Hypertension Jared Helms D.O. OGME-2 22 August 2007

Hypertension The treatment of hypertension is the most common reason for office visits of non-pregnant adults to physicians in the United States and for use of prescription drugs. Cherry, DK, Burt, CW, Woodwell, DA. Advance data from vital and health statistics. No 337. Hyattsville, MD. National Center for Health Statistics, 2003.

Definitions Normotensive: systolic <120 mmHg and diastolic <80 Normotensive: systolic <120 mmHg and diastolic <80 Prehypertension: systolic or diastolic Prehypertension: systolic or diastolic Hypertension Hypertension Stage 1: systolic or diastolic Stage 1: systolic or diastolic Stage 2: systolic 160 or diastolic 100 Stage 2: systolic 160 or diastolic 100 The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. Chobanian AV; et al. JAMA 2003 May 21;289(19): Epub 2003 May 14.

Definitions Hypertensive urgency: Severe hypertension (as defined by a diastolic blood pressure above 120 mmHg) in asymptomatic patients Hypertensive urgency: Severe hypertension (as defined by a diastolic blood pressure above 120 mmHg) in asymptomatic patients Malignant hypertension: marked hypertension with retinal hemorrhages, exudates, or papilledema; usually associated with a diastolic pressure above 120 mmHg Malignant hypertension: marked hypertension with retinal hemorrhages, exudates, or papilledema; usually associated with a diastolic pressure above 120 mmHg

Causes Essential Hypertension Essential Hypertension Secondary Hypertension Secondary Hypertension Primary renal disease Primary renal disease Renovascular disease Renovascular disease Oral contraceptives Oral contraceptives Pheochromocytoma Pheochromocytoma Primary hyperaldosteronism Primary hyperaldosteronism endocrine disorders endocrine disorders Sleep apnea syndrome Sleep apnea syndrome Coarctation of the aorta Coarctation of the aorta

Essential vs. Secondary There are four major general clinical clues that are suggestive of secondary hypertension Severe or refractory hypertension. Severe or refractory hypertension. An acute rise in blood pressure over a previously stable value. An acute rise in blood pressure over a previously stable value. Proven age of onset before puberty or above the age of 50 to 55 years Proven age of onset before puberty or above the age of 50 to 55 years Age less than 30 years in non-obese, non-black patients with a confirmed negative family history of hypertension. Age less than 30 years in non-obese, non-black patients with a confirmed negative family history of hypertension.

Essential Hypertension pathogenesis of essential hypertension is poorly understood pathogenesis of essential hypertension is poorly understood Increased sympathetic neural activity, with enhanced beta-adrenergic responsiveness Increased sympathetic neural activity, with enhanced beta-adrenergic responsiveness Increased angiotensin II activity and mineralocorticoid excess Increased angiotensin II activity and mineralocorticoid excess genetic factors genetic factors Reduced adult nephron mass may predispose to hypertension Reduced adult nephron mass may predispose to hypertension

Risk Factors A variety of risk factors have been associated with essential hypertension: A variety of risk factors have been associated with essential hypertension: tends to be both more common and more severe in blacks tends to be both more common and more severe in blacks Increased salt intake Increased salt intake excess alcohol intake excess alcohol intake weight gain weight gain Dyslipidemia Dyslipidemia Risk factors for arterial hypertension in adults with initial optimal blood pressure: the Strong Heart Study Hypertension Feb Dyslipidemia and the risk of incident hypertension in men. Hypertension Jan

Complications Increase in risk begins as the blood pressure rises above 110/75 mmHg Increase in risk begins as the blood pressure rises above 110/75 mmHg At any blood pressure, is importantly affected by the presence or absence of other risk factors At any blood pressure, is importantly affected by the presence or absence of other risk factors Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002 Dec

Complications- CV premature cardiovascular disease premature cardiovascular disease heart failure heart failure Left ventricular hypertrophy Left ventricular hypertrophy

Complications- Neurological Stroke Stroke Intracerebral hemorrhage Intracerebral hemorrhage Hypertensive encephalopathy Hypertensive encephalopathy

Complications- Renal Chronic renal insufficiency Chronic renal insufficiency End-stage renal disease End-stage renal disease Anemia Electrolyte disorders

Diagnosis 3-6 visits over the space of weeks to months 3-6 visits over the space of weeks to months No evidence of end organ damage No evidence of end organ damage Cuff Size Cuff Size Too small can overestimate by mmHg Too small can overestimate by mmHg Arm circumference 22 to 26 cm, 'small adult' cuff, 12 x 22 cm Arm circumference 22 to 26 cm, 'small adult' cuff, 12 x 22 cm Arm circumference 27 to 34 cm, 'adult' cuff: 16 x 30 cm Arm circumference 27 to 34 cm, 'adult' cuff: 16 x 30 cm Arm circumference 35 to 44 cm, 'large adult' cuff: 16 x 36 cm Arm circumference 35 to 44 cm, 'large adult' cuff: 16 x 36 cm Arm circumference 45 to 52 cm, 'adult thigh' cuff; 16 x 42 Arm circumference 45 to 52 cm, 'adult thigh' cuff; 16 x 42 Confirming the diagnosis of mild hypertension. Br Med J (Clin Res Ed) 1983 Jan 22;286(6361): Variation in cuff blood pressure in untreated outpatients with mild hypertension--implications for initiating antihypertensive treatment. J Hypertens 1987 Apr;5(2):

Diagnosis White Coat Hypertension White Coat Hypertension Ambulatory monitoring Ambulatory monitoring Masked Hypertension Masked Hypertension How common is white coat hypertension? JAMA 1988 Jan 8;259(2): Prevalence, persistence, and clinical significance of masked hypertension in youth. Hypertension 2005 Apr;45(4):493-8.

Work up-History “When was the last time you were told your blood pressure was normal” “When was the last time you were told your blood pressure was normal” Family History Family History Noncompliance Noncompliance Symptoms of target organ damage Symptoms of target organ damage Headaches Headaches Visual changes Visual changes Chest pain Chest pain Claudication Claudication Dyspnea Dyspnea

Work up-History Presence of other risk factors for cardiovascular disease Presence of other risk factors for cardiovascular disease Smoking Smoking Diabetes Diabetes Dyslipidemia Dyslipidemia Physical inactivity Physical inactivity

Work up-History Signs and symptoms that suggest an identifiable cause of hypertension Signs and symptoms that suggest an identifiable cause of hypertension Muscle weaknessMuscle weakness Thinning of the skinThinning of the skin Flank painFlank pain Symptoms suggestive of pheochromocytoma Symptoms suggestive of pheochromocytoma Spells of tachycardia, sweating, tremorSpells of tachycardia, sweating, tremor

Work up-PE Evaluate for signs of end-organ damage Evaluate for signs of end-organ damage Retinopathy (Hemorrhage, Papilledema, Cotton wool spots) Retinopathy (Hemorrhage, Papilledema, Cotton wool spots) Pulses Pulses Cardiac (rhythm, murmurs) Cardiac (rhythm, murmurs) Abdominal bruits Abdominal bruits Edema Edema Neurologic Assessment Neurologic Assessment

Work up- Lab CBC, CMP CBC, CMP TSH TSH Lipid Profile Lipid Profile UA UA EKG EKG +/- CXR +/- CXR

Lifestyle Modifications ModificationRecommendation Approximate systolic BP reduction, range* Weight reduction Maintain normal body weight (BMI, 18.5 to 24.9 kg/m2) 5-20 mmHg per 10-kg weight loss Adopt DASH eating plan Consume a diet rich in fruits, vegetables, and low- fat dairy products with a reduced content of saturated and total fat 8 to 14 mmHg Dietary sodium reduction Reduce dietary sodium intake to no more than 100 meq/day (2.4 g sodium or 6 g sodium chloride) 2 to 8 mmHg Physical activity Engage in regular aerobic physical activity such as brisk walking (at least 30 minutes per day, most days of the week) 4 to 9 mmHg Moderation of alcohol consumption Limit consumption to no more than 2 drinks per day in most men and no more than 1 drink per day in women and lighter-weight persons 2 to 4 mmHg

TherapeuticsBP Systolic BP mmHg* Diastolic BP mmHg* Lifestyle Modification Initial Drug therapy WITHOUT compeling indication Initial Drug therapy WITH compeling indication Normal<120And<80Encourage Prehypertension OR80-89YES No antihypertensive drug indicated Drug(s) for the compelling indications Stage OR90-99YES Thiazide-type diuretics for most; may consider ACE inhibitor, ARB, beta blocker, CCB, or combination Drug(s) for the compelling indications; other anti-hypertensive drugs (diuretics, ACE inhibitor, ARB, beta blocker, CCB) as needed Stage 2 >160 >160OR>100YES 2-drug combination for most (usually thiazide-type diuretic and ACE inhibitor or ARB or beta blocker or CCB) Drug(s) for the compelling indications; other antihypertensive drugs (diuretics, ACE inhibitor, ARB, beta blocker, CCB) as needed

Getting to Goal Uncomplicated HTN: < 140/90 mmHg Uncomplicated HTN: < 140/90 mmHg If older than 65 keep Diastolic above 65 mmHg If older than 65 keep Diastolic above 65 mmHg Chronic Renal Disease: < 130/80 mmHg Chronic Renal Disease: < 130/80 mmHg Diabetes Mellitus: < 130/80 mmHg Diabetes Mellitus: < 130/80 mmHg Cardiovascular Disease: < 130/80 mmHg Cardiovascular Disease: < 130/80 mmHg The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. Chobanian AV; et al. JAMA 2003 May 21;289(19): Epub 2003 May 14.

Initial Drug Therapy Uncomplicated HTN: Low dose diuretic Uncomplicated HTN: Low dose diuretic Heart Failure: ACEI Heart Failure: ACEI Asymptomatic LV dysfunction: ACEI Asymptomatic LV dysfunction: ACEI MI: ACEI MI: ACEI Diabetes: ACEI Diabetes: ACEI Renal Failure: ACEI Renal Failure: ACEI Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002 Dec 18

Initial Drug Therapy Severe HTN with EKG evidence of LVH: ARB Severe HTN with EKG evidence of LVH: ARB S/p AMI with heart failure or asymptomatic LV dysfunction: Beta blockers w/o ISA S/p AMI with heart failure or asymptomatic LV dysfunction: Beta blockers w/o ISA There are no absolute indications for calcium channel blockers in hypertensive patients There are no absolute indications for calcium channel blockers in hypertensive patients Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). ALLHAT Collaborative Research Group. JAMA 2000 Apr 19;283(15): Should beta blockers remain first choice in the treatment of primary hypertension? A meta-analysis. Lancet 2005 Oct 29-Nov 4;366(9496):

Initial Drug Therapy Switching vs. Additive therapy Switching vs. Additive therapy Age & Race Predictors Age & Race Predictors Younger patients: beta blockers and ACEI & ARBs Younger patients: beta blockers and ACEI & ARBs Older patients: diuretics and CCBs Older patients: diuretics and CCBs Black patients: diuretics and CCBs Black patients: diuretics and CCBs 1. Optimisation of antihypertensive treatment by crossover rotation of four major classes. Lancet 1999 Jun ACE inhibitors, beta-blockers, calcium blockers, and diuretics for the control of systolic hypertension. Am J Hypertens 2001 Mar 3. Response to a second single antihypertensive agent used as monotherapy for hypertension after failure of the initial drug. Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents. Arch Intern Med 1995 Sep The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. Chobanian AV; et al. JAMA 2003 May 21;289(19): Epub 2003 May 14.

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