Changing Strategies

1

• Changing Strategies
• Of Treatment Of Hypertension
• Dr Sunita Dodani
• Family Medicine Department
• The Aga Khan University
• Karachi, Pakistan

2
Objectives

• At the end of this presentation, we should be
  able to
• Learn about recent guidelines of hypertension
  management.
• Define hypertension by the JNC-VI guidelines.
• Discuss the management steps recommended by JNC
  VI.
• Define the providers role in patient
  compliance.
• Controversies of stepped care therapy.

3
New Guidelines

• Joint National Committee (JNC) sixth report on
  prevention, detection, evaluation and treatment
  of high blood pressure (JNC-VI) - 1997.
• WHO/International Society of Hypertension (ISH),
  Guidelines of Hypertension Management for Primary
  Care Physicians - 1999.
• British Hypertension Society Guidelines for
  Hypertension Management - 1999.
• Local First report of National Task Force on
  Hypertension, Pakistan Hypertension League -
  1998.

4
JNC-VI Guidelines

• (Drawn from consensus and evidence - based
  findings)
• Discuss hypertension treatment in
  step-wise-manner.
• Cover treatment strategies in special population
  like Black Americans, pregnancy and patients with
  co-morbid conditions.

5
Definition

• ? Normal pressure into 3 categories.
• ? Abnormal pressure into 3 stages for adults gt
  18 and older.

6
Classification of Blood Pressurefor Adults
Age 18 and Olders

• Category Systolic Diastolic
• (mm Hg) (mm Hg)
• Optimal lt120 and lt80
• Normal lt130 and lt85
• High-normal 130-139 or 85-89
• Hypertension
• Stage 1 140-159 or 90-99
• Stage 2 160-179 or 100-109
• Stage 3 gt 180 or gt 110

7
Changing Strategies Of Treatment Of Hypertension
(Contd)

• Elevated BP (gt140/90) on 2 or more visits with
  BP taken 2 or more times on each visit and then
  averaged.
• Seated in a chair with arm supported at heart
  level.
• Must not smoke or drink caffeine for 30 minutes
  prior to measuring the BP.
• Cuff size should encircle 80 of the patients
  arm.

8
Changing Strategies Of Treatment Of Hypertension
(Contd)

• BP measurements should be attempted only after 5
  minutes of rest.
• BP should be at least 2 minutes apart, averaged,
  and then repeated if 2 measurements differ by
  more than 5 mmHg.
• Anxious patient may falsely give high reading
  (white coat hypertension).

9
Changing Strategies Of Treatment Of
Hypertension(Contd)

• BP rises in most people as they age, ? BP is not
  considered a normal part of aging.
• Isolated systolic hypertension is considered in
  patients with systolic BP gt140 mmHg and diastolic
  BP lt90 mmHg

10
Management

• Three-pronged approach
• Lifestyle modifications.
• Appropriate medications (based on the patients
  demographic and medical profile).
• Professional health care support to foster
  compliance.

11
Life Style Modification

• Lifestyle modifications for all stages of
  hypertension and are the initial recommendations
  for both high normal and stage 1 hypertension.

12
Life Style Modifications (Contd)

• Weight reduction
• also ? cholesterol and DM
• Patients with abdominal obesity
• waist size gt34 cms Females
• gt39 cms Males
• ? Hypertension risk

13
Exercise

• Brisk walking.
• 30-45 minutes at 40 - 60 of maximal activity ?
  determined by pulse rate (220 - age x 0.4 0.6).

14
Changing Strategies Of Treatment Of Hypertension
(Contd)

• DASH Dietary approaches to stop hypertension.
• Like DM diet, DASH diet includes a specific
  number of servings and the weight of servings.
• Unlike DM Diet, DASH diet does not offer the
  option of food exchanges.
• Plant food sources
• Only 2 - 3 animal protein servings/day

15
Changing Strategies Of Treatment Of Hypertension
(Contd)

• ? in Dietary sodium.
• Esp. for African Americans
• Elderly
• DM
• 75 meq/day of dietary sodium or less (? 5 mmHg
  systolic 2.6 mm diastolic).
• Cessation of smoking.
• ? alcohol intake.
• lt 10 oz wine
• lt 2 oz whisky
• lt 24 oz beer

16
Initial Drug Therapy

• Step-wise approach
• 1. First line - Diuretic or ?-blocker.
• 2. New agents - Ca channel blocker, ACE
  inhibitor, vasodilator etc. should be considered
  if patient is not responsive to initial therapy
  or has co-morbid conditions.
• 3. Adrenergic agents should only be used as a
  last choice b/c of their side effect profile.

17
Choosing the right medication
foryour patient

• Choice of the treatment regimen depends on
• Degree of BP elevation.
• Number of associated concurrent risk factors.
• Presence of TOD.
• Clinical CVD or associated clinical conditions
  (ACC).

18
Risk Stratification
Risk Factors for
Target Organ Damage
Associated Clinical
Cardiovascular Diseases
(TOD)
Conditions (ACC)
1. Used for risk
Cerebrovascular

LVH (ECG, Echo, XR)

stratification
Disease


Levels of systolic and
Ischemic stroke

Proteinuria / or slight


diastolic BP
Cerebral
hemorhage
elevation of plasma
(Stages 1-3)
Transient
ischemic attack
creatinine 1 . 2 2

Men gt 55 years
mg/dl


Women gt 65 years
(106- 177
mmol/L)

Heart Disease

Smoking

Myocardial Infarction

Total
Cholestrol gt 6.5

Ultrasound or


Angina Pectoris
mmol/L
radiological evidence

Diabetes
Coronary
of
atherosclerotic


FH of premature CVD

revascularization
plaques

Congestive Heart

failure
(carotid,
illiac
f
emoral arteries, aorta)
19
Risk Stratification (Contd)
Risk Factors For
Associated Clinical
Target Organ Damage
Cardiovascular Diseases
Conditions (ACC)
2. Other factors
Renal Diseases

adversely influencing

Diabetic nephropathy

the prognosis
(TOD)

Generalized or focal

Reduced HDL

narrowing of the retinal

Raised LDL

arteries ( retinopathy)
Microalbuminuria in
diabetes

Impaired GTT


Obesity


Sedentary life style


Raised fibrinogen


High risk

socioeconomic
ethnic group

High risk geographic

region
20
Dosage Combination Therapy

• Single daily dose ? interval of 4 - 6 weeks to
  observe the full response, unless it is necessary
  to lower BP more urgently.
• If drug well tolerated but response is small, ?
  the dose or add drugs stepwise until BP control
  is attained.
• Treatment can be stepped down later if BP falls
  substantially below the optimal level.
• Most hypertensives require a combinations of
  antihypertensive therapy to achieve optimal
  control.

21
Dosage Combination Therapy (Contd)

• Drugs from different classes generally have
  additive effect on BP.
• Submaximal doses of 2 drugs results in larger
  response of BP fewer side effects
• eg Diuretic B-blocker
• Diuretic ACE inhibitor
• Ca-channel blocker ACE inhibitor
• Fixed dose combination may be convenient and are
  acceptable when monotherapy is ineffective

22
Dosage Combination Therapy (Contd)

• In Elderly
• 1. Initial drug therapy
• Diuretics
• Ca channel blockers

23
Specific Medication Recommendations For
Concurrent Medical Problems
Concurrent
Recommended
Intermediate
Usually Not
Conditions/
Drug Therapy
Drug Therapy
Used or
Contra-
Charactersticks
indicated
Medications
ACE Inhibitors
ACE Inhibitors
Diuretics with care
Diabetes with
proteinuria
Ca antagonists
Angiotensin
B
Blockers
(both types)
Receptor
Blockers
ACE Inhibitors
B
Blockers
Heart Failure
Diuretics
Ca Antagonists
Carvadilol
Losartin
Isolated Systolic
Diuretics
ACE Inhibitors
B
Blockers
Hypertension
Ca Antagonists
Angiotensin
(non-DHP central
Receptor
Blockers
effects), long
acting forms
24
Specific Medication Recommendations For
Concurrent Medical Problems
Concurrent
Recommended
Intermediate
Usually Not
Conditions/
Drug Therapy
Drug Therapy
Contraindicated
Characteristics
B
Blockers (non-ISA)
Diuretics
DHP Ca
Myocardial
Infarction
ACE Inhibitors
ACE Inhibitors
Antagonists
eg
reduce mortality
Receptor
Blockers
nifedipine
after MI
Non
DHP,CaAntago-
(immediate
nists, (
Diltiazem,
release can
Verapamil)
worsen myocardial
ischemia)
Diuretics
Angiotensin
B
Blockers
African
American race
Calcium Antagonists
Receptor
Blockers
ACE Inhibitors
(both types)
Atrial
B
Blockers
Diuretics
Ca Antagonists
ACE Inhibitors
Tachycardia/
(Both Types)
Angiotensin.
Fibrillation
Receptor
Blockers
25
Specific Medication Recommendations For
Concurrent Medical Problems
26
Specific Medication Recommendations For
Concurrent Medical Problems (Contd)
Concurrent
Recommended
Intermediate
Usually not
Conditions/
Drug Therapy
Drug Therapy
used
Characteristics
Contraindicated
Medications
Essential or
B
Blockers
ACE Inhibitors
senile tremors
Receptor
Blocker
Ca Antagonists
Diuretics
Hyperthyroidism
B
Blockers
Migraine
B
Blockers (Non
Diuretics
ISA)
ACE Inhibitors
Calcium
Receptor
Blocker
Antagonist
DHP Calcium
(non DHP)
Antagonists
27
Specific Medication Recommendations For
Concurrent Medical Problems (Contd)
Concurrent
Recommended
Usually Not
Intermediate
Conditions/
Used/
Drug Therapy
Drug Therapy
Contraindicated
Characteristics
Medications
Osteoporosis
Thiazides
Pre-operative
B
Blockers
Hypertension
Diuretics
Angiotensin
Prostatism
ACE Inhibitors
Receptor
Blockers
( cant be given
with severe renal
impairment)
Angiotensin
Renal
Blockers
B
Receptor
Insufficiency
Blockers
Ca Antagonists
(both types)
28
WHO/ISH Guidelines for Hypertension Management

• Summary Points
• Use of Grades rather than stages, otherwise
  values choosen are same as JNC-VI.
• Mild, moderate and severe are not used in the
  WHO-ISH guidelines - they correspond to grades
  1,2 3.
• Term borderline hypertension is subgroup of Grade
  1 i.e. Systolic 140-149
• Diastolic 90-94

29
British Hypertension Society Guidelines for
Hypertension Management

• Summary Points
• Grades rather than stages are used to classify
  hypertension.
• Uses coronary heart disease risk accessors or
  risk charts.
• Isolated systolic hypertension defined as
  systolic gt 160 and diastolic lt 90.
• Use of aspirin (primary prevention ) in
  hypertension patients.
• Use of statins in patients with hypertension.

30
Indications for specialist referral

• Urgent treatment indicated Malignant
  hypertension, impending complications.
• To investigate potential underlying causes of
  hypertension when initial evaluation suggests
  this possibility.
• To evaluate therapeutic problems or failures.
• Special circumstances Unusually variable blood
  pressure, possible white coat hypertension,
  pregnancy.

31
Conclusion

• New guidelines like JNC-VI, unlike previous
  guidelines, has introduced the concept of
  aggressive blood pressure control at optimal
  levels.
• For elderly patients , the achievement of at
  least 140/90 mm Hg or below blood pressure is
  acceptable.
• Life style modification alone for those patients
  at relatively low overall risk for cardiovascular
  diseases and with drugs for those at higher risk.

32
Conclusion (Contd)

• Diuretics or B-blockers for those as first choice
  with uncomplicated hypertension.
• ACE inhibitors for Diabetic patients with
  proteinuria.
• ACE inhibitors / 0r diuretics for patients with
  heart failure systolic dysfunction.
• Long-acting dihydropyridine Ca antagonist for
  systolic hypertension in the elderly.
• Follow-up during evaluation stabilization of
  treatment should be frequent to monitor BP and
  other risk factors.
• Follow-up is important to establish good
  relationship with patient and to educate the
  patient.

33
Figure 1 Stepped Care Algorithm for treatment of
Hypertension
Life style modification,Reduce wt Quit
smoking,Regular exc. , Decrease sodium and
alcohol
Inadequate response
Continue lifestyle modifica- tion,Initiate
pharmacotherapy
Inadequate response
Increase daily dose
Substitute another drug
Add 2nd drug from diff.class
Inadequate response
Inadeq, response
Refer
Add 2nd or 3rd Drug
34
Changing Strategies Of Treatment Of
Hypertension (Contd) Goal

• JNC-VI uses a lower goal BP (lt140/90
  mmHg) for hypertension in the elderly.

35
Changing Strategies Of Treatment Of Hypertension
(Contd)

• Diuretics
• ? plasma volume.
• cause peripheral vasodilation.
• potentiate the effect of other
  anti-hypertensive drugs.
• Caution Renal disease , Gout, DM, Dyslipidemia.
• Start low dose.
• ?-blockers
• ?1 selective start low dose
  gradually-increase.
• Should not be used in COPD, CHF or ? left
  ventricular function.
• ACE inhibitors
• DM with proteinuria.
• CHF or myocardial infarction.

36
Stratifying risk and quantifying prognosis
37
Which Drug treatment should be used?
Compelling contra-indications
Possible Contra-indications
Compelling Indications
Class of Drug
Possible Indications

• Heart failure
• Elderly
• Systolic Hypertension

Diuretics

• Gout

• Diabetes

• Dyslipidemias
• Sexually active males

• Dyslipidemia
• Athletes
• Physically active patients
• Peripheral vascular. disease

• Angina
• Post MI
• Tachy-arrythmias

• Asthma
• COPD
• Heart Blocks

• Heart failure
• Pregnancy
• Diabetes

B Blockers
38
Which Drug treatment should be used
Possible Contra-indications
Compelling contra-indications
Possible Indications
Compelling Indications
Class of Drug

• Heart Failure
• LV. Dysfunction
• After MI
• Diabetic neph-
• ropathy

ACE Inhibitors

• Pregnancy
• Bilateral Renal artery Stenosis
• Hyperkalemia
• Heart Blocks

Calcium Antagonists

• Angina
• Elderly
• Systolic Hypertension

Peripheral Vascular Disease
Congestive Heart Failure
39
Which Drug treatment should be used
Possible Contra-indications
Compelling contra-indications
Possible indications
Compelling Indiacations
Class of Drug
Orthostatic hypotension

• Prostrate
• Hypertrophy

Alpha Blockers

• Glucose Intolerance
• Dyslipidemias

Angiotensin II Antagonists

• Pregnancy
• Bilateral Renal artery Stenosis
• Hyperkalemia
• Heart Blocks

• Side Effects with other drugs e.g. ACE
  inhibitors (cough)

Heart Failure
40
References

• BMJ 1999 Sep 4 319630- 635 - British
  Hypertension Society guidelines for Hypertension
  management 1999 Summary NEW 9 - 13
• Editorial - British guidelines on managing
  hypertension
• World Health Organization- International Society
  of Hypertension - 1999 WHO-ISH Guidelines for the
  management of Hypertension - Journal of
  Hypertension (see on line articles, Volume 17,
  Issue 2, pages 151 - 183, February 1999).
• The Sixth Report of the Joint National Committee
  on the Prevention, Detection, Evaluation and
  Treatment of High Blood Pressure JNC-V1- PDF
  format from the National Heart, Lung and Blood
  Institute (NHLBI), National Institutes of Health
  (NIH) NEW updated URL 2-11

41
References (Contd)

• NHLBL JNC IV References Sheet.
• National Guideline Clearing House - Brief
  Summary NEW 2 - 11.
• Archives of Internal Medicine 1997 Nov 24 BAD
  LINK -NEW URL -waiting for 1997 back issues to be
  placed on-line ?
• JNC V1 timing is everything Commentary - The
  Lancet 15 Nov 97.
• JNC - 6 Guidelines Editorial - American Journal
  of Kidney Diseases May 1998
• JNC Redux Editorial - American Journal of
  Kidney Diseases May 1998
• Treatment of hypertension insights from the JNC
  V1 report. Am Fam Physician 1998 Oct 15 58 (6
  1323 - 30 - PubMed abstract)