Transcript Hypertension

Hypertension
Jared Helms D.O. OGME-2
22 August 2007
Hypertension
The treatment of hypertension is the
most common reason for office visits
of non-pregnant adults to physicians
in the United States and for use of
prescription drugs.
Cherry, DK, Burt, CW, Woodwell, DA. Advance data from vital and health statistics. No 337.
Hyattsville, MD. National Center for Health Statistics, 2003.
Definitions



Normotensive: systolic <120 mmHg
and diastolic <80
Prehypertension: systolic 120-139
or diastolic 80-89
Hypertension
 Stage 1: systolic 140-159 or
diastolic 90-99
 Stage 2: systolic 160 or diastolic
100
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure: the JNC 7 report. Chobanian AV; et al.
JAMA 2003 May 21;289(19):2560-72. Epub 2003 May 14.
Definitions


Hypertensive urgency: Severe
hypertension (as defined by a diastolic
blood pressure above 120 mmHg) in
asymptomatic patients
Malignant hypertension: marked
hypertension with retinal hemorrhages,
exudates, or papilledema; usually
associated with a diastolic pressure above
120 mmHg
Causes


Essential Hypertension
Secondary Hypertension








Primary renal disease
Renovascular disease
Oral contraceptives
Pheochromocytoma
Primary hyperaldosteronism
endocrine disorders
Sleep apnea syndrome
Coarctation of the aorta
Essential vs. Secondary
There are four major general clinical clues
that are suggestive of secondary
hypertension
 Severe or refractory hypertension.
 An acute rise in blood pressure over a
previously stable value.
 Proven age of onset before puberty or above
the age of 50 to 55 years
 Age less than 30 years in non-obese, non-black
patients with a confirmed negative family
history of hypertension.
Essential Hypertension

pathogenesis of essential
hypertension is poorly understood




Increased sympathetic neural activity, with
enhanced beta-adrenergic responsiveness
Increased angiotensin II activity and
mineralocorticoid excess
genetic factors
Reduced adult nephron mass may predispose
to hypertension
Risk Factors

A variety of risk factors have been associated
with essential hypertension:
 tends to be both more common and more severe in
blacks
 Increased salt intake
 excess alcohol intake
 weight gain
 Dyslipidemia
Risk factors for arterial hypertension in adults with initial optimal blood pressure: the Strong Heart Study
Hypertension. 2006 Feb
Dyslipidemia and the risk of incident hypertension in men. Hypertension. 2006 Jan
Complications


Increase in risk begins as the blood
pressure rises above 110/75 mmHg
At any blood pressure, is importantly
affected by the presence or absence
of other risk factors
Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults
in 61 prospective studies. Lancet 2002 Dec
Complications- CV



premature cardiovascular
disease
heart failure
Left ventricular hypertrophy
Complications- Neurological



Stroke
Intracerebral
hemorrhage
Hypertensive
encephalopathy
Complications- Renal


Chronic renal insufficiency
End-stage renal disease


Anemia
Electrolyte disorders
Diagnosis

3-6 visits over the space of weeks to months


No evidence of end organ damage
Cuff Size

Too small can overestimate by 10-50 mmHg




Arm
Arm
Arm
Arm
circumference
circumference
circumference
circumference
22
27
35
45
to
to
to
to
26
34
44
52
cm,
cm,
cm,
cm,
'small adult' cuff, 12 x 22 cm
'adult' cuff: 16 x 30 cm
'large adult' cuff: 16 x 36 cm
'adult thigh' cuff; 16 x 42
Confirming the diagnosis of mild hypertension. Br Med J (Clin Res Ed) 1983 Jan 22;286(6361):287-9.
Variation in cuff blood pressure in untreated outpatients with mild hypertension--implications for initiating antihypertensive treatment. J Hypertens
1987 Apr;5(2):207-11.
Diagnosis

White Coat Hypertension


Ambulatory monitoring
Masked Hypertension
How common is white coat hypertension? JAMA 1988 Jan 8;259(2):225-8.
Prevalence, persistence, and clinical significance of masked hypertension in youth. Hypertension 2005 Apr;45(4):493-8.
Work up-History




“When was the last time you were told your blood
pressure was normal”
Family History
Noncompliance
Symptoms of target organ damage





Headaches
Visual changes
Chest pain
Claudication
Dyspnea
Work up-History

Presence of other risk factors for
cardiovascular disease




Smoking
Diabetes
Dyslipidemia
Physical inactivity
Work up-History

Signs and symptoms that suggest an
identifiable cause of hypertension




Muscle weakness
Thinning of the skin
Flank pain
Symptoms suggestive of
pheochromocytoma

Spells of tachycardia, sweating, tremor
Work up-PE

Evaluate for signs of end-organ damage






Retinopathy (Hemorrhage, Papilledema, Cotton wool spots)
Pulses
Cardiac (rhythm, murmurs)
Abdominal bruits
Edema
Neurologic Assessment
Work up- Lab






CBC, CMP
TSH
Lipid Profile
UA
EKG
+/- CXR
Lifestyle Modifications
Modification
Recommendation
Approximate systolic
BP reduction, range*
Weight reduction
Maintain normal body weight (BMI, 18.5 to 24.9
kg/m2)
5-20 mmHg per 10-kg
weight loss
Adopt DASH eating plan
Consume a diet rich in fruits, vegetables, and lowfat dairy products with a reduced content of
saturated and total fat
8 to 14 mmHg
Dietary sodium reduction
Reduce dietary sodium intake to no more than 100
meq/day (2.4 g sodium or 6 g sodium chloride)
2 to 8 mmHg
Physical activity
Engage in regular aerobic physical activity such as
brisk walking (at least 30 minutes per day, most
days of the week)
4 to 9 mmHg
Moderation of alcohol
consumption
Limit consumption to no more than 2 drinks per
day in most men and no more than 1 drink per day
in women and lighter-weight persons
2 to 4 mmHg
Therapeutics
BP
Systolic BP
mmHg*
Diastolic
BP
mmHg*
Lifestyle
Modification
Normal
<120
Prehypertension
Initial Drug
therapy
WITHOUT
compeling
indication
Initial Drug therapy
WITH compeling
indication
And
<80
Encourage
120-139
OR
80-89
YES
No antihypertensive
drug indicated
Drug(s) for the
compelling indications
Stage 1
140-159
OR
90-99
YES
Thiazide-type
diuretics for most;
may consider ACE
inhibitor, ARB, beta
blocker, CCB, or
combination
Drug(s) for the
compelling indications;
other anti-hypertensive
drugs (diuretics, ACE
inhibitor, ARB, beta
blocker, CCB) as
needed
Stage 2
>160
OR
>100
YES
2-drug combination
for most (usually
thiazide-type diuretic
and ACE inhibitor or
ARB or beta blocker
or CCB)
Drug(s) for the
compelling indications;
other antihypertensive
drugs (diuretics, ACE
inhibitor, ARB, beta
blocker, CCB) as
needed
Getting to Goal

Uncomplicated HTN: < 140/90 mmHg




If older than 65 keep Diastolic above 65
mmHg
Chronic Renal Disease: < 130/80 mmHg
Diabetes Mellitus: < 130/80 mmHg
Cardiovascular Disease: < 130/80 mmHg
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure: the JNC 7 report. Chobanian AV; et al.
JAMA 2003 May 21;289(19):2560-72. Epub 2003 May 14.
Initial Drug Therapy






Uncomplicated HTN: Low dose diuretic
Heart Failure: ACEI
Asymptomatic LV dysfunction: ACEI
MI: ACEI
Diabetes: ACEI
Renal Failure: ACEI
Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel
blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002
Dec 18
Initial Drug Therapy



Severe HTN with EKG evidence of LVH: ARB
S/p AMI with heart failure or asymptomatic LV
dysfunction: Beta blockers w/o ISA
There are no absolute indications for calcium
channel blockers in hypertensive patients
Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: the antihypertensive and lipid-lowering treatment to prevent
heart attack trial (ALLHAT). ALLHAT Collaborative Research Group. JAMA 2000 Apr 19;283(15):1967-75.
Should beta blockers remain first choice in the treatment of primary hypertension? A meta-analysis. Lancet 2005 Oct 29-Nov 4;366(9496):1545-53.
Initial Drug Therapy


Switching vs. Additive therapy
Age & Race Predictors



Younger patients: beta blockers and ACEI &
ARBs
Older patients: diuretics and CCBs
Black patients: diuretics and CCBs
1. Optimisation of antihypertensive treatment by crossover rotation of four major classes. Lancet 1999 Jun 12
2. ACE inhibitors, beta-blockers, calcium blockers, and diuretics for the control of systolic hypertension. Am J Hypertens 2001 Mar
3. Response to a second single antihypertensive agent used as monotherapy for hypertension after failure of the initial drug.
Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents. Arch Intern Med 1995 Sep 11
4. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.
Chobanian AV; et al. JAMA 2003 May 21;289(19):2560-72. Epub 2003 May 14.
Questions?
fin