Transcript Hypertension and the Use of Antihypertensives

HYPERTENSION and the use of
ANTI-HYPERTENSIVES
Joshua M.Crasner, DO,FACC,FACOI
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JNC-6 (old criteria)
STAGE
SYSTOLIC BP
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160-179 or
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≥180 or
hypertension
DIASTOLIC BP
100-109
≥ 110
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JNC-7 Definition of HTN
CATEGORY
normal
SYSTOLIC BP
< 120 and
Pre-HTN
120-139
or
DIASTOLIC BP
< 80
80-89
Hypertension
Stage 1
140-159 or
90-99
Stage 2
≥ 160 or
≥ 100
JAMA 289; 2560-72: 2003
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TYPES OF HYPERTENSION
SYSTOLIC AND DIASTOLIC
• Primary(Essential, Idiopathic)
• Secondary
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Renal: Acute GN, Diabetic Nephropathy
Endocrine: TSH, cortisol, calcium
aortic coarctation
pregnancy-induced
neurologic: tumor, sleep apnea
stress: surgery, burns, EtOH withdrawal,S.cell
Drugs: decongestants, antidepressants, OCP
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RED FLAGS FOR SECONDARY
HYPERTENSION
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Abdominal bruit: renal artery stenosis
Palps,HA,pallor,perspiration: pheochromocytoma
Obesity,moon face,purple striae: Cushing’s
Abd mass: polycystic kidney,hydroneph
Obesity,hypersomnolence: OSAS
Agitation, sweating: cocaine, ethanol
Hypokalemia: hyperaldosteronism
Hypercalcemia: hyperparathyroidism
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TYPES OF HYPERTENSION
SYSTOLIC
• Increased Cardiac Output:
– aortic regurgitation, PDA/AVF,
thyrotoxicosis, Paget’s disease
• Aortic rigidity
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HYPERTENSION WITH AGE
• Systolic BP rises continuously with age
• Diastolic rises up to age 50, then falls
• Pulse pressure then widens with age
Vasan, et al.JAMA, 2002; 287(8):1003-10
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ETIOLOGY HTN
• “essential” > 90 %
• Genetics, environment
• African descent and elderly have low renin;
more sensitive to salt and volume
• non-African/young pts. have high renin
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ESSENTIAL HYPERTENSION
• Most common HBP( > 90 %)--multifactorial
• increased peripheral resistance perpetuates the process of
high blood pressure and all of its secondary effects
• structural hypertrophy giving rise to smooth muscle
hypercontractility
• pressure varies throughout the day
• major risk factor for coronary, renal, and cerebrovascular
disease (50% of all USA deaths)
• leading cause of doctor’s visit
• carries prognostic value: 16X increased risk 40 y.o.
smokes
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TARGET ORGAN DAMAGE
Left Ventricular Hypertrophy
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End result of hypertensive heart disease
structural adaptation to pressure overload
initially adaptive and later pathologic
mass >100-130 g/m2
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TARGET ORGAN DAMAGE
LEFT VENTRICULAR HYPERTROPHY
• Eccentric: isotonic exercise, increased volume load
mass/volume ratio low
• Concentric: isometric exercise, increased pressure load
mass/volume ratio high
• degree does not correlate with blood pressure
• Prognostic value:
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sudden cardiac death, ischemia/decreased coronary flow, CHF,
increased vascular tone
• Who?
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Increases with age
2-3 more times likely in obese
athletes
African descent higher LV mass response
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TARGET ORGAN DAMAGE
LEFT VENTRICULAR DYSFUNCTION
• Diastolic dysfunction
– reduced rate rapid early filling/incr.atrial portion
– correlates with degree of LVH
– CHF
• Systolic dysfunction
– less common as BP tighter controlled
– myofibril degeneration/lysis
– occurs late
– CHF: will predispose to other causes(CAD, valve)
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TARGET ORGAN DAMAGE
CORONARY ARTERY DISEASE
• HTN accelerates progression of CAD
• increased oxygen demand
• increased silent MI/sudden cardiac
death/infarct size(33%)
• ischemia caused by diastolic dysfunction
• oxygen demand is different than for
epicardial occlusion
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TARGET ORGAN DAMAGE
RENAL DISEASE
• Increased intraglomerular hypertension
• loss of concentrating ability
– nocturia
– reduced creatinine clearance
– albuminuria
• salt and water retention
• HTN is the leading cause of ESRD
• nephrosclerosis
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TARGET ORGAN DAMAGE
CEREBRO/PERIPHERAL VASCULAR
DISEASE
• major risk factor for CVA/TIA
• similar physiology
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DETECTION OF HYPERTENSIVE
HEART DISEASE
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PHYSICAL EXAM
ELECTROCARDIOGRAM
2-D ECHOCARDIOGRAM
STRESS TESTING
LAB TESTING
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PHYSICAL EXAM
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Forceful sustained apical impulse early
S4 gallop early
S3 gallop later
LV dilation: laterally displaced apical
impulse
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BP MEASUREMENT
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Patient seated/back supported/feet on floor
Should rest 5 minutes prior
Arm at heart level
No recent caffeine, tobacco, cocaine
Take medications as directed
Cuff size important
orthostatics
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ELECTROCARDIOGRAM
• All patients should have as baseline
• no LVH on ECG does not mean no LVH in
vivo
• the presence of LVH suggests target end
organ damage…….poorer prognosis
• Left atrial enlargement?
• Conduction abnormalities
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2D ECHOCARDIOGRAM
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Wall thickness
chamber size
systolic and diastolic function
valve pathology
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2-D Echo (Parasternal Long
Axis)
• The parasternal long axis view
is obtained from the left sternal
border.
RV
LV Apex
• Displayed in this view:
IVS
LV
RV
Aortic Valve
IVS
LV
Mitral Valve
Left Atrium
Aortic Valve (AV)
Mitral Valve (MV)
Left Atrium (LA)
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Motion Mode (M-Mode)
•In M-Mode, the
motion of all cardiac
structures along the
sample line is displayed
over time (left to right)
•Systole and Diastole
are evident by the
decrease in LV cavity
size.
•The motion of the IVS
and LV Posterior wall
are synchronous in
contraction.
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DIASTOLIC DYSFUNCTION
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DIASTOLIC DYSFUNCTION
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DIASTOLIC DYSFUNCTION
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DIASTOLIC DYSFUNCTION
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STRESS TESTING
• Detects patients at increased risk
• silent ischemia/subclinical CAD
• hypertensive response portends poor
prognosis
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LAB TESTING
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Urine analysis
Chemistry panel
Cholesterol
CBC
Endocrine
Drug screen?
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GOALS AT FIRST EVAL.
• Diagnose secondary or remediable causes
• Uncover target organ damage
• Identify coexisting risk factors that could
affect treatment plans
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TREATMENT OF HYPERTENSION
• Prevent development/progression of LVH
• JNC-7: 120/80 optimal
• reduction of target organ damage: brain,
heart, kidney, eyes
• pharmacologic
• Lifestyle modifications
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LIFESTYLE MODIFICATION
Weight reduction Maintain BMI
18.5-24.9kg/m²
DASH diet
Fruits, veggies,
low fats
Sodium restrict 2.4 g
sodium/day
Physical activity Aerobic
30min/day
Alcohol
1 oz.Etoh
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5-10 mm Hg /
10 kg loss
8-14 mm Hg
2-8 mm Hg
4-9 mm Hg
2-4 mm Hg
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PHARMACOLOGIC TREATMENT OF
HYPERTENSION
• inhibitors of the renin-angiotensin system a must in
diabetic, renal, or CAD patients
• identify co-morbidities (slide 19)
• ACE inhibitors/A-II blockers
• Calcium channel blockers
• Beta blockers
• diuretics
• alpha blockers
• central agents
• vasodilators
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PHARMACOLOGIC TREATMENT
• Heart failure: ACEi, A-II, diuretics, B-blockers
• Diabetes: ACEi, A-II
• CAD/post-MI: B-blockers, ACEi, +/- calcium
blocker
• Systolic HTN: ACEi/A-II with diuretic, Bblocker, calcium blocker
• Pregnancy: labetalol, methydopa, calcium blocker
• Prostate enlargement: alpha blocker
• Renal disease: ACEi or A-II blocker
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SJHG Heartbeat “Update on Hypertension”; July/Aug ‘02
Mario Maiese,DO,FACC,FACOI
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ACCOMPLISH: A Novel
Hypertension Trial
• Traditional approach to hypertension management:
– Initiate monotherapy then sequentially add
medications to achieve target BP
• ACCOMPLISH:
– Initiate single tablet combination therapy in highrisk hypertension
– Specific combinations may confer target organ
protection in addition to their BP-lowering effects
ACCOMPLISH Organizational Structure
DSMB
Executive Committee
Henry R. Black, Chair
Lloyd Fisher, Ph.D., Statistician
Suzanne Oparil, M.D., Member
Stevo Julius, M.D., Sc.D., Member
Lars H. Lindholm, Member
Operations Committee
Kenneth Jamerson, Chair
George L. Bakris
Björn Dahlöf
Bertram Pitt
Eric Velazquez
Michael A. Weber
Kenneth Jamerson
Eric Velazquez
Victor Shi, Novartis
Jitendra Gupte, Novartis
Novartis
Trial Team
Steering
Committee
Sverre Kjeldsen
Jan Östergren
Jaakko Tuomilehto
Hans Ibsen
William C. Cushman
Richard Devereux
Brent Egan
Barry M. Massie
Shawna D. Nesbitt
Elizabeth Ofili
Vasilios Papademetriou
Matthew R. Weir
Jackson T. Wright, Jr.
Independent
Statistician
Endpoint
Committee
Tom Greene
Marc A. Pfeffer
Scott D. Solomon
Kenneth Mahaffey
Endpoint
Coordinating
Center
Duke Clinical
Research
Institute/
Brigham and
Women’s
Hospital
Investigational Sites
Central
Clinical
Labs
Novartis
Vendors
Primary Endpoint and Components
Incidence of adjudicated primary endpoints, based upon cut-off analysis date 3/24/2008
(Intent-to-treat population)
Risk Ratio
(95%)
Composite CV mortality/morbidity
0.80 (0.72–0.90)
Cardiovascular mortality
0.81 (0.62-1.06)
Non-fatal MI
0.81 (0.63-1.05)
Non-fatal stroke
0.87 (0.67-1.13)
Hospitalization for unstable angina
0.74 (0.49-1.11)
Coronary revascularization procedure
0.85 (0.74-0.99)
Resuscitated sudden death
1.75 (0.73-4.17)
0.5
INTERIM RESULTS Mar 08
Favors
CCB / ACEI
1.0
2.0
Favors
ACEI / HCTZ
Conclusions
ACCOMPLISH achieved exceptional BP control
with combination therapy providing a new option for
cardiovascular risk reduction to millions of patients
with hypertension.
The results of ACCOMPLISH provide compelling
evidence for initial combination therapy with ACEI /
CCB and challenge current diuretic-based
guidelines.
10 KEY POINTS
• “white coat” HTN contributes to vascular risk
• BMI may be the strongest predictor of pre-HTN (SBP 120139 and/or DBP 80-89) with 10-15% per 1 kg/m2
• Pre-HTN carries increased CV risk
• Arterial stiffness independent risk marker for target organ
damage, cognition, CV and renal events
• When SBP > 220 and/or DBP > 120, 15-20% reduction
first day
• Excess EtOH, OSAS/sleep deprivation, salt all contribute
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JACC; 51: 1803-1817
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REVIEW POINTS
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Familiarity with target end-organ damage
What is ideal BP?
Causes of secondary hypertension
Ideal agents for condition(s)
Familiarity with treatment options
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