
 Physically
active patients
 Peripheral
vascular.
disease

B
Blockers
Angina
Post
MI
Tachyarrythmias
Heart failure
 Pregnancy
 Diabetes

Asthma
 COPD
 Heart
Blocks

Which Drug treatment should be used
Class of
Drug
ACE
Inhibitors
Calcium
Antagonists
Compelling
Indications
Possible
Indications
Heart Failure
 LV.
Dysfunction
 After MI
 Diabetic
nephropathy
Compelling
contraindications
Possible
Contraindications

Angina
 Elderly
 Systolic
Hypertension

Pregnancy
 Bilateral Renal
artery Stenosis
 Hyperkalemia
 Heart Blocks

Peripheral
Vascular
Disease
Congestive
Heart Failure
Which Drug treatment should be used
Class of
Drug
Alpha
Blockers
Angiotensin II
Antagonists
Compelling Possible
Indiacations indications
Prostrate
Hypertrophy

Possible
Contraindications
Orthostatic
hypotension
Glucose
Intolerance
Dyslipidemias
Side Effects
Heart Failure
with other
drugs e.g.
ACE inhibitors
(cough)

Compelling
contraindications
Pregnancy
 Bilateral
Renal artery
Stenosis
 Hyperkalemia
 Heart Blocks

References:



BMJ 1999 Sep 4; 319:630- 635 - British Hypertension
Society guidelines for Hypertension management 1999;
Summary NEW: 9 - 13
Editorial - British guidelines on managing hypertension
World Health Organization- International Society of
Hypertension - 1999 WHO-ISH Guidelines for the
management of Hypertension - Journal of Hypertension
(see on line articles, Volume 17, Issue 2, pages 151 - 183,
February 1999).
The Sixth Report of the Joint National Committee on the
Prevention, Detection, Evaluation and Treatment of High
Blood Pressure JNC-V1- PDF format from the National
Heart, Lung and Blood Institute (NHLBI), National
Institutes of Health (NIH) NEW updated URL 2-11
References (Cont’d):
NHLBL JNC IV References Sheet.
National Guideline Clearing House - Brief Summary
NEW: 2 - 11.
Archives of Internal Medicine 1997 Nov 24 BAD LINK NEW URL -waiting for 1997 back issues to be placed
on-line ?
JNC V1: timing is everything Commentary - The Lancet
15 Nov 97.
 JNC - 6 Guidelines Editorial - American Journal of
Kidney Diseases May 1998
JNC Redux Editorial - American Journal of Kidney
Diseases May 1998
Treatment of hypertension; insights from the JNC V1
report. Am Fam Physician 1998 Oct 15; 58 (6; 1323 - 30
- PubMed abstract)