Management of Hypertension

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Management of Hypertension

• David Putnam, MD
• Albany Medical College
• September 21, 2000

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Percent Decline in Age-Adjusted Mortality Rates
for Stroke by Sex and Race United States, 1972-94
The decline in age-adjusted mortality for stroke
in the total population is 59.0. Age-adjusted
to the 1940 U.S. census population.
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Percent Decline in Age-Adjusted Mortality Rates
for CHD by Sex and Race United States, 1972-94
The decline in age-adjusted mortality for CHD in
the total population is 53.2. Age-adjusted to
the 1940 U.S. census population.
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Incidence of Reported End-Stage Renal Disease
Therapy, 1982-1995
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Provisional data. Adjusted for age, race, and
sex.
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Prevalence of Heart Failure,by Age, 1976-80 and
1988-91
1988-91
1976-80
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Hypertension

• One of the most well established and important
  risk factors for CVD
• Most recent surveys show that HTN remains largely
  untreated and uncontrolled

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Awareness, Treatment, and Control of High Blood
Pressure in Adults
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Hypertension

• JNC-VI has provided widely used definitions of
  high blood pressure categories
• Relationship between SBP and DBP and CVD is
  strong, graded, and continuous
• SBP is a better predictor of CVD at all ages but
  particularly in older age groups

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Blood Pressure Measurement

• Patients should be seated with back supported and
  arm bared and supported.
• Patients should refrain from smoking or ingesting
  caffeine for 30 minutes prior to measurement.
• Measurement should begin after at least 5 minutes
  of rest.
• Appropriate cuff size and calibrated equipment
  should be used.
• Both SBP and DBP should be recorded.
• Two or more readings should be averaged.

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Advantages of Self-Measurement

• Identifies white-coat hypertension
• Assesses response to medication
• Improves adherence to treatment
• Potentially reduces costs
• Usually provides lower readings than those
  recorded in clinic (hypertension is defined as
  SBP gt 135 or DBP gt 85 mm Hg)

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Ambulatory Measurement

• Ambulatory monitoring can provide
• readings throughout day during usual activities
• readings during sleep to assess nocturnal changes
• measures of SBP and DBP load
• Ambulatory readings are usually lower than in
  clinic (hypertension is defined as SBP gt 135 or
  DBP gt 85 mm Hg)

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Classification of Blood Pressure for Adults
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Recommendations for Followup Based on Initial
Measurements
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Evaluation Objectives

• To identify known causes
• To assess presence or absence of target organ
  damage and cardiovascular disease
• To identify other risk factors or disorders that
  may guide treatment

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Evaluation Components

• Medical history
• Physical examination
• Routine laboratory tests
• Optional tests

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Medical History

• Duration and classification of hypertension
• Patient history of cardiovascular disease
• Family history
• Symptoms suggesting causes of hypertension
• Lifestyle factors
• Current and previous medications

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Physical Examination

• Blood pressure readings (2 or more)
• Verification in contralateral arm
• Height, weight, and waist circumference
• Funduscopic examination
• Examination of the neck, heart, lungs, abdomen,
  and extremities
• Neurological assessment

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Laboratory Tests and Other Diagnostic Procedures

• Determine presence of target organ damage and
  other risk factors
• Seek specific causes of hypertension

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Laboratory Tests Recommended Before Initiating
Therapy

• Urinalysis
• Complete blood count
• Blood chemistry (potassium, sodium, creatinine,
  and fasting glucose)
• Lipid profile (total cholesterol and HDL
  cholesterol)
• 12-lead electrocardiogram

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Optional Tests and Procedures

• Creatinine clearance
• Microalbuminuria
• 24-hour urinary protein
• Serum calcium
• Serum uric acid
• Fasting triglycerides
• LDL cholesterol
• Glycosolated hemoglobin

• Thyroid-stimulating hormone
• Plasma renin activity/ urinary sodium
  determination
• Limited echocardiography
• Ultrasonography
• Measurement of ankle/arm index

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Hypertension

• Secondary Causes

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Examples of IdentifiableCauses of Hypertension

• Renovascular disease
• Renal parenchymal disease
• Polycystic kidneys
• Aortic coarctation

• Pheochromocytoma
• Primary aldosteronism
• Cushing syndrome
• Hyperparathyroidism
• Exogenous causes

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HTN Renal Artery Stenosis

• Onset of HTN before age 30 or after age 55 in
  absence of family history of HTN
• Abdominal bruit
• Accelerated or resistant HTN
• Renal failure of uncertain cause
• Acute renal failure induced by ACE
• Diagnosis captopril renal flow scan

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HTN Hypersecretion of Aldosterone

• Suspect in patients with spontaneous hypokalemia
• Unilateral adenoma more common in women
• Bilateral adrenal hyperplasia more common in men
• Diagnosis Measurement of PRA and plasma or
  24-hour urine aldosterone after 2 days of high
  sodium diet

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HTN Pheochromocytoma

• Suspect in patients with episodic headaches,
  tachycardia, diaphoresis with labile HTN
• Diagnosis resting supine plasma catecholeamine
  levels gt 2000 pg/ml
• Urine metanephrine and VMA less sensitive but
  very specific

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Hypertension

• Risk Stratification

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HTN Major Risk Factors

• Smoking
• Dyslipidemia
• Diabetes mellitus
• Sex (men and postmenopausal women)
• Family history of cardiovascular disease women
  lt 65 yr or men lt 55 yr

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Hypertension CAD Risk Factors

• Estimated that 90 of patients with hypertension
  have other risk factors for CAD

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Target Organ DamageClinical Cardiovascular
Disease

• Heart diseases
• Left ventricular hypertrophy
• Angina or prior MI
• Prior coronary revascularization
• Heart failure
• Stroke or TIA
• Nephropathy
• Peripheral artery disease
• Retinopathy

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HTN LVH

• LVH is the most important risk factor for
  cardiovascular events that we have
• Epidemiological data indicate that LVH is an
  ominous harbinger of cardiovascular disease in
  the hypertensive patient

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Fundoscopic Exam
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Risk Stratification
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Hypertension

• Treatment

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Goal of HypertensionPrevention and Management

• To reduce morbidity and mortality by the least
  intrusive means possible. This may be
  accomplished by achieving and maintaining
• SBP lt 140 mm Hg
• DBP lt 90 mm Hg
• controlling other cardiovascular risk factors

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Treatment Strategies andRisk Stratification
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Algorithm for Treatment of Hypertension
Not at Goal Blood Pressure
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HTN TONE Study

• Randomized, controlled study
• 875 men/women aged 60 to 80 years old
• SBPlt145, DBPlt85 on treatment
• 585 obese patients randomized
• Reduced sodium intake ( lt 1800mg )
• Weight loss ( gt10 )
• Sodium reduction and weight loss

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HTN TONE Study

• Results
• BP lower and decreased BP meds in weight loss
  group and sodium reduction group

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Algorithm for Treatment of Hypertension
Begin or Continue Lifestyle Modifications
Not at Goal Blood Pressure (lt 140/90 mm Hg)
lower goals for patients with diabetes or renal
disease
Initial Drug Choices
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Algorithm for Treatment of Hypertension
(continued)
Not at Goal Blood Pressure
Initial Drug Choices
Uncomplicated
Specific Indications
Compelling Indications

• Start at low dose and titrate upward.
• Low-dose combinations may be appropriate.

Not at Goal Blood Pressure
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Classes ofAntihypertensive Drugs

• ACE inhibitors
• Adrenergic inhibitors
• Angiotensin II receptor blockers
• Calcium antagonists
• Direct vasodilators
• Diuretics

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Algorithm for Treatment ofHypertension
(continued)
Initial Drug Choices

• Uncomplicated
• Diuretics
• ?-blockers

Based on randomized controlled trials.
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JNC VI Treatment Algorithm
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Treatment of Hypertension
HTN
CHD
Medical Problems
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HTN Pharmacologic RxCompelling Indications

• Diabetes mellitus
• Heart failure
• Post-myocardial infarction
• Isolated systolic HTN and HTN in older patients

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HTN Patients with DM

• ACE inhibitors are a good first choice
• Calcium channel antagonists and low dose
  diuretics are a good second choice
• ARBs may be considered as an alternative to ACE
  inhibitors but renal protection is still unproven
• Beta blockers may mask hypoglycemia but can be
  used safely

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HTN Patients with CHF

• ACE inhibitors preferred with systolic
  dysfunction
• ARBs may be an alternative to ACE inhibitors but
  mortality reduction remains unproven
• Diuretics
• Beta blockers in low doses
• Amlodipine/Felodipine may be used safely with
  systolic dysfunction

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HTN Patients Post-MI

• Beta blockers
• ACE inhibitors with LV dysfunction

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HTN Older Patients

• Extremely common
• Present in more than 60 of Americans age 60 and
  older
• SBP a better predictor of events then DBP
• Elevated pulse pressure a predictor of increased
  risk

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HTN Older Patients

• Primary HTN is the most common form
• Some patients have pseudohypertension due to
  excessive vascular stiffness
• Orthostasis is more common

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Systolic HTN European Trial

• 4695 patients aged 60 years or older
• SBP 160 to 219 mmHg w/ DBP lt95 mmHg
• Dihydropyridine with possible addition of
  enalapril and HCTZ
• Median follow-up of 2 years
• Lancet 1997350757-64.

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Systolic HTN European Trial
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Hypertension in the Elderly
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HTN Older Patients

• Thiazide diuretics recommended first
• Dihydropyridine calcium antagonists recommended
  as an alternative agent
• Beta blockers are not as effective ( JAMA
  1998(JUN)2791903-1907 )

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HTN Pharmacologic RxSpecific Indications

• Coronary artery disease
• LVH
• Renal Disease
• Dyslipidemia

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HTN Patients with CAD

• Beta blockers, calcium channel antagonists
• Avoid short-acting calcium channel antagonists
• Beta blockers post MI
• ACE inhibitors with LV dysfunction

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HTN Patients with LVH

• Major independent risk factor for cardiac events
• Observational data indicate that regression of
  LVH associated with reduction in cardiac events

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HTN LVH
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HTN Patients with LVH

• All antihypertensive agents except direct acting
  vasodilators reduce LVH
• ACE inhibitors, ARBs, calcium antagonists may be
  better at reversing LVH

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HTN Patients with Renal Insuficiency

• Goal BP of 125/75 in patients with gt1g/d of
  proteinuria
• Goal BP of 130/85 in patients with lt1g/d of
  proteinuria
• ACE inhibitors have additional renoprotective
  effects

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HTN Patients with Dyslipidemia

• Beta blockers may increase Trig and reduce HDL-C
• Alpha blockers may decrease Chol, and increase
  HDL-C
• ACE, ARBs, and calcium antagonists tend to have
  a neutral effect

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HTN Patients with Dyslipidemia

• In most cases dietary modification will correct
  any drug effect on dyslipidemia

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Other Situations

• African Americans
• Oral Contraceptives
• Hormone Replacement Therapy
• Pregnancy

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Hypertension African Americans

• Prevalence of HTN among the highest in the world
• Develops earlier in life
• Average blood pressures are much higher
• Higher rates of Stage 3 HTN

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Hypertension African Americans

• 80 higher stroke rate mortality
• 50 higher heart disease mortality rate
• 320 greater rate of hypertension-related
  end-stage renal disease

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Hypertension African Americans

• Diuretics should be agent of first choice
• Calcium antagonists and alpha-beta blockers are
  also effective
• Beta blockers and ACE inhbitors are less effective

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HTN Oral Contraceptives

• HTN 2 to 3 times more common in women taking oral
  contraceptives
• Advisable to stop contraceptives
• In certain cases may need to continue and treat
  hypertension

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HTN Hormone Replacement Therapy

• Presence of HTN is not a contraindication to
  postmenopausal estrogen therapy
• BP does not increase significantly in most women
• A few women may experience a rise in BP

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Pregnant Women

• Chronic hypertension is high blood pressure
  present before pregnancy or diagnosed before 20th
  week of gestation.
• Preeclampsia is increased blood pressure that
  occurs in pregnancy (generally after the 20th
  week) and is accompanied by edema, proteinuria,
  or both.
• ACE inhibitors and angiotensin II receptor
  blockers are contraindicated for pregnant women.
  
• Methyldopa is recommended for women diagnosed
  during pregnancy.

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Antihypertensive Drugs Used in Pregnancy
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Antihypertensive Drugs Used in Pregnancy
(continued)
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HTN PregnancyBeta Blockers

• Review of 312 pregnancies complicated by HTN in
  the UK
• Atenolol associated with significantly lower
  birth weights
• Am J HTN 199912541-547

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Sleep Apnea

• Obstructive sleep apnea is more common in
  patients with hypertension and is associated with
  several adverse clinical consequences.
• Improved hypertension control has been reported
  following treatment of sleep apnea.

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HTN HOT Study

• Lowest risk for major cardiovascular events seen
  at DBP of 82.6 mm Hg
• 51 reduction in major cardiovascular events in
  diabetics with DBP lt80 mm Hg vs lt90 mm Hg

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Special Considerationsin Selecting Drug Therapy

• Demographics
• Coexisting diseases and therapies
• Quality of life
• Physiological and biochemical measurements
• Drug interactions
• Economic considerations

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Drug Therapy

• A low dose of initial drug should be used, slowly
  titrating upward.
• Optimal formulation should provide 24-hour
  efficacy with once-daily dose with at least 50
  of peak effect remaining at end of 24 hours.
• Combination therapies may provide additional
  efficacy with fewer adverse effects.

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Combination Therapies

• ?-adrenergic blockers and diuretics
• ACE inhibitors and diuretics
• Angiotensin II receptor antagonists and diuretics
• Calcium antagonists and ACE inhibitors
• Other combinations

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Followup

• Follow up within 1-2 months after initiating
  therapy.
• Recognize that high-risk patients often require
  high dose or combination therapies and shorter
  intervals between changes in medications.
• Consider reasons for lack of responsiveness if
  blood pressure is uncontrolled after reaching
  full dose.
• Consider reducing dose and number of agents after
• 1 year at or below goal.

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Causes for InadequateResponse to Drug Therapy

• Pseudoresistance
• Nonadherence to therapy
• Volume overload
• Drug-related causes
• Associated conditions
• Identifiable causes of hypertension

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HTN Prescribing Patterns
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• Judge a man by his questions rather than by his
  answers.
• Voltaire