Cure Pathologic Fear of Hypertension

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Objectives

• Cure Pathologic Fear of Hypertension
• Create Rational Approach to Drug Choice
• Complement Rational Choice with Pearls
• Consolidate new information with cases

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• Those who do not have high blood pressure at age
  55 face a 90 percent chance of developing it
  during their lifetimes.
• So high blood pressure is a condition that most
  people have at some point in their lives.
• 90 of Americans over 65 have hypertension or
  Prehypertension

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If you cannot prevent disease
You can at least cause Dys-Ease
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Your Blood pressure is 128/84
While drug treatment is recommended if your BP is
at or above 140/90,
new medical guidelines state that a normal BP for
most adults is less than 120/80. Ask your doctor
what is right for you.
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The risk of cardiovascular disease begins at
115/75
In individuals aged 40 to 70 years, each 20/10 mm
Hg increase in blood pressure doubles the risk of
cardiovascular disease, including heart attack,
stroke or kidney disease
This program includes A free 30 day trial of
Diovan, Diovan HCT and Lotrel, 3 medications
proven to help lower blood pressure.
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180/100
115/75
High Risk
Low Risk
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115/75
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Were Doomed, Were Doomed
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Home Blood Pressures
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Hypertension

• The Silent Killer

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69 of people who have a heart attack,   77 of
people who have a first stroke, and 74 of
people with chronic CHF have high blood pressure.
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95 of people who have a heart attack,   95 of
people who have a first stroke, and 95 of
people with chronic CHF
Have eaten pickles in the previous 10 years
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http//cybersmokeblog.blogspot.com/2013/03/do-you-
agree-to-tell-whole-truth-and.html
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Hypertension Outcomes
Disease Low Dose Diuretic Ace Inhibitors Beta Blockers
Death 28 27 27
Stroke 37 35 11
Coronary Heart Disease 28 19 NS
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So What does it mean

• 45 Year Old Female
• Cholesterol 200
• Non-Smoker
• Systolic of 190
• 10 Year Risk?

• 2 Risk of Heart Attack
• 1.4 if treated

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So What does it mean

• 65 Year Old Male
• Cholesterol 200
• Non-Smoker
• Systolic of 155
• 10 Year Risk?

90 Chance of Going 10 years with NO heart
attack 92.8 If they Are Treated

• 10 Risk of Heart Attack
• 7.2 if treated

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So What does it mean

• 65 Year Old Male
• Cholesterol 200
• Smoker
• Systolic of 180
• 10 Year Risk?

75 Chance of Going 10 years with NO heart
attack 82 If they Are Treated

• 25 Risk of Heart Attack
• 18 if treated

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But Aggressive Is Better
Right?

• Accord Trial NEJM 201036217
• Diabetes PLUS
• Heart Disease
• OR
• Albuminuria
• OR
• Hypertrophy
• OR
• Two Risk Factors

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But Aggressive Is Better

• Accord Trial NEJM 201036217
• Systolic of lt120 vs Systolic of lt140
• Achieved 119 vs 133

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But Aggressive Is Better
Right?

• Accord Trial NEJM 201036217
• Outcome
• nonfatal myocardial infarction, nonfatal stroke,
  or death from cardiovascular causes
• Followed Almost 5 years

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But Aggressive Is Better
Right?

• Accord Trial NEJM 201036217
• Composite Outcome
• 1.87 vs 2.09 p0.2
• Death
• 1.28 vs 1.19

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But Aggressive Is Better
Right?

• Accord Trial NEJM 201036217
• Stroke
• 0.32 vs 0.53 p0.01

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Cochrane ReviewAggressive is Better?

• Seven trials (22,089 subjects)
• -4/-3 better
• at present there is no evidence to support
  aiming for a blood pressure target lower than
  140/90 mmHg in any hypertensive patient.

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Fear Of Hypertension

• Fear of Hypertension

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• Rational Approach to
• Treat HTN

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Two Major Divisions of HTN

• High Renin
• Low Renin

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High Renin

• Intuitive
• Renin? Angiotensin?Aldosterone
• Sympathetic Nervous System
• Angiotensin? Vasoconstriction
• Aldosterone? Sodium and Water

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High Renin

• Characteristics
• Systolic and Diastolic Equally Elevated
• Higher Hemoglobin
• Younger
• High Stress?
• White?

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Low Renin

• Not Intuitive
• Why is Renin Low?
• Flaws in Sodium Excretion
• ? Volume
• Paradoxical ? Aldosterone
• Stiff Arteries Volume Excess

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Low Renin

• Characteristics
• Isolated Systolic Hypertension
• Older
• Women
• African American
• Diabetes

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• So What?

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Stimulate RAA
Inhibit RAA
Diuretics CCBs
ACEs / ARBs Beta Blockers
?
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Salt and Hypertension

• Salt retaining Steroids
• Corticosteroids
• Anabolic Steroids
• Oral contraceptives
• Estrogens
• NSAIDS

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46 year old AA female
HCTZ
Chlorthalidone Or Indapamide

• Weight 276 pounds
• BP 170/90
• Blood sugars run 200-250
• Glucophage 500mg BID
• Micronase 5mg qd
• Zestril 20mg qd
• Complaining of palpitations.

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She has Diabetes!!You cant do that, Can You??
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Good Question !!
Transition
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Diuretics
0 12.5 25 50 100
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Diuretics

• Lasix for Hypertension
• Only if
• Serious Edema
• CrCl lt 30
• Torsemide probably better

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Alpha Blockers

• Women Only the ones with Prostate Glands
• Men only the ones with BIG Prostate Glands
• When in Doubt, Cut It Out.

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Clonidine

• All the outcomes data are on the next slide

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Atenolol is Dead
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Hydralazine
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Resistant Hypertension

• Causes
• Drugs
• Street Drugs
• Sleep Apnea
• Renal Artery Stenosis

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Resistant Hypertension

• The Situation
• All 4 Classes added
• Still No Joy
• Add Spironolactone
• Especially if the potassium is on the low side

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Last Pearl

• The number one cause of Resistant Hypertension

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• A Couple Stories

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The Silent Killer in Guatemala
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Uncle Barney

• 67 years old
• Norvasc 5
• Lisinopril 40
• Carvedilol 25 BID
• Chlorthalidone 25mg
• Blood Pressure is 192/105

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Uncle Barney

• Assess Compliance
• Assess Compliance
• Assess Compliance
• Consider Sleep Apnea
• Consider Spironolactone

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Aunt Betty

• 52 year old female
• Non-smoker
• Blood Pressure 152/94
• Which drug should be started?

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Aunt Betty

• Leave the Poor Woman Alone !!
• Take away her home blood pressure machine
• Exercise, Salt and Healthy Food

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• Cured Pathologic Fear of Hypertension
• Created a Rational Approach to Drug Choice
• Complemented Rational Choice with Pearls
• Consolidated new information with cases