HYPERTENSION

1
HYPERTENSION

• Background for understandingthe Hypertension
  literature.

Jeffrey J. Kaufhold, MDNephrology
2
HYPERTENSIONSUMMARY

• Background for understanding the literature of
  Hypertension
• Review of Joint National Commission
  Recommendations (VII) 2003
• Clinical Evaluation and Case histories.

3
Natl Health Nutrition Exam Survey NHANES
JNC 7 Dec 2003
4
HypertensionLiterature Summary

• Malignant Hypertension - 1958 Kincaid-Smith and
  others DBP gt 130
• VA Cooperative Studies - 1967 DBP 115-129 mm
  Hg - 1970 DBP 90 -114 mm Hg

5
HYPERTENSIONLiterature Summary

• US Public Health Service 1977 Prospective
  placebo controlled trial for DBP 90-115 mm
  Hg
• HDFP 1979 Introduced concept of Stepped Care
• Oslo Study 1980 Treatment of Mild Hypertension
• Medical Research Clinics (MRC) 1985 Single
  blind and community based.

6
HYPERTENSIONPARALLEL WORK

• 1948 to 1972 Framingham Study 20 year
  follow-up on 5000 pts
• 1982 MRFIT Randomized primary prevention
  trial Lower than expected rate of mortality in
  controls led to NS reduction.
• 1984 LRC (Lipid Research Clinics) Treatment
  of hyperlipidemia reduced risk of heart
  disease, all-cause mortality not effected.

7
HYPERTENSIONRecent Works

• 1985 HDFP follow-up Study Long term
  surveillence for drug side effects 9-25
• 1992 Gurwitz Ann Int Med Antihypertensive
  therapy and the initiation of Tx for DM.
  Diabetes and HTN are linked, drugs and diabetes
  are NOT.
• 1993 VA Cooperative Study, Materson, NEJM
  Compares 6 agents. Efficacy in 55 range. Drug
  intolerance 6 to 14 .

8
Joint National Commission

• JNC 1 1980 founded on HDFP
• JNC 2 1984 Intro of ACE, alpha B.
• JNC 3 1986 Special situations
• JNC 4 1988 Many agents 1st line
• JNC 5 1993 Back to stepped care.
• JNC 6 1997 ACE for Diabetics
• JNC 7 2003

9
HYPERTENSIONJNC V

• "Because diuretics and B-Blockers are the only
  classes of drugs that have been used in
  long-term controlled trials and shown to reduce
  morbidity and mortality, they are recommended as
  first- choice agents unless they are
  contraindicated or unacceptable, or unless there
  are special indications for other agents."

10
HYPERTENSIONJNC VII Outline

• Epidemiology of HTN
• Evaluation of HTN
• NON Pharmacologic treatments Wt loss, diet,
  exercise, alcohol
• Drug treatment
• Special Issues in HTN

11
Stages of Hypertension

• Normal
• Prehypertension
• Stage 1
• Stage 2

• lt 120 / 80
• 120 -139 / 80-89
• 140-159 / 90-99
• gt 160 / gt100

12
Treatment of Hypertension

• Single agent HCTZ for most pts. B-Blocker for
  females/ high heart rate.
• Stage 2 I start with DHP CCB (procardia XL)
• plus one or both of above.
• Resistant HTN I look for CLASSES of agents

13
Case Presentation

• 56 y.o. A.A. male prior weight lifter presents
  for refractory HTN.
• Normal labs and UA. Normal CXR and EKG.
• Meds Clonidine 0.2 BID
• ACE inhibitor
• Diltiazem 300 mg daily

14
Case Presentation

• Physical Exam
• BP 170 / 110 Pulse 85
• Edema 2

15
Case Presentation

• Special populations help define your approach.
• African Americans
• CHF
• Diabetics

16
Case Presentation

• Special populations help define your approach.
• African Americans Volume Mediated, Low
  renin low Aldo.
• CHF ACE, Diuretics, B-blocker
• Diabetics ACE or ARB.

17
Case Presentation

• 56 y.o. A.A. male with edema, HTN
• Normal labs and UA. Normal CXR and EKG.
• Meds Clonidine 0.2 BID
• ACE inhibitor
• Diltiazem 300 mg daily
• Whats Missing???

18
Case Presentation

• 56 y.o. A.A. male with refractory HTN.
• Meds Clonidine 0.2 BID
• ACE inhibitor - Stopped
• Diltiazem 300 mg daily
• I added HCTZ 50 mg daily.

19
Case Presentation

• 56 y.o. A.A. male with refractory HTN.
• Meds Clonidine 0.2 BID
• Diltiazem 300 mg daily
• HCTZ 50 mg daily.
• Still swelling, BP a little better. 156 / 100.

20
Case

• 56 y.o. AA male with refractory HTN.
• I changed diuretics to Lasix and Zaroxolyn.
• I get a call 3 days later Swellings gone, but I
  cant get out of bed too dizzy!

21
Case Presentation

• 56 y.o. A.A. male with refractory HTN.
• Meds Lasix 40 mg BID
• Zaroxolyn 5 mg weekly
• No swelling, BP 126 / 80.
• Pt reports joint pain and swelling. What test do
  you order next?

22
Case

• Uric acid level is 12
• Creatinine 1.4
• K 3.8
• Glucose 244 (nonfasting)

23
Case

• Started Allopurinol for gout.
• Pt started exercising and watching diet.
• Sugars normalized without treatment.

24
Classes of Antihypertensives

• Diuretics
• Rate control agents
• ACE/ ARBs
• Vasodilators
• Central agents clonidine, aldomet.
• Big Guns

25
Classes of Antihypertensives

• Diuretics
• Thiazide HCTZ/ Combination drugs,
• Metolazone
• K sparing Spironolactone, Triamterine
• Amiloride
• Loop Diuretic
• Lasix, Bumex, Demedex
• Edecrin (non sulfa)

26
Classes of Antihypertensives

• Diuretics
• Rate control agents
• BBlocker,
• Verapamil, Diltiazem (CCBs)
• Amiodorone, Digoxin
• target pulse rate less than 70 to achieve
  maximal effectiveness. (not much bang for the
  buck once pulse lower than 60, with increased
  risk.)

27
Classes of Antihypertensives

• Diuretics
• Rate control agents
• ACE/ ARBs
• Multitude of benefits for the
• Kidneys and heart
• May get extra benefit from addition of HCT.

28
Classes of Antihypertensives

• Diuretics, Rate control agents, ACE/ ARBs
• Vasodilators
• Alpha blockers - Cardura, Hytrin
• DHP CCBs Nifedipine, Amlodipine, Felodipine
• Nitric oxide synthase stimulators -
  hydralazine, Minoxidil, Isordil

29
Classes of Antihypertensives

• Diuretics, Rate control agents, ACE/ ARBs
• Vasodilators
• Central agents
• clonidine, (remember to consider the
  patch)
• aldomet - (used more commonly by
  Obstetrics)

30
Classes of Antihypertensives

• Diuretics, Rate control agents, ACE/ ARBs
• Vasodilators, Central agents
• Big Guns
• Minoxidil - must have rate control and loop
  diuretic on board before starting this.
• Phenoxybenzamine - peripheral alpha-1 blocker.

31
Nephrology level htn

• I tell the pt that will need to control the main
  route plus the main detours causing the HTN.
• Rate control (pulse lt 78)
• Diuretic
• Vasodilator DHP CCB, Hydralazine, Cardura,
  Minoxidil.
• ACE / ARB (accept 30 increase in creat if BP
  responds)

32
Refer to Nephrologist

• If unable to control on 3 drug regimen which
  includes Rate control, diuretic.
• If you are considering Minoxidil
• If creatinine climbs more than 30 or if
  creatinine is over 2.0.