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

2. 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

3. You can at least cause Dys-Ease

4. 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.

5. 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.

7. 115/75 180/ 100 Low Risk High Risk

8. 115/75

10. We’re Doomed, We’re Doomed

12.  The Silent Killer

13. 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.

14. 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

15. http://cybersmokeblog.blogspot.com/2013/03/do-you- agree-to-tell-whole-truth-and.html

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

17.  45 Year Old Female  Cholesterol 200  Non-Smoker  Systolic of 190  10 Year Risk?  2% Risk of Heart Attack  1.4% if treated

18.  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

19.  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

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

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

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

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

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

25.  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.

26. Fear of Hypertension Fear Of Hypertension

27. Rational Approach to Treat HTN

28.  High Renin  Low Renin

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

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

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

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

33.  So What?

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

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

36.  Weight 276 pounds  BP 170/90  Blood sugars run 200-250 ◦ Glucophage 500mg BID ◦ Micronase 5mg qd ◦ Zestril 20mg qd  Complaining of palpitations. HCTZ Chlorthalidone Or Indapamide

38. Transition

39.  https://encrypted- tbn0.gstatic.com/images?q=tbn:ANd9 GcSZnyeB7hSiohvoaUK2XPf8I3RkGhJcn xmgTzAxVstB5KyIxXmC https://encrypted- tbn3.gstatic.com/images?q=tbn:ANd9GcRJ9hLG9b ZqehwMhM3Au6sq1xi4x8gb1LY- PnnvCiqbwv7HJeJW

40. 0 12.5 25 50 100

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

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

43.  All the outcomes data are on the next slide

46. https://www.toledoblade.com/image/2013/01/09 /670x_b1_a4-3_cCM_z_cT/Cedar-Point- GateKeeper.jpg

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

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

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

50. A Couple Stories

52.  67 years old  Norvasc 5  Lisinopril 40  Carvedilol 25 BID  Chlorthalidone 25mg  Blood Pressure is 192/105

53.  Assess Compliance  Consider Sleep Apnea  Consider Spironolactone

54.  52 year old female  Non-smoker  Blood Pressure 152/94  Which drug should be started?

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

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