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Management of Hypertension David Putnam, MD Albany Medical College September 21, 2000 The decline in age-adjusted mortality for stroke in the total population is 59.0%. *Age-adjusted to the 1940 U.S. census population. Percent Decline in Age-Adjusted* Mortality Rates for Stroke by Sex and Race: United States, 1972-94 The decline in age-adjusted mortality for CHD in the total population is 53.2%. *Age-adjusted to the 1940 U.S. census population. Percent Decline in Age-Adjusted* Mortality Rates for CHD by Sex and Race: United States, 1972-94 Incidence of Reported End-Stage Renal Disease Therapy, 1982-1995 253* *Provisional data. Adjusted for age, race, and sex. Prevalence of Heart Failure, by Age, 1976-80 and 1988-91 1988-91 1976-80 Hypertension One of the most well established and important risk factors for CVD Most recent surveys show that HTN remains largely untreated and uncontrolled Awareness, Treatment, and Control of High Blood Pressure in Adults* Hypertension JNC-VI has provided widely used definitions of high blood pressure categories Relationship between SBP and DBP and CVD is strong, graded, and continuous SBP is a better predictor of CVD at all ages but particularly in older age groups Blood Pressure Measurement Patients should be seated with back supported and arm bared and supported. Patients should refrain from smoking or ingesting caffeine for 30 minutes prior to measurement. Measurement should begin after at least 5 minutes of rest. Appropriate cuff size and calibrated equipment should be used. Both SBP and DBP should be recorded. Two or more readings should be averaged. Advantages of Self-Measurement Identifies “white-coat hypertension” Assesses response to medication Improves adherence to treatment Potentially reduces costs Usually provides lower readings than those recorded in clinic (hypertension is defined as SBP 135 or DBP 85 mm Hg) Ambulatory Measurement Ambulatory monitoring can provide: readings throughout day during usual activities readings during sleep to assess nocturnal changes measures of SBP and DBP load Ambulatory readings are usually lower than in clinic (hypertension is defined as SBP 135 or DBP 85 mm Hg) Classification of Blood Pressure for Adults Recommendations for Followup Based on Initial Measurements Evaluation Objectives To identify known causes To assess presence or absence of target organ damage and cardiovascular disease To identify other risk factors or disorders that may guide treatment Evaluation Components Medical history Physical examination Routine laboratory tests Optional tests Medical History Duration and classification of hypertension Patient history of cardiovascular disease Family history Symptoms suggesting causes of hypertension Lifestyle factors Current and previous medications Physical Examination Blood pressure readings (2 or more) Verification in contralateral arm Height, weight, and waist circumference Funduscopic examination Examination of the neck, heart, lungs, abdomen, and extremities Neurological assessment Laboratory Tests and Other Diagnostic Procedures Determine presence of target organ damage and other risk factors Seek specific causes of hypertension Laboratory Tests Recommended Before Initiating Therapy Urinalysis Complete blood count Blood chemistry (potassium, sodium, creatinine, and fasting glucose) Lipid profile (total cholesterol and HDL cholesterol) 12-lead electrocardiogram Optional Tests and Procedures Creatinine clearance Microalbuminuria 24-hour urinary protein Serum calcium Serum uric acid Fasting triglycerides LDL cholesterol Glycosolated hemoglobin Thyroid-stimulating hormone Plasma renin activity/ urinary sodium determination Limited echocardiography Ultrasonography Measurement of ankle/arm index Hypertension Secondary Causes Examples of Identifiable Causes of Hypertension Renovascular disease Renal parenchymal disease Polycystic kidneys Aortic coarctation Pheochromocytoma Primary aldosteronism Cushing syndrome Hyperparathyroidism Exogenous causes HTN: Renal Artery Stenosis Onset of HTN before age 30 or after age 55 in absence of family history of HTN Abdominal bruit Accelerated or resistant HTN Renal failure of uncertain cause Acute renal failure induced by ACE Diagnosis: captopril renal flow scan HTN: Hypersecretion of Aldosterone Suspect in patients with spontaneous hypokalemia Unilateral adenoma more common in women Bilateral adrenal hyperplasia more common in men Diagnosis: Measurement of PRA and plasma or 24-hour urine aldosterone after 2 days of high sodium diet HTN: Pheochromocytoma Suspect in patients with episodic headaches, tachycardia, diaphoresis with labile HTN Diagnosis: resting supine plasma catecholeamine levels 2000 pg/ml Urine metanephrine and VMA less sensitive but very specific Hypertension Risk Stratification HTN: Major Risk Factors Smoking Dyslipidemia Diabetes mellitus Sex (men and postmenopausal women) Family history of cardiovascular disease: women 10# ) Sodium reduction and weight loss HTN: TONE Study Results BP lower and decreased BP meds in weight loss group and sodium reduction group Initial Drug Choices Algorithm for Treatment of Hypertension Not at Goal Blood Pressure (1g/d of proteinuria Goal BP of 130/85 in patients with 1g/d of proteinuria ACE inhibitors have additional renoprotective effects HTN: Patients with Dyslipidemia Beta blockers may increase Trig and reduce HDL-C Alpha blockers may decrease Chol, and increase HDL-C ACE, ARBs, and calcium antagonists tend to have a neutral effect HTN: Patients with Dyslipidemia In most cases dietary modification will correct any drug effect on dyslipidemia Other Situations African Americans Oral Contraceptives Hormone Replacement Therapy Pregnancy Hypertension: African Americans Prevalence of HTN among the highest in the world Develops earlier in life Average blood pressures are much higher Higher rates of Stage 3 HTN Hypertension: African Americans 80% higher stroke rate mortality 50% higher heart disease mortality rate 320% greater rate of hypertension-related end-stage renal disease Hypertension: African Americans Diuretics should be agent of first choice Calcium antagonists and alpha-beta blockers are also effective Beta blockers and ACE inhbitors are less effective HTN: Oral Contraceptives HTN 2 to 3 times more common in women taking oral contraceptives Advisable to stop contraceptives In certain cases may need to continue and treat hypertension HTN: Hormone Replacement Therapy Presence of HTN is not a contraindication to postmenopausal estrogen therapy BP does not increase significantly in most women A few women may experience a rise in BP Pregnant Women Chronic hypertension is high blood pressure present before pregnancy or diagnosed before 20th week of gestation. Preeclampsia is increased blood pressure that occurs in pregnancy (generally after the 20th week) and is accompanied by edema, proteinuria, or both. ACE inhibitors and angiotensin II receptor blockers are contraindicated for pregnant women. Methyldopa is recommended for women diagnosed during pregnancy. Antihypertensive Drugs Used in Pregnancy Antihypertensive Drugs Used in Pregnancy (continued) HTN: Pregnancy Beta Blockers Review of 312 pregnancies complicated by HTN in the UK Atenolol associated with significantly lower birth weights Am J HTN 1999;12:541-547 Sleep Apnea Obstructive sleep apnea is more common in patients with hypertension and is associated with several adverse clinical consequences. Improved hypertension control has been reported following treatment of sleep apnea. HTN: HOT Study Lowest risk for major cardiovascular events seen at DBP of 82.6 mm Hg 51% reduction in major cardiovascular events in diabetics with DBP 80 mm Hg vs 90 mm Hg Special Considerations in Selecting Drug Therapy Demographics Coexisting diseases and therapies Quality of life Physiological and biochemical measurements Drug interactions Economic considerations Drug Therapy A low dose of initial drug should be used, slowly titrating upward. Optimal formulation should provide 24-hour efficacy with once-daily dose with at least 50% of peak effect remaining at end of 24 hours. Combination therapies m