Systemic Hypertension

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Systemic Hypertension

• Craig A Chasen MD FACC
• Associate Professor of Medicine

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Overview of Hypertension

• JNC VI on Prevention, Detection, Evaluation, and
  Rx of High Blood Pressure (1997)
• 50 million hypertensive patients in the U.S.
• National Health and Nutrition Examination Survey
  III (NHANES III) (1995)
• only 21 are controlled to
• 35 are unaware of their condition
• High-normal BP is associated with an increased
  risk of cardiovascular disease
• N Eng J Med 2001 345 1291-7

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Joint National Committee VI

• Category Systolic BP Diastolic BP
• Optimal
• High normal 130 139 85 - 89
• Mild HTN 140 159 90 - 99
• Mod HTN 160 179 100 - 109
• Severe HTN 180 110

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MacMahon et al 1990

• Diastolic BP increased by 5 mm Hg
• 34 increase in stroke risk
• 21 increase in coronary risk

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Hypertension Adverse EffectsFramingham Study

• Triples risk of stroke
• Triples risk of CHF
• Doubles risk of SCD
• Doubles risk of MI

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Increases Risk of CV Event

• Gender
• Race
• Age
• Pulse pressure

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Types of Variation in BP

• Short-term HR and RR, autonomic NS
• Daytime degree of activity
• Diurnal BP fall during sleep
• Seasonal cold weather increases BP

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Obtaining BP Measurements

• Sitting 5 minutes
• Appropriate cuff size
• Cuff level with heart
• Legs uncrossed
• Self vs. RN vs. MD

Mancia et al., Hypertension 19879209
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False BP Elevations

• Examinee pain, alcohol, caffeine
• Equipment leaky bulb valve, noise
• Examiner expectation bias, hearing
• Examination cuff uncentered, narrow or
• low elbow too low

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Australian Therapeutic Trial
Overall, 80 of the patients with mild-mod. HBP
placed on placebo maintained a diastolic BP mm Hg and, during the average 3-yr follow-up, had
no excess CV events. Only 12.2 of the placebo
treated patients noted a rise in diastolic BP
110 mm Hg.
Management Committee.Lancet 198011261
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Cardiovascular Consequences of Hypertension

• Increased cardiac afterload leads to LVH
• Increased LV mass is associated with elevated CV
  morbidity and mortality independent of other risk
  factors
• Pts with BP 160/95 have CAD, PVD CVA 3x
  than in normotensives

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BP, Stroke CHD
In nine prospective observational studies and
420,000 patients with DBP ranging from 70 110
mm Hg who were followed for 6 25 years, the
associations (with the above CV events) were
positive, continuous and apparently
independent.
MacMahon et al. Lancet 1990335765 Kaplans
Clinical Hypertension 2002
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Hypertension Treatment and CV Outcomes over 5
Yrs.

• Reduce BP by 15/6 mm Hg
• Reduce stroke by 34
• Reduce CHD by 19

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Patient Evaluation

• Determine type of hypertension
• Identify target organ damage
• Assess risk for early CV event

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Patient History I

• Duration and prior Rx
• Pharmaceutical profile
• Family history
• Symptoms of secondary causes
• Target organ damage
• Presence of other risk factors

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Patient History II

• Concomitant Diseases
• Dietary History
• Sexual Function
• Features of Sleep Apnea
• Ability to modify life-style

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HBP and Cardiac Risk Factors
Kaplan NM. Dis Mon 1992 38769-838
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Physical Examination I

• Accurate measure of BP, BMI
• Fundoscopy
• Carotid and thyroid abnormalities
• Heart sounds, rhythm, size
• Rales, rhonchi on lung exam

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Physical Examination II

• Renal masses, waist circumference
• Aorta bruits, femoral pulses
• Peripheral pulses and edema
• Neurologic assessment, i.e. congnitive

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Routine Laboratory

• Hematocrit
• BMP
• Urinalysis
• Lipid profile
• ECG

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JNC VI BP Rx
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Lifestyle Changes for HTN

• Reduce excess body weight
• Reduce dietary sodium to
• Adequate dietary intake of K, Ca and Mg
• Limit daily alcohol consumption
• Moderate aerobic exercise each day
• Cessation of cigarette smoking
• Garlic, fish oils, co-enzyme Q ???

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NIH Consensus Conference on Physical Activity and
CV Health (1995)

• Review of 47 studies of exercise and HTN
• 70 of exercise groups decreased SBP by an avg.
  of 10.5 mm Hg from 154
• 78 of subjects decreased DBP by an avg. of 8.6
  mm Hg from 98
• Beneficial responses are 80 times more frequent
  than negative responses

Hagberg, J., et.al., NIH, 1995 69-71
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Medical Therapy and Implications for Exercise
Training

• Pharmacologic and nonpharmocologic treatment can
  reduce morbidity
• Some antihypertensive agents have side-effects
  and some worsen other risk factors
• Exercise and diet improve multiple risk factors
  with virtually no side-effects
• Exercise may reduce or eliminate the need for
  antihypertensive medications

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Oral Contraceptives and HBP

• BP rises a little in most women on OCs
• RR1.5 for current users vs. never users
• 41 cases per 10,000 person-years of OC use
• RR1.1 for current users vs. previous users
• ERT is associated with lower BPs

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Drug Therapy of HypertensionCV Events Reduction
Randomized controlled trials

• Diuretics
• BBs
• ACEIs
• CCBs

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Slow Breathing

• Guided slow breathing to
• 15 minutes, 3-4 times per week
• Sustained reductions in SBP DBP
• FDA approved July 2002
• J Hum Hypertension 200115263
• Am J Hypertension 20011474

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Malignant HypertensionTreatment I

• Loop diuretic
• Nitroprusside
• Fenoldopam
• Labetolol
• Enalaprilat

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Malignant HypertensionTreatment II

• Esmolol
• Hydralazine
• Nitroglycerin
• CCBs
• Phentolamine

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Hypertension and Pregnancy

• 5 enter pregnancy with chronic HTN
• BP 140/90 _at_ 6 wks PP
• Drug of choice alpha-methyldopa
• 10 develop gestational HTN 20 wks
• PE HTN proteinuria (300 mg/24 hrs)
• Eclampsia PE seizures

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Rx of acute, severe HBP in Pre-eclampsia

• Hydralazine
• Labetolol
• Nifedipine
• Nitroprusside

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Renovascular HypertensionIncidence

• Unselected hypertensives 1
• Resistant to 2 drug therapy 10
• Severe, rapidly progressive HBP 15
• Accelerated-malignant HBP 32 4

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Renovascular HypertensionClinical Clues
Testing

• Low suspicion No testing
• No clinical clues
• Moderate suspicion Non-invasive
• Severe HBP (DBP 120)
• Abdominal or flank bruit
• High suspicion Angiography
• Severe HBP elevated Cr
• Malignant HBP

Mann/Pickering. Ann Int Med 1992117845
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Renovascular HypertensionDiagnostic Tests

• Captopril-enhanced renal scan
• Doppler ultrasonography
• Gadolinium MRA
• Spiral CT
• Angiography

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EB Pedersens Guidelines

• Moderate or high index of suspicion
• No to mod. renal failure Cr
• Doppler vs. (ACEI) Renography, if then
• Spiral CT vs. MRA, if then, angiography
• Severe renal impairment
• No doppler, no renography
• MRA preferred, o/w spiral CT or angiography

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Renovascular HypertensionMedical Treatment

• Aggressive BP control
• Lipid reduction therapy
• Antiplatelet therapy

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Renovascular HypertensionTreatment

• Renal Artery Revascularization
• Intolerant of medical Rx
• Unresponsive to medical Rx
• Progressive renal impairment

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Renovascular HypertensionTreatment
In patients with a high likelihood of success and
low risk of complications, such as the majority
of patients with fibromuscular hyperplasia and
uncomplicated atherosclerotic RVHT, it is usually
reasonable to proceed directly to
revascularization.
Block/Pickering. Semin Nephrol 200020474
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Pheochromocytoma

• HBP, palpitation, sweating, HA
• Plasma / spot urine metanephrines
• CT scan with adrenal cuts/ MRI
• If adrenal cuts nl 131IMIBG scan
• Phentolamine / Phenoxybenzamine

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Primary Aldosteronism

• HBP, weakness, alkalosis, hypokalemia
• Upright PAC/PRA ratio, if 25, then
• Saline 500 cc/hr X 4 or NACl 10g/day X 3
• Adrenal CT P 18-OH corticosterone
• Suppression scintiscan NP-59 dexameth
• Surgical therapy vs. spironolactone

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Primary Aldosterone Excess

• Aldosterone producing adenoma
• Bilateral adrenal hyperplasia
• Glucocorticoid-remediable
• chimeric11B-hydroxylase aldosterone synthase
  gene
• Glucocorticoids suppress ACTH
• Adrenal carcinoma
• Extra-adrenal tumors

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Corticosteroid induced HBP

• Obesity, purple striae, osteopenia, DM
• Must r/o depression, alcoholism
• 1 mg dexamethasone (dexa) overnight plasma
  suppression test
• Low dose dexa suppression test (urinary) 24-hr
  urinary free cortisol plus sleeping midnight
  plasma cortisol test

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Localization of Cortisol Excess

• Localization Pituitary Adrenal Ectopic CTH
• Corticotropin normal/high Low High
• CRH Response No response No response
• Dexa 8 mg Suppression No supp. No suppression
• Adrenal CT Nl/enlarged Tumor Nl/enlarged
• Pituitary CT Tumor Normal Normal
• Inferior petrosal Central/periph No
  central/peri sinus sampling gradient gradient
  

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Secondary Hypertension

• Hormonal thyroid, hyperpara, acromegaly
• Neurologic brain tumors, quadriplegia
• Acute physical stress burns, resp distress
• Increased volume EryP Rx, SIADH, PRV
• Chemical agents cyclosporine, tacrolimus
• Sleep apnea

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Reasons for Decline in CHD deaths from 1980-1990

• 43 from improved Rxs (i.e. CABG)
• 29 from secondary prevention (i.e. BP)
• 25 from primary prevention (i.e. BP)

Hunink et al JAMA1997277535
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Exaggerated BP Response to Exercise

• Among normotensive men who had an exercise test
  between 1971-1982, those who developed HTN in
  1986 were 2.4 times more likely to have had an
  exaggerated BP response to exercise

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Exaggerated BP Response to Exercise

• Exaggerated BP was change from rest in SBP 60 mm
  Hg at 6 METs SBP 70 mm Hg at 8 METs DBP 10
  mm Hg at any workload.
• CARDIA study subjects with exaggerated exercise
  BP were 1.7 times more likely to develop HTN 5
  years later

J Clin Epidemiol 51 (1) 1998
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Sleep, BP and CV Events

• Inverted Dippers
• Non-dippers
• Excessive Dippers
• Dippers

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Treatment of Orthostatic Hypotension

• Avoid overtreatment of BP
• Slow rising from chair/bed
• Supportive panty hose
• Avoid dehydration
• Volume expanders
• Sympathomimetics

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NHANES III, phase 2Hypertension

• Awareness 68.4
• Treated 53.6
• Controlled 27.4

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Acute BP Response to Exercise