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ManagementofHypertension DavidPutnam MDAlbanyMedicalCollegeSeptember21 2000 Thedeclineinage adjustedmortalityforstrokeinthetotalpopulationis59 0 Age adjustedtothe1940U S censuspopulation PercentDeclineinAge Adjusted MortalityRatesforStrokebySexandRace UnitedStates 1972 94 Thedeclineinage adjustedmortalityforCHDinthetotalpopulationis53 2 Age adjustedtothe1940U S censuspopulation PercentDeclineinAge Adjusted MortalityRatesforCHDbySexandRace UnitedStates 1972 94 IncidenceofReportedEnd StageRenalDiseaseTherapy 1982 1995 253 Provisionaldata Adjustedforage race andsex PrevalenceofHeartFailure byAge 1976 80and1988 91 1988 91 1976 80 Hypertension OneofthemostwellestablishedandimportantriskfactorsforCVDMostrecentsurveysshowthatHTNremainslargelyuntreatedanduncontrolled Awareness Treatment andControlofHighBloodPressureinAdults Hypertension JNC VIhasprovidedwidelyuseddefinitionsofhighbloodpressurecategoriesRelationshipbetweenSBPandDBPandCVDisstrong graded andcontinuousSBPisabetterpredictorofCVDatallagesbutparticularlyinolderagegroups BloodPressureMeasurement Patientsshouldbeseatedwithbacksupportedandarmbaredandsupported Patientsshouldrefrainfromsmokingoringestingcaffeinefor30minutespriortomeasurement Measurementshouldbeginafteratleast5minutesofrest Appropriatecuffsizeandcalibratedequipmentshouldbeused BothSBPandDBPshouldberecorded Twoormorereadingsshouldbeaveraged AdvantagesofSelf Measurement Identifies white coathypertension AssessesresponsetomedicationImprovesadherencetotreatmentPotentiallyreducescostsUsuallyprovideslowerreadingsthanthoserecordedinclinic hypertensionisdefinedasSBP 135orDBP 85mmHg AmbulatoryMeasurement Ambulatorymonitoringcanprovide readingsthroughoutdayduringusualactivitiesreadingsduringsleeptoassessnocturnalchangesmeasuresofSBPandDBPloadAmbulatoryreadingsareusuallylowerthaninclinic hypertensionisdefinedasSBP 135orDBP 85mmHg ClassificationofBloodPressureforAdults RecommendationsforFollowupBasedonInitialMeasurements EvaluationObjectives ToidentifyknowncausesToassesspresenceorabsenceoftargetorgandamageandcardiovasculardiseaseToidentifyotherriskfactorsordisordersthatmayguidetreatment EvaluationComponents MedicalhistoryPhysicalexaminationRoutinelaboratorytestsOptionaltests MedicalHistory DurationandclassificationofhypertensionPatienthistoryofcardiovasculardiseaseFamilyhistorySymptomssuggestingcausesofhypertensionLifestylefactorsCurrentandpreviousmedications PhysicalExamination Bloodpressurereadings 2ormore VerificationincontralateralarmHeight weight andwaistcircumferenceFunduscopicexaminationExaminationoftheneck heart lungs abdomen andextremitiesNeurologicalassessment LaboratoryTestsandOtherDiagnosticProcedures DeterminepresenceoftargetorgandamageandotherriskfactorsSeekspecificcausesofhypertension LaboratoryTestsRecommendedBeforeInitiatingTherapy UrinalysisCompletebloodcountBloodchemistry potassium sodium creatinine andfastingglucose Lipidprofile totalcholesterolandHDLcholesterol 12 leadelectrocardiogram OptionalTestsandProcedures CreatinineclearanceMicroalbuminuria24 hoururinaryproteinSerumcalciumSerumuricacidFastingtriglyceridesLDLcholesterolGlycosolatedhemoglobin Thyroid stimulatinghormonePlasmareninactivity urinarysodiumdeterminationLimitedechocardiographyUltrasonographyMeasurementofankle armindex Hypertension SecondaryCauses ExamplesofIdentifiableCausesofHypertension RenovasculardiseaseRenalparenchymaldiseasePolycystickidneysAorticcoarctation PheochromocytomaPrimaryaldosteronismCushingsyndromeHyperparathyroidismExogenouscauses HTN RenalArteryStenosis OnsetofHTNbeforeage30orafterage55inabsenceoffamilyhistoryofHTNAbdominalbruitAcceleratedorresistantHTNRenalfailureofuncertaincauseAcuterenalfailureinducedbyACEDiagnosis captoprilrenalflowscan HTN HypersecretionofAldosterone SuspectinpatientswithspontaneoushypokalemiaUnilateraladenomamorecommoninwomenBilateraladrenalhyperplasiamorecommoninmenDiagnosis MeasurementofPRAandplasmaor24 hoururinealdosteroneafter2daysofhighsodiumdiet HTN Pheochromocytoma Suspectinpatientswithepisodicheadaches tachycardia diaphoresiswithlabileHTNDiagnosis restingsupineplasmacatecholeaminelevels 2000pg mlUrinemetanephrineandVMAlesssensitivebutveryspecific Hypertension RiskStratification HTN MajorRiskFactors SmokingDyslipidemiaDiabetesmellitusSex menandpostmenopausalwomen Familyhistoryofcardiovasculardisease women 65yrormen 55yr Hypertension CADRiskFactors Estimatedthat90 ofpatientswithhypertensionhaveotherriskfactorsforCAD TargetOrganDamageClinicalCardiovascularDisease HeartdiseasesLeftventricularhypertrophyAnginaorpriorMIPriorcoronaryrevascularizationHeartfailureStrokeorTIANephropathyPeripheralarterydiseaseRetinopathy HTN LVH LVHisthemostimportantriskfactorforcardiovasculareventsthatwehaveEpidemiologicaldataindicatethatLVHisanominousharbingerofcardiovasculardiseaseinthehypertensivepatient FundoscopicExam RiskStratification Hypertension Treatment GoalofHypertensionPreventionandManagement Toreducemorbidityandmortalitybytheleastintrusivemeanspossible Thismaybeaccomplishedbyachievingandmaintaining SBP 140mmHgDBP 90mmHgcontrollingothercardiovascularriskfactors TreatmentStrategiesandRiskStratification NotatGoalBloodPressure AlgorithmforTreatmentofHypertension HTN TONEStudy Randomized controlledstudy875men womenaged60to80yearsoldSBP10 Sodiumreductionandweightloss HTN TONEStudy ResultsBPloweranddecreasedBPmedsinweightlossgroupandsodiumreductiongroup InitialDrugChoices AlgorithmforTreatmentofHypertension NotatGoalBloodPressure 140 90mmHg lowergoalsforpatientswithdiabetesorrenaldisease BeginorContinueLifestyleModifications NotatGoalBloodPressure InitialDrugChoices Uncomplicated CompellingIndications NotatGoalBloodPressure AlgorithmforTreatmentofHypertension continued Startatlowdoseandtitrateupward Low dosecombinationsmaybeappropriate SpecificIndications ClassesofAntihypertensiveDrugs ACEinhibitorsAdrenergicinhibitorsAngiotensinIIreceptorblockersCalciumantagonistsDirectvasodilatorsDiuretics InitialDrugChoices UncomplicatedDiuretics blockers AlgorithmforTreatmentofHypertension continued Basedonrandomizedcontrolledtrials JNCVITreatmentAlgorithm TreatmentofHypertension HTN CHD MedicalProblems HTN PharmacologicRxCompellingIndications DiabetesmellitusHeartfailurePost myocardialinfarctionIsolatedsystolicHTNandHTNinolderpatients HTN PatientswithDM ACEinhibitorsareagoodfirstchoiceCalciumchannelantagonistsandlowdosediureticsareagoodsecondchoiceARB smaybeconsideredasanalternativetoACEinhibitorsbutrenalprotectionisstillunprovenBetablockersmaymaskhypoglycemiabutcanbeusedsafely HTN PatientswithCHF ACEinhibitorspreferredwithsystolicdysfunctionARB smaybeanalternativetoACEinhibitorsbutmortalityreductionremainsunprovenDiureticsBetablockersinlowdosesAmlodipine Felodipinemaybeusedsafelywithsystolicdysfunction HTN PatientsPost MI BetablockersACEinhibitorswithLVdysfunction HTN OlderPatients ExtremelycommonPresentinmorethan60 ofAmericansage60andolderSBPabetterpredictorofeventsthenDBPElevatedpulsepressureapredictorofincreasedrisk HTN OlderPatients PrimaryHTNisthemostcommonformSomepatientshavepseudohypertensionduetoexcessivevascularstiffnessOrthostasisismorecommon SystolicHTN EuropeanTrial 4695patientsaged60yearsorolderSBP160to219mmHgw DBP 95mmHgDihydropyridinewithpossibleadditionofenalaprilandHCTZMedianfollow upof2yearsLancet1997 350 757 64 SystolicHTN EuropeanTrial HypertensionintheElderly HTN OlderPatients ThiazidediureticsrecommendedfirstDihydropyridinecalciumantagonistsrecommendedasanalternativeagentBetablockersarenotaseffective JAMA1998 JUN 279 1903 1907 HTN PharmacologicRxSpecificIndications CoronaryarterydiseaseLVHRenalDiseaseDyslipidemia HTN PatientswithCAD Betablockers calciumchannelantagonistsAvoidshort actingcalciumchannelantagonistsBetablockerspostMIACEinhibitorswithLVdysfunction HTN PatientswithLVH MajorindependentriskfactorforcardiaceventsObservationaldataindicatethatregressionofLVHassociatedwithreductionincardiacevents HTN LVH HTN PatientswithLVH AllantihypertensiveagentsexceptdirectactingvasodilatorsreduceLVHACEinhibitors ARB s calciumantagonistsmaybebetteratreversingLVH HTN PatientswithRenalInsuficiency GoalBPof125 75inpatientswith 1g dofproteinuriaGoalBPof130 85inpatientswith 1g dofproteinuriaACEinhibitorshaveadditionalrenoprotectiveeffects HTN PatientswithDyslipidemia BetablockersmayincreaseTrigandreduceHDL CAlphablockersmaydecreaseChol andincreaseHDL CACE ARB s andcalciumantagoniststendtohaveaneutraleffect HTN PatientswithDyslipidemia Inmostcasesdietarymodificationwillcorrectanydrugeffectondyslipidemia OtherSituations AfricanAmericansOralContraceptivesHormoneReplacementTherapyPregnancy Hypertension AfricanAmericans PrevalenceofHTNamongthehighestintheworldDevelopsearlierinlifeAveragebloodpressuresaremuchhigherHigherratesofStage3HTN Hypertension AfricanAmericans 80 higherstrokeratemortality50 higherheartdiseasemortalityrate320 greaterrateofhypertension relatedend stagerenaldisease Hypertension AfricanAmericans DiureticsshouldbeagentoffirstchoiceCalciumantagonistsandalpha betablockersarealsoeffectiveBetablockersandACEinhbitorsarelesseffective HTN OralContraceptives HTN2to3timesmorecommoninwomentakingoralcontraceptivesAdvisabletostopcontraceptivesIncertaincasesmayneedtocontinueandtreathypertension HTN HormoneReplacementTherapy PresenceofHTNisnotacontraindicationtopostmenopausalestrogentherapyBPdoesnotincreasesignificantlyinmostwomenAfewwomenmayexperienceariseinBP PregnantWomen Chronichypertensionishighbloodpressurepresentbeforepregnancyordiagnosedbefore20thweekofgestation Preeclampsiaisincreasedbloodpressurethatoccursinpregnancy generallyafterthe20thweek andisaccompaniedbyedema proteinuria orboth ACEinhibitorsandangiotensinIIreceptorblockersarecontraindicatedforpregnantwomen Methyldopaisrecommendedforwomendiagnosedduringpregnancy AntihypertensiveDrugsUsedinPregnancy AntihypertensiveDrugsUsedinPregnancy continued HTN PregnancyBetaBlockers Reviewof312pregnanciescomplicatedbyHTNintheUKAtenololassociatedwithsignificantlylowerbirthweightsAmJHTN1999 12 541 547 SleepApnea Obstructivesleepapneaismorecommoninpatientswithhypertensionandisassociatedwithseveraladverseclinicalconsequences Improvedhypertensioncontrolhasbeenreportedfollowingtreatmentofsleepapnea HTN HOTStudy LowestriskformajorcardiovasculareventsseenatDBPof82 6mmHg51 reductioninmajorcardiovasculareventsindiabeticswithDBP 80mmHgvs 90mmHg SpecialConsiderationsin