Diagnosis and Management of Hypertension Davin Haraway DO,FACOI,CWS Associate Professor of Medicine – OSU Center for Health Sciences

Why talk about the Same Old Thing? ● Those age 55 with normal blood pressure will have a 90 percent lifetime risk of developing hypertension ● Hypertension control reduces excess morbidity and mortality. ● Beginning with 115/75 – CVD risk doubles for each increment of 20/10mmHg ● >50million americans have High Blood Pressure warranting some form of treatment ● 30% adults are still unaware of their hypertension ● >40% of individuals with hypertension are not on treatment ● 2/3 of patients on treatment are not controlled to BP levels of less than 140/90 ● Hypertensive patients are 2.5 times more likely to develop diabetes within 5 years

Risk of hypertension (%) Residual lifetime risk of developing hypertension among people with blood pressure <140/90 mmHg Years Lifetime Risk of Developing Hypertension Beginning at Age 65 MenWomen Vasan RS, et al. JAMA. 2002; 287: Copyright 2002, American Medical Association. g

Table 1. Classification and Management of Blood Pressure for Adults Aged 18 Years or Older HTN Classification

?Prehypertension ● NOT a DISEASE category – Should encourage Lifestyle modification as this group has an increased risk of becoming hypertensive ● NOT candidates for drug therapy (unless compelling indications ie DM etc goal <130/80)

Table 3. Lifestyle Modifications to Manage Hypertension*

Physician Practices in Treating HTN With and Without Diabetes Hyman DJ, Pavlik VN. Arch Intern Med. 2000;160(15): Reprinted by permission, American Medical Association. DBP (mmHg) to Start Treatment % of respondents

Accurate BP measurement ● Who checks your patients BP? – You or Staff ● IF Staff – Do they know what to listen for or do they use automated equipment – Seated quietly for 5 minutes – Appropriate size cuff – Inflate mmHg above loss of radial pulse – Deflate at 2mmHg per second – 1 st sound SBP ; Disappearance of Korotkoff sound (phase 5) is DBP – Confirm Elevated blood pressure within 2months(stage 1) – shorter for stage 2 if new onset

If HTN diagnosed Evaluate for Cardiovascular Risk Factors Age,Fm Hx, Lipids, Obesity, microalbuminuria, Inactivity,Smoking Evaluate for Target Organ Damage LVH or reduced EF, Angina,stroke,dementia,Kidney disease, PAD,retinopathy Think about Secondary Hypertension with any new onset Hypertension or uncontrolled hypertension

Identifiable causes of hypertension ● Chronic kidney disease\ ● Coarctation of the Aorta ● Cushing’s Syndrome ● Drug induced ● Obstructive uropathy ● Pheochromocytoma ● Primary aldosteronism and other mineralocorticoid excess states ● Renovascular HTN – stenosis and fibromuscular dysplasia ● Sleep Apnea ● Thyroid (either HYPER or HYPO) or parathyroid disease

Box 3. Causes of Resistant Hypertension Improper blood pressure measurement Volume overload and pseudotolerance Excess sodium intake Volume retention from kidney disease Inadequate diuretic therapy) Drug-induced or other causes Nonadherence Inadequate doses Inappropriate combinations Nonsteroidal anti-inflammatory drugs; cyclooxygenase 2 inhibitors Cocaine, amphetamines, other illicit drugs Sympathomimetics (decongestants, anorectics) Oral contraceptives Adrenal steroids Cyclosporine and tacrolimus Erythropoietin Licorice (including some chewing tobacco) Selected over-the-counter dietary supplements and medicines (eg, ephedra, ma haung, bitter orange) Associated conditions Obesity Excess alcohol intake Identifiable causes of hypertension (see Box 2)Box 2

Which Drugs do you use? ● Stage 1 – Thiazide 1 st unless compelling indication ● Stage 2 – Two drugs (one of the two should be a diuretic or ACE/ARB) ● Compelling Indications for certain disease modifying meds should be considered

Table 6. Clinical Trial and Guideline Basis for Compelling Indications for Individual Drug Classes

Table 4. Oral Antihypertensive Drugs*

Table 5. Combination Drugs for Hypertension

OK Now what? ● 2/3 of patients with hypertension will need at least two medicines for BP control

Pearls ● For resistant HTN – sit down and take a good history – How much water,pop, coffee,milk,juice,tea,ice – anything liquid do you drink daily. – Food preferences and salt intake – Drugs/Alcohol – Compliance

Pearls cont. ● The only thiazide that will work with an elevated creat. Is metolazone(zaroxolyn) ● If elevated creat. Than will need to use a loop diuretic ● If potassium is elevated – evaluate current meds and use a diuretic ● If potassium is low – ask why ● Check for edema – and ask why ● Elderly patients benefit from blood pressure management ● Black patients benefit from ACE/ARB – may need to use larger doses to obtain BP lowering effect

Pearls Cont. ● Metabolic acidosis and hyperkalemai? – use diuretic – loop if creat. Elevated ● Take blood pressure periodically lying and standing so as not to miss supine hypertension associated with autonomic insufficiency – this is treated differently

Escape of Angiotensin II Despite ACE Inhibition Biollaz J, et al. J Cardiovasc Pharmacol. 1982;4(6): Plasma Ang II (pg/mL) Plasma ACE (nmoL/mL/min) * * * * * * * * * Placebo4 h24 h HospitalMonths *P <.001 vs placebo

Osterberg, L. et al. N Engl J Med 2005;353: Adherence to Medication According to Frequency of Doses

Osterberg, L. et al. N Engl J Med 2005;353: Barriers to Adherence

Figure. Algorithm for Treatment of Hypertension