Hypertension

1
Hypertension

• Jared Helms D.O. OGME-2
• 22 August 2007

2
Hypertension

• The treatment of hypertension is the most common
  reason for office visits of non-pregnant adults
  to physicians in the United States and for use of
  prescription drugs.

Cherry, DK, Burt, CW, Woodwell, DA. Advance data
from vital and health statistics. No 337.
Hyattsville, MD. National Center for Health
Statistics, 2003.
3
Definitions

• Normotensive systolic lt120 mmHg and diastolic
  lt80
• Prehypertension systolic 120-139 or diastolic
  80-89
• Hypertension
• Stage 1 systolic 140-159 or diastolic 90-99
• Stage 2 systolic 160 or diastolic 100

The Seventh Report of the Joint National
Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure the JNC 7
report. Chobanian AV et al. JAMA 2003 May
21289(19)2560-72. Epub 2003 May 14.
4
Definitions

• Hypertensive urgency Severe hypertension (as
  defined by a diastolic blood pressure above 120
  mmHg) in asymptomatic patients
• Malignant hypertension marked hypertension with
  retinal hemorrhages, exudates, or papilledema
  usually associated with a diastolic pressure
  above 120 mmHg

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Causes

• Essential Hypertension
• Secondary Hypertension
• Primary renal disease
• Renovascular disease
• Oral contraceptives
• Pheochromocytoma
• Primary hyperaldosteronism
• endocrine disorders
• Sleep apnea syndrome
• Coarctation of the aorta

6
Essential vs. Secondary

• There are four major general clinical clues that
  are suggestive of secondary hypertension
• Severe or refractory hypertension.
• An acute rise in blood pressure over a previously
  stable value.
• Proven age of onset before puberty or above the
  age of 50 to 55 years
• Age less than 30 years in non-obese, non-black
  patients with a confirmed negative family history
  of hypertension.

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Essential Hypertension

• pathogenesis of essential hypertension is poorly
  understood
• Increased sympathetic neural activity, with
  enhanced beta-adrenergic responsiveness
• Increased angiotensin II activity and
  mineralocorticoid excess
• genetic factors
• Reduced adult nephron mass may predispose to
  hypertension

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Risk Factors

• A variety of risk factors have been associated
  with essential hypertension
• tends to be both more common and more severe in
  blacks
• Increased salt intake
• excess alcohol intake
• weight gain
• Dyslipidemia

Risk factors for arterial hypertension in adults
with initial optimal blood pressure the Strong
Heart Study Hypertension. 2006 Feb Dyslipidemia
and the risk of incident hypertension in men.
Hypertension. 2006 Jan
9
Complications

• Increase in risk begins as the blood pressure
  rises above 110/75 mmHg
• At any blood pressure, is importantly affected by
  the presence or absence of other risk factors

Age-specific relevance of usual blood pressure to
vascular mortality a meta-analysis of individual
data for one million adults in 61 prospective
studies. Lancet 2002 Dec
10
Complications- CV

• premature cardiovascular disease
• heart failure
• Left ventricular hypertrophy

11
Complications- Neurological

• Stroke
• Intracerebral hemorrhage
• Hypertensive encephalopathy

12
Complications- Renal

• Chronic renal insufficiency
• End-stage renal disease
• Anemia
• Electrolyte disorders

13
Diagnosis

• 3-6 visits over the space of weeks to months
• No evidence of end organ damage
• Cuff Size
• Too small can overestimate by 10-50 mmHg
• Arm circumference 22 to 26 cm, 'small adult'
  cuff, 12 x 22 cm
• Arm circumference 27 to 34 cm, 'adult' cuff 16 x
  30 cm
• Arm circumference 35 to 44 cm, 'large adult'
  cuff 16 x 36 cm
• Arm circumference 45 to 52 cm, 'adult thigh'
  cuff 16 x 42

Confirming the diagnosis of mild hypertension. Br
Med J (Clin Res Ed) 1983 Jan 22286(6361)287-9.
Variation in cuff blood pressure in untreated
outpatients with mild hypertension--implications
for initiating antihypertensive treatment. J
Hypertens 1987 Apr5(2)207-11.
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Diagnosis

• White Coat Hypertension
• Ambulatory monitoring
• Masked Hypertension

How common is white coat hypertension? JAMA 1988
Jan 8259(2)225-8. Prevalence, persistence, and
clinical significance of masked hypertension in
youth. Hypertension 2005 Apr45(4)493-8.
15
Work up-History

• When was the last time you were told your blood
  pressure was normal
• Family History
• Noncompliance
• Symptoms of target organ damage
• Headaches
• Visual changes
• Chest pain
• Claudication
• Dyspnea

16
Work up-History

• Presence of other risk factors for cardiovascular
  disease
• Smoking
• Diabetes
• Dyslipidemia
• Physical inactivity

17
Work up-History

• Signs and symptoms that suggest an identifiable
  cause of hypertension
• Muscle weakness
• Thinning of the skin
• Flank pain
• Symptoms suggestive of pheochromocytoma
• Spells of tachycardia, sweating, tremor

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Work up-PE

• Evaluate for signs of end-organ damage
• Retinopathy (Hemorrhage, Papilledema, Cotton wool
  spots)
• Pulses
• Cardiac (rhythm, murmurs)
• Abdominal bruits
• Edema
• Neurologic Assessment

19
Work up- Lab

• CBC, CMP
• TSH
• Lipid Profile
• UA
• EKG
• /- CXR

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Lifestyle Modifications
Modification Recommendation Approximate systolic BP reduction, range
Weight reduction Maintain normal body weight (BMI, 18.5 to 24.9 kg/m2) 5-20 mmHg per 10-kg weight loss
Adopt DASH eating plan Consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat 8 to 14 mmHg
Dietary sodium reduction Reduce dietary sodium intake to no more than 100 meq/day (2.4 g sodium or 6 g sodium chloride) 2 to 8 mmHg
Physical activity Engage in regular aerobic physical activity such as brisk walking (at least 30 minutes per day, most days of the week) 4 to 9 mmHg
Moderation of alcohol consumption Limit consumption to no more than 2 drinks per day in most men and no more than 1 drink per day in women and lighter-weight persons 2 to 4 mmHg
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Therapeutics
BP Systolic BP mmHg Diastolic BP mmHg Lifestyle Modification Initial Drug therapy WITHOUT compeling indication Initial Drug therapy WITH compeling indication
Normal lt120 And lt80 Encourage
Prehypertension 120-139 OR 80-89 YES No antihypertensive drug indicated Drug(s) for the compelling indications
Stage 1 140-159 OR 90-99 YES Thiazide-type diuretics for most may consider ACE inhibitor, ARB, beta blocker, CCB, or combination Drug(s) for the compelling indications other anti-hypertensive drugs (diuretics, ACE inhibitor, ARB, beta blocker, CCB) as needed
Stage 2 gt160 OR gt100 YES 2-drug combination for most (usually thiazide-type diuretic and ACE inhibitor or ARB or beta blocker or CCB) Drug(s) for the compelling indications other antihypertensive drugs (diuretics, ACE inhibitor, ARB, beta blocker, CCB) as needed
22
Getting to Goal

• Uncomplicated HTN lt 140/90 mmHg
• If older than 65 keep Diastolic above 65 mmHg
• Chronic Renal Disease lt 130/80 mmHg
• Diabetes Mellitus lt 130/80 mmHg
• Cardiovascular Disease lt 130/80 mmHg

The Seventh Report of the Joint National
Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure the JNC 7
report. Chobanian AV et al. JAMA 2003 May
21289(19)2560-72. Epub 2003 May 14.
23
Initial Drug Therapy

• Uncomplicated HTN Low dose diuretic
• Heart Failure ACEI
• Asymptomatic LV dysfunction ACEI
• MI ACEI
• Diabetes ACEI
• Renal Failure ACEI

Major outcomes in high-risk hypertensive patients
randomized to angiotensin-converting enzyme
inhibitor or calcium channel blocker vs diuretic
The Antihypertensive and Lipid-Lowering Treatment
to Prevent Heart Attack Trial (ALLHAT). JAMA 2002
Dec 18
24
Initial Drug Therapy

• Severe HTN with EKG evidence of LVH ARB
• S/p AMI with heart failure or asymptomatic LV
  dysfunction Beta blockers w/o ISA
• There are no absolute indications for calcium
  channel blockers in hypertensive patients

Major cardiovascular events in hypertensive
patients randomized to doxazosin vs
chlorthalidone the antihypertensive and
lipid-lowering treatment to prevent heart attack
trial (ALLHAT). ALLHAT Collaborative Research
Group. JAMA 2000 Apr 19283(15)1967-75. Should
beta blockers remain first choice in the
treatment of primary hypertension? A
meta-analysis. Lancet 2005 Oct 29-Nov
4366(9496)1545-53.
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Initial Drug Therapy

• Switching vs. Additive therapy
• Age Race Predictors
• Younger patients beta blockers and ACEI ARBs
• Older patients diuretics and CCBs
• Black patients diuretics and CCBs

1. Optimisation of antihypertensive treatment by
crossover rotation of four major classes. Lancet
1999 Jun 12 2. ACE inhibitors, beta-blockers,
calcium blockers, and diuretics for the control
of systolic hypertension. Am J Hypertens 2001
Mar 3. Response to a second single
antihypertensive agent used as monotherapy for
hypertension after failure of the initial drug.
Department of Veterans Affairs Cooperative Study
Group on Antihypertensive Agents. Arch Intern Med
1995 Sep 11 4. The Seventh Report of the Joint
National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure
the JNC 7 report. Chobanian AV et al. JAMA 2003
May 21289(19)2560-72. Epub 2003 May 14.
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Questions?
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fin