treatment of hypertension jai radhakrishnan, m.d. division of nephrology based on the seventh report...
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Treatment of Hypertension
Jai Radhakrishnan, M.D.Division of Nephrology
Based on the Seventh Report of the
Joint National Committee on
Prevention, Detection ,Evaluation and Treatment
of High Blood Pressure (JNC-7)
Objectives Define hypertension Principles of treatment Special groups
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Blood Pressure Classification
BP CLASSIFICATION
SBP DBP
Normal <120 and <80
Prehypertension120-139 or 80-89
Stage 1 HTN 140-159 or 90-99
Stage 2 HTN >160 >100
Why Treat Hypertension ? To decrease:
Cerebrovascular Accidents 35-40% Coronary events 20-25% Heart failure 50% Progression of renal disease Progression to severe hypertension All cause mortality
Awareness, Treatment and Control of Blood Pressure 1976-2000 (NHANES)
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1976-1980 1988-1991 1991-1994 1999-2000
AwarenessTreatmentControl
Factors to Consider in Treating Hypertension
Repeat readings r/o secondary causes Estimate CV risk status Co-morbid conditions Lifestyle changes Drugs
“Secondary” Hypertension
Difficult to control Sudden onset of HTN Well controlled-> difficult to
control Severe hypertension History/physical/labs
Initial Workup of Secondary HTN Renal parenchymal disease
UA, spot urine protein/creatinine, serum creatinine, USG.
Renovascular Captopril scan
Coarctation Lower Extremity BP
Primary aldosteronism Serum and urinary K Plasma renin and aldosterone ratio
Pheochromocytoma Spot urine for metanephrine/creatinine
Laboratory Tests in Uncomplicated HTN ECG Urine analysis Blood glucose, hematocrit Basic metabolic panel Lipid profile after 9-12 hour fast Urine microalbumin
Estimate Risk Status Hypertension Smoking Obesity (BMI > 30kg/m2) Dyslipidemia Diabetes Microalbuminuria or GFR <60ml/min Age > 55 (men), 65 (women) Family history of CVD
(Men< 55, Women <65)
Metabolic Syndrome
Target Organ Damage Heart Disease
CAD (Angina, myocardial infarction, coronary revascularization
Left Ventricular Hypertrophy Heart Failure
Stroke/TIA Chronic kidney disease Peripheral arterial disease Retinopathy
Goals of Therapy BP <140/90 mmHg
BP <130/80 mmHg in patients with diabetes or chronic kidney disease.
Achieve SBP goal especially in persons >50 years of age.
Lifestyle ModificationModification Approximate SBP
reduction(range)Weight reduction 5–20 mmHg/10 kg weight loss
Adopt DASH eating plan
8–14 mmHg
Dietary sodium reduction
2–8 mmHg
Physical activity 4–9 mmHg
Moderation of alcohol consumption
2–4 mmHg
Drugs for Hypertension Diuretics
Thiazide Loop diuretics Aldosterone antagonists K-sparing
Adrenergic inhibitors Peripheral agents Central (α-agonists) alpha -blockers* beta-blockers Alpha+beta-blockers
Direct Vasodilators *
Calcium channel blockers
Dihydropyridine Non dihydropyridine
ACE-inhibitors
Angiotensin-II blockers
* Usually not monotherapy
Algorithm for Treatment of Hypertension
Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease)
Initial Drug Choices
Drug(s) for the compelling indications
Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB)
as needed.
With Compelling Indications
Lifestyle Modifications
Stage 2 Hypertension (SBP >160 or DBP >100 mmHg)
2-drug combination for most (usually thiazide-type diuretic and
ACEI, or ARB, or BB, or CCB)
Stage 1 Hypertension(SBP 140–159 or DBP 90–99
mmHg) Thiazide-type diuretics for most.
May consider ACEI, ARB, BB, CCB,
or combination.
Without Compelling Indications
Not at Goal Blood Pressure
Optimize dosages or add additional drugs until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
Classification and Management of BP for adults
*Treatment determined by highest BP category.†Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.‡Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.
BP Class SBP DBP Lifestyl
e
Initial drug therapy
Without compelling indication
Compelling indications
Normal <120 <80 Encourage
None None
Pre-hypertension
120–139
or 80–89
Yes No antihypertensive drug indicated.
Drug(s)
Stage 1 Hypertension
140–159
or 90–99
Yes Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination.
Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed.
Stage 2 Hypertension
>160 or >100
Yes Two-drug combination (usually thiazide and ACEI or ARB or BB or CCB).
Special Considerations
Compelling IndicationsSpecial populations
HTN with COPD and MIA 55 year old patient with COPD and HTN
(controlled with nifedipine) is admitted with severe chest pain x24 hrs.
BP is 170/100 and she has a soft S3 gallop.
ECG shows an anterior wall MI.
She is not a candidate for thrombolysis. ECHO shows an ejection fraction of 35%.
How will you manage her hypertension?
Compelling Indications for Certain Drug Classes
HTN with CAD Beta blockers: cardioprotective
(reinfarction, arrhythmias and sudden death)
ACE inhibitors: MI with systolic dysfunction- heart failure and mortality improved
Renal Insufficiency A 30 year old patient with IDDM is referred
with difficult-to-control HTN on diltiazem and clonidine.
Exam reveals BP=190/100 and 3+ edema.
Labs: Creatinine = 2.2 mg/dL
Serum K = 5.1 meq/L24 hour protein = 5 g
Hypertension with Renal Insufficiency
Goal BP <130/80 ACE-inhibitors/angiotensin receptor
blockers should be used if no contraindications
Most patients have volume overload: Diuretics should be included in the regimen. Thiazides ineffective if S Creat>2.5
A 40 year old previously healthy male is brought to the E.R. with 3 days of progressive shortness of breath and has experienced blurred vision in both eyes.
Physical exam:
Blood pressure 230/140. Lethargic. Eye exam: PapilledemaChest: Bibasilar cracklesCardiac: S1S2S4Neuro: Bilateral upgoing plantars:Extr: 2+ edema
Labs: K=3.4, BUN=35, Creatinine: 2.2
CXR: Pulmonary edema
Urine: 10-15 red cells, 2+ albumin.
Hypertensive Urgencies and Emergencies
HYPERTENSIVE EMERGENCIES Require immediate blood pressure reduction (not
necessarily to normal range) to prevent or limit target organ damage.
HYPERTENSIVE URGENCIES Require reduction of blood pressure within a few
hours
Emergencies & Urgencies
HYPERTENSIVE EMERGENCIES
Require immediate blood pressure reduction (not necessarily to normal range) to prevent or limit target organ damage.
HYPERTENSIVE URGENCIES
Require reduction of blood pressure within a few hours
Parenteral Drugs For Treatment of Hypertensive Emergencies
VASODILATORS Nitroprusside Fenoldopam Nitroglycerine Enalaprilat Nicardipine Hydralazine
ADRENERGIC INHIBITORS
Labetalol Esmolol Phentolamine
Pregnancy and HypertensionA 24 year old primiparous woman is seen in
the obstetric clinic at 30 weeks gestation.
BP: 160/100, 2 + pedal edemaOtherwise unremarkable physical exam.Urine shows 1000 mg of protein. Other labs: N
After 2 days of bed rest BP remains 160-170/100
Drug Therapy of the Hypertensive Pregnant Patient
Methyldopa: Drug of choice. Beta blockers (not early pregnancy). Hydralazine is the parenteral drug of
choice.
Most agents if used prior to pregnancy may be continued (except ACE-I OR A-II BLOCKERS)
Resistant Hypertension Improper BP measurement Excess sodium intake Inadequate diuretic therapy Medication
• Inadequate doses• Drug actions and interactions (e.g., nonsteroidal anti-inflammatory
drugs (NSAIDs), illicit drugs, sympathomimetics, oral contraceptives)• Over-the-counter (OTC) drugs and herbal supplements
Excess alcohol intake Identifiable causes of HTN
Conclusions The initial approach to hypertension should start with ruling out secondary
causes, detecting and treating other cardiovascular risk factors, and looking for target organ damage.
Treatment should always include lifestyle changes. Medication use should be guided by the severity of HTN and the
presence of “compelling” indications. Thiazide-type diuretics should be initial drug therapy for most, either
alone or combined with other drug classes. Most patients will require two or more antihypertensive drugs
Conclusions HTN is a risk factor for mortality
and cardiovascular and renal disease
HTN is common but not controlled. Target BP 140/90 (130/80 in DM,
CKD) Remember Compelling Indications
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