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

Objectives Define hypertension Principles of treatment Special groups

Blood Pressure Classification BP CLASSIFICATION SBP DBP Normal <120 and <80 Prehypertension 120-139 or 80-89 Stage 1 HTN 140-159 or 90-99 Stage 2 HTN >160 >100

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

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

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

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

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

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

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

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

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.

Lifestyle Modification Approximate SBP reduction (range) Weight reduction 5–20 mmHg/10 kg weight loss Adopt DASH eating plan 8–14 mmHg Dietary sodium reduction 2–8 mmHg Physical activity 4–9 mmHg Moderation of alcohol consumption 2–4 mmHg

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

Algorithm for Treatment of Hypertension Lifestyle Modifications Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices Stage 2 Hypertension (SBP >160 or DBP >100 mmHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) Stage 1 Hypertension (SBP 140–159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Without Compelling Indications Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. With Compelling Indications Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist.

Classification and Management of BP for adults BP Class SBP DBP Lifestyle Initial drug therapy Without compelling indication Compelling indications Normal <120 <80 Encourage None Pre-hypertension 120–139 or 80–89 Yes No antihypertensive drug indicated. Drug(s) Stage 1 Hypertension 140–159 or 90–99 Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Stage 2 Hypertension >160 or >100 Two-drug combination (usually thiazide and ACEI or ARB or BB or CCB). *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.

Heterogeneity of “Essential” Hypertension

Special Considerations Compelling Indications Special populations

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?

Compelling Indications for Certain Drug Classes

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

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

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

A 40 year old previously healthy male is brought to the E. R 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.

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

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

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

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

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)

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

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

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

www.nhlbi.nih.gov/