1. HYPERTENSION RECOMMENDATIONS FOR FOLLOW UP BASED ON INITIAL BP READING <130/852 YEARS 130-139/85-891 YEAR 140-149/90-99E & M < 2 MONTHS 160-179/100-109 E & M < 1 MONTHS >180/110E & M NOW MODIFY BASED ON AGE, CO-MORBIDITY ALMOST LINEAR RISE IN INCIDENCE WITH AGE

2. HYPERTENSION AWARENESS, DETECTION, TREATMENT 1988-1981 AWARENESS - 73% TREATED - 55% CONTROLLED - 29% 1991-1994 - 68% - 53% - 27%

3. HYPERTENSION BENEFITS OF TREATMENT TREATEDUNTREATED STROKE @ 6 YRS 9.8% 5.0% CVS EVENT REDUCTION 30% IN ALL FEMALES 48% IN BLACK MALES >50% IN WHITE MALES

4. HYPERTENSION CVS RISK STRATIFICATION MAJOR. TOD OR CCD SMOKING HEART DISEASE DIABETES LVH DYSLIPIDEMIA ANGINA, PRIOR MI GENDER PRIOR CABG/CHF FAMILY HISTORY STROKE OR TIA AGE > 60 YEARS RENAL DIS/ PVD

5. HYPERTENSION RISK STRATIFICATION & RX BLOOD PRESSURE NO RISK GROUP A 1 RISK GROUP B TOD/ CCD/ DM GROUP C HIGH NORMAL (130-139/85-89) LIFE STYLE CHANGE DRUG THERAPY STAGE I (140-149/90-99) LIFE STYLE CHANGE UPTO 1 YEAR LIFE STYLE CHANGE UPTO 6 MOS. DRUG THERAPY STAGE II –III (>160/100) DRUG THERAPY

6. HYPERTENSION NON PHARMACOLOGIC INTERVENTIONS WEIGHT REDUCTION ++++ SODIUM REDUCTION +++ STRESS REDUCTION + CALCIUM, MAGNESIUM, POTASSIUM FISH OIL +/-

7. HYPERTENSION ANTIHYPERTENSIVE RESPONSE RESPONSE RATE IN AA POPULATION DILTIAZEM - 85% HCTZ - 60% CLONIDINE - 56% PRAZOSIN - 40% ATENOLOL - 35% CAPTOPRIL - 30% PLACEBO - 20%

8. SYSTOLIC HYPERTENSION > 60 YRS OF AGE. SYSTOLIC BP RISES. DIASTOLIC BP FALLS. WIDER PULSE PRESSURE. DECREASED ARTERIAL COMPLIANCE INDEPENDENT CVS RISK. ISH – 2-4 FOLD RISK OF MI, LVH, CVA

9. SYSTOLIC HYPERTENSION SYSTOLIC > 160 mm.Hg. DIASTOLIC < 90 mm.Hg. SYSTOLIC BP > 140 mm.Hg. ABNORMAL AT ANY AGE. ASSOCIATED WITH HIGHER RISK OF STROKE, CVS EVENTS

10. SYSTOLIC HYPERTENSION SLEW OF TRIALS : SHEP (SYSTOLIC HYPERTENSION IN THE ELDERLY) SYS-EUR STONE TRIAL FROM SHANGHAI SYST-CHINA TRIAL TONE TRIAL STOP TRIAL ALLHAT TRIAL ROTTERDAM STUDY FRAMINGHAM STUDY

11. SYSTOLIC HYPERTENSION GOALS OF THERAPY LOWER SYSTOLIC BP BY 20mmHg. TO 140 mmHg CONSIDER NON-PHARMACOLGIC APPROACH CAUTIOUS REDUCTION IN ELDERLY SCREEN FOR POSTURAL OR PP BP DROP START WITH “HALF” DOSE CONTROVERSY RE: J – CURVE EXCESSIVE LOWERING (<65 mmHg) OF DIASTOLIC BP MAY INCREASE RISKS.

12. SYSTOLIC HYPERTENSION THIAZIDE DIURETICS BETA BLOCKERS RESERPINE (!) CA ++ CHANNEL BLOCKERS LONG ACTING NITRATES ACE INHIBITORS ARB-S ALPHA BLOCKERS

13. SYSTOLIC HYPERTENSION ISOLATED SYSTOLIC HYPERTENSION (ISH) GENERALLY INADEQUATELY TREATED BP > 160 mm.Hg. SHOULD BE ACTIVELY TREATED WITH OR W/O DIASTOLIC HTN MORE STRINGENT CRITERION FOR R X IF ADDITIONAL RISK FACTORS COEXIST SMOKING, DIABETES

14. SYSTOLIC HYPERTENSION SHEP TRAL (SYST. HYP. IN THE ELDERLY. JAMA 1991) MEAN AGE 72 YRS. 57% FEMALE. 14% AA 4736 PTS. MEAN BP 170/77 mm.Hg. 2365 IN R X GROUP. BP ACHIEVED 143/68 mm.Hg. 2371 PLACEBO. BP ACHIEVED 155/72 mm.Hg. AIM TO REDUCE BP AT LEAST 20 mm.Hg. TO <160 SYSTOLIC CHLORTHALIDONE, ATENOLOL, RESERPINE RELATIVE RISK CVA 0.64 CVS 0.73 (NORMOKALEMIA REQUIRED) OVERALL MORTALITY 0.87. 18 PATIENTS R X FOR 5 YRS TO PREVENT A MAJOR EVENT.

15. SYSTOLIC HYPERTENSION SYS-EUR TRIAL (LANCET 1997) LONG ACTING DIHYDROPYRIDINES NITRENDIPINE, NIFEDIPINE ACCEPTABLE ALTERNATIVE R X FOR ISH BETA BLOCKERS W/O DIURETICS DO NOT REDUCE CORONARY MORTALITY LONG ACTING NITRATES PREFERENTIALLY LOWER SYSTOLIC BP W/O TACHYPHYLAXIS

16. SYSTOLIC HYPERTENSION TONE TRIAL (TRIAL OF NON-PHARMACOLOGIC INTERVENTION IN THE ELDERLY) 975 PTS. 60-80 YRS. BP <145/<85 mmHg ON ONE R X Na + RESTRICTION 100-120 MEQ/DAY. TENDENCY TO INCREASE SALT B/O DIMINISHED TASTE DEPENDENCE ON PROCESSED/PACAKAGED FOOD WEIGHT REDUCTION BOTH NONE

17. SYSTOLIC HYPERTENSION STOP TRIAL (SWEDISH TRIAL IN OLD PATIENTS) 6614 PTS. 70-84 YRS OF AGE SYSTOLIC > 180 DIASTOLIC > 105 mmHg. BETA BLOCKER/DIURETIC (CAD; TACHYCARDIA) ACEI (ENALAPRIL, LISINOPRIL IN LV DYSFX/CRI/DM) Ca++ CHANNEL BLOCKERS (ANGINA, DIASTOLIC DYSFX, PVD -- ISRADIPINE, FELODIPINE) BP 194/98 TO 159/81 mmHg. NO DIFFERENCE IN 3 GROUPS @ 4-5 YR FOLLOW UP.

18. SYSTOLIC HYPERTENSION ALLHAT TRIAL (ANTIHYPERTENSIVE & LIPID LOWERING R X TO PREVENT HEART ATTACK TRIAL JAMA 1967, ANN INT MED 2002) ALPHA BLOCKERS - CHF RISK MAY HELP IN PROSTATISM

19. SYSTOLIC HYPERTENSION TREATMENT THERAPY IS BENEFICIAL IN ISH AIM @ 20 MM.Hg REDUCTION IN BP TO A LEVEL BELOW 160 MM.Hg (SHEP TRIAL) DIURETICS IN LOW DOSE (THIAZIDE/ K-SPARING) ATENOLOL (25-50 MG) OR RESERPINE (!!! 0.5 MG) ADDED IF REQUIRED LONG ACTING DHP Ca++ CHANNEL BLOCKERS SUSTAINED RELEASE NITRATES ALPHA BLOCKERS (SYS-EUR/ STONE TRIAL) SPECIAL BENEFIT IN DIABETES