Title: Hypertension
1Hypertension
- Howard L. Sacher, D.O.
- Long Island Cardiology and Internal Medicine
2Learning Objectives
- To know how to detect and diagnose hypertension
and its secondary causes. - To become familiar with updated recommendations
for classifying hypertensive patients. - To understand the pharmacologic options for
treating hypertension and their appropriate use. - To grasp the importance of counseling patients on
lifestyle modification to help control
hypertension
3Hypertension
- Hypertension is the most well established and
important risk factor for - 1 Cardiovascular disease
- 2 Cerebrovascular events
- 3 Congestive Heart Failure (CHF)
- 4 End stage renal disease (ESRD)
4Hypertension (cont)
- There have been enormous advances in our
understanding of the value of treating
hypertension over the past three decades, yet the
most recent surveys show that hypertension
remains largely untreated and uncontrolled
5Hypertension (cont)
- The relationship between systolic and diastolic
blood pressure is strong, graded and continuous - The higher the BP, the higher the risk
- Systolic BP is a better predictor of
cardiovascular disease at all ages but
particularly in the older age group - Diastolic BP does not rise with age after the
fifth decade, a time when isolated systolic BP
begins to increase sharply in prevalence
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9Patient Evaluation
- Repeat BPs
- Teach Patients to take BPs
- Promotes participation by patient
- May reduce costs by reducing visits
- Ambulatory BP monitoring
- BP
- Evaluate diurnal variations
- Patient at a greater risk for end organ disease
10Patient Evaluation (cont)
- History medication , lifestyle habits such as
diet, exercise, smoking history, family history
and review of symptoms that may reflect secondary
hypertension, target organ disease or co-morbid
conditions
11Patient Evaluation (cont)
- Physical Exam
- BP standing and sitting in both arms and legs
- Looking for patients with orthostatic hypotension
over 60 - Coarctation of the aorta in younger patients
- Peripheral vascular disease
- Fundoscopic exam looking for evidence of
hypertensive retinopathy
12Patient Evaluation (cont)
- Evaluation of the Heart
- S4 decreased LV function compliance precedes
systolic dysfunction or S3 gallop - Evidence of CHF
- Rales (Crackles)
- Hepatomegaly
- Peripheral Edema
- Neurological exam for evidence of Cerebrovascular
disease
13Patient Evaluation (cont)
- Laboratory Evidence
- Complete blood count (CBC)
- Renal failure and polycythemia
- Chemistries Na, K, creatinine, fasting
glucose and lipid profile - K - low in hyperaldosteronism, high in renal
failure - Urinalysis
- 12 lead EKG
- LVH, Ischemia
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17Pheochromocytoma
- Pheochromocytoma
- Catacholamine producing tumors can occur in the
adrenal gland or anywhere along the
neuroectodermal crest 10 of adults have
multiple tumors - Triad
- Episodic Headaches
- Tachycardia
- Diaphoresis with labile hypertension
- Associated with multiple endocrine neoplastic
(MEN) syndromes, neurofibromatosis, and Van
Hipple Landau syndrome
18Pheochromocytoma
- Diagnosis
- Postural hypertension
- Resting tachycardia
- Café au lait spots
- Resting supine catacholamine levels gt 2000 pg/ml
(nep, ep) - Clonidine suppression test
- Lowers catacholamine levels in essential HTN but
not pheochromocytoma - Glucagon (2mg IV) increases plasma catecholamines
at least three fold or gt2000 1 to 3 minutes after
administration in patients with pheochromocytoma
19Pheochromocytoma
- Tumor Localization accomplished by
- CT scan
- MRI
- Radioisotope uptake studies
- Treatment
- Surgical removal of tumor
- Alpha and beta adrenergic blockers are useful for
chronic management or non-surgical cases (alpha
blockers commonly used)
20Hyperaldosteronism
- Spontaneous hypokalemia while on diuretics and
potassium supplements - Primary Hyperaldosteronism
- Small unilateral adenoma (lt1cm) is more common
in women - Bilateral adrenal hyperplasia is more common in
men - Diagnosis
- Measure 24 hour urinary aldosterone measurements
for two days on high sodium diet (gt!4g/ 24 hours) - Increased aldosterone with low levels of plasma
renin activity - Adenomas detected by MRI
21Hyperaldosteronism (cont)
- Treatment
- Surgery for small solitary adenomas
- Medical treatment for adrenal hyperplasia
- Diuretics and vasodilators
- Aldosterone antagonists do not reduce BP
adequately but may be needed to correct
hypokalemia
22Renal Artery Stenosis
- More commonly found stage 3 or resistant
hypertension - When bilateral can have reduced kidney function
- Clinical clues to renovascular disease
- Onset before age 30 or recent onset of
significant high BP after age 55 - Abdominal bruit if diastolic and lateralized
- Accelerated or resistant high blood pressure
- Recurrent flash pulmonary edema
- Renal failure with normal sediment
- Co-exiting ASVD especially in long smokers
- Acute renal failure particularly after ACE I or
Angiotensin receptors blockers
23Renal Artery Stenosis (cont)
- Diagnosis
- Captopril enhances radionuclide renal scan
- Duplex doppler flow studies
- MRI and MRA
- Definitive diagnosis angiography
- Treatment
- Revascularization
- Fibromuscular dysplasia Percutaneous
transluminal renal angioplasty (PTRA) is
comparable to surgery - Atherosclerotic renal artery stenosis ideal for
PTCA with stenting if renal function normal - Surgery or PTCA with stenting to preserve renal
function
24- LVH with left atrial enlargement
25 26- HTN 2nd to Fibromuscular Dysplasia
2710-Minute Break
28JNC - VI
- Joint National Committee (JNC) on the Detection,
Evaluation and Control of High Blood Pressure - Emphasis risk stratification for cardiovascular
disease - Smoking
- Dyslipidemia
- Diabetes Mellitus
- Old age
- Male sex
- Post-Menopausal
- Family History of cardiovascular disease
29At any given level of SBP the absolute risk of a
coronary event increases dramatically as compared
to those with no risks
30Classifying patients with HTN with consideration
to target end organ damage/clinical
cardiovascular disease (TOD/CCD)
31Lifestyle Modifications
- Weight redistribution lowers BP but also has
effect on lipids and glucose metabolism - There is a Metabolic Syndrome
- Obesity
- High BP
- Hyperlipidemia
- Insulin resistance or Diabetes
- Reduction of dietary sodium
- Correlation between dietary sodium and blood
pressure most patients benefit from reducing
intake to below 2400mg/day, 6 g salt. Also
enhances the efficacy of anti-hypertensive agents
and may reduce potassium effect of diuretic
agents and minimize hypokalemia. (i.e. processed
foods)
32Lifestyle Modifications (cont)
- Alcohol
- 1 ounce of ethanol
- 24 ounces of beer
- 10 ounces of wine
- 2 ounce of 100 proof whisky
- Tobacco
- Aerobic Exercise
33Diabetic Hypertensive patients
- Blood glucose controlled
- Weight loss
- Aerobic exercise
- Angiotensin Converting Enzyme (ACE) Inhibitors or
Angiotensis Receptor Blockers (ARB) - Treatment to lower BP using ACE-I and ARB
- Microvascular retinopathy, nephropathy
- Macrovascular CAD, angina, AAA, CVA
- BP goals lt or to 120 / 80
34Congestive Heart Failure
- Treatment
- ACE I
- ARB
- Diuretics
- B-Blockers
- Digitalis
- Monitor for
- Orthostatic hypotension
- Renal function
- K levels
35Post-Myocardial Infarction
- Treatment
- ß-Blockers
- ACE- I in patients with systolic dysfunction
- Diltiazem or Verapamil in patients with non
Q-wave infarction may be used if B-blocker
ineffective or contraindicated
36Isolated Systolic Hypertension (ISH) and
Hypertension in older patients
- Higher risk for cardiovascular disease
- Lifestyle modifications
- Decreased vascular compliance due to loss of
arterial elasticity associated with aging - Drug of choice
- Low dose thiazide diuretics
- Be concerned about postural hypotension or
cognitive dysfunction (central alpha 2 agonists)
37Ischemic Heart Disease
- Treatment
- B-Blockers
- Calcium channel blockers as a second choice if
beta blockers are contraindicated or both drugs
can be used together to achieve BP goals - Treat risk factors
- High lipids
- Diabetes or Insulin resistance
- Weight loss
- ACE-Inhibitors
38Renal Disease
- Aggressive treatment to lower BP
- lt or 130/85
- Goal will slow rate of disease progression
- ACE inhibitors are drugs of choice but must be
used with caution if creatinine gt3 mg/dl and are
not used when renovascular hypertension is
suspected - Thiazide diuretics are not effective if serum
creatinine is gt 2.5 mg/dl and loop diuretics are
required
39African-Americans and HTN
- High prevalence
- Occurs earlier, more severe and is associated
with higher risks of cardiovascular disease - Stroke and heart disease mortality rates 80 and
50 higher respectively - End stage renal disease 320 higher
- Lifestyle modifications
- Diuretics are drugs of choice for uncomplicated
hypertension - Ca channel blockers and alpha blockers are also
effective - All other drugs can be used to achieve BP goals
40Women and HTN
- Same therapy as men
- If on OCP stop and monitor BP
- During pregnancy ACE-I and ARB should be stopped
- Alpha-Methyldopa during pregnancy
41Patients Undergoing Surgery
- If BP is gt 180/110, patient must be treated to
reduce the risk of perioperative ischemic events - Cardio-selective beta-blockers, unless
contraindicated, are drugs of choice - Hypertensive patients who are well controlled
prior to surgery should be continued on their own
regimen as soon as possible after surgery
42Meta-analysis on the various first line drug
treatments
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47BP gt 95th percentile is considered elevated in
children
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51Hypertensive Emergencies
- Reduce mean arterial pressure (MAP) no more than
25 (minutes to several hours) and then to
160/100 mmHg avoiding excessively rapid falls
that may precipitate cerebral or coronary
ischemia - Sublingual nifedipine is not recommended because
of the relatively high risk for these adverse
events
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54Patient Education and Lifestyle modifications
- Lose excess weight.
- Cut the fat.
- Limit alcohol intake.
- Exercise regularly.
- Reduce sodium intake.
- Stop smoking.
55Follow-up
- Once stable, patients should be re-evaluated at
least every 3 to 6 months - Review compliance, effectiveness and adverse
reactions - Quality of life issues should be considered,
including sexual function - At least annual evaluation of urinalysis,
creatinine and potassium are appropriate,
generally as part of a screening laboratory panel