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

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

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

4. Hypertension Literature Summary
Malignant Hypertension Kincaid-Smith and others DBP > 130
VA Cooperative Studies DBP mm Hg DBP mm Hg

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

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

7. HYPERTENSION Recent Works
1985 HDFP follow-up Study Long term surveillence for drug side effects: %
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 %.

8. Joint National Commission
JNC founded on HDFP
JNC Intro of ACE, alpha B.
JNC Special situations
JNC Many agents 1st line
JNC Back to stepped care.
JNC ACE for Diabetics
JNC

9. 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."

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

11. Stages of Hypertension
Normal
Prehypertension
Stage 1
Stage 2
< 120 / 80
/ 80-89
/ 90-99
> 160 / >100

12. 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

13. 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

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

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

16. 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.

17. 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???

18. 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.

19. 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 / 100.

20. 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!

21. 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?

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

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

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

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

26. 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.)

27. 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.

28. 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

29. 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)

30. 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.

31. 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)

32. 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.