Clinical Aspects of Hypertension

Anna Maio, M.D.

Incidence and Prevalence58-65 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.

JNC 7 Report-JAMA-May, 2003 Classification of BP

Systolic Diastolic

Normal <120 and <80

Prehyper-

tension

120-139 or 80-99

Stage 1 140-159 or 90-99

Stage 2 >160 or >100

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

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

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

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

Identifiable CausesDrug-Induced or Drug-Related

NSAIDS/COX-2 inhibitors Cocaine, amphetamines, other illicit drugs Sympathomimetics OCPs Adrenal steroids Cyclosporine and tacrolimus Erythropoietin Licorice

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

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

Laboratory and Other Studies

Urinalysis Glucose, serum potassium, creatinine, calcium Hematocrit? TSH? Pregnancy test? EKG? Lipids?

Essential vs.. Secondary Causes

Use clues in the history and physical to order other testing

Acute BP rise over stable baseline Age<20 or >50 years of age Severe HTN with retinal involvement Unexplained hypokalemia No family history Abdominal bruit

Complication Associated With Untreated Hypertension

Coronary Artery Disease Cerebrovascular Disease Left ventricular hypertrophy with

congestive heart failure Renal failure Aortic dissection Retinal hemorrhages/papilledema

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

Benefits of Treatment

35-40% mean reduction in stroke 20-25% in myocardial infarction 50% reduction in heart failure

Initial Drug Therapy

Without CI With CI

Prehyper-tension

No drugtreatment

Drug Tx forCI

Stage 1 Thiazidediuretics formost

Drug Tx forCI//Others asneeded

Stage 2 2 DrugCombinationsfor most

Drug Tx forCI//Others asneeded

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

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

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

Compelling Indications

Chronic kidney disease-ACEI, ARB Recurrent stroke prevention-diuretic, ACEI

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

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

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

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

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

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

Improving Hypertension Control

Clinical inertia

Questions?????