Transcript Hypertension

Joshua M. Crasner,DO,FACC,FACOI
50 million people USA
 SBP>115 incr risk CAD/CVA
 Q 20mm incr=2X risk
 JNC-8 has changed aggressive Tx
 Pseudo-HTN
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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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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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Determine lifestyle/CV risk factors
 ID and Tx secondary causes
 ID target end organ damage
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brain, heart, kidney, eyes, arteries
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Cigarette smoking
 Obesity
 Inactivity
 Dyslipidemia
 Diabetes mellitus
 Microalbuminuria
 Male>55; Female>65
 Fam Hx: male<55; female<65
 Metabolic syndrome
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Endocrine
 Cardiac
 Renal
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Pheochromocytoma
 Primary Aldosteronism
 Cushing’s disease
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5 P’s: pressure,pain,palps,perspiration,pallor
Adrenal tumor or sympth ganglia
2-8 cases/million/year
0.5% in hypertensive patients
Usually sustained HBP,sometimes paroxysmal
Associated with MEN-2 a/b
Plasma metanephrines most sensitive
CT after plasma, then surgery
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Adrenal oversecretion
 Hypertension,hypokalemia,alkalosis,hyperglycemia
 2-15% incidence
 Screen w/aldo-renin ratio
 Unusual hypokalemia,adrenal mass, early HTN,
primary relative w/same
 Tx w/spironolactone,eplerenone,surgery
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Hyperglycemia, hypokalemia,HTN
 24hr cortisol
 Obese, moon facies, purple striae
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Coarctation
 Obstructive sleep apnea
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Constriction beyond subclavian
 Weak,delayed,absent FA pulse
 Rib notching on CXR
 Childhood
 Tx surgical
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Obese, retrognathia,large neck
 Loud snoring
 Daytime hypersomnolence, morning
headache
 Polysomnography test
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Renal parenchymal disease
 Renovascular HTN
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 Renal artery stenosis
 Fibromuscular dysplasia
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Common cause secondary HTN
 Rapid loss renal fxn if HTN-ive
 Creat,urine analysis,protein
 Decr elimination of salt and water,incr
renin, decr vasodilation all lead to incr
volume/fluid retention
 Dihydropyridine CCB help decr
proteinuria
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Atherosclerotic, e.g.CAD
White female<30
Smokers>50, new HTN
No family Hx HTN
Systolic/diastolic high
PTA treatment of choice
pitched abd bruit
Suspect B/L if decr renal fxn
w/ use of ACEi/ARB
PTA but higher restenosis
Rx
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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,narc
w/d
Hypokalemia: hyperaldosteronism
Hypercalcemia: hyperparathyroidism
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Simple Guide to work up secondary causes of HTN
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Alpha methyldopa first DOC
 Hydralazine,some BB ok, diuretics
 Avoid ACEi/ARB/renin inhibitors
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BCPs
EtOH
Decongestants,diet pills
NSAIDs
MOA
Cocaine
Marijuana
Licorice
cyclosporine
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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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1. In the general population aged ≥60 years, initiate pharmacologic treatment to lower blood pressure (BP) at systolic blood pressure (SBP) ≥150 mm Hg or
diastolic blood pressure (DBP) ≥90 mm Hg and treat to a goal SBP <150 mm Hg and goal DBP <90 mm Hg. (Strong Recommendation – Grade A) In the
general population aged ≥60 years, if pharmacologic treatment for high BP results in lower achieved SBP (e.g., <140 mm Hg) and treatment is well tolerated
and without adverse effects on health or quality of life, treatment does not need to be adjusted. (Expert Opinion – Grade E)
2. In the general population <60 years, initiate pharmacologic treatment to lower BP at DBP ≥90 mm Hg and treat to a goal DBP <90 mm Hg. (For ages 3059 years, Strong Recommendation – Grade A; for ages 18-29 years, Expert Opinion – Grade E)
3. In the general population <60 years, initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg and treat to a goal SBP <140 mm Hg. (Expert
Opinion – Grade E)
4. In the population aged ≥18 years with chronic kidney disease (CKD), initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg
and treat to goal SBP <140 mm Hg and goal DBP <90 mm Hg. (Expert Opinion – Grade E)
5. In the population aged ≥18 years with diabetes, initiate pharmacological treatment to lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg and treat to a goal
SBP <140 mm Hg and goal DBP <90 mm Hg. (Expert Opinion – Grade E)
6. In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, calcium channel
blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin-receptor blocker (ARB). (Moderate Recommendation – Grade B)
7. In the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or CCB. (For general
black population: Moderate Recommendation – Grade B; for black patients with diabetes: Weak Recommendation – Grade C)
8. In the population aged ≥18 years with CKD, initial (or add-on) antihypertensive treatment should include an ACEI or ARB to improve kidney outcomes. This
applies to all CKD patients with hypertension regardless of race or diabetes status. (Moderate Recommendation – Grade B)
9. The main objective of hypertension treatment is to attain and maintain goal BP. If goal BP is not reached within a month of treatment, increase the dose of
the initial drug or add a second drug from one of the classes in recommendation 6 (thiazide-type diuretic, CCB, ACEI, or ARB). The clinician should continue to
assess BP and adjust the treatment regimen until goal BP is reached. If goal BP cannot be reached with two drugs, add and titrate a third drug from the list
provided. Do not use an ACEI and an ARB together in the same patient. If goal BP cannot be reached using only the drugs in recommendation 6 because of a
contraindication or the need to use more than three drugs to reach goal BP, antihypertensive drugs from other classes can be used. Referral to a hypertension
specialist may be indicated for patients in whom goal BP cannot be attained using the above strategy or for the management of complicated patients for whom
additional clinical consultation is needed. (Expert Opinion – Grade E)
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10. Although this guideline provides evidence-based recommendations for the management of high BP and should meet the clinical needs of most patients,
these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics
and circumstances of each individual patient. Future guidelines should cover the full range of cardiovascular care topics, to develop an integrated approach for
prevention, detection, and evaluation, along with treatment goals. Individual recommendations from discrete guidelines—such as for hypertension, cholesterol,
and obesity—may not reflect the integrated care needed for many patients seen in practice. There is also a need to harmonize the hypertension guideline with
other cardiovascular risk guidelines and recommendations, thereby resulting in a more coherent overall cardiovascular prevention strategy. Author(s):
Debabrata Mukherjee, M.D., F.A.C.C. (Disclosure
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Patient Subgroup
Target SBP
Target DBP
> 60 years
<150
<90
<60 years
<140
<90
>18 years w CKD
<140
<90
>18 years w DM
<140
<90
James PA, et al.,JAMA,2013 Dec18
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General non-African population
 Thiazides, CCB,ACEi,or ARB initially
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General African population
 Thiazides or CCB initially
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CKD
 Include ACEi or ARB
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Uptitrate/add RX after 1mo.if not at goal
 Don’t use ACEi and ARB jointly
 If >3 Rx needed refer to specialist
James PA, et al.,JAMA, 2013 Dec 18
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ANSWER??
 FOLLOW THE AHA/ACC BP guidelines
 Start lifestyle changes and then Rx at 140/90 up to
age 80, then at 150/90
 Position paper of JACC July 2014 refutes, citing
placement of mostly elderly African-American
women at incr. risk for CVD mortality**
**Krakoff, et al; JACC, July 29,2014;394-402
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Urine analysis
 Chemistry panel
 Cholesterol
 CBC
 Endocrine
 Drug screen
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Heart failure: ACEi, ARB, diuretics, BB
Diabetes: ACEi, ARB
CAD/post-MI: BB, ACEi,(CCB for intol.)
Systolic HTN: ACEi/ARB with diuretic, BB,
CCB
Pregnancy: labetalol, methyldopa, CCB
Prostate enlargement: alpha blocker
Renal disease: ACEi or ARB
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<140/90
 Diabetics/CKD/High risk CAD <130/80
 Reduced EF; proteinuria <120/80
 Stay tuned for AHA/ACC update 2015
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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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