presentation hypertension 1

8/6/2019 Presentation Hypertension 1

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Copyright 2007 The Permanente Medical Group

Objectives

Describe benefits of blood pressure control

Understand changes in treatmentrecommendations

Update on appropriate medications


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Blood pressure is important!

Risk of stroke mortality doubles per 20 mm Hg increase in systolic bloodpressure

Fields LE. Mortality from stroke and ischemic heart disease increases exponentially with blood pressure. Hypertension. 2004 Apr;43(4):e28; author reply e28. Epub 2004 Feb 23.


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Ischemic Heart DiseaseIschemic Heart Disease

JNC 7, 2003


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Benefit of HTN Treatment


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Progress in Stroke Prevention

Stroke death rates have plummeted, due in great

measure to improvements in detection and treatment ofhigh blood pressure. The average American can expectto live 5 years longer today than was the case 30 yearsago, and nearly 4 years of that gain in life expectancycan be attributed to our progress against cardiovasculardiseases.

Claude Lenfant, M.D.Director, National Heart, Lung, and Blood Institute June 6, 2002Speech to the House Committee on Energy and Commerce Subcommitteeon Health


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Hypertension w CHF, DM, or CKD


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Blood Pressure and Heart Failure

BP targets in HF have not beenfirmly established

Most trials had SBP 110-130JNC 7 advises goal BP


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Blood Pressure and Diabetes

Hypertension Optimal Treatment (HOT) trial Lancet 1998


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Blood Pressure and Diabetes

HOT trial + UKPDS showed BP matters

HOT trial showed DBP


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Blood Pressure and Chronic

Kidney Disease

Cr Cl and Risk of CAD Event

Manjunath G, et al J Am Coll Cardiol 2003


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Blood Pressure and CKD

Kidney Disease Outcome Quality Initiative, Am J Kidney Dis 2002


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Blood Pressure and CKD

Reduced GFR (


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Blood Pressure and Elderly

CV events increase if SBP > 110Especially if BP >140

Trials show benefit when BP


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SHEP: Avg SBP 143 (diuretic txd)

Syst-Eur: Avg SBP 151

Did not get all people to SBP goal

Much CV benefit from BP reduction

Experts wonder if greater reductionwould lead to greater benefitMarvin Moser, MD, Medscape Cardiology 7(1), 2003.


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Appropriate Use of Medications*

Diuretics still the foundation for HTN care

ACE Inhibitors 2nd agentProven benefit in high risk groupsIn convenient combo pill w/HCTZ

Beta blockers 3rd - work well as add on med

DHP-Calcium Blockers 4th- some evidence existsavoid NonDHP Ca Blockers if on BB

*Without DM, CAD, CKD, or CHF

Kaiser Permanente Hypertension Clinical Guidelines


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ACE Inhibitor + Thiazide

(such as Lisinopril/HCTZ 10/12.5mg)

tab daily

Continue Treatment

SBP = 140s SBP = 150s

ACE Inhibitor + Thiazide

(such as Lisinopril/ HCTZ 10/12.5mg)

1 tab daily

Uncontrolled BP

Controlled BP

Continue treatment

Uncontrolled BP

See Hypertension ClinicalGuidelines page for next

steps.

Controlled BP

Combo Therapy for Stage 1 or 2 HTNHypertension Clinical Guidelines


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Combination Therapy

ACE Inhibitor + ThiazideSeparately or together as combination

BP > 159/99 (stage 2) advised

BP 140-159/90-99 (stage 1) an option

Very different from traditional step care


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CautionHCTZ+Triamterene combination formulations

should be avoided

ACE-I + Triamterene therapy CAN lead tohyperkalemia


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Generic Prinzide (HCTZ+Lisinopril) is an

excellent 1st

line drug Increased HTN control Reduced hypokalemia

Cardioprotective Available as a generic medication Increased adherence

ACE Inhibitor + HCTZ


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ACE-I CoughConsider continuing the ACE-I: 38-55% Likelihood the cough will resolve within 6 months (Reisin) Consider changing the time of administration or lowering the dose Consider antitussives or lozenges while waiting for symptom to

resolve

Consider switching to a 2 ND ACE-I : Effective for 1 in 10 patients (Charlon, Ravid)

Consider using a different drug class :

Diuretic, beta-blocker or calcium channel blocker If an ACE-I is indicated because of comorbid conditions (e.g. DM,

HF, CKD) an ARB (i.e. LOSARTAN) can be used as an alternative

Reisin L, J Hum Hypertens 1992Charlon V et al, Br J Clin Pharmacol 1995Ravid, D et al, J Clin Pharmacol 1994


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ALLHAT TREATMENT GROUP

CUMULATIVE EVENT RATES FOR THE PRIMARY OUTCOME(FATAL CHD OR NON-FATAL MI)

YEARS TO CHD EVENT

C U M U L A T I V

E C H D E V E N T R A T E

CHLORTHALIDONE 15,255 14,477 13,820 13.102 11,362 6,340 2,956 209AMLODIPINE 9,048 8,576 8,218 7,843 6,824 3,870 1,878 215

LISINOPRIL 9,054 8,535 8,123 7,711 6,662 3,832 1,770 195

NUMBER AT RISK:

CHLORTHALIDONE

AMLODIPINE

LISINOPRIL

10 2 3 4 5 6 70

.04

.08

.12

.16

.20RR (95% CI) p VALUE

A/C 0.98 (.90 1.07) 0.65L/C 0.99 (.91 1.08) 0.81

Copyright 2007 The Permanente Medical Group ALLHAT JAMA 2002


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ALLHAT TREATMENT GROUP

CUMULATIVE EVENT RATES FOR HEART FAILURE

CHLORTHALIDONE

AMLODIPINE

LISINOPRIL

10 2 3 4 5 6 70

.03

.06

.09

.12

.15

YEARS TO HEART FAILURE

C U M U L A

T I V E C H F R A T E

NUMBER AT RISK:

CHLORTHALIDONE 15,255 14,528 13,898 13.224 11,511 6,369 3,016 384AMLODIPINE 9,048 8,535 8,185 7,801 6,785 3,775 1,780 210

LISINOPRIL 9,054 8,496 8,096 7,689 6,698 3,789 1,837 313

RR (95% CI) p VALUE

A/C 0.98 (1.25 1.52) < 0.001

L/C 1.19 (1.07 1.31) < 0.001

Copyright 2007 The Permanente Medical Group ALLHAT JAMA 2002


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Appropriate Use of Medications

Same Med Pathway: ACE-I

add Diuretic

add BB

add DHP-CCB

In setting of Diabetes

AndChronic KidneyDisease


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Q: Which is better for people with diabetesand/or Chronic Kidney Disease-an ACE-I or diuretic?

Hint: this is a trick question.


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Q: Which is better for people with diabetesand/or Chronic Kidney Disease-an ACE-I or diuretic?

Hint: this is a trick question.

A: BOTH are usually needed!!


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BB

+ ACE-I

add Diuretic

add long acting

DHP-CCB (likefelodipine)

In setting of Coronary Artery

Disease


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2-4 BP Meds Usually Required for Control

UKPDS(

presentation hypertension 1

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