Background for understanding the Hypertension literature. Jeffrey J. Kaufhold, MD Nephrology

HYPERTENSION SUMMARY Background for understanding the literature of Hypertension Review of Joint National Commission Recommendations (VII) 2003 Clinical Evaluation and Case histories.

Nat’l Health & Nutrition Exam Survey NHANES JNC 7 Dec 2003

Hypertension Literature Summary Malignant Hypertension - 1958 Kincaid-Smith and others DBP > 130 VA Cooperative Studies - 1967 DBP 115-129 mm Hg - 1970 DBP 90 -114 mm Hg

HYPERTENSION Literature Summary US Public Health Service 1977 Prospective placebo controlled trial for DBP 90-115 mm Hg HDFP 1979 Introduced concept of Stepped Care Oslo Study 1980 Treatment of Mild Hypertension Medical Research Clinics (MRC) 1985 Single blind and community based.

HYPERTENSION PARALLEL WORK 1948 to 1972 Framingham Study 20 year follow-up on 5000 pts 1982 MRFIT Randomized primary prevention trial Lower than expected rate of mortality in controls led to NS reduction. 1984 LRC (Lipid Research Clinics) Treatment of hyperlipidemia reduced risk of heart disease, all-cause mortality not effected.

HYPERTENSION Recent Works 1985 HDFP follow-up Study Long term surveillence for drug side effects: 9-25 % 1992 Gurwitz Ann Int Med Antihypertensive therapy and the initiation of Tx for DM. Diabetes and HTN are linked, drugs and diabetes are NOT. 1993 VA Cooperative Study, Materson, NEJM Compares 6 agents. Efficacy in 55 % range. Drug intolerance 6 to 14 %.

Joint National Commission JNC 1 1980 founded on HDFP JNC 2 1984 Intro of ACE, alpha B. JNC 3 1986 Special situations JNC 4 1988 Many agents 1st line JNC 5 1993 Back to stepped care. JNC 6 1997 ACE for Diabetics JNC 7 2003

HYPERTENSION JNC V "Because diuretics and B-Blockers are the only classes of drugs that have been used in long-term controlled trials and shown to reduce morbidity and mortality, they are recommended as first- choice agents unless they are contraindicated or unacceptable, or unless there are special indications for other agents."

HYPERTENSION JNC VII Outline Epidemiology of HTN Evaluation of HTN NON Pharmacologic treatments: Wt loss, diet, exercise, alcohol Drug treatment Special Issues in HTN

Stages of Hypertension Normal Prehypertension Stage 1 Stage 2 < 120 / 80 120 -139 / 80-89 140-159 / 90-99 > 160 / >100

Treatment of Hypertension Single agent – HCTZ for most pts. B-Blocker for females/ high heart rate. Stage 2 I start with DHP CCB (procardia XL) plus one or both of above. Resistant HTN I look for CLASSES of agents

Case Presentation 56 y.o. A.A. male prior weight lifter presents for refractory HTN. Normal labs and UA. Normal CXR and EKG. Meds: Clonidine 0.2 BID ACE inhibitor Diltiazem 300 mg daily

Case Presentation Physical Exam: BP 170 / 110 Pulse 85 Edema 2 +

Case Presentation Special populations help define your approach. African Americans: CHF Diabetics:

Case Presentation Special populations help define your approach. African Americans: Volume Mediated, Low renin low Aldo. CHF: ACE, Diuretics, B-blocker Diabetics: ACE or ARB.

Case Presentation 56 y.o. A.A. male with edema, HTN Normal labs and UA. Normal CXR and EKG. Meds: Clonidine 0.2 BID ACE inhibitor Diltiazem 300 mg daily Whats Missing???

Case Presentation 56 y.o. A.A. male with refractory HTN. Meds: Clonidine 0.2 BID ACE inhibitor - Stopped Diltiazem 300 mg daily I added HCTZ 50 mg daily.

Case Presentation 56 y.o. A.A. male with refractory HTN. Meds: Clonidine 0.2 BID Diltiazem 300 mg daily HCTZ 50 mg daily. Still swelling, BP a little better. 156 / 100.

Case 56 y.o. AA male with refractory HTN. I changed diuretics to Lasix and Zaroxolyn. I get a call 3 days later: Swellings gone, but I can’t get out of bed – too dizzy!

Case Presentation 56 y.o. A.A. male with refractory HTN. Meds: Lasix 40 mg BID Zaroxolyn 5 mg weekly No swelling, BP 126 / 80. Pt reports joint pain and swelling. What test do you order next?

Case Uric acid level is 12 Creatinine 1.4 K 3.8 Glucose 244 (nonfasting)

Case Started Allopurinol for gout. Pt started exercising and watching diet. Sugars normalized without treatment.

Classes of Antihypertensives Diuretics Rate control agents ACE/ ARB’s Vasodilators Central agents: clonidine, aldomet. Big Guns

Classes of Antihypertensives Diuretics Thiazide: HCTZ/ Combination drugs, Metolazone K sparing: Spironolactone, Triamterine Amiloride Loop Diuretic: Lasix, Bumex, Demedex Edecrin (non sulfa)

Classes of Antihypertensives Diuretics Rate control agents BBlocker, Verapamil, Diltiazem (CCB’s) Amiodorone, Digoxin target pulse rate less than 70 to achieve maximal effectiveness. (not much bang for the buck once pulse lower than 60, with increased risk.)

Classes of Antihypertensives Diuretics Rate control agents ACE/ ARB’s Multitude of benefits for the Kidneys and heart May get extra benefit from addition of HCT.

Classes of Antihypertensives Diuretics, Rate control agents, ACE/ ARB’s Vasodilators Alpha blockers - Cardura, Hytrin DHP CCB’s Nifedipine, Amlodipine, Felodipine Nitric oxide synthase stimulators - hydralazine, Minoxidil, Isordil

Classes of Antihypertensives Diuretics, Rate control agents, ACE/ ARB’s Vasodilators Central agents: clonidine, (remember to consider the patch) aldomet - (used more commonly by Obstetrics)

Classes of Antihypertensives Diuretics, Rate control agents, ACE/ ARB’s Vasodilators, Central agents Big Guns: Minoxidil - must have rate control and loop diuretic on board before starting this. Phenoxybenzamine - peripheral alpha-1 blocker.

Nephrology level htn I tell the pt that will need to control the main route plus the main detours causing the HTN. Rate control (pulse < 78) Diuretic Vasodilator DHP CCB, Hydralazine, Cardura, Minoxidil. ACE / ARB (accept 30% increase in creat if BP responds)

Refer to Nephrologist If unable to control on 3 drug regimen which includes Rate control, diuretic. If you are considering Minoxidil If creatinine climbs more than 30 % or if creatinine is over 2.0.