Hypertension

Robin Felker

Bloomer Hill-NCSRHC

September 16, 2009

Outline

Epidemiology of HTN Clinical Presentation

Symptoms BP measurement and interpretation

Interventions Behavior Modification Drugs

Comorbitities and Complications HTN at Bloomer Hill

Epidemiology

Epidemiology

Hypertension is the most common primary diagnosis in US (PDx in 35 million office visits)

Framingham Heart Study suggests that individuals who are normotensive at age 55 have a 90 percent lifetime risk for developing hypertension

In Stage I HTN, achieving a sustained 12 mmHg reduction in SBP over 10 years will prevent 1 death for every 11 patients treated If CVD or organ damage, only 9 patients would require such

BP reduction to prevent a death

Epidemiology

Age-adjusted prevalence of hypertension is significantly higher among blacks (39%) than among whites (29%)

Racial disparity in SBP control contributes to nearly 8,000 excess deaths annually from heart disease and stroke among blacks

Hypertension is the single largest contributor, of any medical condition, to racial disparity in adult mortality

Identifying HTN in the Clinic

Clinical Symptoms

Commonly ASYMPTOMATIC! “Classic Sx”: Headache, epistaxis, dizziness

No more frequent in HT than non-HT patients Flushing, sweating, blurred vision Family history (first degree relatives) Manifestations of organ damage

Will discuss later

Natural History Essential Hypertension (95% of cases)

Age of onset: 20-50 years Family history of hypertension (1st degree relatives) Gradual onset, mild-to-moderate BP Normal serum K+, urinalysis

Chronic Renal Disease (2-4%) Increased creatinine, abnormal urinalysis

Primary aldosteronism (1-2%) Decreased serum K+

Proper BP measurement Persons should be seated quietly for at least

5 minutes in a chair (rather than on an exam table), with feet on the floor, and arm supported at heart level

Need an appropriate-sized cuff (cuff bladder encircling at least 80 percent of the arm)

Release air so needle falls 2-3 mmHg/sec Be wary of stress, discomfort, and other

evidence of “White Coat HTN” Need elevated HTN on 2 separate occasions

Things to think about

Ideal PE should include BP confirmation, with verification in the contralateral arm Examination of the optic fundi Body mass index(BMI)/waist circumference Auscultation for carotid, abdominal, and femoral bruits Palpation of the thyroid gland Thorough examination of the heart and lungs Examination of the abdomen for enlarged kidneys, masses,

and abnormal aortic pulsation Palpation of the lower extremities for edema and pulses Neurological assessment

Things to think about

Laboratory tests Urinalysis and serum Cr/BUN (rule out renal disease) Serum potassium (aldosteronism) Blood glucose level (diabetes strongly linked to HTN and

renal disease) Serum Cholesterol (global vascular screen) ECG (to monitor for LVH)

Interpreting Blood Pressure

HTN Interventions

Interventions

Goal of treatment is to reduce cardiovascular and renal morbidity and mortality

A combination of lifestyle modifications and drug therapy are recommended

REMEMBER: The most effective therapy prescribed by the most careful clinician will control hypertension only if patients are motivated

Behavior Modifications

Lifestyle modifications are recommended even for those with near normal BP: ≥ 120/80

Eight modifications are recommended by the AHA: Eat a better diet, which may include reducing salt Enjoy regular physical activity Maintain a healthy weight Manage stress Avoid tobacco smoke Understand hot tub safety Comply with medication prescriptions If you drink, limit alcohol

= Cardiac disease, renal & diabetes

Drugs (on the $4 list…) Diuretics

Hydrochlorothiazide (HCTZ) and Chlorthalidone Thiazide-like diuretics have been shown to be best first-line

treatment ACEI

Lisinopril, Enalapril, Captopril, Benazepril ARB BB

Atenolol, Bisoprolol, Carvedilol, Metoprolol, Naldolol, Pindolol, Propranolol, Sotalol

CCB Diltiazem, verapamil

Most patients will need at least 2 drugs to achieve BP goals Combos: Lisinopril-HCTZ, Enalopril-HCTZ, Atenolol-Chlorthalidone,

Comorbidities and Complications

Comorbidities: Obesity

BMI >30 is an increasingly prevalent risk factor for the development of hypertension and CVD

Intensive lifestyle modification should be pursued in these individuals

Consider drug treatment for components of metabolic syndrome Obesity, glucose intolerance, high BP, high TGs,

low HDL

Comorbidities : Diabetes

Target of <130/80 mmHg Thiazide diuretics, BBs, ACEIs, ARBs, and

CCBs are beneficial in reducing CVD and stroke incidence in diabetics

ACEI- or ARB-based treatments favorably affect the progression of diabetic nephropathy and reduce albuminuria

Old Age

Hypertension occurs in more than two-thirds of individuals after age 65 However, this group has worst BP control

Lower initial drug doses may be indicated to avoid symptoms

But, standard recommendations should apply

Tx in Women

Oral contraceptives may increase BP Risk of hypertension increases with duration

of use Women taking oral contraceptives should

have their BP checked regularly Development of hypertension is a reason to

consider other forms of contraception

Tx in Minorities Impact of hypertension are increased in African

Americans African-Americans develop high blood pressure at younger ages

than other groups in the U.S. Complications are more likely to develop with high blood

pressure, including stroke, kidney disease, blindness, dementia, and heart disease

Reduced BP responses to monotherapy with BBs, ACEIs, or ARBs; want to include diuretic in treatment!

Differences in adherence by race may be due to affordability of medicines, personal beliefs, anticipated adverse effects, and health

BP control is lowest in Mexican American and Native American populations

Target organ damage Heart

Left ventricular hypertrophy Angina or prior myocardial infarction Prior coronary revascularization

Heart failure Brain

Stroke or transient ischemic attack Chronic kidney disease Peripheral arterial disease Retinopathy

Take Home Points

Hypertension is a VERY common medical condition Proper identification and treatment is essential to

preventing CHF and target organ damage Lifestyle modifications should start even in persons

with near-normal BP (≥120/80) Proper BP interventions include lifestyle

modifications and drug interventions Two-drug therapy may be necessary for control First line control is usually thiazide-like diuretic

Tx of BP with comorbidities must take into account concurrent treatment of comorbid conditions

HTN at Bloomer Hill

It is essential to follow BP trends and address HTN in our patients If someone has a high reading, ask about

caffeine/smoking, have them sit for 5 mins and recheck BP in the exam room

Try for repeat visit in anyone with high BP, especially >140/90

Follow-up: every 6 months for well-controlled, monthly/bi-monthly if uncontrolled, monthly with med changes

Counseling on lifestyle modifications for almost every patient is warranted! Try for discrete goals that the patient is on-board with and document them for follow-up

References Seventh Report of the Joint National Committee on Preventio

n, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7 Express).

Drugs for hypertension. Treatment Guidelines from the Medical Letter 2009; 7(77). http://medlet-best.securesites.com.libproxy.lib.unc.edu/restrictedtg/t77.html

Fiscella K, Holt K. Racial disparity in hypertension control: tallying the death toll. Ann Fam Med 2008;6:497-502.

Lilly. Pathophysiology of Heart Disease, ed 4. http://www.webmd.com/hypertension-high-blood-pressure/hyp

ertension-in-african-americans