Download Update on Hypertension - Lourdes Health System

Update on Hypertension
Troy L. Randle, DO, FACC, FACOI
S
Financial Disclosures
S I have no financial disclosures at this time.
Objectives
S Update on JNC-8 and understand the differences in
treatment of hypertension according to the newer
guidelines.
Cardiovascular Statistics
S Heart Disease
S Leading causes of death in US
S Accounts for more than 40% of all deaths
S About 95,000 Americans die of heart disease or stroke each
year
S Amounts to one death every 33 seconds
S Heart Disease is the leading cause of disability among
working adults
CVD Risk Factors









Hypertension*
Cigarette smoking
Obesity* (BMI >30 kg/m2)
Physical inactivity
Dyslipidemia*
Diabetes mellitus*
Microalbuminuria or estimated GFR <60 ml/min
Age (older than 55 for men, 65 for women)
Family history of premature CVD
(men under age 55 or women under age 65)
*Components of the metabolic syndrome.
Hypertension
About 1 in 3 U.S. adults—
as estimated 68 million—
have high blood pressure,
which increases the risk
for heart disease and
stroke, leading causes of
death in the United States.
Causes of Hypertension
Causes of Hypertension
Sleep apnea
Drug-induced or related causes
Chronic kidney disease
Primary aldosteronism
Renovascular disease
Chronic steroid therapy and Cushing’s syndrome
Pheochromocytoma
Coarctation of the aorta
Thyroid or parathyroid disease
Hypertension
S
Assessment
S Start with the basics: Take
your own blood pressures for
patient with Hypertension!
S Two measurements
S Both arms
S Patient seated for at least two
minutes
Testing
S
Electrocardiogram
S
Urinalysis
S
Blood glucose, and hematocrit
S
Serum potassium, creatinine (or the corresponding estimated GFR), and calcium
S
Lipid profile, after 9 to 12-hour fast, that includes high-density and low-density lipoprotein
cholesterol, and triglycerides
S
Echocardiogram
S
Ambulatory Blood Pressure Monitoring
S
Optional tests
•
Measurement of urinary albumin excretion or albumin/creatinine ratio
• More extensive testing for identifiable causes is not generally indicated unless BP
control is not achieved
Hypertension
S High Blood Pressure
Hypertension on Heart
Hypertension on the Body
Target End Organ Damage
 Heart
• Left ventricular hypertrophy
• Angina or prior myocardial infarction
• Prior coronary revascularization
• Heart failure
 Brain
• Stroke or transient ischemic attack
 Chronic kidney disease
 Peripheral arterial disease
 Retinopathy
Causes of
Resistant Hypertension







Compliance
Improper BP measurement
Excess sodium intake
Inadequate diuretic therapy
Medication
•
Inadequate doses
•
Drug actions and interactions (e.g., nonsteroidal anti-inflammatory drugs (NSAIDs),
illicit drugs, sympathomimetics, oral contraceptives)
•
Over-the-counter (OTC) drugs and herbal supplements
Excess alcohol intake
Identifiable causes of HTN
Hypertension – The Numbers
Blood pressure classification
Questions Leading to JNC-8
S In adults with hypertension, does initiating antihypertensive
pharmacologic therapy at specific BP thresholds improve health
outcomes?
S In adults with hypertension, does treatment with antihypertensive
pharmacologic therapy to a specified BP goal lead to
improvements in health outcomes?
S In adults with hypertension, do various antihypertensive drugs or
drug classes differ in comparative benefits and harms on specific
health outcomes?
Recommended Treatment
Goals
S In adults (general population) greater than 60 years of age:
S SBP<150, DBP<90
S In adults (general population) less than 60 years of age:
S SBP<140, DBP<90
S In adults with diabetes or chronic kidney disease:
S SBP<140, DBP<90
JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427
Recommend Treatment Meds
S Nonblack population
S Thiazide diuretic
S Calcium-channel blocker
S ACE-I/ARB
S Black population
S Thiazide diuretic
S Calcium-channel blocker
S CKD
S ACE-I/ARB
JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427
JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427
Additional Considerations in
Antihypertensive Drug Choices
S
Potential unfavorable effects

Thiazide diuretics should be used cautiously in gout or a history of significant
hyponatremia.

BBs should be generally avoided in patients with asthma, reactive airways disease, or
second- or third-degree heart block.

ACEIs and ARBs are contraindicated in pregnant women or those likely to become
pregnant.

ACEIs should not be used in individuals with a history of angioedema.

Aldosterone antagonists and potassium-sparing diuretics can cause hyperkalemia.
Benefits of Lowering BP
Average Percent Reduction
Stroke incidence
35–40%
Myocardial infarction
20–25%
Heart failure
50%
Recommended Treatment
Goals
S In adults (general population) greater than 60 years of age:
S SBP<150, DBP<90
S In adults (general population) less than 60 years of age:
S SBP<140, DBP<90
S In adults with diabetes or chronic kidney disease:
S SBP<140, DBP<90
Recommend Treatment Meds
S Nonblack population
S Thiazide diuretic
S Calcium-channel blocker
S ACE-I/ARB
S Black population
S Thiazide diuretic
S Calcium-channel blocker
S CKD
S ACE-I/ARB
Comparing BP Control –
JNC 7 to JNC8
S Atherosclerosis Risk in Communities Study
S 6088 participants
S
JNC 7 Prevalence: 82%
S
JNC 7 Controlled: 63%
S
JNC 8 Controlled: 79%
S
Despite criteria used, >20% still uncontrolled.
S Therapeutic Inertia
Case #1
S TR is a 50 yo Black male with history of DM, dyslipidemia.
S BP is 180/110mmHg HR 84bpm
S What do you do next?
Case #1
S TR is a 50 yo Black male with history of DM, dyslipidemia.
S BP is 180/110mmHg HR 84bpm
S What do you do next?
S Education
S Studies
S Medication Treatment
Case #1
S TR is a 50 yo Black male with history of DM, dyslipidemia.
S Calcium-channel blocker (Norvasc 5mg daily)
S BP 160/90
S What do you do next?
Case #2
S TL is a 38 yo Non-black female with history of DM,
dyslipidemia.
S BP is 160/90mmHg HR 84bpm
S What do you do next?
S Education
S Studies
S Medication Treatment
Case #2
S TL is a 38 yo Non-black female with history of DM,
dyslipidemia.
S BP is 160/90mmHg HR 84bpm
S Medication Options
S Thiazide diuretic
S Calcium-channel blocker
S ACE-I/ARB(???)
Case #3
S LR is a 83 yo Non-black female with history of
hypothyroidism and dyslipidemia.
S BP is 148/90mmHg HR 84bpm
S What would you do next?
Case #4
S LR is a 83 yo Non-black female with history of
hypothyroidism and dyslipidemia.
S BP is 168/90mmHg HR 84bpm
S What would you do next?
S Medications?
References
S James PA, Oparil S, Carter BL, et al. 2014 Evidence-
Based Guideline for the Management of High Blood
Pressure in Adults: Report From the Panel Members
Appointed to the Eighth Joint National Committee (JNC
8). JAMA. 2014;311(5):507-520.
doi:10.1001/jama.2013.284427.
S Mozaffarian, D. et al. 2014. AHA Statistical Update
Heart Disease and Stroke Statistics—2015 Update.
Circulation. 2015; 131: e29-e322
Questions
???