【高血压精品英文课件】the pharmacists' role in treating hypertension

The Pharmacists Role in Treating Hypertension,Thomas Owens, MD Saint Francis University CERMUSA,Objectives,Enhance your understanding of hypertension to include cardiovascular risks, management, and goals for individual patients Review and discuss the current pharmacotherapy standards of care for hypertension Describe the pharmacists role in counseling patients on hypertensive medications,Hypertension 140/90 mm Hg,United States: 65 million adults Risk factors include: Stroke, myocardial infarction, heart failure, peripheral vascular disease, aortic dissection, chronic renal failure Hypertension price tag: $59.7 billion,Wexler & Feldman, 2005,Hypertension,Typical onset second decade of life Primary Hypertension identifiable behaviors Secondary Hypertension more discrete,Cecil, 2004,Ethnic Groups,African Americans 43% female & 39% male Ratio 1:3 Increase in sodium sensitivity? Caucasians 28% female 29% male Mexican Americans Ratio 1:4 or 1:5,DASH Diet,Cecil, 2004,Dietary Sodium Intake,Salt Hypothesis? Strong genetic underpinning,ADA, 2005,Metabolic Syndrome,Risk of Hypertension increases with BMI Obesity accounts for 50% to 60% of new cases of hypertension,Cecil, 2004,Potential Causes of Hypertension,Expanded plasma volume plus sympathetic over activity Peripheral vasoconstriction Renal salt retention Renal water retention,Sleep Apnea,, 2007,Cecil, 2004,Blood Pressure Equation,Blood Pressure = Cardiac Output x Peripheral Vascular Resistance,Most pharmacologic agents lower,Some pharmacologic agents lower,Some pharmacologic agents lower both,Cecil, 2004,Genetics of High BP,Sympathetic up-regulation leads to a cascade of events Peripheral vascular resistance Genetic factors 30% of cases 2x as likely if parents have hypertension,D, 2007; ADA, 2003,Systolic & Diastolic ?,What is more important? Depends on age Live long enough almost all develop systolic hypertension,120 80,systolic,diastolic,Cecil, 2004,Age Dependant Rise in BP,(Whelton & Rocella, 1995),Framingham Study (age: 50-79),(Khan, Wong, Larson, & Levy, 1999),Systolic Hypertension,Decreased distensibility of large arteries Majority of uncontrolled hypertension Due to focus on diastolic BP,Cecil, 2004,Risk of cardiovascular mortality by systolic BP,(National High Blood Pressure Education Program Working Group, 1993),Hypertension Study Results,Hypertension is excess of 140/90 mm Hg Studies found Increase risk when above 115 mm Hg systolic or 75 mm Hg diastolic High normal BP had twice increased risk for cardio disease More studies are needed to fully understand,Cecil, 2004,The Silent Killer,1/3 of adults do not know they have hypertension Hypertension: 60% are treated 45% of treated remain uncontrolled Despite over 75 different antihypertensive agents in 9 different classes!,Cecil, 2004,Reclassification of BP Stages,Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) New category “pre-hypertension” Pharmacotherapy not recommended Lifestyle modification recommended!,Cecil, 2004; JNC, 2007,JNC Drug Therapy Recommendations,recommendation (healthy),130/80 (w/ heart and kidney disease or diabetes mellitus),JNC, 2007,Modest reduction in BP = big benefits !,Decrease 5 mm Hg decreases risks Small changes can have a big difference Results of studies Systolic surge 34 mm Hg = 3x increase of stroke Systolic 135 mm Hg = 74% increase of cardio event,Cecil, 2004; JNC, 2007,Clinical Presentation,No specific signs or symptoms Possible symptoms Occipital headache, dizziness, tinnitus, dimmed vision, palpitations, fatigue Physical Exam May reveal evidence,Cecil, 2004,Hypertensive Retinopathy,Grades of hypertensive retinopathy shown (Forbes, Jackson, 2003),Electrocardiogram (ECG or EKG),GOOD (Normal),BAD (Antero-Septal MI),physiol.umin.jp/cardiovasc, 2007,Counseling Patients: Proper BP Readings,At least 30 minutes before NO Caffeine, decongestants, oral contraceptives, alcohol, tobacco Sit down for at least 5 minutes,Cecil, 2004; ADA, 2005,Counseling Patients: Proper Fit of BP Cuff,Length of bladder of the cuff at least 80% circumference of arm,Bladder of cuff at least 40% circumference of arm,Place the center of the bladder over the brachial artery,Pump until radial pulse disappears, then continue for additional 30 mm Hg,Help Patients Understand: White Coat Hypertension,Anxiety of going to doctor office raises BP Recommend self-monitoring Daytime: 135/85 mm Hg Nighttime: 120/70 mm Hg 24 hr: 130/80 mm Hg Follow patients every 6 months for possible progression to persistent hypertension,Cecil, 2004,Closely Monitor Medications with High-Risk Patients,Cecil, 2004,Counseling Patients: Causes of Organ Damage,Counseling Patients: Treatment,JNC, 2005,Counseling Patients: Lifelong Treatment,Objective: reduce BP and metabolic abnormalities Pharmacotherapy & lifestyle modification Reduce sodium intake Weight loss Exercise Moderating alcohol Reduce systolic BP by 21 to 55 mm Hg,Cecil, 2004,Counseling Patients: Dietary Changes,Losing only 10 to 12 lbs lowers BP by 10/5 mm Hg Reduce daily salt 10 to 6 grams Teach patients to read food labels DASH Diet /health/public/heart/dash,Cecil, 2004,Counseling Patients: Health Behaviors,JNC, 2005,Counseling Patients: Helpful Resources,,Barriers to Successful Health Behavior Modifications,Lack of education Lack of access to safe places to exercise Added salt in prepared foods and restaurant meals Higher cost of foods low in salt Patient self-management is realistic and feasible!,Cecil, 2004,Pharmacologic Therapy,Scientific proof lowering BP reduces organ damage Certain classes of antihypertensive agents exert organoprotective effects Not all medications equal,Cecil, 2004; JNC, 2005,Major Challenges for Science,Identify the key gene-environment interactions Eliminate the patient and medical provider barriers,ADA, 2003,Counseling Patients: Target Blood Pressure,Most patients below 140/90 mm Hg Patients w/ diabetes or chronic disease 130/80 mm Hg Help patients self-monitor BP 1/3 do not know they are hypertensive Research studies on targeting BP,Cecil, 2004,Improve Hypertension Control Rates,Titrating blood pressure medications to achieve target goals Most patients require 2 or 3 antihypertensive medications Patient compliance with multi-drug regimens,ADA, 2005,Patient Compliance and Quality of Life,Hypertension requires lifelong treatment Medications can produce side effects Men often concerned with sexual dysfunction Patients with controlled BP, rate a significantly higher quality of life,Cecil, 2004,Patient Compliance Principles,Titrating medical therapy based on home readings Long-acting preparations w/ once daily dosing Low dose combinations of medications from different drug classes Fixed-dose combinations to reduce overall number of pills,JNC, 2005,Drug Therapy,Old method: high-dose monotherapy Recent studies (ex. ALLHAT) At least 2 medications of different classes to treat mild hypertension 3 or 4 different medications to treat more difficult cases Thiazide-type antihypertensive medications cost-effective Initial treatment: Beta blockers, Angiotensin-converting enzyme (ACE) inhibitors, Angiotensin receptor blockers, Calcium antagonists,Cecil, 2004,Stage 2 Drug Therapy,JNC recommends: 2 drug combination Additional medications needed for each 10 mm Hg of systolic BP above goal Great majority should inclu