Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
HYPERTENSION Llewellyn F Mensah, MD Classification (Adults) BP Classification Systolic BP (mmHg) Diastolic BP (mmHg) Normal < 120 and < 80 Prehypertension 120 – 139 or 80 - 89 Stage 1 hypertension 140 – 159 or 90 – 99 Stage 2 hypertension ≥ 160 or ≥ 100 Measuring BP • Seated quietly for 5 minutes in chair • Feet on floor, arm supported at heart level • No caffeine, exercise or smoking for 30 minutes • Cuff bladder should encircle at least 80% arm circumference • Inflate 20 – 30 mmHg above pulse examination • Deflate at rate of 2 mmHg/sec • Take at least 2 measurements separated by > 2 mins and average Etiologies • Essential onset 25 to 55 years Positive family history Unclear mechanism but ?additive microvascular renal injury over time with contribution of hyperactive sympathetics Older age leads to decreased arterial compliance and systolic HTN • Secondary Consider if patient < 20 or > 50 y or if sudden onset, severe, refractory HTN Standard Workup • Goals: Identify CV risk factors or other diseases that would modify prognosis or treatment Reveal secondary causes of hypertension Assess for target organ damage • History: CAD, HF, TIA/CVA, PAD, DM, Renal insufficiency, sleep apnea, preeclampsia, Fhx of HTN, diet, Na intake, smoking, alcohol, prescription and OTC meds, OCP • Physical exam: Check BP in both arms, fundoscopy, CV exam, abdominal, neuro • Testing: K, BUN, Cr, Ca, glc, Hct, U/A, Lipids, TSH, urinary albumin:creatinine (if Cr, DM, peripheral edema), ?renin, ECG (for LVH), CXR, TTE (eval for valve abnormalities, LVH) Complications of HTN • Each 20 mmHg increase in SBP or 10 mmHg increase in DBP leads to a 2 fold increase in CV complications • Neurologic: TIA/CVA, ruptured aneurysms, vascular dementia • Retinopathy: stage I - arteriolar narrowing; II – copper wiring, AV nicking; III – hemorrhages and exudates; IV – papilledema • Cardiac: CAD, LVH, HF, AF • Vascular: aortic dissection, aortic aneurysm (HTN is key risk factor for aneurysms) • Renal: proteinuria, renal failure BP and cardiovascular risk • The relationship between BP and risk of CVD events is continuous, consistent and independent of other risk factors • Death from IHD and stroke increase progressively and exponentially from a normal pressure of 115/75 mmHg • For every 20 mmHg systolic or 10 mmHg diastolic increase in BP, there is a doubling of mortality from both IHD and stroke Management • Goal: < 140/90 mmHg; if DM or CKD goal is < 140/90 mmHg (in DM, target of < 120 systolic does not decrease CV risk and increases adverse events) • Treatment results in 50% decrease in HF, 40% decrease in stroke, 20 – 25% decrease in MI Lifestyle modifications Modification Recommendation Approx. SBP reduction Weight reduction Maintain normal body weight (BMI 18.5 – 24.9) 5 – 20 mmHg/10 kg DASH eating plan Fruits, vegetables, low fat dairy products 8 – 14 mmHg Dietary Na reduction No more than 100 mmol per day (2.4 g Na/6 g NaCl) 2 – 8 mmHg Physical activity Regular aerobics e.g. brisk walking (at least 30 mins/d, most days of the week) 4 – 9 mmHg Moderation of alcohol No more than 2 drinks (e.g. 24 oz consumption beer, 10 oz wine, or 3 oz 80 – proof whiskey) per day in most men, and to no more than 1 drink per day in women and lighter weight persons 2 – 4 mmHg JNC 8 summary • 60 years or older, treat to SBP < 150 mmHg and a DBP < 90 mmHg • Younger than 60 years, treat to a SBP of < 140 mmHg and a diastolic BP of < 90 mmHg • CKD (eGFR < 60) and in patients with albuminuria (> 30 mg of albumin per gram of creatinine), treat to SBP < 140 and a DBP < 90 mmHg • In DM, treat to a SBP < 140 and DBP < 90 mmHg • If minimal or no response to monotherapy, optimize drug dosing before attempting to add a second drug JNC 8 summary • In the general black population, including those with diabetes, the appropriate initial choice is a thiazide diuretic or CCB. • In the general nonblack population, including patients with diabetes, the appropriate initial choice is a thiazide diuretic, CCB, ACE-I, or ARB • Initial Rx with a thiazide diuretic is most effective in improving heart failure outcomes • βB and alpha blockers are not recommended for initial treatment • Do not use an ACE-I and an ARB together Evidence based summary • The AHA and European Society of Hypertension/European Society of Cardiology, as well as various meta analyses all concluded that the amount of BP reduction is the major determinant of reduction in CV risk and not the choice of antihypertensive drug • This conclusion also applies to patients at increased CV risk (ALLHAT, VALUE, CAMELOT trials) • ACCOMPLISH trial however demonstrated that with combination drug therapy, choice may be important (20% lower rate of CV events with amlodipine plus benazepril vs hctz plus benazepril) Evidence based summary • Monotherapy: for patients who are less than 20/10 mmHg above goal • Consider ACE/ARB for monotherapy in younger patients and dihydropyridine CCB for elderly/black patients • If a thiazide diuretic is chosen evidence is stronger for use of chlorthalidone rather than HCTZ. • Patients who have minimal or no response to the initial antihypertensive drug should be treated with sequential monotherapy c.f. JNC 8 guidelines (50% will respond after a change Materson et al 1995). If monotherapy is with a thiazide switch to a long acting ACE/ARB plus a long acting CCB Evidence based summary • Combination therapy recommended for patients with initial BP > 20/10 mmHg above goal • Start off with long acting ACEI/ARB plus long acting dihydropyridine CCB • Among nonobese patients who are already being treated with an ACEI/ARB plus a thiazide, d/c the thiazide and use long acting dihydropyridine CCB • Among obese patients can continue this regimen • Continue any other combination regimens if they are working • At least one antihypertensive should be taken at bedtime if on multiple medicines (not the diuretic) Evidence based summary • UKPDS – United Kingdom Prospective Diabetes Study (BMJ 1998) • VALUE – Valsartan Antihypertensive Long Term Use Evaluation (Lancet, 2004) • ACCOMPLISH - Avoiding Cardiovascular Events through Combination Therapy in Patients living with Systolic Hypertension (NEJM, 2008) • ALLHAT - Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (JAMA 2002) • CAMELOT – Comparison of Amlodipine vs Enalapril to Limit Occurrences of Thrombosis (JAMA 2004) Antihypertensives in diabetes • 20 – 60% of diabetics have concomitant HTN • Diabetics with HTN have twice the risk of cardiovascular disease as non diabetics with HTN • In the UKPDS, each 10 mmHg decrease in mean SBP was associated with reductions in risk of: 12% for any complication related to diabetes 15% for deaths related to diabetes 11% for MI 13% for microvascular complications Antihypertensives in diabetes • Reduction in CV events and microvascular complications in diabetics is seen with multiple drug classes including ACE-Is, ARBs, diuretics, β blockers • Dihydropyridine CCBs appear inferior to ACE-Is and β – blockers in reducing MI and heart failure • Non dihydropyridine CCBs have been shown to reduce albumin excretion • The α2 blocker arm of the ALLHAT study was terminated due to an increase in cases of new onset heart failure in patients assigned to the α2 blocker. HTN and erectile dysfunction • ARBs, ACEIs and CCBs have a neutral effect on erectile function. • Centrally acting α1 agonists, β blockers and diuretics have a negative effect on erectile function • Nitrates are contraindicated with PDE-5 inhibitor use; combination may trigger severe hypotension/circulatory collapse Allow 48 h after last tadalafil dose Allow 24 h after last sildenafil or vardenafil dose • α2 blockers should be used with caution; combination may trigger hypotension Initiate PDE – 5 inhibitor at lowest dose HTN in minority populations • African American patients exhibit somewhat reduced BP responses to monotherapy with ACEIs, ARBs, β – blockers when compared with diuretics or CCBs • These differential responses are largely eliminated by drug combinations that include adequate doses of a diuretic • Thiazide diuretics should be used in drug treatment for most patients with uncomplicated hypertension either alone or combined with drugs from other classes • ACEI induced angioedema occurs 2 – 4 times more frequently in African American patients than in other groups Treatment induced decline in renal function • A 20 – 30% increase in creatinine, which then stabilizes, represents a hemodynamic change, and not a structural change • Slight rise in creatinine serves as an indirect indicator that intraglomerular pressure has been reduced • ACEI/ARBs also dilate efferent arteriole, exaggerating decline in intraglomerular pressure • If creatinine increases by more than 30%, agent should be discontinued and other causes of renal dysfunction should be evaluated Thiazide diuretics in HTN • Should be used in drug treatment for most, either alone or combined with drugs from other classes • Reduce excretion of Calcium (slow demineralization in osteoporosis) Uric acid (increasing likelihood of gout) Lithium • Increase excretion of Potassium (average decrease of 0.3 – 0.4 mmol/L; dietary salt restriction can minimize thiazide induced K loss) Magnesium (complicates correction of hypokalemia) Thiazide diuretics in HTN • Average increase in glucose attributed to thiazide use: 3 – 5 mg/dL • Presence of diabetes is not a contraindication to use of thiazides • Typically considered ineffective when GFR < 30 – 40 mL/min (exception is metolazone) • Substitute furosemide or torsemide Systolic hypertension in the elderly • Approx 2/3 of those over 60 have HTN • Most cases of isolated systolic HTN are caused by reduced elasticity and compliance of large arteries resulting from age and atherosclerosis • In the systolic hypertension in the elderly program (SHEP study), treatment with chlorthalidone resulted in reduction of: Stroke incidence (36%) Coronary heart disease (27%) CHF (55%) • The therapeutic approach and goals for isolated systolic HTN are similar to those for other types of HTN: target < 140/90; 140/90 mmHg in diabetics and those with CKD Secondary causes of hypertension DISEASES Renal Endocrine SUGGESTIVE FINDINGS INITIAL WORKUP Renal parenchyma DM, Polycystic kidneys, GN (2 – 3%) CrCl, albuminuria Renovascular (1 – 2 %) ARF induced by ACE-I/ARB, Recurrent flash pulmonary edema, renal bruit MRA, CTA, Duplex U/S, angio, plasma renin (low Sp) Conn’s / Cushings (1 – 5%) Hypokalemia Metabolic alkalosis Pheo (< 1%) Paroxysmal HTN, H/A, Palp Myxedema (< 1%) Ca2+ (< 1%) TFTs Polyuria, dehydration, AMS iCa Obstructive sleep apnea Other Medications: OCP, Steroids, licorice, NSAIDs (esp COX-2), Epo, cyclosporine Aortic coarctation: LE pulses, systolic murmur, radial – femoral artery delay, abnormal TTE, CXR Polycythemia vera: Hct Secondary causes • Renovascular: control BP with diuretic + ACE-I/ARB or CCB Atherosclerosis risk – factor modification: quit smoking, decrease cholesterol If refractory HTN, recurrent flash pulmonary edema, worse CKD, consider revascularisation For atherosclerosis: stenting decreases restenosis compared with PTA alone, but no clear improvement in BP or renal function compared with medical therapy For FMD (usually more distal lesions): PTA +/- bailout stenting • Renal parenchymal disease: salt and fluid restriction, +/- diuretics • Pregnancy: methyldopa, labetalol, nifedipine, hydralazine; avoid diuretics; no ACE-I/ARB Resistant HTN • Failure to reach goal BP taking at least 3 drugs, one of which is a diuretic Identify and treat secondary causes Centrally acting alpha agonists Direct vasodilators Aldosterone antagonists Renal artery denervation Hypertensive crises • Hypertensive urgency: SBP > 180 or DBP > 120 (?110) with minimum or no target organ damage • Hypertensive emergency: neurologic ischemia: encephalopathy, stroke, papilledema cardiac ischemia: ACS, HF/Pulmonary edema, aortic dissection renal ischemia: proteinuria, hematuria, AKI, scleroderma renal crisis, microangiopathic hemolytic anemia, pre-eclampsia/eclampsia Precipitants • Progression of essential HTN +/- medical noncompliance (esp. clonidine) or change in diet • Progression of renovascular disease; acute GN, scleroderma, preeclampsia • Endocrine: pheochromocytoma, Cushing’s • Sympathomimetics: cocaine, amphetamines, MAOIs + foods rich in tyramine • Cerebral injury (do not treat HTN in acute ischemic stroke unless patient is getting lysed, extreme BP > 220/120, aortic dissection, active ischemia or HF) Treatment • Tailor goals to clinical context (e.g. more rapid lowering for aortic dissection) • Emergency: Decrease MAP by ~ 25% in minutes to 2 hours with IV agents (may need arterial line for monitoring); goal DBP < 110 within 2 – 6 h, as tolerated • Urgency: decrease BP in hours using oral agents; goal normal BP in ~ 1 – 2 days • Watch urine output, creatinine, mental status: may indicate a lower BP is not tolerated • Drugs for hypertensive crises IV – nitroprusside, nitroglycerin, labetalol, esmolol, fenoldopam, hydralazine, nicardipine, clevidipine, phentolamine, enalaprilat PO – captopril, labetalol, clonidine, hydralazine Summary of pharmacologic options • Pre – HTN: ARB prevents onset of HTN • HTN: uncomplicated: thiazide if likely salt sensitive (e.g. elderly, black, obese), otherwise start with ACE-I or CCB. βB not first line. + high risk CAD: ACE-I or ARB; ACE-I + CCB superior to ACE-I + thiazide or βB + diuretic + angina: βB, CCB, nitrates + post – MI: ACE-I, βB +/- aldosterone antagonist + HF: ACE-I/ARB, βB, diuretics, aldosterone antagonist, hydralazine, isosorbide + secondary stroke prevention: ACE-I, ?ARB + diabetes mellitus: ACE-I or ARB; can also consider diuretic, βB or CCB + CKD: ACE-I/ARB Indications for individual drug classes Indication Diuretics Heart failure ✓ ΒB ACEI ARB ✓ ✓ Post - MI ✓ ✓ High coronary disease risk ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Diabetes CKD Recurrent stroke prevention ✓ ✓ CCB ✓ Aldost antagonis t ✓ ✓ ✓ ✓ ABFM Questions • A postmenopausal female who has recently been diagnosed with hypertension returns for follow-up 3 months after the initiation of therapeutic lifestyle changes. Her blood pressure has improved but remains higher than goal at 142/90 mm Hg, and pharmacologic treatment is indicated. The patient has a family history of osteoporosis. Which one of the following may slow the demineralization of bone in this patient? • A) An ACE inhibitor • B) An -blocker • C) A -blocker • D) A calcium channel blocker • E) A thiazide diuretic • ANSWER: E • Thiazide-type diuretics are useful in slowing demineralization from osteoporosis. • A 58-year-old male has a history of type 2 diabetes mellitus that is not well controlled. He has recently developed mild hypertension that has not been controlled by lifestyle changes. You prescribe lisinopril (Prinivil, Zestril), 20 mg daily, for the hypertension and 2 months later you note that his serum creatinine level has increased from 1.25 mg/dL to 1.5 mg/dL (N 0.64–1.27) and his blood pressure has decreased from 142/88 mm Hg to 128/78 mm Hg. Which one of the following should you do now? • A) Continue the current dosage of lisinopril • B) Decrease the dosage of lisinopril to 10 mg • C) Increase the dosage of lisinopril to 40 mg • D) Discontinue lisinopril and initiate chlorthalidone • E) Discontinue lisinopril and initiate losartan (Cozaar) • ANSWER: A • ACE inhibitors such as lisinopril do not need to be discontinued unless baseline creatinine increases by >30%. (This patient’s creatinine increased by 20%.) The current dosage of lisinopril is appropriate, as the blood pressure meets the diabetic goal of <130/80 mm Hg. Small increases in creatinine have been associated with long-term preservation of renal function, and may be a marker of changes in intraglomerular pressure. • A 62-year-old male underwent percutaneous coronary intervention and placement of two stents for a myocardial infarction yesterday. He is currently taking simvastatin (Zocor), aspirin, lisinopril (Prinivil, Zestril), and hydrochlorothiazide. His last LDL-cholesterol level was 70 mg/dL and his blood pressure is 130/80 mm Hg. Which one of the following additions to his current regimen would be most appropriate at this time? • A) Amlodipine (Norvasc) • B) Diltiazem (Cardizem) • C) Verapamil (Calan, Verelan) • D) Metoprolol (Lopressor, Toprol-XL) • E) No changes • ANSWER: D • β-Blockers are first-line antihypertensive medications for patients with coronary artery disease (CAD) and have been shown to reduce the risk of death by 23% at 2 years. They should also be given to normotensive patients with CAD if tolerated. Cardioselective (1) blockers such as metoprolol and atenolol are preferred, as they cause fewer adverse effects. • A 55-year-old male with a 4-year history of type 2 diabetes mellitus was noted to have microalbuminuria 6 months ago, and returns for a follow-up visit. He has been on an ACE inhibitor and his blood pressure is 140/90 mm Hg. The addition of which one of the following medications would INCREASE the likelihood that dialysis would become necessary? • A) Hydrochlorothiazide • B) Amlodipine (Norvasc) • C) Atenolol (Tenormin) • D) Clonidine (Catapres) • E) Losartan (Cozaar) • Answer: E • Do not use an ACE and ARB together • A 48-year-old female presents as a new patient to your office. She has not seen a physician for several years and her medical history is unknown. Her BMI is 24.4 kg/m2 and she is not taking any medication. Her blood pressure is 172/110 mm Hg in the left arm sitting and 176/114 mmHg in the right arm sitting; her cardiovascular examination is otherwise unremarkable. A baseline metabolic panel reveals a creatinine level of 0.68 mg/dL (N 0.6–1.1) and a potassium level of 3.3 mEq/L (N 3.5–5.5). If the patient’s hypertension should prove refractory to treatment, which one of the following tests is most likely to reveal the cause of her secondary hypertension? • A) A 24-hour urine catecholamine level • B) A plasma aldosterone/renin ratio • C) MRA of the renal arteries • D) Echocardiography • E) A sleep study (polysomnography) • ANSWER: B • Primary hyperaldosteronism is the most common cause of secondary hypertension in the middle-aged population, and can be diagnosed from a renin/aldosterone ratio. This diagnosis is further suggested by the finding of hypokalemia, which suggests hyperaldosteronism even though it is not present in the majority of cases. • Which one of the following is a preferred first-line agent for managing hypertension in patients with stable coronary artery disease? • A) A thiazide diuretic • B) An angiotensin receptor blocker • C) A β-blocker • D) A long-acting calcium channel blocker • E) A long-acting nitrate • ANSWER: C • American Heart Association guidelines recommend treating hypertension in patients with stable heart failure with ACE inhibitors and/or β-blockers. Other agents, such as thiazide diuretics or calcium channel blockers, can be added if needed to achieve blood pressure goals (SOR B). • An 11-year-old male is brought to your clinic for follow-up after a recent well child visit revealed elevated blood pressure. The parents have restricted his intake of sodium and fatty foods during the last several weeks. His blood pressure today is 140/92 mm Hg, which is similar to the reading at his last visit. The parents checked the child’s blood pressure with a home unit several times and found it consistently to be in the 130s systolic and low 80s diastolic. The child had a normal birth history and has no known chronic medical conditions. Both of his parents and his two younger siblings are healthy. He is at the 75th percentile for both height and weight with a BMI in the normal range. He eats a balanced diet and is active. What should be the next step for this patient? • A) Reassurance that this is likely white-coat hypertension • B) A goal weight loss of at least 5 lb • C) Evaluation for causes of secondary hypertension • D) Hydrochlorothiazide • E) Lisinopril (Prinivil, Zestril) • ANSWER: C • Hypertension in a patient this young should prompt a search for secondary causes, which are more common in young hypertensive patients than in adults with hypertension. The recommended workup includes blood and urine testing, as well as renal ultrasonography. An evaluation for end-organ damage is also recommended, including retinal evaluation and echocardiography. • A 54-year-old male sees you for a 6-month follow-up visit for hypertension. He feels well, but despite the fact that he takes his medications faithfully, his blood pressure averages 150/90 mmHg. He has had an intensive workup for hypertension in the recent past, with normal repeat laboratory results, including a CBC, serum creatinine, an electrolyte panel, and a urinalysis. His medications include chlorthalidone, 12.5 mg daily; carvedilol (Coreg), 25 mg twice daily; amlodipine (Norvasc), 10 mg daily; and lisinopril (Prinivil, Zestril), 40 mg daily. He has been intolerant to clonidine (Catapres) in the past. Which one of the following medication changes would be most reasonable? • A) Adding isosorbide mononitrate (Imdur) • B) Adding spironolactone (Aldactone) • C) Substituting furosemide (Lasix) for chlorthalidone • D) Substituting losartan (Cozaar) for lisinopril • ANSWER: B • Spironolactone is now recommended for treating resistant hypertension, even when hyperaldosteronism is not present. A longer-acting diuretic such as chlorthalidone is also recommended for treating hypertension, particularly in resistant cases with normal renal function. • A 62-year-old African-American male is admitted to the hospital for the third time in 6 months with heart failure. He has dyspnea with minimal activity. Echocardiography reveals an ejection fraction of 40%. Which one of the following combinations of medications is most appropriate for long-term management of this patient? • A) Enalapril (Vasotec) plus digoxin • B) Hydralazine plus isosorbide dinitrate • C) Losartan (Cozaar) plus amlodipine (Norvasc) • D) Spironolactone (Aldactone) plus bisoprolol (Zebeta) • ANSWER: B • The combination of the vasodilators hydralazine and isosorbide dinitrate has been shown to be effective in the treatment of heart failure when standard treatment with diuretics, β-blockers, and an ACE inhibitor (or ARB) is insufficient to control symptoms or cannot be tolerated. This combination is particularly effective in AfricanAmericans with NYHA class III or IV heart failure, with advantages including reduced mortality rates and improvement in quality-of-life measures. • Treatment with which one of the following antihypertensive medications may mimic the effects of primary hyperparathyroidism? • A) Amlodipine (Norvasc) • B) Doxazosin (Cardura) • C) Hydrochlorothiazide • D) Lisinopril (Prinivil, Zestril) • E) Metoprolol (Lopressor, Toprol-XL) • ANSWER: C • These laboratory findings may occur with lithium or thiazide use. • A 32-year-old gravida 2 para 1 with long-standing untreated hypertension presents at 8 weeks gestation for prenatal care. Her physical examination is normal except for a blood pressure of 156/114 mm Hg. Which one of the following would be most appropriate as initial treatment? • A) Labetalol (Trandate) • B) Lisinopril (Prinivil, Zestril) • C) Losartan (Cozaar) • D) Metoprolol (Lopressor, Toprol-XL) • E) Nifedipine, immediate release (Procardia) • Answer: A • The drug most often recommended as first-line therapy for hypertension in pregnancy is labetalol. Immediate-release nifedipine is not recommended due to the risk of hypotension. • A 60-year-old male is referred to you by his employer for management of his hypertension. He has been without primary care for several years due to a lapse in insurance coverage. During a recent employee health evaluation, he was noted to have a blood pressure of 170/95 mm Hg. He has a 20-year history of hypertension and suffered a small lacunar stroke 10 years ago. He has no other health problems and does not smoke or drink alcohol. A review of systems is negative except for minor residual weakness in his right upper extremity resulting from his remote stroke. His blood pressure is 168/98 mm Hg when initially measured by your nurse, and you obtain a similar reading during your examination. In addition to counseling him regarding lifestyle modifications, which one of the following is the most appropriate treatment for his hypertension? • A) An angiotensin receptor blocker • B) A -blocker • C) A calcium channel blocker • D) A thiazide diuretic/ACE inhibitor combination • E) No medication • Answer: D • This patient has stage 2 hypertension, and his history of stroke is a compelling indication to use combination therapy with a diuretic and an ACE inhibitor. • A 45-year-old male has diabetes mellitus and hypertension. He has no other medical problems. Which one of the following classes of medications is the preferred first-line therapy for the treatment of hypertension in this patient? • A) Potassium-sparing diuretics • B) ACE inhibitors • C) -Receptor blockers • D) Calcium channel blockers • E) -Blockers • ANSWER: B • ACE inhibitors and angiotensin receptor blockers (ARBs) are the preferred first-line agents for the management of patients with hypertension and diabetes.