1. HYPERTENSION “DILEMMAS IN TREATMENT” Dr. N. Dean MBBS FRCP (UK)
Dilemmas, issues, grey areas
Dr. N. Dean MBBS FRCP (UK)
Clinical Professor,
Royal Alexandra Hospital

2. 2008 Canadian Hypertension Education Program Recommendations
BURDEN
1 in 5 adult Canadians have hypertension
40% of Canadians at age 55 have hypertension
90% of normotensive persons aged developed hypertension in the next 20 year in the Framingham study
2008 Canadian Hypertension Education Program Recommendations

3. What percent of Canadians have hypertension?
CCHS CMAJ 1992
2008 Canadian Hypertension Education Program Recommendations

4. Modifiable Risk Factors for IS
Factor Relative Risk Prevalence
Hypertension
Diabetes
Smoking
Hyperlipidemia
Atrial fibrillation
Alcohol abuse
Cardiac disease
Physical inactivity
Obesity
Asym Car Sten
Sacco R. Neurology 1995;45:

5. Hypertension outcome trials
Percent (%)
Hypertension outcome trials
Kjeldsen et al. Blood Pressure 2001;10: 7 6 5 4 3 2 1
STOP-1
SHEP
STONE
SYST-EUR
SYST-CHINA
HOT
CAPP
STOP-2
NICS
NORDIL
INSIGHT
Stroke
Myocardial infarction
Key point
Stroke is consistently more common than myocardial infarction (MI) in hypertension outcome trials and is considered the clearest indication for antihypertensive therapy.
In all hypertension outcome trials (across various types of hypertensive patients) stroke has been more common than MI.1 Progress in stroke prevention over the past several decades has largely been due to improvements in BP control. Reductions of 5–6 mmHg in usual diastolic blood pressure (DBP) are associated with approximately 35–40% fewer strokes, making high risk of stroke the clearest indication for antihypertensive treatment.
References
Kjeldsen SE, Julius S, Hedner T, Hansson L. Stroke is more common than myocardial infarction in hypertension: analysis based on 11 major randomized intervention trials. Blood Pressure 2001;10:

6. Treatment of high blood pressure results in long-term benefit
Total no. of
individuals affected
1200
800
768 T
964 C
Stroke
38% ± 4
<
CHD
16% ± 4
<0.001
Reduction in odds:
2p-value:
T = treated
C = control
fatal events
non-fatal events
Vascular deaths
21% ± 4
1104
560
934
470
835
234
525
140
600
200
1000
400
These combined results of 17 randomised trials involving a total of hypertensive individuals, illustrate the benefit in morbidity and mortality that can be achieved by reducing high blood pressure with antihypertensive treatment. Overall, with average BP reductions of 5–6 mmHg diastolic and 10–12 mmHg systolic compared to the control groups, treating hypertension reduced the incidence of stroke by 38% and CHD by 16%. There were similar reductions in fatal and non-fatal events. In treated patients, death from all vascular causes was reduced by 21%.
With regard to stroke, this reduction in events achieved after just a few years of treatment (mean duration of the trials was 4.9 years) represents much or all of the full long-term potential effect of BP reduction. For CHD, however, it is somewhat less than the full benefit, representing about two thirds of that which can be achieved when blood pressure is treated for a longer period of time.
Reference: MacMahon S, Rodgers A. The effects of antihypertensive treatment on vascular disease: Reappraisal of the evidence in J Vasc Med Biol 1993; 4(5-6):
McMahon & Rodgers 1993

7. The Challenge In Canada
22% of Canadians years of age have hypertension
50% of Canadians >65 years of age have hypertension
Joffres et al. Am J Hyper 2001;14:1099 –1105
21%
13%
43%
22%
Hypertensive patients
who are treated
but BP uncontrolled
and BP controlled
who are unaware
Patients who are aware
but remain untreated
and BP uncontrolled
Data suggests that we are not successful in treating Rfs

8. Changes in Diagnosis of Hypertension in Canada
Post 1999 compared
to pre 1999
Marked increase in the rate of diagnosis of hypertension
Closing of the gender gap
1999
Marked increase in diagnosis of hypertension in Canada in The data are from the cross sectional surveys and represent the Canadian adult population
NPHS, CCHS
Onysko J, Hypertension 2006;48:853-60

9. Changes in Treatment of Hypertension in Canada
Post 1999 compared
to pre 1999
Doubling of the rate of treatment of hypertension
Closing of the gender gap
Marked increase in treatment of hypertension in The data are from the cross sectional surveys and represent the Canadian adult population
NPHS, CCHS
Onysko J, Hypertension 2006;48:853-60

10. Changes in proportion of aware hypertensive Canadians not treated with antihypertensive drugs
Post 1999 compared
to pre 1999
Marked decrease in proportion of aware hypertensives that are untreated
Closing of the gender gap
There is a large reduction in the proportion of Canadians who know they have hypertension and are not treated with drugs. The data are from the cross sectional surveys and represent the Canadian adult population
So we have improved in diagnosing and treating BP but still there are number of dilemmas we face when treating BP
NPHS, CCHS
Onysko J, Hypertension 2006;48:853-60

11. DIURNAL VARIATION IN BP?

12. Nocturnal dipping and AM surge
190
+38%
+20%
Systolic
170
150
Blood Pressure (mm Hg)
130
110
+38%
+57% 90
Diastolic 70 3 6 9 12 15 18 21
Clock Time (hours)
Millar-Craig M. Lancet 1978;i:795

13. Diurnal /Circadian variation in disease presentation
Many disease presentations have cyclical patterns
Seasonal, monthly, weekly, most importantly daily
Asthma (2-4 AM)
Rupture of Abdominal aortic aneurysm (early morning hours)
Angina (6 AM to 4 PM)
MI (winter >> summer, AM>>PM)
Based on meta-analysis of studies:
5-12 AM (awakening hours)
~50% higher risk of Stroke
~40% higher risk of Myocardial Infarction
~30% higher risk of Sudden Cardiac Death

14. Diurnal /Circadian variation in disease presentation
Based on meta-analysis of studies:
5-12 AM (awakening hours)
~50% higher risk of Stroke
~40% higher risk of Myocardial Infarction
~30% higher risk of Sudden Cardiac Death

15. # of Patients in 6 hr period (x 1000) Time of Onset of Stroke Symptoms
4.5
P<
31 studies
4.0
49%
3.5
3.0
2.5
# of Patients in 6 hr period (x 1000)
2.0
1.5
1.0
0.5
0:00 to 5:59
6:00 to 11:59
12:00 to 17:59
18:00 to 23:59
Time of Onset of Stroke Symptoms
Elliot W. Stroke 1998;29:992

16. Circadian Rhythm of Ischemic & Hemorrhagic Strokes Gallerani et al, Acta Neurol Scand 1993; 87: 482)
% of strokes
Hemorrhagic
Hour of day

17. Patients with significant AM BP surge
have increased risk of stroke (ischemic or hemorrhagic)
with worse prognosis

18. Patients with nocturnal BP increase (Risers)
have increased risk of stroke and MI
with worse prognosis

19. In Hypertensive individuals we should aim for BP control in : a) AM
Question
In Hypertensive individuals we should aim for BP control in :
a) AM
b) PM
c) 24 hour

20. potential clinical implications of
If there is clear diurnal variation in BP and there is definite diurnal changes in CV events,
then what are the
potential clinical implications of
Circadian Rhythm of BP

21. WHAT IS THE OPTIMAL BP?

22. Impact of High-Normal Blood Pressure on the Risk of Cardiovascular Disease
CUMULATIVE INCIDENCE OF CV EVENTS IN MEN WITHOUT HYPERTENSION ACCORDING TO BASELINE BLOOD PRESSURE
Expliquer les catégories normales et normales haute.
N Engl J Med 2001;345:1291-7

23. I. Indications for Pharmacotherapy
Usual blood pressure threshold values for initiation of pharmacological treatment of hypertension
Condition
Initiation
SBP or DBP mmHg
• Systolic or Diastolic hypertension
140/90
• Diabetes
• Chronic Kidney Disease
130/80

24. Blood pressure target values for treatment of hypertension
II. Goals of Therapy
Blood pressure target values for treatment of hypertension
Condition
Target
SBP and DBP mmHg
Isolated systolic hypertension
<140
Systolic/Diastolic Hypertension
• Systolic BP
• Diastolic BP
<90
Diabetes or Chronic Kidney Disease
• Systolic
• Diastolic
<130
<80

25. ACCORD ( NEJM: March14,2010 ) 4733 patienst with type 2 diabetes
Intensive therapy ( BP <120)
Standard therapy (less than 140)
Primary out come: Non-fatal MI, Non-fatal stroke, death from cardiovascular disease)

27. Conclusion
Mean SBP in intensive therapy group was 119.3mm Hg and 133.5mm Hg in standard therapy group
In patients with type 2 diabetes targeting SBP to <120 as compared to <140 does not improve outcomes

28. I. Indications for Pharmacotherapy
In low risk patients with stage 1 hypertension ( /90-99 mmHg) lifestyle modification can be the sole therapy.
Over 90% of Canadians with hypertension have other risk factors and pharmacotherapy should be considered in these patients if blood pressure remains equal to or above 140/90 mmHg with lifestyle modification.
Patients with target organ damage (e.g. left ventricular hypertrophy) are recommended to be treated with pharmacotherapy if blood pressure is equal to or above 140/90
Patients with known atherosclerotic disease (e.g. past stroke) are recommended to be treated with pharmacotherapy even if the blood pressure is normal (see compelling indications)
Patients with diabetes or chronic kidney disease should be considered for pharmacotherapy if the blood pressure is equal or over 130/80 mmHg

29. II. Goals of Therapy
To optimally reduce cardiovascular risk reduce the blood pressure to specified targets.
This usually requires two or more drugs and lifestyle changes
The systolic target is more difficult to achieve however controlling systolic blood pressure is as important if not more important than controlling diastolic blood pressure

30. WHICH ANTI HYPERTENSIVE AGENT?

31. INITIAL TREATMENT AND MONOTHERAPY Lifestyle modification
Treatment of Adults with Systolic/Diastolic Hypertension without Other Compelling Indications
TARGET <140/90 mmHg
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification
therapy
A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mmHg systolic or >10 mmHg diastolic above target
Thiazide
ACE-I
ARB
Long-acting
CCB
Beta- blocker*
* BBs are not indicated as first line therapy for age 60 and above
ACEI and ARB are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potential

32. INITIAL TREATMENT AND MONOTHERAPY Lifestyle modification
Treatment Algorithm for Isolated Systolic Hypertension without Other Compelling Indications
TARGET <140 mmHg
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification
therapy
Thiazide diuretic
ARB
Long-acting
DHP CCB

33. Choice of drug also depends on underlying disease?
Underlying CAD
Underlying CHF
Underlying Diabetes
Underlying Renal impairment

35. Take home messages – 2008 CHEP recommendations
Home BP and ABP monitoring are crucial
Use lifestyle +/- pharmacologic interventions
Diet, exercise, wt control, salt reduction, reduce EtOH consumption
Assess adherence at each visit
Use specific interventions to improve adherence
Once-daily dosing (most individuals require 2-4 drugs to control their BP
Patient education about reducing cardiovascular risk
***Theoretically, antihypertensive medicines that are particularly efficacious over 24 hours with sustained or peak effect in the morning hours may reduce the incidence of CV events more.

36. ACE vs ARB

37. ACE-I are shown to be beneficial ARBs are also shown to be beneficial
ACE or ARB or both???
ACE-I are shown to be beneficial
ARBs are also shown to be beneficial
ACE better than ARBS?
Combination?

38. ONTARGET study ( NEJ: April 10,2008 )
Compared the benefits of an ACE-inhibitor (Ramipril 10mg ) , ARB (Telmesartan 80 mg) and their combination in high cardiovascualr risk patients but no CHF

40. Combination Therapy ( ARB +ACEI )
Was associated with side effects like renal dysfunction, syncope and postural hypotension
Some evidence of benefit in patients with proteinuria and CHF
Combination therapy has no added benefit in patients with hypertension

41. Implications
Telmisartan is as effective as ramipril, with a slightly better tolerability.
Combination therapy is not superior to ramipril, and has increased side effects.

42. ONTARGET: The ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial
ACE-inhibitors (e.g. ramipril in the HOPE trial) reduces CV death, MI, stroke and HF hosp in those with CVD or DM in the absence of ventricular dysfunction or heart failure
ACE-inhibitors are not tolerated by 15% to 25% of patients
Will an ARB (telmisartan) be as effective and better tolerated?
Is the combination superior?

43. Systolic -6.0 -6.9 -8.4 Diastolic -4.6 -5.2 Change in BP (mmHg)
Ramipril
Telmisartan
Combination
Systolic
-6.0
-6.9
-8.4
Diastolic
-4.6
-5.2

44. Time to Primary Outcome
ONTARGET

45. Time to Primary Outcome
ONTARGET

46. Conclusions: Telmisartan plus Ramipril vs. Ramipril
Combination therapy does not reduce the primary outcome to a greater extent compared to ramipril alone
2. Higher rates of adverse events:
-hypotension related, including syncope
-renal dysfunction

47. Do anti-hypertensive agents have more than BP lowering properties?

48. Evidence for other than BP lowering properties
HOPE : Ramipril ( Ace- inhibitor )
SECURE: Ramipril ( Ace inhibitor )
PROGRESS: Perindopril ( Ace- inhibitor)
LIFE : Losartan ( Angiotensin RB )
SCOPE : Candersartan ( ARB )
PATS: Indapamide ( Diuretic)
PREVENT : Amlodipine ( CCB)

49. BP-Independent effects
Ventricular Hypertrophy and remodelling:
( SAVE, SOLVD, Val-HeFT)
Microalbuminuria and nephropathy:
( IDNT,IRMA,RENAAL, MARVEL)
New onset Diabetes:
( HOPE,LIFE,VALUE)
Endothelial Dysfunction:
( TREND,CHARM)

50. 55 year old man , smoker , stressful job.
Case 1 & 2
55 year old man , smoker , stressful job.
A few clinic visits over the last few months. Very upset about his BP . High values at home and at work. BP < 140 / 90 in the office
65 year old on Ramipril and HCT. High BP in the office but is adamant that BP in normal range at home

51. The concept of masked hypertension
140
White Coat HTN
True
Normotensive
Masked HTN
hypertensive
True
hypertensive
Masked HTN
Home or ABPM SBP mmHg
135
135
True
Normotensive
White Coat HTN
140
Office SBP mmHg
Derived from Pickering et al. Hypertension 2002: 40:

52. The prognosis of masked hypertension
Prevalence of masked hypertension is approximately 10%
J Hypertension 2007;25:

53. Masked hypertension represents a strong predictor of cardiovascular risk and was present in 16% of subjects without antihypertensive medication and 18% of those with antihypertensive medication.

54. Which patients to screen?
Known hypertensives on routine 24 BP monitoring
Individuals with family history of high BP
Abdominal obesity?

55. Treatment of Masked hypertension
Dilemma
Life style modification
Medication for target organ damage?
Adjust medication in individuals with known hypertension

56. 2008 Canadian Hypertension Education Program (CHEP)
What's New for 2008
IMPORTANT ROLE FOR HOME MEASUREMENT OF BLOOD PRESSURE
Encourage hypertensive patients to use an approved blood pressure measuring device and use proper technique to assess blood pressure at home.
Measuring blood pressure at home has a stronger association with cardiovascular prognosis than office based readings.
Home measurement can confirm the diagnosis of hypertension, improve blood pressure control, reduce the need for medications in some, screen for white coat and masked hypertension and improve medication adherence in non adherent patients.

57. 2008 Canadian Hypertension Education Program (CHEP)
IMPORTANT ROLE FOR HOME MEASUREMENT OF BLOOD PRESSURE
An internet-based toolkit for home blood pressure measurement and including recording and tracking blood pressures can be found at
Patient information on selecting an approved device, and how to measure and track home blood pressure can be found at

58. Suggested Protocol for Home Measurement of Blood Pressure for the diagnosis of hypertension
Home blood pressure values should be based on:
duplicate measures,
morning and evening,
for an initial 7-day period.
Singular and first day home BP values should
not be considered.
Daytime average BP equal to or over 135/85
mmHg should be considered elevated.

59. AMBULATORY BP MONITORING? HOME BP MONITORING ?
HBM and ABPM more reliable and better indicators of future events than OBMvand mre useful in diagnosing WCH and MH > strong recommendations by CHEP for HBPM and ABPM

60. Home measurement of blood pressure
Home BP measurement should be encouraged to increase patient involvement in care
Which patients?
Uncomplicated hypertension
Diabetes mellitus
Chronic kidney disease
Suspected non adherence
Office-induced blood pressure elevation (white coat effect)
Masked hypertension
Average BP equal to or over 135/85 mm Hg should be considered elevated

61. Potential advantages of home blood pressure measurement
More rapid confirmation of the diagnosis of hypertension
Improved ability to predict cardiovascular prognosis
Improved blood pressure control
Can screen for white coat hypertension (WCH) and masked hypertension
Reduced medication use in some (WCH)
Improved adherence to drug therapy in the non adherent

62. Not all patients are suited to home measurement
Undue anxiety in response to high blood pressure readings
Physical or mental impairment prevents accurate technique or recording
Arm not suited to blood pressure cuff (e.g. conical shaped arm)
Irregular pulse or arrhythmias prevent accurate readings
Lack of interest
The vast majority of patients can be trained to measure blood pressure
2008 Canadian Hypertension Education Program Recommendations

63. 24 H BP monitoring Target organ damage caused by average BP
Poor correlation between office BP and 24 H average BP
ABPM superior to clinic BP in predicting organ damage and vascular events

65. Indications of AMBPM White coat hypertension Masked hypertension
Resistant hypertension
Hypotensive episodes
Postural Hypotension

66. Ambulatory BP Monitoring:
Beyond the diagnosis of hypertension, ABPM measurement may also be considered for selected patients for the management of HTN
Which patients?
Untreated
- Mild (Grade 1) to moderate (Grade 2) clinic BP elevation and without target organ damage.
Treated patients
- Blood pressure that is not below target values despite receiving appropriate chronic antihypertensive therapy.
- Symptoms suggestive of hypotension.
Fluctuating office blood pressure readings.

67. Patterns of AMBPM Dippers ( 10-20%) Non-Dippers (0-10%)
Reverse Dipping ( high night time BP)
Extreme Dipping ( >20%)
Morning Surges
Reverse dippers in which BP at night is slightly higher than day time and is associated with perhaps increased events. Extreme dippers in which BP dropps >10% of day time and is in some studies associated with caerebro vascualr events. One study showed risk of stroke greatest in reverse dippers then extreme dippers, non dppiers and trhen dippers
OSA in reverse dippers
No evidence of benefir for reversal of non dippers

68. Ambulatory BP Monitoring Specific Role in Selected Patients
How to ?
Use validated devices
How to interpret?
Mean daytime ambulatory blood pressure >135/85 mmHg
is considered elevated.
Mean 24 h ambulatory blood pressure >130/80 mmHg
A drop in nocturnal BP of <10% is associated with increased risk of CV events

69. Clinic, Home, Ambulatory (ABP) Blood Pressure Measurement equivalence numbers
A clinic blood pressure of 140/90 mmHg
has a similar risk of a:
Description
Blood Pressure mmHg
Home pressure average
135 / 85
Daytime average ABP
24-hour average ABP
130 / 80

70. Patients with high normal blood pressure should be followed annually.
Follow up algorithm for high Blood Pressure using Ambulatory Blood Pressure Measurement
24-h ABPM
Awake BP
>135 SBP or
>85 DBP or
24-hour
>130 SBP or
>80 DBP
Awake BP
< 135/85
and
24-hour
< 130/80
Consistent with HTN
Continue
to follow-up
Patients with high normal blood pressure should be followed annually.

71. Search for target organ damage
III. Assessment of the overall cardiovascular risk
Search for target organ damage
Cerebrovascular disease
- transient ischemic attacks
- ischemic or hemorrhagic stroke
- vascular dementia
Hypertensive retinopathy
Left ventricular dysfunction
Coronary artery disease
- myocardial infarction
- angina pectoris
- congestive heart failure
Chronic kidney disease
- hypertensive nephropathy (GFR < ml/min/1.73 m2)
- albuminuria
Peripheral artery disease
- intermittent claudication

72. Case 3
60 year old male of african – american back ground . Known high BP. On Lisinopril . BP always in the range of /
Treatment ?

73. Stroke – Subgroup Comparisons – RR (95% CI)
Amlodipine Better Chlorthalidone Better
0.50 1 2
Non-Diabetic
0.96 (0.81, 1.14)
Diabetic
0.90 (0.75, 1.08)
Non-Black
0.93 (0.79, 1.10)
Black
0.93 (0.76, 1.14)
Women
0.84 (0.69, 1.03)
Men
1.00 (0.85, 1.18)
Age >= 65
0.93 (0.81, 1.08)
Age < 65
0.93 (0.73, 1.19)
Total
0.93 (0.82, 1.06)
Lisinopril Better Chlorthalidone Better
0.50 1 2
Non-Diabetic
1.23 (1.05, 1.44)
Diabetic
1.07 (0.90, 1.28)
Non-Black
1.00 (0.85, 1.17)
Black
1.40 (1.17, 1.68)
Women
1.22 (1.01, 1.46)
Men
1.10 (0.94, 1.29)
Age >= 65
1.13 (0.98, 1.30)
Age < 65
1.21 (0.97, 1.52)
Total
1.15 (1.02, 1.30)
There was no difference across the pre-defined subgroups for the amlodipine vs chlorthalidone comparison.
For stroke, there was a significant differential effect by race, with p = .01 for interaction. The relative risks (lisinopril versus chlorthalidone) for stroke were 1.40 (p < .001) in Blacks and 1.00 (p=.96) in non-Blacks.
The mean follow-up systolic BP for all participants was 2 mm Hg higher in the lisinopril group than the chlorthalidone group, 4 mm Hg higher in Blacks. Adjustment for follow-up BP as time-dependent covariates in a proportional hazards model slightly reduced the relative risks for stroke (RR 1.15 to 1.11), overall and in the Black subgroup (stroke RR 1.40 to 1.36), but the results remained statistically significant. For various reasons, such adjusted analyses need to be interpreted cautiously.
P = .01 for interaction

74. Which drugs for blacks

75. Considerations Regarding the Choice of First-Line Therapy
Use caution in initiating therapy with 2 drugs where substantive blood pressure lowering is more likely or more poorly tolerated (e.g. those with postural hypotension).
ACE inhibitors and ARBs are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potential.
Beta adrenergic blockers are not recommended for patients age 60+ without another compelling indication.
Diuretic-induced hypokalemia should be avoided through the use of potassium sparing agent if required.
ACE-I are not recommended (as monotherapy) for black patients without another compelling indication.

76. CAUSES OF TREATED BUT UNCONTROLLED BP?

77. Case 5
50 year old hypertensive lady. On 3 BP lowering meds but BP uncontrolled. Non compliant with meds !!

78. Adherence to anti-hypertensive management can be improved by a multi-pronged approach
Assess adherence to pharmacological and non-pharmacological therapy at every visit
Teach patients to take their pills on a regular schedule associated with a routine daily activity e.g. brushing teeth.
Simplify medication regimens using long-acting once-daily dosing
Utilize fixed-dose combination pills
Utilize unit-of-use packaging e.g. blister packaging

79. Adherence to anti-hypertensive management can be improved by a multi-pronged approach
Encourage greater patient responsibility/autonomy in regular monitoring of their blood pressure
Educate patients and patients' families about their disease/treatment regimens verbally and in writing

80. Exogenous factors which can induce / aggravate BP
NSAIDs , Coxibs
Corticosteroids and anabolic steroids
OCP and sex hormones
Decongestants
Erythropoietin
MAOIs

81. Other substances and conditions
Licorice
Cocaine
Salt
Excessive alcohol
Sleep apnea

82. Case 4
60 year old male. Heavy smoker. Diabetes. Dyslipidemia. High BP and on Ramipril, HCT, Diltiazem. B/L carotid bruit. Worsening renal function over the last 6 months.
Thoughts ?

83. Renovascular Hypertension
Patients presenting with two or more of the following clinical clues listed below suggesting renovascular hypertension should be investigated.
sudden onset or worsening of hypertension and > age 55 or < age 30
the presence of an abdominal bruit
hypertension resistant to 3 or more drugs
a rise in creatinine of 30% or more associated with use of an angiotensin converting enzyme inhibitor or angiotensin II receptor blocker
other atherosclerotic vascular disease, particularly in patients who smoke or have dyslipidemia
recurrent pulmonary edema associated with hypertensive surges

84. Renovascular Hypertension
The following tests are recommended, when
available, to aid in the usual screening for renal
vascular disease:
captopril-enhanced radioisotope renal scan*
doppler sonography
magnetic resonance angiography
CT-angiography (for those with normal renal function
* captopril-enhanced radioisotope renal scan is not recommended for those with glomerular filtration rates <60 mL/min)

85. Hyperaldosteronism ( Conns syndrome)
Should be considered for patients with the following characteristics:
Spontaneous hypokalemia (<3.5 mmol/L).
Profound diuretic-induced hypokalemia (<3.0mmol/L).
Hypertension refractory to treatment with 3 or more drugs.
Incidental adrenal adenomas.

86. Hyperaldosteronism
Screening for hyperaldosteronism should include plasma aldosterone and plasma renin activity (or renin concentration)
- measured in morning samples.
- taken from patients in a sitting position after
resting at least 15 minutes.
Aldosterone antagonists, ARBs, beta-blockers and clonidine should be discontinued prior to testing.
A positive screening test should lead to referral or further testing.

87. Pheochromocytoma
Should be considered for patients with the following characteristics:
Paroxysmal and/or severe sustained hypertension refractory to usual antihypertensive therapy;
Hypertension and symptoms suggestive of catecholamine excess (two or more of headaches, palpitations, sweating, etc);
Hypertension triggered by beta-blockers, monoamine oxidase inhibitors, micturition, or changes in abdominal pressure;
Incidentally discovered adrenal mass;
Multiple endocrine neoplasia (MEN) 2A or 2B; von Recklinghausen’s neurofibromatosis, or von Hippel-Lindau disease. 

88. Pheochromocytoma
Screening for pheochromocytoma should include a 24 hour urine for metanephrines and creatinine.
Assessment of urinary VMA is inadequate.
A normal plasma metanephrine level can be used to exclude pheochromocytoma in low risk patients but the test is performed by few laboratories.

89. Life Style Modifications actually work?

90. Impact of Lifestyle Therapies on Blood Pressure in Hypertensive Adults
Intervention
Amount
SBP/DBP
Reduce foods with added sodium
mg sodium
hypertensive
-5.1 / -2.7
Weight loss
per kg lost
-1.1 / -0.9
Alcohol intake
- 3.6 drinks/day
-3.9 / -2.4
Aerobic exercise
min/week
-4.9 / -3.7
Dietary patterns
DASH diet
Hypertensive
Normotensive
-11.4 / -5.5
-3.6 / -1.8
Note: the extent of blood pressure change from each intervention should not be compared because the participants, the type and duration of intervention, and the basic design of the trials differed substantially.
Applying the 2005 Canadian Hypertension Education Program recommendations: 3. Lifestyle modifications to prevent and treat hypertension Padwal R. et al. CMAJ ･ SEPT. 27, 2005; 173 (7)

91. Thank You

92. Lifestyle Therapies in Hypertensive Adults: Summary
Intervention
Target
Reduce foods with added sodium
< 2300 mg /day
Weight loss
BMI <25 kg/m2
Alcohol restriction
Less or equal to 2 drinks/day
Physical activity
at least 30 minutes 4 times/week
Dietary patterns
DASH diet
Smoking cessation
Smoke free environment
Waist Circumference
- Europid, Sub-Saharan African, Middle Eastern
- South Asian, Chinese
- Japanese
Men Women
<94 cm <80 cm
<90 cm <80 cm
<85 cm <90 cm
Note: the extent of blood pressure change from each intervention should not be compared because the participants, the type and duration of intervention, and the basic design of the trials differed substantially.

93. Acute stroke

94. Current Recommendations
Do not treat high BP for 7-10days after stroke unless:
•Target organ damage
•SBP > 220 mm Hg or mean arterial pressure > 130
or DBP >120 mm Hg. ( AHA guide lines)
• Candidate for thrombolysis : SBP < 185 mm Hg and
DBP <110 mm Hg
More aggressive treatment of BP in patients with ICH
Most patients can be treated with oral agents.
IV Labetalol and Nitroprusside in more urgent situations
Avoid SL calcium channel blockers.