Hypertension With updated guidelines from AAFP

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HypertensionWith updated guidelines from AAFP
JNC VII

• Omar A. Khan, MD MHS
• January 2006

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Objectives

• Review the AAFP/JNC VII diagnostic criteria for
  hypertension
• Review various treatment options, indications and
  side effects

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Fast Facts about Hypertension in the US

• Hypertensive population 42,000,000
• Controlled hypertensives 27
• Those unaware of Dx 13,000,000
• Aware but untreated 7,000,000
• Of those treated 58 uncontrolled

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JNC VII
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JNC VII
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JNC 7 Classification and Management of Blood
Pressure for Adults
JNC 7. May 2003. NIH publication 03-5233.
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Diagnostic Workup
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CVD Risk Factors

• HTN
• Obesity
• Hyperlipidemia
• Diabetes
• Cigarette Smoking

• Inactivity
• Age
• gt55 in men
• gt65 in women
• Fam history of premature CVD

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JNC 7 Treatment Algorithm for Hypertension
Lifestyle modifications
SBPsystolic blood pressure DBPdiastolic blood
pressure ACEIangiotensin- converting enzyme
inhibitor ARBangiotensin receptor blocker
BBb-blocker CCBcalcium channel blocker JNC 7.
May 2003. NIH publication 03-5233.
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Compelling Indications

• Heart Failure
• Post- MI
• High CVD risk
• DM
• CRF
• Cr gt 1.5 in men
• Cr gt 1.3 in women
• S/P CVA

• Thiazide/loop, BB, ACEi, ARB, Aldosterone
  antagonist
• BB, ACE, Aldosterone antagonist
• Thiazide, BB, ACE, Ca channel blocker
• Thiazide, BB, ACE, ARB, CCB
• ACE, ARB. For creatinine 2-3 try loop diuretic
• Thiazide, ACE inhibitor

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Lifestyle Modifications to Manage HTN
Source The Seventh Report of the Joint National
Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure JNCVII.
JAMA. 20032892560-2572.
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Failures of Patient Education

• 50 of patients discontinue their
  anti-hypertensive within 1 year of initiating
  treatment.
• DASH diet for hypertension
• limit sodium
• Increase fruits and vegetables (8-10/d)
• Increase low fat dairy (3-4/d)
• Focus on diet history for hypertensive patients

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Key Diet History Questions for Patients with HTN

• Do you use a salt shaker?
• Do you taste your food before you add salt?
• How often do you eat salty foods, such as chips,
  pretzels, salted nuts, canned and smoked foods?
• Do you read labels for sodium content?
• How many servings of fruits and vegetables do you
  eat everyday?
• How often do you eat or drink dairy products?
  What kind?
• How often do you eat out? What kinds of
  restaurants?
• Do you like to drink alcohol? How much?
• How often do you exercise, including walking?

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TIPS on drugs for HT

• CCB OK for isolated systolic hypertension (ISH)
• For DM ACEi or ARB with or without diuretic,
  then add BB or CCB
• When ACEi causes cough, substitute ARB
• Dont use short acting CCB (increases deaths due
  to arrhythmias).
• Alpha blockers (e.g. clonidine) only as second
  line (more side effects).

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• Most patients should start with a diuretic as
  they enhance the effectiveness of other agents.
• Most patients will require more than one agent.
• Add a baby aspirin to improve cardiovascular
  outcomes.

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Special Populations

• Blacks have greater prevalence, severity, and
  impact and poorer response to monotherapy. ACE
  induced angioedema is more common
• Estrogen containing oral contraceptives elevate
  BP. Aldomet, BB, and vasodilators OK in pregnancy
• Higher prevalence, ISH more common, more frequent
  complications from ACE, CCB

• Minorities
• Women
• Aged

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Thiazides

• Chlorothiazide (Diuril)
• Chlorthalidone
• Hydrochlorthiazide(Microzide,
• Hydrodiuril)
• Polythiazide (Renese)
• Indapamide (Lozol)
• Metolazone (Mykrox, Zaroxolyn)

All trade / brand / generic names are specific
to the USA
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Benefits of Thiazide Diuretics

• Evidence-based support for end points that matter
  (prevention of CV and all-cause mortality).
• Reduced calcium excretion is a potential benefit
  for osteoporosis prevention.

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Loop Diuretics

• Bumetanide (Bumex)
• Furosemide (Lasix)
• Torsemide (Demadex)

Potassium-sparing Diuretics

• Amiloride (Midamor)
• Triamterene (Dyrenium)

All trade / brand / generic names are specific
to the USA
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Aldosterone Receptor Blockers

• Eplerone (Inspra)
• Spironolactone (Aldactone)

Combined alpha- and beta- blockers

• Carvedilol (Coreg)
• Labetalol (Normodyne, Trandate)

All trade / brand / generic names are specific
to the USA
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Beta-blockers

• Atenolol (Tenormin)
• Betaxolol (Kerlone)
• Bisoprolol (Zebeta)
• Metoprolol (Lopressor, Toprol XL)
• Nadolol (Corgard)
• Propranolol (Inderal/XL)
• Timolol (Blocadren)

All trade / brand / generic names are specific
to the USA
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ACE inhibitors

• Benzapril (Lotensin)
• Captopril (Capoten)
• Enalpril (Vasotec)
• Fosinopril (Monopril)
• Lisinopril (Prinivil, Zestril)
• Moexipril (Univasc)
• Perindopril (Aceon)
• Quinapril (Accupril)
• Ramipril (Altace)
• Trandolapril (Mavik)

All trade / brand / generic names are specific
to the USA
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Angiotensin II Receptor Blockers

• Candesartan (Atacand)
• Eprosartan (Tevetan)
• Irbesartan (Avapro)
• Losartan (Cozaar)
• Olmesartan (Benicar)
• Telmisartan (Micardis)
• Valsartan (Diovan)

All trade / brand / generic names are specific
to the USA
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Calcium channel blockers

• Dihydropyridines
• Amlodipine (Norvasc)
• Felodipine (Plendil)
• Isradipine (Dynacirc CR)
• Nicardipine (Cardene SR)
• Nifedipine (Adalat CC, Procardia XL)
• Nisoldipine (Sular)

• DHPs can have negative inotropic effects, unlike
  non-DHPs, so use with caution in pts with
  impaired cardiac function

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Calcium channel blockers

• non-Dihydropyridines
• Diltiazem (Cardizem CD, Dilacor XR, Tiazac,
  Cardizem LA)
• Verapamil (Calan SR, Isoptin SR)

All trade / brand / generic names are specific
to the USA

• DHPs can have negative inotropic effects, unlike
  non-DHPs, so use with caution in pts with
  impaired cardiac function

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Alpha1 blockers

• Doxazosin (Cardura)
• Prazosin (Minipress)
• Terazosin (Hytrin)

All trade / brand / generic names are specific
to the USA
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Direct Vasodilators

• Hydralazine (Apresoline)
• Minoxidil (Loniten)

All trade / brand / generic names are specific
to the USA
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Centrally acting drugs

• Clonidine (Catapres)
• Methyldopa (Aldomet)
• Reserpine (generic)
• Guanfacine (generic)

All trade / brand / generic names are specific
to the USA
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Again Treatment Algorithm
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References

• JNC 7 report available via NIH (Publication
  03-5233)
• JAMA 289 (19), May 21 2003 (online)
• AAFP monograph 305

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HTN True or False

• ACE Inhibitors should be initial drug therapy for
  most, either alone or combined with other drug
  classes.

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False

• ACE Inhibitors Thiazides should be initial drug
  therapy for most, either alone or combined with
  other drug classes.

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True or False

• For persons over age 50, DBP is more important
  than SBP as CVD risk factor.

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False

• For persons over age 50, SBP is a more important
  than DBP as CVD risk factor.

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True or False

• Normal blood pressure is defined as SBP lt 135 and
  DBP lt 90.

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False

• Normal blood pressure is defined as SBP lt 120 and
  DBP lt 80. People with SBP 120 139 OR DBP 80
  89 should be considered prehypertensive.

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True or False

• Those people whose BP is classified as
  prehypertensive should be initially treated with
  lifestyle modification from the time they are
  identified.

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True

• Those people whose BP is classified as
  prehypertensive should be initially treated with
  lifestyle modification from the time they are
  identified.

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• Key lifestyle modification measures that, if
  initiated in all prehypertensive and hypertensive
  individuals, are likely to lower BP, include all
  except..
• a) Weight reduction
• b) DASH Eating Plan
• c) Smoking cessation
• d) Dietary sodium reduction
• e) Physical activity
• f) Moderation of alcohol intake

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• Key lifestyle modification measures that should
  be initiated in all prehypertensive and
  hypertensive individuals in order to lower BP
  include all except..
• a) Weight reduction
• b) DASH Eating Plan
• c) Smoking cessation
• d) Dietary sodium reduction
• e) Physical activity
• f) Moderation of alcohol intake

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True or False

• If BP is gt20/10 mmHg above goal, initiate
  therapy with a single agent and lifestyle
  modification.

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False

• False. If BP is gt20/10 mmHg above goal, initiate
  therapy with two agents, one usually should be a
  thiazide-type diuretic.

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True or False

• Self measurement can help assess white-coat HTN.

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True

• Self measurement can help improve adherence with
  therapy, provide helpful information on response
  to therapy and assist in assessing white-coat
  HTN.

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True or False

• Most patients will only require one
  antihypertensive drug to achieve goal BP.

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False

• Most patients will require 2 or more
  antihypertensive drugs to achieve goal BP