 Cure Pathologic Fear of Hypertension  Create Rational Approach to Drug Choice  Complement Rational Choice with Pearls  Consolidate new information with cases

Those who do not have high blood pressure at age 55 face a 90 percent chance of developing it during their lifetimes. So high blood pressure is a condition that most people have at some point in their lives. 90% of Americans over 65 have hypertension or Prehypertension

You can at least cause Dys-Ease

Your Blood pressure is 128/84While drug treatment is recommended if your BP is at or above 140/90, new medical guidelines state that a normal BP for most adults is less than 120/80. Ask your doctor what is right for you.

The risk of cardiovascular disease begins at 115/75 In individuals aged 40 to 70 years, each 20/10 mm Hg increase in blood pressure doubles the risk of cardiovascular disease, including heart attack, stroke or kidney disease This program includes: A free 30 day trial of Diovan, Diovan HCT and Lotrel, 3 medications proven to help lower blood pressure.

115/75 180/ 100 Low Risk High Risk

115/75

We’re Doomed, We’re Doomed

 The Silent Killer

69% of people who have a heart attack, 77% of people who have a first stroke, and 74% of people with chronic CHF have high blood pressure.

95% of people who have a heart attack, 95% of people who have a first stroke, and 95% of people with chronic CHF Have eaten pickles in the previous 10 years

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DiseaseLow Dose Diuretic Ace InhibitorsBeta Blockers Death 28%27% Stroke 37%35%11% Coronary Heart Disease 28%19%NS

 45 Year Old Female  Cholesterol 200  Non-Smoker  Systolic of 190  10 Year Risk?  2% Risk of Heart Attack  1.4% if treated

 65 Year Old Male  Cholesterol 200  Non-Smoker  Systolic of 155  10 Year Risk?  10% Risk of Heart Attack  7.2% if treated 90% Chance of Going 10 years with NO heart attack 92.8% If they Are Treated

 65 Year Old Male  Cholesterol 200  Smoker  Systolic of 180  10 Year Risk?  25% Risk of Heart Attack  18% if treated 75% Chance of Going 10 years with NO heart attack 82% If they Are Treated

 Accord Trial NEJM 2010;362:17  Diabetes PLUS ◦ Heart Disease ◦ OR ◦ Albuminuria ◦ OR ◦ Hypertrophy ◦ OR ◦ Two Risk Factors

 Accord Trial NEJM 2010;362:17  Systolic of <120 vs Systolic of <140  Achieved 119 vs 133

 Accord Trial NEJM 2010;362:17  Outcome:  nonfatal myocardial infarction, nonfatal stroke, or death from cardiovascular causes  Followed Almost 5 years

 Accord Trial NEJM 2010;362:17  Composite Outcome:  1.87 vs 2.09 p=0.2  Death  1.28 vs 1.19

 Accord Trial NEJM 2010;362:17  Stroke:  0.32 vs 0.53 p=0.01

 Seven trials (22,089 subjects) -4/-3 better  …at present there is no evidence to support aiming for a blood pressure target lower than 140/90 mmHg in any hypertensive patient.

Fear of Hypertension Fear Of Hypertension

Rational Approach to Treat HTN

 High Renin  Low Renin

 Intuitive  Renin  Angiotensin  Aldosterone  Sympathetic Nervous System  Angiotensin  Vasoconstriction  Aldosterone  Sodium and Water

 Characteristics  Systolic and Diastolic Equally Elevated  Higher Hemoglobin  Younger  High Stress?  White?

 Not Intuitive  Why is Renin Low?  Flaws in Sodium Excretion   Volume  Paradoxical  Aldosterone  Stiff Arteries & Volume Excess

 Characteristics  Isolated Systolic Hypertension  Older  Women  African American  Diabetes

 So What?

Stimulate RAAInhibit RAA Diuretics CCB’s ACE’s / ARB’s Beta Blockers ?

 Salt retaining Steroids ◦ Corticosteroids ◦ Anabolic Steroids ◦ Oral contraceptives ◦ Estrogens  NSAIDS

 Weight 276 pounds  BP 170/90  Blood sugars run ◦ Glucophage 500mg BID ◦ Micronase 5mg qd ◦ Zestril 20mg qd  Complaining of palpitations. HCTZ Chlorthalidone Or Indapamide

Transition

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 Lasix for Hypertension  Only if: ◦ Serious Edema ◦ CrCl < 30 ◦ Torsemide probably better

 Women: Only the ones with Prostate Glands  Men: only the ones with BIG Prostate Glands  When in Doubt, Cut It Out.

 All the outcomes data are on the next slide

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 Causes  Drugs  Street Drugs  Sleep Apnea  Renal Artery Stenosis

 The Situation  All 4 Classes added  Still No Joy  Add Spironolactone  Especially if the potassium is on the low side

 The number one cause of Resistant Hypertension tbn3.gstatic.com/images?q=tbn:ANd9 GcR7w6eOwm6ymMSLZxuF_7PpZ- oCCQo8xh_oJKrxhdtC4PfFtYWr

A Couple Stories

 67 years old  Norvasc 5  Lisinopril 40  Carvedilol 25 BID  Chlorthalidone 25mg  Blood Pressure is 192/105

 Assess Compliance  Consider Sleep Apnea  Consider Spironolactone

 52 year old female  Non-smoker  Blood Pressure 152/94  Which drug should be started?

 Leave the Poor Woman Alone !!  Take away her home blood pressure machine  Exercise, Salt and Healthy Food

 Cured Pathologic Fear of Hypertension  Created a Rational Approach to Drug Choice  Complemented Rational Choice with Pearls  Consolidated new information with cases