Download The Pharmacists` Role in Treating Hypertension

The Pharmacists’ Role in
Treating Hypertension
Thomas Owens, MD
Saint Francis University
CERMUSA
Objectives
1. Enhance your understanding of hypertension to
include cardiovascular risks, management, and
goals for individual patients
2. Review and discuss the current pharmacotherapy
standards of care for hypertension
3. Describe the pharmacist’s role in counseling
patients on hypertensive medications
Hypertension >140/90 mm Hg
• United States:
65 million adults
• Risk factors include:
– Stroke, myocardial infarction,
heart failure, peripheral
vascular disease, aortic
dissection, chronic renal failure
• Hypertension
price tag: $59.7 billion
Wexler & Feldman, 2005
Hypertension
• Typical onset
– second decade of life
• Primary Hypertension
– identifiable behaviors
• Secondary
Hypertension
– more discrete
Cecil, 2004
Ethnic Groups
• African Americans
– 43% female & 39% male
– Ratio 1:3
– Increase in sodium
sensitivity?
• Caucasians
– 28% female
– 29% male
• Mexican Americans
– Ratio 1:4 or 1:5
Cecil, 2004
DASH Diet
Dietary Sodium Intake
Salt Hypothesis?
- Strong genetic
underpinning
ADA, 2005
Metabolic Syndrome
• Risk of
Hypertension
increases with BMI
• Obesity accounts
for 50% to 60% of
new cases of
hypertension
Cecil, 2004
Potential Causes of
Hypertension
• Expanded plasma
volume plus
sympathetic over activity
– Peripheral
vasoconstriction
– Renal salt retention
– Renal water retention
Sleep Apnea
www.sleepconsultants.com, 2007
Cecil, 2004
Blood Pressure Equation
Blood Pressure = Cardiac Output x Peripheral Vascular Resistance
Some pharmacologic
agents lower
Most pharmacologic
agents lower
Some pharmacologic
agents lower both
Cecil, 2004
Genetics of High BP
• Sympathetic upregulation leads to a
cascade of events
– Peripheral vascular
resistance
• Genetic factors
Discoveryedge.mayo.com, 2007;
ADA, 2003
– 30% of cases
– 2x as likely if parents
have hypertension
Systolic & Diastolic ??
• What is more
important?
– Depends on age
• Live long enough
almost all develop
systolic hypertension
120
80
Cecil, 2004
systolic
diastolic
Age Dependant Rise in BP
(Whelton & Rocella, 1995)
Framingham Study (age: 50-79)
(Khan, Wong, Larson, & Levy,
1999)
Systolic Hypertension
• Decreased
distensibility of
large arteries
• Majority of
uncontrolled
hypertension
– Due to focus on
diastolic BP
Cecil, 2004
Risk of cardiovascular mortality
by systolic BP
(National High Blood Pressure
Education Program Working
Group, 1993)
Hypertension Study Results
• Hypertension is excess of 140/90 mm Hg
• Studies found
– Increase risk when above 115 mm Hg systolic or
75 mm Hg diastolic
– High normal BP had twice increased risk for
cardio disease
– More studies are needed to fully understand
Cecil, 2004
The Silent Killer
• 1/3 of adults do not know they have
hypertension
• Hypertension: 60% are treated
– 45% of treated remain uncontrolled
Despite over 75 different antihypertensive
agents in 9 different classes!
Cecil, 2004
Reclassification of BP Stages
• Joint National Committee on
Prevention, Detection,
Evaluation, and Treatment of
High Blood Pressure (JNC)
Blood Pressure
(mm Hg)
Classification
<120/80
Normal
120-139/80-89
Pre-hypertension
≥140/90
Hypertension
– Pharmacotherapy not recommended
140-159/90-99
Stage 1
– Lifestyle modification
recommended!
160-179/100-109
Stage 2
• New category “pre-hypertension”
Cecil, 2004; JNC, 2007
JNC Drug Therapy
Recommendations
≥130/80
(w/ heart and kidney
disease or diabetes
mellitus)
recommendation
(healthy)
Blood Pressure
(mm Hg)
Classification
<120/80
Normal
120-139/80-89
Pre-hypertension
≥140/90
Hypertension
140-159/90-99
Stage 1
160-179/100-109
Stage 2
JNC, 2007
Modest reduction in
BP = big benefits !!
• Decrease 5 mm Hg
decreases risks
– Small changes can have a big
difference
• Results of studies
– Systolic surge 34 mm Hg = 3x
increase of stroke
– Systolic ≥135 mm Hg = 74%
increase of cardio event
Blood Pressure
(mm Hg)
Cardiovascular
Risk
Exceeds 115/75
Increases
Each increase of
20/10 mm Hg
Doubles
Cecil, 2004; JNC, 2007
Clinical Presentation
• No specific signs or symptoms
• Possible symptoms
– Occipital headache, dizziness, tinnitus, dimmed
vision, palpitations, fatigue
• Physical Exam
– May reveal evidence
Cecil, 2004
Hypertensive Retinopathy
Grades of hypertensive
retinopathy shown
(Forbes, Jackson, 2003)
Electrocardiogram (ECG or EKG)
GOOD
(Normal)
BAD
(Antero-Septal MI)
physiol.umin.jp/cardiovasc, 2007
Counseling Patients:
Proper BP Readings
• At least 30 minutes before NO
– Caffeine, decongestants, oral contraceptives, alcohol,
tobacco
• Sit down for at least 5 minutes
Arm above heart
level
Falsely low blood pressure
reading
Arm below heart
level
Falsely elevated blood
pressure reading
Loose cuff or bladder
=
Falsely elevated blood
pressure reading
Cecil, 2004; ADA, 2005
Counseling Patients:
Proper Fit of BP Cuff
Length of bladder of the cuff at
least 80% circumference of arm
Bladder of cuff at least 40%
circumference of arm
Place the center of the bladder
over the brachial artery
Pump until radial pulse
disappears, then continue for
additional 30 mm Hg
Help Patients Understand:
White Coat Hypertension
• Anxiety of going to doctor office
raises BP
– Recommend self-monitoring
• Daytime: >135/85 mm Hg
• Nighttime: >120/70 mm Hg
• 24 hr: >130/80 mm Hg
• Follow patients every 6 months
for possible progression to
persistent hypertension
Cecil, 2004
Closely Monitor Medications
with High-Risk Patients
Cecil, 2004
Counseling Patients:
Causes of Organ Damage
Major Risk Factors
Target Organ Damage
Cigarette smoking
Heart
Obesity (BMI >30 kg/m2) *
Left ventricular hypertrophy
Physical inactivity
Angina pectoris
Dyslipidemia *
Myocardial infarction
Diabetes mellitus *
Coronary revascularization
Age
Heart Failure
Brain
Stroke
Men: Older than 55
Women: Older than 65
Family History of pre-mature CVD
Men: Older than 55
Women: Older than 65
Transient ischemic attack
Hypertensive nephrosclerosis
GFR <60 mL/min
Any chronic disease
GFR <60 mL/min
Urine protein >150 mg/24hr
Urine protein >150 mg/24hr
Retinopathy
Peripheral atherosclerosis
•Components of metabolic syndrome
(The JNC 7 Report. JAMA 2003)
Counseling Patients:
Treatment
Risk Group
Mild Risk
Treatment
Lifestyle modification
Free of CVD
Low Risk
Pre-hypertension or
Stage 1 or 2
Moderate Risk
Pre & Stage 1: Lifestyle modification
Stage 2: Lifestyle modification and medications
Lifestyle modification and medications
1 or more cardio
risk factors
High Risk
Evident organ
damage, diabetes,
renal insufficiency
Lifestyle modification and medications
JNC, 2005
SUSPECTED
DIAGNOSIS
CLINICAL FEATURES
DIAGNOSTIC TESTING
Renal parenchymal
hypertension
Elevated serum creatinine or abnormal
urinalysis
24-Hour urine creatinine and protein, renal
ultrasound
Renovascular
disease
New elevation in serum creatinine, marked
elevation in serum creatinine with
initiation of ACEI or ARB, refractory
hypertension, flash pulmonary edema,
abdominal bruit
Captopril renogram, duplex Doppler
sonography, magnetic resonance or CT
angiogram, invasive angiogram
Coarctation of the
aorta
Arm pulses > leg pulses, arm BP > leg BP,
chest bruits, rib notching on chest
radiograph
MRI, aortogram
Primary
aldosteronism
Hypokalemia, refractory hypertension
Plasma renin and aldosterone, 24-hour urine
potassium, 24-hour urine aldosterone
and potassium after salt loading,
adrenal CT scan
Cushing's syndrome
Truncal obesity, purple striae, muscle
weakness
Plasma cortisol, urine cortisol after
dexamethasone, adrenal CT scan
Pheochromocytoma
Spells of tachycardia, headache,
diaphoresis, pallor, and anxiety
Plasma metanephrine and normetanephrine,
24-hour urine catechols, adrenal CT
scan
Obstructive sleep
apnea
Loud snoring, daytime somnolence,
obesity
Sleep study
ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; BP = blood pressure; CT
= computed tomography. (Williams & Wilkins, 2002)
Counseling Patients:
Lifelong Treatment
• Objective: reduce BP and metabolic
abnormalities
• Pharmacotherapy & lifestyle
modification
–
–
–
–
–
Reduce sodium intake
Weight loss
Exercise
Moderating alcohol
Reduce systolic BP by 21 to 55 mm Hg
Cecil, 2004
Counseling Patients:
Dietary Changes
• Losing only 10 to 12 lbs
lowers BP by 10/5 mm Hg
• Reduce daily salt
– 10 to 6 grams
• Teach patients to read
food labels
• DASH Diet
– www.nhlbi.nih.gov/health/public/heart/dash
Cecil, 2004
Counseling Patients:
Health Behaviors
Lifestyle
modification
Recommendation
Range of systolic blood
pressure reduction
(mm Hg)
Weight loss
Maintain a normal body weight based
on BMI
5–20
Dietary
Approaches
Diet high in fruits and vegetables, and
reduced fat
8–14
Low sodium
diet
Less than 6 grams
2–8
Exercise
30 min of aerobic activity at least 4
d/wk
4–9
Moderate
Alcohol
consumption
2 drinks or less per day for men, and 1
drink or less per day for women
2–4
JNC, 2005
Counseling Patients:
Helpful Resources
Barriers to Successful Health
Behavior Modifications
• Lack of education
• Lack of access to safe places to exercise
• Added salt in prepared foods and restaurant
meals
• Higher cost of foods low in salt
Patient self-management is
realistic and feasible!
Cecil, 2004
Pharmacologic Therapy
• Scientific proof lowering
BP reduces organ
damage
• Certain classes of
antihypertensive agents
exert organoprotective
effects
– Not all medications equal
Cecil, 2004; JNC, 2005
Major Challenges for Science
1. Identify the key geneenvironment
interactions
2. Eliminate the patient
and medical provider
barriers
ADA, 2003
Counseling Patients:
Target Blood Pressure
• Most patients below 140/90 mm Hg
• Patients w/ diabetes or chronic disease
130/80 mm Hg
• Help patients self-monitor BP
– 1/3 do not know they are hypertensive
• Research studies on targeting BP
Cecil, 2004
Improve Hypertension
Control Rates
1. Titrating blood pressure
medications to achieve
target goals
2. Most patients require
2 or 3 antihypertensive
medications
3. Patient compliance with
multi-drug regimens
ADA, 2005
Patient Compliance and
Quality of Life
• Hypertension requires
lifelong treatment
• Medications can produce
side effects
– Men often concerned with
sexual dysfunction
• Patients with controlled
BP, rate a significantly
higher quality of life
Cecil, 2004
Patient Compliance Principles
1. Titrating medical therapy based on home
readings
2. Long-acting preparations w/ once daily
dosing
3. Low dose combinations of medications from
different drug classes
4. Fixed-dose combinations to reduce overall
number of pills
JNC, 2005
Drug Therapy
• Old method: high-dose monotherapy
• Recent studies (ex. ALLHAT)
– At least 2 medications of different classes to treat mild
hypertension
– 3 or 4 different medications to treat more difficult cases
• Thiazide-type antihypertensive medications costeffective
• Initial treatment:
– Beta blockers, Angiotensin-converting enzyme (ACE)
inhibitors, Angiotensin receptor blockers, Calcium
Cecil, 2004
antagonists
Stage 2 Drug Therapy
• JNC recommends:
– 2 drug combination
– Additional medications needed for each 10 mm Hg
of systolic BP above goal
– Great majority should include low-dose diuretic
• High-risk conditions (heart failure/diabetes)
– Angiotensin-converting enzyme inhibitors (ACE-Is)
– Angiotensin receptor blockers (ARBs)
Cecil, 2004
Cardio Events in
Hypertensive Patients
Verdecchia, Carin, Circo,2001
Left Ventricular Hypertrophy
www.medem.com, 2007
Counseling Patients:
Contradictions & Side Effects
Considerations For
Individualizing
Antihypertensive
Drug Therapy
Hypertensive Sub-Populations
• Hypertensive patients with nephrosclerosis
• Diabetic hypertensive patients
• Hypertensive patients with coronary artery disease
• Isolated systolic hypertension in older persons
• Hypertensive disorders of women
– Oral contraceptives
– Pregnancy
Cecil, 2004
Hypertension Case Study
How would we modify his
treatment since he did not change
his health behaviors (and he is
diabetic)?
Thank you for attending