Transcript Hypertension Review Cases

Hypertension Review Cases
By
Mayssa Ibrahim Aly
Professor of Internal Medicine-Cairo University
2009
A 50-year-old black man
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has a blood pressure of 160/110 mm Hg on repeated
measurements.
He is 9 kg overweight,
has a family history of hypertension, and
smokes one pack of cigarettes daily.
Classification according to
BP level
•Normal <120/80
•Pre-hypertension 129/80—139/89
•Hypertension >140/90
Hypertension
 Stage
I
140-159/90-99
 Stage
2
>160/100
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Stage II HTN
The five-year risk of a major
cardiovascular event in a 50-year-old
man with a blood pressure of 160/110
mm Hg is 2.5 to 5.0 percent;
The risk doubles if the man has a
high cholesterol level and triples if
he is also a smoker
The primary goal of the
treatment of hypertension is to
prevent cardiovascular disease
and
death
In stage 1 or 2 hypertension lowering
systolic pressure by 10 to 12 mm Hg
and diastolic pressure by 5 to 6 mm Hg
reduces the risk of
stroke by 40 %,
coronary disease by 16 %, and
death from any cardiovascular cause
by 20 %.
<135/85
Risk Factors
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1. Smoking
2. Dyslipidemia
3. DM
4.>60ys
5. Men& postmenopausal women
6. Obesity
7. FH of CVD:
Men<55ys or Women<65ys
Obesity
BMI
Range
Underweight
Normal
<18.5 Kg/m2
Overweight
Obesity grade I
Obesity grade II
25-29.9
30-34.9
>35
18.5- 24.9
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Patients with stage 1 HTN can be
treated with lifestyle modifications
alone for up to one year, if they have
no other risk factors, or
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for up to six months, if they have
other risk factors.
 Lifestyle modifications and
antihypertensive therapy are indicated for:
 patients with cardiovascular or other
target-organ disease (renal, cardiac,
cerebrovascular, or retinal disease) and
 those with stage 2
Patients with diabetes are at high
risk, and drug therapy is indicated
in such patients even if BP is at the
high end of the normal range
Restriction of sodium intake to 2 g /d
lowers systolic pressure, on average, by
3.7 to 4.8 mm Hg and lowers diastolic
pressure, on average, by 0.9 to 2.5 mm
Hg.
Salt sensitivity is common in elderly
patients with hypertension
• Most antihypertensive drugs
reduce blood pressure by 10 to
15 percent.
• Monotherapy is effective in
about 50 percent of unselected
patients
• Those with stage 2 HTN often
need more than one drug.
• Evaluation for 2ry HTN should
be considered when three or
more antihypertensive drugs of
different classes do not control
blood pressure
Step1
Step2
Step3
Step4
Algorithm
for
Manag.
of HTN
•Diuretics are appropriate as first-line
therapy for patients without coexisting
conditions
•ACE inhibitors or angiotensin-receptor
antagonists are recommended for
patients with type 2 diabetes, kidney
disease, or both and are also useful in
patients with heart failure.
•Beta-blockers and ACE inhibitors are
recommended in patients with prior
myocardial infarction, and
•Calcium-channel antagonists benefit
elderly patients at risk for stroke
Which Stage of HTN?
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The patient should be advised to:
A) lose weight,
B) stop smoking,
C) engage in regular exercise, and
D) modify his diet and
He should be screened for vascular
disease and other cardiovascular risk
factors.
• The increase in dietary salt may
also have contributed to the
growing obesity problem by
causing increased intake of fluids,
particularly of high-calorie soft
drinks
If No coexisting disease was
detected
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Hydrochlorothiazide at a dose of 12.5
mg daily.
If this dose did not control his blood
pressure increase it or add a second
drug
for example, an ACE inhibitor to
prevent the adverse metabolic
effects of higher doses of diuretics
Use of Diuretics in Patients with
Hypertension
 The upstream portion of the distal
convoluted tubule is the major site of
action of the thiazides, where they
interfere with sodium re-absorption.
 Sodium is reabsorbed in the distal tubule
and collecting ducts through an
aldosterone-sensitive sodium channel and
by activation of an ATP-dependent
sodium–potassium pump.
Through both mechanisms, potassium
is secreted into the lumen.
"K+-sparing agents" collectively refers
to the epithelial sodium-channel
inhibitors (e.g., amiloride and
triamterene) and mineralocorticoidreceptor antagonists (e.g.,
spironolactone and eplerenone).
 The onset of action occurs after
approximately 2 to 3 hours for most
thiazides, with little natriuretic effect
beyond 6 hours.
 Most thiazides have a half-life of
approximately 8 to 12 hours, just permitting
effective once-daily dosing
 Initial decreases in blood pressure are
attributed to the reductions in extra-cellular
fluid and plasma volumes, leading to
depressed cardiac preload and output.
 Activation of the sympathetic NS and the
renin–angiotensin–aldosterone system
induces a transient rise in peripheral
vascular resistance but not sufficient to
negate the blood-pressure reduction
Combining a Thiazide with (ACE)
inhibitor or an angiotensin II–
receptor blocker (ARB) can oppose
this transient rise in resistance and
increase the antihypertensive
response.
• Thiazides induce a reduction in
the systolic and diastolic blood
pressures of 10 to 15 mm Hg and
5 to 10 mm Hg, respectively
• Hypertension responding
preferentially to thiazides is
considered to be low-renin or
salt-sensitive hypertension.
• The elderly, blacks, and
patients with characteristics
associated with high cardiac
output (e.g., obesity) tend to
have this type of HTN.
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Hydrochlorothiazide at a dose of 12.5
to 25 mg /d.
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Approximately 50% of patients will
respond initially to these low doses.
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Increasing the dose of hydrochlorothiazide
from 12.5 to 25 mg /d may result in a
response in an additional 20%
(approximately) of patients.
At 50 mg /d, 80 to 90% of patients should
have measurable decreases in blood
pressure.
Increased electrolyte losses at the higher
doses of diuretics may preclude their
routine use
Case II
A 68-year-old man visits
his physician
• He was told a year earlier that his
blood pressure was somewhat
elevated and was advised to reduce
salt intake and increase physical
activity.
• Otherwise no history or signs of
cardiovascular or renal disease.
Examination
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BP is 178/72 mm Hg, with no
clinically significant differences
between arms or on standing.
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Body-mass index is 28.4.
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The examination is otherwise
unremarkable
Obesity
BMI
Range
Underweight
Normal
<18.5 Kg/m2
Overweight
Obesity grade I
Obesity grade II
25-29.9
30-34.9
>35
18.5- 24.9
Investigation
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Urinalysis is normal.
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The non-fasting blood glucose level
is 98 mg /dl .
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Creatinine 1.2 mg /dl.
Isolated Systolic
HTN
 Grade
1
140-145/<80
 Grade
2
>160/<80
Above 115/75
CVD risk doubles
For each
of 20/10
Investigation
 Laboratory
Urinalysis,
 Blood glucose,
 Estimated GFR, and
 Lipoprotein profile
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tests
ECG studies should be
performed to evaluate
cardiovascular risk.
• The recommended target level of
blood pressure is below 140/90 mm
Hg,
• except
• in diabetes or CRF disease, for
whom a lower goal (130/80 mm Hg
or lower) is advised.
Evaluation
Treatment
Not at target BP
Optimize dosage or Add other drug till
Target BP
a cigarette within
the previous 15 to 30
minutes, can cause an
elevation in systolic blood
pressure of 5 to 20 mm Hg.
Smoking
increase
in systolic blood
pressure occur after one cup
of caffeinated coffee is
usually only 1 to 2 mm Hg.
Long-term
smoking or coffee
drinking does not cause
persistently elevated blood
pressure
 In
most older
patients,
elevation of
systolic blood
pressure occurs
because of
reduced elasticity
of conduit
arteries.
Age related changes in BP
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SBP rises linearly with age:
25 mmHg in men and 23 mmHg in
women between 4th and 9th
decades.
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DBP tends to plateau before 60ys
and drops after 60ys.
 Strong
predictor of CV
complications
 Lowering SBP is associated with
significant reduction in :
–CV mortality
–Stroke
–HF
–MI
–Dementia
 The patient described has stage 2
systolic hypertension (160 mm Hg).
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 Non-pharmacologic interventions
should be recommended (can reduce
the number and dosage of bloodpressure medications required).
Therapy : why?
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Greater benefit than in younger
patients.
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Stroke reduced
30%
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CV events
20%
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Dementia
50%
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Morality
13%
Target of therapy in
elderly
DBP < 90mmHg
SBP < 160mmHg
Therapy
Non pharmacology
therapy
1- Life style modification :
elderly respond as
younger patients .
2- Salt restriction : elderly
especially women have
increased sensitivity to
salt.
3- Moderate
exercise.
4- Relaxation
therapy.
Therapy
Pharmacology therapy
Started when
• Hypertension noted in multiple
visits
• Non phamocological therapy have
not lower BP level into desired range
• Evidence of end organ damage
AB-CD Trials
Step1:
Younger A or B
Elderly C or D
Step2:
A or B +C or D
Step3:
A or B+ C +D
Step 4:
Add either a blocker or other
diuretics
A=
B=
C=
D=
ACEI
B blocker
Ca channel blocker
Thiazide diuretics
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Initially treat with a Thiazide-type diuretic.
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If a second or third drug is required,
 Second
drug of choice :
Ca channel blockers.
ARBs and ACEIs are
effective in preventing complications.
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 The choice will depend on
the patient's clinical status
Follow up after start of treatment of
HTN
Low/intermediate
Risk
Every 2Ms
Remains at target level
For 2 consecutive visits
Every 6Ms
High risk
Every 1M
Remains at target level
For 2 consecutive visits
Every 3Ms
 Initial follow-up can be carried out
at approximately monthly intervals
until the target blood pressure of
less than 140/90 mm Hg is
achieved.
 Once the target blood pressure is
achieved, follow-up can occur
every 3 to 6 months.
Serum potassium, Creatinine, and
blood glucose levels should be
measured at least annually.
Low serum potassium levels
should be managed with potassium
supplementation, use of a
potassium-sparing diuretic, or both.
Drugs to be avoided
Centrally acting drugs :
drowsiness
depression
Impaired cognitive function.
Adrenergic antagonists :
postural hypotension.
NSAID :
exacerbate hypertension.
Risk of therapy
Risk of therapy is increased with age.
Drugs
 Hyponatremia & hypokalemia with
diuretics
 Confusion & depression with drugs
affecting CNS as B blocker
 Postural hypotension which may lead to
fall & fracture
Cerebral hypoperfusion if BP is
acutely lowered
Increased glucose intolerance,
Creatinine and uric acid with
Thiazide treatment
Benefit of therapy
 Greater benefit than in younger patients.
 Stroke reduced
30%
 CV events
20%
 Dementia
50%
 Morality
13%
1- start with half standard doses.
2- increase dose gradually over
several weeks.
3- check BP in both supine and
standing position.
4- Adjust dose according to
standing position.
5- Monitor renal function and
electrolyte status.
6- A adverse drug reaction are 23 times more common.
7- Consider co-morbid condition.
When to stop
Withdrawal of antihypertensive drugs
should be done carefully if :
The original level of BP was
mild to moderate
BP of patient has been in good
control for continues period 12
months
Follow up
for life long with or without
medical treatment
A 36-Year-Old Man
was admitted to the hospital
because of seizures and severe
hypertension.
had an 18-year history of
intravenous drug abuse (heroin)
 One year before admission, he
discontinued his use of illicit drugs
Three months before admission,
tingling developed in the left toes
and progressed to numbness in the
foot;
these symptoms were accompanied
by recurrent vomiting, night
sweats, intermittent diarrhea,
abdominal pain, subjective fever,
and a weight loss of 16 kg.
He noted erythematous lumps over
the shins and ankles
Five weeks before admission
HTN was diagnosed.
Tests for HBV and HCV were
+ve.
The initial blood pressure was
240/130 mm Hg.
Lungs and heart were normal on
auscultation.
No peripheral edema was found.
On neurologic examination the
strength was 5/5 except at the left
gastrocnemius 2/5
The tone was normal
All sensation was normal
The deep-tendon reflexes were + in
the arms, ++ at the knees and right
ankle, and absent at the left ankle;
Plantar responses were flexor.
Fundus showed optic-disk
edema.
Investigations
Urine was positive (+++) for protein
and trace-positive for glucose; the
sediment contained 0 to 2 white
cells and no red cells/HPF
Creatinine was 2.5 and rising to
3.5mg/dl.
ECG showed a normal rhythm with
voltage criteria for left ventricular
hypertrophy
ESR was 107mm /hr
Imaging
A chest radiograph was
unremarkable.
An U/S of the abdomen showed that
the gallbladder was distended and
contained gallstones, without
evidence of cholecystitis.
The liver was normal, and the
spleen unremarkable;
the kidneys were unchanged.
What will you do
with our case?
REFER
intensive care unit
for control
of his hypertension.
Hypertensive
Urgencies and
Emergencies
Hypertensive crisis
•BP > 220/120 mmHg + acute TOD
(encephalopathy or cereberal
hemorrhage).
–Emergency, refer to hospital.
–Reduce BP to 160/100 over
several hours
IV diuretics should not be used
as initial therapy in
hypertensive crisis unless
acute pulmonary edema.
Sublingual nifedipine plus IV
loop diuretic should be avoided
it as it may result in organ
hypoperfusion.
A single dose of sublingual captopril
12.5 mg can be used until the patient
transfer to hospital.
BP > 220/120 mmHg but no acute
TOD.
– Urgency, refer to hospital
–Treatment by combination of rapidly
acting oral antihypertensive drugs.
The distinction depends upon
the clinical assessment of
the degree ,
the rate of rise of blood
pressure and
the presence of potential for
end-organ damage
Management of Rapid Severe
HTN
Rapid BP>220/130
Severe S of acute TOD
YES
CAPTOPRIL
SL(½ tab)
NO
Retinal He/exudates/ papilloedema
(malignant HTN)
YES
Refer
Combination of rapid
Acting oral anti-HTN
NO
Start oral anti-HTN
Assessment of end organ damage
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Examination of retina for hypertensive
changes
Examination of peripheral pulses
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Chest x-ray & ECG for signs of LVH
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Kidney function tests
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• This patient had involvement of the NS,
the skin, kidneys, the liver, and the
heart, and
• He also had malignant hypertension, as
evidenced by the headache and opticdisk edema
• ESR was 107mm /hr
• positive tests for hepatitis C & B
virus Ab.
Management
Refer