1. Joshua M. Crasner,DO,FACC,FACOI

2.  50 million people USA  SBP>115 incr risk CAD/CVA  Q 20mm incr=2X risk  JNC-8 almost changed aggressive Tx  Pseudo-HTN Hypertension 2015 2

3. 3  Most common HBP( > 90 %)--multifactorial  increased peripheral resistance perpetuates the process of high blood pressure and all of its secondary effects  structural hypertrophy giving rise to smooth muscle hypercontractility  pressure varies throughout the day  major risk factor for coronary, renal, and cerebrovascular disease (50% of all USA deaths)  leading cause of doctor’s visit  carries prognostic value: 16X increased risk 40 y.o. smokes

4. Hypertension 2015 4  Patient seated/back supported/feet on floor  Should rest 5 minutes prior  Arm at heart level  No recent caffeine, tobacco, cocaine  Take medications as directed  Cuff size important  orthostatics

5.  Determine lifestyle/CV risk factors  ID and Tx secondary causes  ID target end organ damage brain, heart, kidney, eyes, arteries Hypertension 2015 5

6.  CNS: headache,confusion,visual,weakness,di sorientation, seizures  Renal: nocturia,hematuria,oliguria,edema  Opthal: blurred,diplopia,papilledema  CV:chest pain, palp’s,dyspnea,murmur,bruits,rhythm Hypertension 2015 6

7.  Cigarette smoking  Obesity  Inactivity  Dyslipidemia  Diabetes mellitus  Microalbuminuria  Male>55; Female>65  Fam Hx: male<55; female<65  Metabolic syndrome Hypertension 2015 7

8.  Endocrine  Cardiac  Renal Hypertension 2015 8

9.  Pheochromocytoma  Primary Aldosteronism  Cushing’s disease Hypertension 2015 9

10.  5 P’s: pressure,pain,palps,perspiration,pallor  Adrenal tumor or sympth ganglia  2-8 cases/million/year  0.5% in hypertensive patients  Usually sustained HBP,sometimes paroxysmal  Associated with MEN-2 a/b  Plasma metanephrines most sensitive  CT after plasma, then surgery Hypertension 2015 10

11.  Adrenal oversecretion  Hypertension,hypokalemia,alkalosis,hyper- glycemia  2-15% incidence  Screen w/aldo-renin ratio  Unusual hypokalemia,adrenal mass, early HTN, primary relative w/same  Tx w/spironolactone,eplerenone,surgery Hypertension 2015 11

12.  Hyperglycemia, hypokalemia,HTN  24hr cortisol  Obese, moon facies, purple striae Hypertension 2015 12

13.  Coarctation  Obstructive sleep apnea  Pregnancy  Post-op  Aging  Increased cardiac output Hypertension 2015 13

14.  Constriction beyond subclavian  Weak,delayed,absent FA pulse  Rib notching on CXR  Childhood  Tx surgical Hypertension 2015 14

15.  Obese, retrognathia,large neck  Loud snoring  Daytime hypersomnolence, morning headache  Polysomnography test Hypertension 2015 15

16.  Renal parenchymal disease  Renovascular HTN  Renal artery stenosis  Fibromuscular dysplasia Hypertension 2015 16

17.  Common cause secondary HTN  Rapid loss renal fxn if HTN-ive  Creat,urine analysis,protein  Decr elimination of salt and water,incr renin, decr vasodilation all lead to incr volume/fluid retention  Dihydropyridine CCB help decr proteinuria Hypertension 2015 17

18.  Atherosclerotic, e.g.CAD  Smokers>50, new HTN  Systolic/diastolic high pitched abd bruit  Suspect B/L if decr renal fxn w/ use of ACEi/ARB  PTA but higher restenosis  Rx  White female<30  No family Hx HTN  PTA treatment of choice Hypertension 2015 18

19. Hypertension 2015 19  Abdominal bruit: renal artery stenosis  Palps,HA,pallor,perspiration: pheochromocytoma  Obesity,moon face,purple striae: Cushing’s  Abd mass: polycystic kidney,hydroneph  Obesity,hypersomnolence: OSAS  Agitation, sweating: cocaine, ethanol,narc w/d  Hypokalemia: hyperaldosteronism  Hypercalcemia: hyperparathyroidism

20. Hypertension 2015 20 Simple Guide to work up secondary causes of HTN

21.  Alpha methyldopa first DOC  Hydralazine,some BB ok, diuretics  Avoid ACEi/ARB/renin inhibitors Hypertension 2015 21

22.  BCPs  EtOH  Decongestants,diet pills  NSAIDs  MAO  Cocaine  Marijuana  Licorice  cyclosporine Hypertension 2015 22

23. Hypertension 2015 23 CATEGORYSYSTOLIC BPDIASTOLIC BP normal < 120 and < 80 Pre-HTN 120-139 or 80-89 Hypertension Stage 1 140-159 or 90-99 Stage 2 ** ≥ 160 or ≥ 100 JAMA 289; 2560-72: 2003 **Add 2 nd Rx

24. Hypertension 2015 24

25. Hypertension 2015 25

26.  1. In the general population aged ≥60 years, initiate pharmacologic treatment to lower blood pressure (BP) at systolic blood pressure (SBP) ≥150 mm Hg or diastolic blood pressure (DBP) ≥90 mm Hg and treat to a goal SBP <150 mm Hg and goal DBP <90 mm Hg. (Strong Recommendation – Grade A) In the general population aged ≥60 years, if pharmacologic treatment for high BP results in lower achieved SBP (e.g., <140 mm Hg) and treatment is well tolerated and without adverse effects on health or quality of life, treatment does not need to be adjusted. (Expert Opinion – Grade E) 2. In the general population <60 years, initiate pharmacologic treatment to lower BP at DBP ≥90 mm Hg and treat to a goal DBP <90 mm Hg. (For ages 30- 59 years, Strong Recommendation – Grade A; for ages 18-29 years, Expert Opinion – Grade E) 3. In the general population <60 years, initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg and treat to a goal SBP <140 mm Hg. (Expert Opinion – Grade E) 4. In the population aged ≥18 years with chronic kidney disease (CKD), initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg and treat to goal SBP <140 mm Hg and goal DBP <90 mm Hg. (Expert Opinion – Grade E) 5. In the population aged ≥18 years with diabetes, initiate pharmacological treatment to lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg and treat to a goal SBP <140 mm Hg and goal DBP <90 mm Hg. (Expert Opinion – Grade E) 6. In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin-receptor blocker (ARB). (Moderate Recommendation – Grade B) 7. In the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or CCB. (For general black population: Moderate Recommendation – Grade B; for black patients with diabetes: Weak Recommendation – Grade C) 8. In the population aged ≥18 years with CKD, initial (or add-on) antihypertensive treatment should include an ACEI or ARB to improve kidney outcomes. This applies to all CKD patients with hypertension regardless of race or diabetes status. (Moderate Recommendation – Grade B) 9. The main objective of hypertension treatment is to attain and maintain goal BP. If goal BP is not reached within a month of treatment, increase the dose of the initial drug or add a second drug from one of the classes in recommendation 6 (thiazide-type diuretic, CCB, ACEI, or ARB). The clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached. If goal BP cannot be reached with two drugs, add and titrate a third drug from the list provided. Do not use an ACEI and an ARB together in the same patient. If goal BP cannot be reached using only the drugs in recommendation 6 because of a contraindication or the need to use more than three drugs to reach goal BP, antihypertensive drugs from other classes can be used. Referral to a hypertension specialist may be indicated for patients in whom goal BP cannot be attained using the above strategy or for the management of complicated patients for whom additional clinical consultation is needed. (Expert Opinion – Grade E) 10. Although this guideline provides evidence-based recommendations for the management of high BP and should meet the clinical needs of most patients, these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient. Future guidelines should cover the full range of cardiovascular care topics, to develop an integrated approach for prevention, detection, and evaluation, along with treatment goals. Individual recommendations from discrete guidelines—such as for hypertension, cholesterol, and obesity—may not reflect the integrated care needed for many patients seen in practice. There is also a need to harmonize the hypertension guideline with other cardiovascular risk guidelines and recommendations, thereby resulting in a more coherent overall cardiovascular prevention strategy. Author(s):  Debabrata Mukherjee, M.D., F.A.C.C. (Disclosure Debabrata Mukherjee, M.D., F.A.C.C. (Disclosure Hypertension 2015 26

27. Patient SubgroupTarget SBPTarget DBP > 60 years<150<90 <60 years<140<90 >18 years w CKD<140<90 >18 years w DM<140<90 Hypertension 2015 27 James PA, et al.,JAMA,2013 Dec18

28.  General non-African population Thiazides, CCB,ACEi,or ARB initially  General African population Thiazides or CCB initially  CKD Include ACEi or ARB  Uptitrate/add RX after 1mo.if not at goal Don’t use ACEi and ARB jointly If >3 Rx needed refer to specialist Hypertension 2015 28 James PA, et al.,JAMA, 2013 Dec 18

29.  ANSWER??  FOLLOW THE AHA/ACC BP guidelines  Start lifestyle changes and then Rx at 140/90 up to age 80, then at 150/90  Position paper of JACC July 2014 refutes, citing placement of mostly elderly African-American women at incr. risk for CVD mortality**  Stage 2(>160/100 or >20 goal, add 2 nd Rx Hypertension 2015 29 **Krakoff, et al; JACC, July 29,2014;394-402

30.  JACC 65, No.18, May 12, 2015, 1998- 2038  “Treatment of HTN in Patients with CAD”  Renal denervation equivocal  JNC-7 supported  Target BP in HF pts <140/90, consider <130/90 Hypertension 2015 30

31.  Ischemic systolic HF  avoid CCB’s s/a diltiazem/verap…..dihydropyridine CCB’s ok (amlodipine/felodipine)..PRAISE and V- HEFT trials  Avoid clonidine  Avoid doxazosin (ALLHAT trial) Hypertension 2015 31

32. Hypertension 2015 32

33. Hypertension 2015 33  Urine analysis  Chemistry panel  Cholesterol  CBC  Endocrine  Drug screen

34. Hypertension 2015 34  Heart failure: ACEi, ARB, diuretics, BB  Diabetes: ACEi, ARB  CAD/post-MI: BB, ACEi,(CCB for intol.)  Systolic HTN: ACEi/ARB with diuretic, BB, CCB  Pregnancy: labetalol, methyldopa, CCB  Prostate enlargement: alpha blocker  Renal disease: ACEi or ARB

35.  Lima, et al., JACC 2015; 65:2679-87  CARDIA study  Conclusion: longterm exposure over 25 yrs leads to systolic/diastolic dysfxn middle age.  Aggressive diastolic BP control rec’d Hypertension 2015 35

36.  <140/90  Diabetics/CKD/High risk CAD <130/80  Reduced EF; proteinuria <120/80 Hypertension 2015 36

37. Hypertension 2015 37  Familiarity with target end-organ damage  What is ideal BP?  Causes of secondary hypertension  Ideal agents for condition(s)  Familiarity with treatment options