1. Clinical Aspects of Hypertension Anna Maio, M.D.

2. Incidence and Prevalence 58-65 million Americans 30% incidence in the 18 and older age group 1/2 of people over 65 are hypertensive  15% of whites and 25% of African Americans--reason unknown  More common in men than in women up to the age of 50.

3. JNC 7 Report-JAMA-May, 2003 Classification of BP SystolicDiastolic Normal<120and<80 Prehyper- tension 120-139or80-99 Stage 1140-159or90-99 Stage 2>160or>100

4. Definition of Isolated Systolic Hypertension  Systolic blood pressure>160 mmHg  Diastolic blood pressure< or = 90 mmHg  Prevalence increases with age  11.7% of individuals >80 years of age  50% higher prevalence in women and African Americans

5. Emergent/Urgent Hypertension  DBP>120 mmHg and papilledema (malignant)  Usually renal failure or stroke or chest pain or confusion or hemolytic anemia is present  Requires admission to an ICU, arterial line and parenteral treatment

6. Risk Factors for Essential HTN  More common and more severe in blacks  Relationship between sodium intake and hypertension  Association between excess alcohol and HTN  Increased prevalence of obesity  More common among those with hostile attitudes

7. Identifiable Causes of Hypertension  Chronic kidney disease and renovascular disease (5-10%)  Sleep apnea  Chronic steroid therapy/Cushing syndrome  Primary aldosteronism  Pheochromocytoma  Coarctation of the aorta  Thyroid or parathyroid disease

8. Identifiable Causes Drug-Induced or Drug-Related  NSAIDS/COX-2 inhibitors  Cocaine, amphetamines, other illicit drugs  Sympathomimetics  OCPs  Adrenal steroids  Cyclosporine and tacrolimus  Erythropoietin  Licorice

9. History  Duration of disease  Prior treatment including drugs, doses, side effects  Use of estrogens, steroids, sympathomimetics, etc. (drugs taken are essential)  Family history of HTN, early cardiac death, pheo, renal disease  ROS focuses on the target organs

10. Physical Exam  Measurement of BP in both arms, BMI  Fundi  Auscultation for carotid, abdominal, and femoral bruits  Palpation of the thyroid  Heart, lungs, abdomen  Edema and pulses  Neuro assessment

11. Laboratory and Other Studies  Urinalysis  Glucose, serum potassium, creatinine, calcium  Hematocrit?  TSH?  Pregnancy test?  EKG?  Lipids?

12. Essential vs.. Secondary Causes  Use clues in the history and physical to order other testing  Acute BP rise over stable baseline  Age 50 years of age  Severe HTN with retinal involvement  Unexplained hypokalemia  No family history  Abdominal bruit

13. Complication Associated With Untreated Hypertension  Coronary Artery Disease  Cerebrovascular Disease  Left ventricular hypertrophy with congestive heart failure  Renal failure  Aortic dissection  Retinal hemorrhages/papilledema

14. Cardiovascular Disease Risk  Relationship is independent of other risk factors  The higher the BP the greater the chance of MI, HF, stroke, and kidney disease  Stage 1 and risk factors--12 mmHg decrease in systolic BP for 10 years will prevent 1 death for every 11 treated patients

15. Benefits of Treatment  35-40% mean reduction in stroke  20-25% in myocardial infarction  50% reduction in heart failure

16. Initial Drug Therapy

17. Treatment  Lifestyle changes  Treatment of hypertension with and without CI  Initiating therapy with 2 drugs if > 20/10 mmHg over goal/side effect problems  Use thiazide diuretics

18. Lifestyle Modifications  Weight reduction BMI=18.5-24.9  Adopt DASH eating plan Consume diet rich in fruits, veggies, and low-fat dairy  Dietary sodium reduction  Physical activity Regular aerobic activity at least 30 minutes/day most days/week  Moderation of alcohol consumption No more than 2/day

19. Compelling Indications  HF-diuretic, beta-blocker, ACEI, ARB, aldosterone antagonist  Post-MI-beta-blocker, ACEI, aldosterone antagonist  High coronary disease risk-diuretic, beta- blocker, ACEI, CCB  Diabetes-diuretic, beta-blocker, ACEI, ARB, CCB

20. Compelling Indications  Chronic kidney disease-ACEI, ARB  Recurrent stroke prevention-diuretic, ACEI

21. Favorable Drug Effects  Thiazides are useful in slowing the demineralization in osteoporosis  Beta-blockers can be used to treat arrhythmias, migraine, thyrotoxicosis, tremor, or stage fright  CCBs can be used in Raynaud’s and some arrhythmias  Alpha-blockers may be useful in prostatic hypertrophy

22. Unfavorable Drug Effects  Pregnancy--methyldopa, beta-blockers, and vasodilators; ACEI and ARBs are contraindicated because of fetal defects and should be avoided in women who are likely to get pregnant  Thiazides should be used with caution in gout or a history of hyponatremia  Avoid beta-blockers in reactive airway disease or heart block

23. Creating a Drug Regimen  Choose first drug very carefully; often a thiazide  Bring patient back in 1-2 weeks  Add second drug if needed; if first drug is not a diuretic the second one should be  Third drug is often a CCB or an alpha2 agonist  If the patient requires a 4th drug it is usually a potent vasodilator

24. Drug Regimen for Isolated Systolic Hypertension  Drugs shown to be of benefit (>33% reduction in stroke) are thiazide diuretics and beta-blockers  Always check orthostatic blood pressure since this can effect quality of life

25. Drug Regimens for Accelerated Hypertension  All drugs should be given in a monitered setting-CCU or ICU; consider an arterial line  Drugs should be given parenterally  Volume overload is common; assess need for loop diuretic  Nitroprusside, Enalapril, Esmolol, Cardizem are just a few of the drugs available IV now

26. Physicians’ Role  Strive for optimal blood pressure control  Look for identifiable causes and treat/eliminate when possible  Partner with the patient to choose the best drug regimen considering cost, convenience, side effects  Follow-up and education

27. Improving Hypertension Control  Clinical inertia

28. Questions?????