Treatment of Hypertension

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V nice ! Will u send me a copy pl ? -Dr Desai Mumbai, India

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Slide 1 :

Treatment of Hypertension Jai Radhakrishnan, M.D. Division of Nephrology Based on the Seventh Report of the Joint National Committee on Prevention, Detection ,Evaluation and Treatment of High Blood Pressure (JNC-7)

Slide 2 :

Objectives Define hypertension Principles of treatment Special groups

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Slide 4 :

Blood Pressure Classification

Slide 5 :

Why Treat Hypertension ? To decrease: Cerebrovascular Accidents 35-40% Coronary events 20-25% Heart failure 50% Progression of renal disease Progression to severe hypertension All cause mortality

Slide 6 :

Awareness, Treatment and Control of Blood Pressure 1976-2000 (NHANES)

Slide 7 :

Factors to Consider in Treating Hypertension Repeat readings r/o secondary causes Estimate CV risk status Co-morbid conditions Lifestyle changes Drugs

Slide 8 :

“Secondary” Hypertension Difficult to control Sudden onset of HTN Well controlled-> difficult to control Severe hypertension History/physical/labs

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Initial Workup of Secondary HTN Renal parenchymal disease UA, spot urine protein/creatinine, serum creatinine, USG. Renovascular Captopril scan Coarctation Lower Extremity BP Primary aldosteronism Serum and urinary K Plasma renin and aldosterone ratio Pheochromocytoma Spot urine for metanephrine/creatinine

Slide 10 :

Laboratory Tests in Uncomplicated HTN ECG Urine analysis Blood glucose, hematocrit Basic metabolic panel Lipid profile after 9-12 hour fast Urine microalbumin

Slide 11 :

Estimate Risk Status Hypertension Smoking Obesity (BMI > 30kg/m2) Dyslipidemia Diabetes Microalbuminuria or GFR <60ml/min Age > 55 (men), 65 (women) Family history of CVD (Men< 55, Women <65) Metabolic Syndrome

Slide 12 :

Target Organ Damage Heart Disease CAD (Angina, myocardial infarction, coronary revascularization Left Ventricular Hypertrophy Heart Failure Stroke/TIA Chronic kidney disease Peripheral arterial disease Retinopathy

Slide 13 :

Goals of Therapy BP <140/90 mmHg BP <130/80 mmHg in patients with diabetes or chronic kidney disease. Achieve SBP goal especially in persons >50 years of age.

Slide 14 :

Lifestyle Modification

Slide 15 :

Drugs for Hypertension Diuretics Thiazide Loop diuretics Aldosterone antagonists K-sparing Adrenergic inhibitors Peripheral agents Central (a-agonists) alpha -blockers* beta-blockers Alpha+beta-blockers Direct Vasodilators * Calcium channel blockers Dihydropyridine Non dihydropyridine ACE-inhibitors Angiotensin-II blockers * Usually not monotherapy

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Slide 18 :

Classification and Management of BP for adults *Treatment determined by highest BP category. †Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension. ‡Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.

Slide 19 :

Heterogeneity of “Essential” Hypertension

Slide 20 :

Special Considerations Compelling Indications Special populations

Slide 21 :

HTN with COPD and MI A 55 year old patient with COPD and HTN (controlled with nifedipine) is admitted with severe chest pain x24 hrs. BP is 170/100 and she has a soft S3 gallop. ECG shows an anterior wall MI. She is not a candidate for thrombolysis. ECHO shows an ejection fraction of 35%. How will you manage her hypertension?

Slide 22 :

Compelling Indications for Certain Drug Classes

Slide 23 :

HTN with CAD Beta blockers: cardioprotective (reinfarction, arrhythmias and sudden death) ACE inhibitors: MI with systolic dysfunction- heart failure and mortality improved

Slide 24 :

Renal Insufficiency A 30 year old patient with IDDM is referred with difficult-to-control HTN on diltiazem and clonidine. Exam reveals BP=190/100 and 3+ edema. Labs: Creatinine = 2.2 mg/dL Serum K = 5.1 meq/L 24 hour protein = 5 g

Slide 25 :

Hypertension with Renal Insufficiency Goal BP <130/80 ACE-inhibitors/angiotensin receptor blockers should be used if no contraindications Most patients have volume overload: Diuretics should be included in the regimen. Thiazides ineffective if S Creat>2.5

Slide 26 :

A 40 year old previously healthy male is brought to the E.R. with 3 days of progressive shortness of breath and has experienced blurred vision in both eyes. Physical exam: Blood pressure 230/140. Lethargic. Eye exam: Papilledema Chest: Bibasilar crackles Cardiac: S1S2S4 Neuro: Bilateral upgoing plantars: Extr: 2+ edema Labs: K=3.4, BUN=35, Creatinine: 2.2 CXR: Pulmonary edema Urine: 10-15 red cells, 2+ albumin.

Slide 27 :

Hypertensive Urgencies and Emergencies HYPERTENSIVE EMERGENCIES Require immediate blood pressure reduction (not necessarily to normal range) to prevent or limit target organ damage. HYPERTENSIVE URGENCIES Require reduction of blood pressure within a few hours

Slide 28 :

Emergencies & Urgencies HYPERTENSIVE EMERGENCIES Require immediate blood pressure reduction (not necessarily to normal range) to prevent or limit target organ damage. HYPERTENSIVE URGENCIES Require reduction of blood pressure within a few hours

Slide 29 :

Parenteral Drugs For Treatment of Hypertensive Emergencies VASODILATORS Nitroprusside Fenoldopam Nitroglycerine Enalaprilat Nicardipine Hydralazine ADRENERGIC INHIBITORS Labetalol Esmolol Phentolamine

Slide 30 :

Pregnancy and Hypertension A 24 year old primiparous woman is seen in the obstetric clinic at 30 weeks gestation. BP: 160/100, 2 + pedal edema Otherwise unremarkable physical exam. Urine shows 1000 mg of protein. Other labs: N After 2 days of bed rest BP remains 160-170/100

Slide 31 :

Drug Therapy of the Hypertensive Pregnant Patient Methyldopa: Drug of choice. Beta blockers (not early pregnancy). Hydralazine is the parenteral drug of choice. Most agents if used prior to pregnancy may be continued (except ACE-I OR A-II BLOCKERS)

Slide 32 :

Resistant Hypertension Improper BP measurement Excess sodium intake Inadequate diuretic therapy Medication Inadequate doses Drug actions and interactions (e.g., nonsteroidal anti-inflammatory drugs (NSAIDs), illicit drugs, sympathomimetics, oral contraceptives) Over-the-counter (OTC) drugs and herbal supplements Excess alcohol intake Identifiable causes of HTN

Slide 33 :

Conclusions The initial approach to hypertension should start with ruling out secondary causes, detecting and treating other cardiovascular risk factors, and looking for target organ damage. Treatment should always include lifestyle changes. Medication use should be guided by the severity of HTN and the presence of “compelling” indications. Thiazide-type diuretics should be initial drug therapy for most, either alone or combined with other drug classes. Most patients will require two or more antihypertensive drugs

Slide 34 :

Conclusions HTN is a risk factor for mortality and cardiovascular and renal disease HTN is common but not controlled. Target BP 140/90 (130/80 in DM, CKD) Remember Compelling Indications

Slide 35 :

www.nhlbi.nih.gov/

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