高血压英文ppt精品课件hypertension in _1

HYPERTENSION IN ELDERLY Dr. Kunal Kothari Emeritus Professor of Medicine and Clinical Cardiology Director Primary Health Care and Strategic initiative HYPERTENSION K I L L E R I S E N T L O W n Sphygmanometer- size of the cuffs n Food n Exercise n Caffeine n Smoking 200 140 160 120 180 20 40 60 80 100 0 A softer blowing sound A sharp thump A softer thump A blowing or whooshing sound K1 K2 K3 K4 K5 Benefits of Lowering Blood Pressure Antihypertensive Therapy has been associated with reductions in: X Stroke Incidence (35-40 %). X MI (20-25 %). X Heart Failure ( averaging 50 %). Guidelines The Seventh Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII) uses the following guidelines to define HTN in adults:Category Systolic Diastolic Normal 160 or 100 135/85 Ambulatory Pressure 140/90 Clinic Pressure Sustained Hypertension White Coat Hypertension True Normotension Masked Hypertension Pseudo Hypertension n Recording of high B.P. but do not have n Common cause of this is brachial artery compression WHITE COAT HYPERTENSION n BP recording in office or clinic is high while at home is normotensive n “white coat“ hypertension appear to have no greater risk than people with normal blood pressure ( Aug. 2, 2005, American college of cardiology ) MASKED HYPERTENSION Proposed the term masked hypertension Pickering et al (Hypertension 2002;102:1139- 44) Documented by Ohkubo et al (N Engl J Medicine 2003;348:2407-15) MASKED HYPERTENSION n HYPERTENSION IS NOT DETECTED BY THE ROUTINE METHODS. “UNDETECTED AMBULATORY HYPERTENSION“ n UNUSUALLY HIGH AMBULATORY PRESSURE OR A LOW CLINIC PRESSURE ON THAT PARTICULAR OCCASION n SHOW MORE EXTENSIVE TARGET ORGAN DAMAGE THAN TRUE NORMOTENSIVE SUBJECTS Blood Pressure in 347,978 men aged 35-57 screened for MRFIT 160 % of Men Systolic pressure mmHg Lifetime Risk of Developing Hypertension in Middle Aged (Vasan et al, JAMA 2002; 287: 1010) Risk for Hypertension in a 55 year old Time, yr Women Men 52% 56% 72% 78% 83% 88% 25 91% 93% Diagnostic Evaluation of the Hypertensive Patient- How much is enough? n How high is the blood pressure? n Why is it high? n What is the risk? Clinical Manifestations I Physical exam: Abdomen Funduscopic Vascular Cardiac Pulmonary Neurological Lab tests: Urinalysis Blood Chemistry ECG Renal ultrasound Echocardiogram Vascular studies Differential Diagnosis Rule out isolated incident of increased blood pressure. Rule out secondary hypertension related to: Renal disease Cushings disease Pheochromocytoma Hyperthyroidism Hyperparathyroidism Complications Complications as a result of HTN include: Stroke Dementia Myocardial Infarction Congestive Heart Failure Retinal Vasculopathy Aortic Dissection Renal Disease or Failure Management Medications Diuretics- Thiazides (HCTZ), Loop (Furosemide), Potassium- sparing (Spironolactone) Beta-Blockers- Atenolol, Nadolol, Propranolol ACE Inhibitors- Benezapril, Captopril, Cilizapril ARBs- Losartan, Valsartan Ca+ Channel Blockers- Nifedipine, Verapamil Alpha blockers- Prazosin, Terazosin Vasodilators- Apresoline Management Primary goal is to reduce cardiovascular and renal morbidity and mortality. Other keys to management are: Prevention Patient education Life-style modification Medication Hospitalization should be considered if Very high BP Severe headache Chest pain Neurologic symptoms Altered mental status Acutely worsening renal failure S 5:12 Bentley Dw, Izzo JL. J Am Geriatr Soc. 1982; 30:352-359. Stroke Volume Aorta Resistance Arterioles Pressure (Flow) Young Artery Systole Diastole Elastic Vessel Arteriosclerotic Artery Stiff Vessel Systole Diastole Arterial Wall Compliance and Pulse Pressure Wave Do lifestyle measures really work for elderly hypertension? Modification Approximate SBP Reduction (range) Weight Reduction 5-10 mmHg/10kg Adopt DASH eating plan 8-14 mmHg Dietary sodium reduction 2-8 mmHg Physical activity 4-9 mmHg Moderation of alcohol consumption 24 mmHg Lifestyle Modifications Bar graph shows change in mean arterial blood pressure used to define salt responsivity as a function of age in normotensive open bars and hypertensive color bars subjects. Change in Mean Arterial Blood Pressure Weinberger M. Hypertens 1991; 18:69 Effect of 30 minute walk 3 days a week Age 70 - 79 Systolic Diastolic Exercise Group Baseline 156 10 mm Hg 86 8 mm Hg 3 months 151 15 mm Hg 80 6 mm Hg Control Group Baseline 153 7 mm Hg 85 8 mm Hg 3 months 156 10 mm Hg 85 6 mm Hg Conone et al. Med Scl in Sports and Exercise. 1991 What is the effect of drug therapy related to age? Are the recommendations different? Antihypertensive Drugs nAACEI, ARBs nBBeta Blocker nCCCB nDDiuretic nDlow dose HCTZ nA nB nC Algorithm for Management of the Elderly - Primarily Systolic Hypertension 1) Lifestyle changes 2) Low dose diuretic (12.5 mg HCTZ) CCB B-Blocker ACE or ARB 3) Stop, Look 160:284 Major Clinical Trials Showing Benefit of Treating Isolated Systolic Hypertension SHEP Syst-Eur Syst-China (n=4736) (n=4695) (n=2394) Baseline 160-219/ 160-219/ 160-219/ SBP/DBP (mm Hg) 90 95 95 BP reduction: 27/9 23/7 20/5 SBP/DBP (mm Hg) Drug therapy Chlorthalidone Nitrendipine Nitrendipine Atenolol Enalapril Captopril HCTZ HCTZ Outcomes (%) Stroke 33 42 38 CAD 27 30 27 CHF 55 29 All CVR disease 32 31 25 Journal of Clinical Hypertension Vol II, No. 5, page 336, September/October 2000. Independent Predictors of Using Antihypertensives Medications in 2000 Variable Adjusted OR (95% CI) of Using Antihypertensives Comorbid conditions Asthma/COPD 0.43 (0.40-0.47) Depression 0.50 (0.45-0.55) GI disorders 0.59 (0.54-0.64) Osteoarthritis 0.63 (0.59-0.67) Cardiovascular conditions Coronary artery disease 1.31 (1.23-1.40) Cerebrovascular disease 1.03 (.97-1.10) Congestive heart failure 1.05 (0.99-1.11) Diabetes 1.16 (1.10-1.22) Wang PS et al. Hypertension 2005; 46:273-279 Barriers to Optimal Control of Hypertension Inaccurate measurement of blood pressure (BP) Focusing on diastolic BP rather than systolic BP goal Failure to consider absolute global risk Failure to advocate lifestyle modifications Failure to use polypharmacy Failure to use effective drug combinations Failure to titrate doses upward Fear of reaching excessively low diastolic BP The patient with truly resistant hypertension Behavioral barriers Franklin S. JCH 2006; 8:524 What is the systolic blood pressure goal? Blood Pressure in SHEP and Syst-Eur (mm Hg) SHEP Syst-Eur Entry 160-219/90 160-219/95 Goal (SBP) 160 + 20 150 + 20 Baseline 170/77 174/86 Achieved: Rx 143/68 151/79 Achieved: Placebo 155/72 161/84 Difference: Rx-Placebo 12/4 10/5 Journal of Clinical Hypertension, Vol II, No. 5, page 336. March/April 2000. REDUCTION OF STROKES WITH BP LOWERING - SHEP TRIAL No. of Patients: 4736 Follow-up: 4.5 years 37% in ischemic strokes 47% in lacunar infarcts 54% in hemorrhagic strokes Lower BPs - fewer strokes Am J Hypertension 2000;13:724-733 Hypertension in the Very Elderly Trial NEJM 2008;358(18):1887-1898 n Double blind, placebo-controlled n International, multicenter n 3845 patients n Mean age 83.6 yrs n BP range 160- 219/90-109 n Mean BP 173.0/90.8 n f/u median of 1.8 yrs n Primary endpoints fatal or non fatal stroke n Indapamide 1.5mg n Perindopril prn (2mg or 4mg) n Mean BP fall 15.0/6.1 at 2 yrs Result Highlights n 21% reduction in relative risk death from any cause n 64% reduction relative risk heart failure n 39% reduction relative risk of death from stroke GOALS OF TREATMENT nTo achieve a target BP of 140/ 90 mm Hg. nIn patients with Hypertension & Diabetes or Renal disease, BP Goal is 130/80 mm Hg. nTo reduce cardiovascular morbidity & mortality. Thiazide Myths n Sulfa cross reactivity n Gout n Renal stones Thiazide Related Gout n Thiazide related hyperuricemia is dose related n HDFP Trial: 15 episodes of gout over 5 years in 3693 patients treated with chlorthalidone 25-