Transcript Hypertension

The 7th Report of JNC
on Hypertension
Dr. Mohammed Othman Al-Rukban, ABFM,SBFM.
Assistant Professor
Department of Family And Community Medicine
Contents
 Methodology
 Classification
 CVD
risk
 Benefits of lowering BP
 BP control rates
 Measurements of BP
 Patients evaluation
 Treatments
 Special considerations
 Improving Hypertension control
 Public health challenges &
Community programs
Methodology
I.
II.
III.
IV.
Publication of many hypertension
observational studies and clinical trials.
Need for a new, clear, and concise
guideline that would be useful for
clinicians.
Need to simplify the classification of blood
pressure.
Clear recognition that the JNC reports
were not being used to their maximum
benefit.
Dr. Mohammed Al Rukban
Methodology


NHLBI
NHBPEP CC
–46 Professional, Voluntary, and Federal
Organizations
–Biannual meetings
–Dr. Aram Chobanian
–5 months work
Medline
searches
English Language
Jan1997—April 2003
>80 Papers
Revised by 33 Hypertension leaders
Dr. Mohammed Al Rukban
Classification
Bp
classification
Normal
Prehypertention
Stage1
Hypertension
Stage 2
Hypertension
Dr. Mohammed Al Rukban
SBP
mmHg
DBP
mmHg
<120
And
<80
120-139
Or
80-89
140-159
Or
90-99
>160
Or
>100
Classification
Bp
classification
SBP
mmHg
DBP
mmHg
Lifestyle
Modifi
-cation
Normal
<120
And
<80
Encourage
Prehypertention
120139
Or
80-89
Yes
Stage1
Hypertension
140159
Or
90-99
Yes
Stage 2
Hypertension
>160
Or
>100
Dr. Mohammed Al Rukban
Yes
Initial Drug Therapy
Without
Compelling
Indication
With
compelling
Indications
No
antihypertensive
drug indicated
Drugs for
compelling
indications
Thiazide-type
diuretics for most.
may consider
ACEI, ARB, CCB,
or combination
Drug(s) for
the
compelling
indications.
other
antihyperte
nsive drugs
(diuretics,
ACEI, ARB,
BB, CCB) as
needed.
Two-drug
combination for
most (usually
thiazide-type
diuretic and ACEI
or ARB or BB or
CCB)
CVD risk
@ In persons older than 50 years, Systolic
blood pressure greater than 140 mmHg is a
much more important cardiovascular disease
(CVD) risk factor than diastolic blood pressure
@ The risk of CVD beginning at 115/75 mmHg
doubles with each increment of 20/10 mmHg
Dr. Mohammed Al Rukban
BENEFITS OF LOWERING BP
# In clinical trials, antihypertensive therapy
has been associated with reductions in
incidence of:
– Stroke (35-40%)
– Myocardial infarction (20-25%)
– Heart failure (>50%)
# In patients with stage 1 hypertension
and additional cardiovascular risk factors,
achieving a sustained 12mmHg reduction
in SBP over 10 years will prevent 1 death
for every 11 patients treated.
# In the presence of CVD or target organ
damage, only 9 patients would require
such BP reduction to prevent a death.
Dr. Mohammed Al Rukban
BLOOD PRESSURE CONTROL RATES
National Health and Nutrition Examination
Survey, percent
II
(1976-80)
III
III
PHASE 1
phase 2
(1988-91) (1991-94) 1999-2000
Awareness
51
73
68
70
Treatment
31
55
54
59
Control
10
29
27
34
Dr. Mohammed Al Rukban
Measurements of BP
ACCURATE BLOOD PRESSURE
MEASUREMENT IN THE OFFICE

(Clinicians should provide to patients,
verbally and in writing, their specific BP
numbers and BP goals)
AMBULATORY BLOOD PRESSURE
MONITORING

SELF-MEASUREMENT OF BLOOD
PRESSURE

Dr. Mohammed Al Rukban
PATIENT EVALUATION
OBJECTIVES:
1. To access lifestyle
2. Identify other cardiovascular risk
factors or concomitant disorders
that may affect prognosis and
guide treatment
3. To reveal identifiable causes of
high BP
4. To assess the presence or absence
of target organ damage and CVD.
Dr. Mohammed Al Rukban
PATIENT EVALUATION
1.
2.
Medical history
Physical examination
- Appropriate measurement of BP
- Auscultation for carotid, abdominal,
and femoral bruits
- Palpation of the thyroid gland
- Examination of the abdomen for
enlarged kidneys, masses, and
abnormal aortic pulsation
- Palpation of the lower extremities
for edema and pulses
- Neurological assessment
Dr. Mohammed Al Rukban
PATIENT EVALUATION
3- LABORATORY TESTS AND OTHER
DIAGNOSTIC PROCEDURES
Electrocardiogram
 Urinalysis
 Blood glucose and hematocrit
 Serum potassium, creatinine & calcium
 Lipid profile
 Optional tests include; measurement of
urinary albumin excretion
or albumin/creatinine ratio.

Dr. Mohammed Al Rukban
TREATMENT
Goals of therapy
@ Reduction of cardiovascular and renal morbidity
and mortality.
@ Treating SBP and DBP to targets that are <140/90
mmHg
@ In patients with Hypertension and diabetes or renal
disease, the BP goal is < 130/80 mmHg.
Dr. Mohammed Al Rukban
Lifestyle Modification
Modification Recommendation
Approximate
SBP Reduction
(RANGE)
Weight
Reduction
Maintain normal body
weight (body mass
index 18.5-24.9 ).
5-20 mmHg/10 kg
weight loss
Adopt DASH
eating plan
Consume a diet rich in
fruits,vegetables, and
low fat diary products
with a reduced content
of saturated and total
fat.
8-14 mmHg
Dietary
sodium
reduction
Reduce dietary sodium
intake to no more than
100 mmol per day (2.4
g sodium or 6 g sodium
chloride).
2-8 mmHg
Dr. Mohammed Al Rukban
Lifestyle Modification
Physical
Activity
Engage in regular
aerobic physical
activity such as
brisk walking (at
least 30 min per
day, most days of
the week
4-9 mmHg
Moderation of
Alcohol
consumption
Limit consumption
to no more than 2
drinks (1 oz or 30
mL ethanol; e.g 24
oz beer, 10 oz wine
or 3 oz 80- proof
whisky) per day in
women and lighter
2-4 mmHg
weight persons.
Dr. Mohammed Al Rukban
Pharmacological Treatment
Class
Drug (Trade Name)
Thiazide
diuretics
Chlorothiazed (Diuril)
Chlorthalidone (generic)
Hydroclorothiazide
(Microzide, Hydro DIURIL)
Polythiazide (Renese)
Indapamide (Lozol)
Metalozol (Mykrox)
Metalazone (zaroxolyn)
125-500
12.5-25
12.5-50
Bumetanide (bumex)
Furosemide (Lasix)
Torsemide (Demadex)
0.5-2
20-80
2.5-10
Loop diuretics
PotassiumAmiloride (Midamor)
sparing diuretics Triamtrene (Dyrenium)
Aldosterone
receptor
blockers
Usual Dose Range
in MG/ DAY
2-4
1.25-2.5
0.5-1.0
2.5-5
5-10
50-100
Eplernone ( Inspra)
50-100
Spironolactone (Aldactone) 25-50
Dr. Mohammed Al Rukban
Pharmacological Treatment
Beta-Blockers
Beta-Blockers with
intrinsic
sypathomimetic
activity
Combined Alpha–
and beta-blockers
Dr. Mohammed Al Rukban
Atenolol (Tenormin)
Betaxolol (Kerlone)
Bisoprolol (zebeta)
Metoprolol (lopressor)
Metoprolol extended
release (Toprol XL)
Nadolol (Corgard)
Propranolol (Inderal)
Propranolol longacting (Inderal LA)
Timolol (Blocadren)
25-100
5-20
2.5-10
50-100
Acebutolol (Sectral)
Penbutolol (Levatol)
Pindolol (generic)
200-800
10-40
10-40
50-100
40-120
40-160
60-180
20-40
Carvedilol (Coreg)
12.5-50
Labetalol (Normodyne) 200-800
Pharmacological Treatment
ACE Inhibitors
Benazepril (Lotensin)
captopril (capoten)
Enalapril (vasotec)
Fosinopril (monopril)
Lisinopril (prinivil, zestril)
Moexipril (Univasc)
Perindopril (Accupril)
Quinapril (Accupril)
Ramipril (Altace)
Trandolapril(Mavik)
10-40
25-100
2.5-40
10-40
10-40
7.5-30
4-8
10-40
2.5-20
1-4
Angiotensin II
Antagonists
Candesartan (Atacand)
Eprosartan (Teveltan)
Irbesartan (Avapro)
Losartan (Cozaar)
Olmesartan (Benicar)
Telmisartan (Micardis)
Valsartan (Diovan)
8-32
400-800
150-300
25-100
20-40
20-80
80-320
Dr. Mohammed Al Rukban
Pharmacological Treatment
Calcium channel
blockers- non
Dihydropyridines
Calcium Channel
Blockers Dihydropyridines
Diltiazem extended release
(cardizem CD, Dilacor XR, Tiazac)
Diltiazem extended release
(Cardizem LA)
Verapamil immediate release
(calan, isoptin)
Verapamil long acting (calan SR,
Isoptin SR)
Verapamil – Coer (Covera HS,
Verelan PM)
Amlodipine ( Norvasc )
Felodipine (plendil)
Isradipine (Dynaciric CR)
Nicardipine sustained release
(Cardene SR)
Nifedipine long-acting (Adalat CC,
procardia XL)
Nisoldipine (Sular)
Dr. Mohammed Al Rukban
180-420
120-540
80-320
120-360
120-360
2.5-10
2.5-20
2.5-10
60-120
30-60
10-40
Pharmacological Treatment
Alpha- Blockers
Doxazosin ( Cardura)
Prazosin (minipress)
Terazosin (Hytrin)
1-16
2-20
1-20
Central alphaagonists and
other centrally
acting drugs
Clonidine (Catapres)
Clonidine patch
(catapres-TTS)
Methyldopa (Aldomet)
Resrpine (generic)
Guanfacine (generic)
0.1-0.8
Hydralazine (Apresoline)
Minoxidil (Loniten)
25-100
2.5-80
Direct
Vasodilators
Dr. Mohammed Al Rukban
0.1-0.3
250-1000
0.05-0.25
0.5-2
Algorithm for treatment of hypertension
LIFESTYLE MODIFICATION
Not at Goal Blood Pressure (<140/90 mmHg)
(<130/80 mmHg for patients with diabetes or chronic kidney disease)
INITIAL DRUG CHOICES
Without Compelling Indications
Stage1
Hypertension
Thiazide –type
diuretics for most.
May consider
ACEI,ARB,BB,CCB,
Or combination
Dr. Mohammed Al Rukban
With Compelling Indications
Stage2
Hypertension
Two drug combination
for most (usually
thiazide type diuretic
and ACEI, or ARB or
BB,or CCB)
Drug(s) for the
compelling indications
Other antihypertensive
drugs (diuretics, ACEI,
ARB, BB, CCB) as
needed.
NOT AT GOAL BLOOD PRESSURE
Optimize dosages or add additional drugs until goal
blood pressure is achieved.
Consider consultation with hypertension specialist.
Dr. Mohammed Al Rukban
SPECIAL CONSIDERATION
Compelling
Indication
Heart failure
RECOMMENDED DRUGS
Diuretic
BB
ACEI
-
-
-
-
-
Post
myocardial
infarction
ARB CCB
-
High
coronary
disease risk
-
-
-
Diabetes
-
-
-
-
-
-
Chronic
Kidney
Disease
Recurrent
stroke
Prevention
-
-
ALDO
ANT
CLINICAL TRIAL
BASIS
-
ACC/AHA heart failure
guideline MERIT HF,
COPERNICUS,
CIBIS,SOLVD, AIRE,
TRACE, VALHEFT,RALES
-
ACC/AHA POST MI
GUIDELINE,BHAT,SAVE
Capricom, EPHISUS
-
ALLHAT,HOPE,ANBP2,
LIFE,CONVINCE
-
NKF-ADA guideline,
UKPDS,ALLHAT
NKF Guild line Captoprill
Trial RENAAL
IDNT,REIN,AASK
PROGRESS
OTHER SPECIAL SITUATION
• Minorities
• Obesity and the metabolic syndrome
• Left Ventricular hypertrophy
• Peripheral arterial disease
• Hypertension in older persons
• Postural hypotension
• Dementia
• Hypertension in Women
• Hypertension in children and adolescents
• Hypertensive urgencies and emergencies
Dr. Mohammed Al Rukban
Antihypertensive Drugs
Potential Favorable effects
• Thiazide-Type diuretics are useful in slowing
demineralization in Osteoporosis.
•BBs useful in the treatment of arterial
tachyarrhythmias/fibrillation, Migraine, thyrotoxicosis,
essential tremor, or preoperative hypertension.
•CCBs may be useful in Raynaud’s syndrome and certain
arrhythmias
• alpha-blockers may be useful in prostatism.
Dr. Mohammed Al Rukban
Antihypertensive Drugs
POTENTIAL UNFAVOURABLE EFFECTS
•Thiazide diuretics should be used cautiously in patients who
have gout or who have a history of significant hyponatremia.
• BBs should generally be avoided in individuals who have
asthma, reactive airways diseases, or heart block.
• ACEIs and ARBs Should not be given to women likely to
become pregnant and contraindicated in those who are.
•ACEIs should not be used in individuals with a history of
angioedema.
•Aldosterone antagonists and potassium-sparing diuretics can
cause hyperkalemia and should generally be avoided
In patients who have serum potassium values more than
5.0 mEq/L while not taking medications.
Dr. Mohammed Al Rukban
Improving Hypertension
control
Public health challenges &
Community programs
In persons older than 50 years, Systolic
blood pressure greater than 140 mmHg is a
much more important cardiovascular
disease (CVD) risk factor than diastolic
blood pressure
Dr. Mohammed Al Rukban
The risk of CVD beginning at 115/75
mmHg doubles with each increment of
20/10 mmHg.
Dr. Mohammed Al Rukban
Individuals who are normotensive at age
55 have a 90 percent lifetime risk for
developing hypertension
Dr. Mohammed Al Rukban
Individuals with a systolic blood pressure of
120-139 mmHg or a diastolic blood pressure
of 80-89 mmHg should be considered as
prehypertensive and require health-promoting
lifestyle modifications to prevent CVD.
Dr. Mohammed Al Rukban
Thiazide -type diuretics should be used in
drug treatment for most patients with
uncomplicated hypertension, either alone
or combined with drug from other classes.
Dr. Mohammed Al Rukban
Certain high-risk conditions are compelling
indications for the initial use of other
antihypertensive drug classes (angiotension
converting enzyme inhibitors, angiotension
receptor blockers, beta-blockers, calcium
channel blockers).
Dr. Mohammed Al Rukban
Most patients with hypertension will
require two or more antihypertensive
medications to achieve goal blood pressure
pressure (<140/90 mmHg,or <130/80
mmHg for patients with diabetes or
chronic kidney disease).
Dr. Mohammed Al Rukban
If blood pressure is >20/10 mmHg above
goal blood pressure, consideration should
be given to initiating therapy with two
agents, one of which usually should be a
thiazide-type diuretic.
Dr. Mohammed Al Rukban
The most effective therapy prescribed by the
most careful clinician will control
hypertension only if patients are motivated.
Motivation improves when patients have
positive experiences with, and trust in, the
clinician. Empathy builds trust and is a
potent motivator
Dr. Mohammed Al Rukban