diagnosis and management of hypertension - osu center for ...课件

Diagnosis and Management of Hypertension,Davin Haraway DO,FACOI,CWS Associate Professor of Medicine OSU Center for Health Sciences,Why talk about the Same Old Thing?,Those age 55 with normal blood pressure will have a 90 percent lifetime risk of developing hypertension Hypertension control reduces excess morbidity and mortality. Beginning with 115/75 CVD risk doubles for each increment of 20/10mmHg 50million americans have High Blood Pressure warranting some form of treatment 30% adults are still unaware of their hypertension 40% of individuals with hypertension are not on treatment 2/3 of patients on treatment are not controlled to BP levels of less than 140/90 Hypertensive patients are 2.5 times more likely to develop diabetes within 5 years,Risk of hypertension (%),Residual lifetime risk of developing hypertension among people with blood pressure 140/90 mmHg,Years,Lifetime Risk of Developing Hypertension Beginning at Age 65,Men,Women,Vasan RS, et al. JAMA. 2002; 287:1003-1010. Copyright 2002, American Medical Association.,,Table 1. Classification and Management of Blood Pressure for Adults Aged 18 Years or Older,HTN Classification,?Prehypertension,NOT a DISEASE category Should encourage Lifestyle modification as this group has an increased risk of becoming hypertensive NOT candidates for drug therapy (unless compelling indications ie DM etc goal 130/80),Table 3. Lifestyle Modifications to Manage Hypertension*,Physician Practices in Treating HTN With and Without Diabetes,Hyman DJ, Pavlik VN. Arch Intern Med. 2000;160(15):2281-2286. Reprinted by permission, American Medical Association.,DBP (mmHg) to Start Treatment,% of respondents,,Accurate BP measurement,Who checks your patients BP? You or Staff IF Staff Do they know what to listen for or do they use automated equipment Seated quietly for 5 minutes Appropriate size cuff Inflate 20-30 mmHg above loss of radial pulse Deflate at 2mmHg per second 1st sound SBP ; Disappearance of Korotkoff sound (phase 5) is DBP Confirm Elevated blood pressure within 2months(stage 1) shorter for stage 2 if new onset,If HTN diagnosed,Evaluate for Cardiovascular Risk Factors Age,Fm Hx, Lipids, Obesity, microalbuminuria, Inactivity,Smoking Evaluate for Target Organ Damage LVH or reduced EF, Angina,stroke,dementia,Kidney disease, PAD,retinopathy Think about Secondary Hypertension with any new onset Hypertension or uncontrolled hypertension,Identifiable causes of hypertension,Chronic kidney disease Coarctation of the Aorta Cushings Syndrome Drug induced Obstructive uropathy Pheochromocytoma Primary aldosteronism and other mineralocorticoid excess states Renovascular HTN stenosis and fibromuscular dysplasia Sleep Apnea Thyroid (either HYPER or HYPO) or parathyroid disease,Which Drugs do you use?,Stage 1 Thiazide 1st unless compelling indication Stage 2 Two drugs (one of the two should be a diuretic or ACE/ARB) Compelling Indications for certain disease modifying meds should be considered,Table 6. Clinical Trial and Guideline Basis for Compelling Indications for Individual Drug Classes,Table 4. Oral Antihypertensive Drugs*,Table 5. Combination Drugs for Hypertension,OK Now what?,2/3 of patients with hypertension will need at least two medicines for BP control,Pearls,For resistant HTN sit down and take a good history How much water,pop, coffee,milk,juice,tea,ice anything liquid do you drink daily. Food preferences and salt intake Drugs/Alcohol Compliance,Pearls cont.,The only thiazide that will work with an elevated creat. Is metolazone(zaroxolyn) If elevated creat. Than will need to use a loop diuretic If potassium is elevated evaluate current meds and use a diuretic If potassium is low ask why Check for edema and ask why Elderly patients benefit from blood pressure management Black patients benefit from ACE/ARB may need to use larger doses to obtain BP lowering effect,Pearls Cont.,Metabolic acidosis and hyperkalemai? use diuretic loop if creat. Elevated Take blood pressure periodically lying and standing so as not to miss supine hypertension associated with autonomic insufficiency this is treated differently,Escape of Angiotensin II Despite ACE Inhibition,Biollaz J, et al. J Cardiovasc Pharmacol. 1982;4(6):966-972.,Plasma Ang II (pg/mL),Plasma ACE (nmoL/mL/min),*P .001 vs placebo,