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
Initial Drug Therapy Initial Drug Therapy Initial Drug Therapy
BP Classification SBP (mm Hg) DBP (mm Hg) Lifestyle Modification Without Compelling Indications With Compelling Indications With Compelling Indications
Normal lt120 and lt80 Encourage No antihypertensive drug indicated. No antihypertensive drug indicated. Drug(s) for compelling indications.
Prehypertension 120139 or 8089 Yes No antihypertensive drug indicated. No antihypertensive drug indicated. Drug(s) for compelling indications.
Stage 1 hypertension 140159 or 9099 Yes Thiazide-type diuretic for most. May consider ACEI, ARB, BB, CCB, or combination. Thiazide-type diuretic for most. May consider ACEI, ARB, BB, CCB, or combination. Drug(s) for compelling indications. Other antihypertensive drugs (diuretic, ACEI, ARB, BB, CCB) as needed.
Stage 2 hypertension ³160 or ³100 Yes Two-drug combination for most (usuallythiazide-type diuretic and ACEI or ARB or BB or CCB). Two-drug combination for most (usuallythiazide-type diuretic and ACEI or ARB or BB or CCB). Drug(s) for compelling indications. Other antihypertensive drugs (diuretic, ACEI, ARB, BB, CCB) as needed.
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
Modification Recommendations Approximate Systolic Blood Pressure Reduction
Weight Reduction Maintain normal body weight (BMI 18.5-24.9) 5-20 mm Hg for each 10 kg weight loss
Adapt DASH eating plan Consume diets rich in fruits, vegetables, low fat dairy and low saturated fat 8-14 mm Hg
Dietary sodium reduction Reduce sodium to no more than 2.4 g/day sodium or 6 g/day NaCl 2-8 mm Hg
Increase physical activity Engage in regular aerobic activity such as walking (30 min/day on most days) 4-9 mm Hg
Moderate alcohol consumption Limit alcohol to no more than 2 drinks/d for men and 1 drinks/day for women. 2-4 mm Hg
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