Download Hypertension, Review and Updates

Hypertension
Review
&
Updates
Tehran Arrhythmia Center
Feb. 2006
Case
• A 40 y/o sedentary man with
a FH of stroke sees you for a
health maintenance visit. His
BP=150/100 mmHg and an
LDL cholesterol of 170 mg/dl
• Which one of the following
would have the greatest
impact on decreasing his
future risk of stroke?
A)
B)
C)
D)
A program of regular physical exercise
Aspirin 81 mg daily
Reduction of LDL to <130 mg/dl
Reduction of BP to normal
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Answer:
D) Reduction of BP to normal
General Facts
•
•
Stroke is the 3rd leading cause of death in the
US
HTN is the most consistently powerful
predictor of stroke
–
•
Primary prevention of stroke. N Engl J Med 1995
Lowering BP results in 35-40% reduction in
stroke incidence
Tehran Arrhythmia Center
Leading diagnoses resulting in visits to
physician offices
Acute respiratory
tract infection
5
Routine medical
exams
10
Diabetes
15
Depression
20
Hypertension
Million visits/year
25
0
Source: IMS HEALTH Canada 2002. http://www.imshealthcanada.com/
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HTN: The Silent Killer
• 50 million Americans & 1 billion worldwide affected
• Most common primary care diagnosis (35 million visits
annually)
• Normotensive at age 55 have 90% lifetime risk of
HTN
• Continuous & consistent relationship with CVD
– Between ages 40-70, starting from 115/75
– CVD risk doubles with each increment of 20/10
Tehran Arrhythmia Center
Blood Pressure Distribution in the
Population According to Age
Men
Women
150
150
130
130
PP
110
80
80
70
70
30-3940-4950-5960-6970-79  80
Age
PP
110
30-3940-4950-5960-6970-79  80
Age
PP=Pulse Pressure.
Adapted from : Third National Health and Nutrition. Examination Survey, Hypertension
1995;25:305-13
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1976-98 Cumulative Incidence of
Hypertension in Women and Men aged 65
years
Risk of Hypertension %
Risk of Hypertension %
100
100
Women
80
80
60
60
40
40
20
20
0
0
2
4
6
8
10
12
14
16
Years to Follow-up
18
20
0
Men
0
2
4
6
8
10
12
14
16
18
20
Years to Follow-up
JAMA 2002: Framingham data.
Tehran Arrhythmia Center
Hypertension as a Risk Factor
Hypertension is a significant risk factor
for:
–
–
–
–
–
–
–
cerebrovascular disease
coronary artery disease
congestive heart failure
renal failure
peripheral vascular disease
dementia
atrial fibrillation
Tehran Arrhythmia Center
Proportion of deaths attributable to leading
risk factors worldwide (2000)
High mortality, developing region
Lower mortality, developing region
Developed region
0
1
2
3
4
5
6
7
Attributable Mortality
8
(In millions; total 55,861,000)
Ezzati et al. WHO 2000 Report. Lancet. 2002;360:1347-1360.
Tehran Arrhythmia Center
Blood Pressure and Risk of CAD Mortality
Risk of CAD mortality per
10,000 person-years
40
Diastolic
35
Systolic
30
25
20
15
10
5
0
75-79
80-89
90-99
100+
<120
120-139 140-159
160+
Blood pressure (mm Hg)
Multiple Risk Factor Intervention Trial (MRFIT); n=347,978 men. Neaton et al. Arch Intern Med
1992;152:56-64
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Blood Pressure and Risk of Stroke Mortality
Risk of stroke mortality per
10,000 person-years
10
Diastolic
Systolic
8
6
4
2
0
<85
85-89
90-99
100+
<130
130-139 140-159
160+
Blood pressure (mm Hg)
Multiple Risk Factor Intervention Trial (MRFIT); n=347,978 men. Neaton et al. In: Laragh et al (eds).
Hypertension: Pathophysiology, Diagnosis, and Management.2 ed. NY: Raven, 1995:127
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Impact of High-Normal Blood Pressure on
the Risk of Cardiovascular Disease
CUMULATIVE INCIDENCE OF CV EVENTS IN MEN WITHOUT HYPERTENSION ACCORDING TO BASELINE
BLOOD PRESSURE
mmHg
(130-139)
(121-129)
(< 120)
N Engl J Med 2001;345:1291-7
Tehran Arrhythmia Center
Effect of SBP and DBP on
Age-Adjusted CAD Mortality: MRFIT
CAD Death Rate per 10,000 Person-years
80.6
48.3
43.8
37.4
31.0
25.8
38.1
34.7
25.3
24.6
25.2
24.9
23.8
20.6
100+
16.9
10.3
90-99
13.9
11.8
80-89
12.6
12.8
8.8
75-79
8.5
70-74
11.8
9.2
<70
160+
140-159
120-139
Systolic BP
<120
(mmHg)
Diastolic BP (mmHg)
Neaton et al. Arch Intern Med 1992;
152:56-64.
Tehran Arrhythmia Center
We CAN make a difference!
• Over 10 years, prevent one death in every 11 patients
whose SBP is lowered by 12mmHg.
• Effective treatment can decrease:
– Heart failure by 50%
– CVA by 35-40%
– MI by 25%
Tehran Arrhythmia Center
Benefits of Treating Hypertension
• Younger than 60
– reduces the risk of stroke by 42%
– reduces the risk of coronary event by 14%
• Older than 60
–
–
–
–
reduces
reduces
reduces
reduces
overall mortality by 20%
cardiovascular mortality by 33%
incidence of stroke by 40%
coronary artery disease by 15%
Tehran Arrhythmia Center
Correlation Between Reduction in SBP and
Cardiovascular Mortality or Events
Cardiovascular mortality
Cardiovascular events
Staessen et al. Lancet 2001;358:1305-15.
Tehran Arrhythmia Center
We are not doing a good job…
• 70% of those with HTN are aware of their diagnosis
• 59% of those with HTN are treated
• 34% of those with HTN are treated to a SBP < 140
Tehran Arrhythmia Center
The Challenge In Canada
22% of Canadians 18-70 years of age have
hypertension
50% of Canadians >65 years of age have
hypertension
Hypertensive patients
who are treated
and BP controlled
Hypertensive patients
who are treated
but BP uncontrolled
21%
22%
Patients who are aware
but remain untreated
and BP uncontrolled
13%
43%
9%
Diabetic patients
who are treated and
BP controlled
Hypertensive patients
who are unaware
Joffres et al. Am J Hyper 2001;14:1099 –1105
Tehran Arrhythmia Center
Results of a survey on awareness on
hypertension (Canada 2002)
67% of aware hypertensive patients believe
that their BP was their own primary
responsibility
Two thirds of these patients stated that high BP
was not a serious concern.
Thus the mandate to improve public awareness of
the consequences of hypertension is clear.
Tehran Arrhythmia Center
BP Control Rates
Trends in awareness, treatment, and control of high
blood pressure in adults ages 18–74
National Health and Nutrition Examination Survey, Percent
II
1976–80
II
(Phase 1)
1988–91
II
(Phase 2)
1991–94
1999–2000
Awareness
51
73
68
70
Treatment
31
55
54
59
Control
10
29
27
34
Sources: Unpublished data for 1999–2000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6.
Tehran Arrhythmia Center
Tehran Arrhythmia Center
BP MEASUREMENT
Which of the following factors
can lower blood pressure
readings?
A) Obese extremities
B) Caffeine ingestion
C) Narrow BP cuff
D) Supporting the patient’s
back
http://www.mco.edu/org/whl/images/belissi.jpg
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BP MEASUREMENT
Answer:
D) Supporting the patient’s back
– relaxes the body, lowering BP an avg of 8
mmHg SBP and DBP
Obese extremities
Caffeine ingestion
Narrow BP cuff
can result in false
elevations
Tehran Arrhythmia Center
BP MEASUREMENT
• Measurement of BP should be obtained:
– In all adults (age >18) at each visit
– > 30 minutes after use of nicotine or
caffeine
– After 5 minutes of rest with arm supported
at heart level
– With appropriate sized cuff
• bladder should encircle 80% of the arm
Tehran Arrhythmia Center
BP MEASUREMENT
• Measurement of BP should be obtained:
– 2X, >2min apart
• repeat if >5 mm pressure difference
– Seated, feet flat on floor
– Back and arm supported, Arm at heart level
– Manual mercury sphygmomanometer or
Recently calibrated aneroid manometer or
Validated automated device (JNCVI and VII)
Tehran Arrhythmia Center
Blood Pressure Assessment:
Patient preparation and posture
Standardized technique:
Patient
1. No caffeine in the preceding hour.
2. No smoking or nicotine in the preceding 15-30
minutes.
3. No use of substances containing adrenergic
stimulants such as phenylephrine or
pseudoephedrine (may be present in nasal
decongestants or ophthalmic drops).
4. Bladder and bowel comfortable.
5. Quiet environment. Comfortable room
temperature.
6. No tight clothing on arm or forearm.
7. No acute anxiety, stress or pain.
8. Patient should stay silent prior and during the
procedure.
Tehran Arrhythmia Center
Blood Pressure Assessment:
Patient preparation and posture
Standardized technique:
Posture
The patient should be calmly seated for
at least 5 minutes, with his or her back
well supported and arm supported at
the level of the heart. His or her feet
should touch the floor and legs should
not be crossed.
The patient should be instructed not to
talk prior and during the procedure.
Tehran Arrhythmia Center
Blood Pressure Assessment:
Patient position
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Recommended Technique
for Measuring Blood Pressure
Standardized technique:
• Use a mercury manometer
or a recently calibrated
aneroid or a validated
electronic device.
• Aneroid devices should only
be used if there is an
established calibration check
every 6-12 months.
Tehran Arrhythmia Center
Recommended Technique
for Measuring Blood Pressure
Electronic oscillometric devices:
• Use a validated electronic device
according to BHS, AAMI or IP
standards.
• For self blood pressure
measurement devices, a logo on
the packaging ensures that this
type of device and model meets
the international standards for
accurate blood pressure
measurement.
Office
Home / Self
AAMI=Association for the Advancement of Medical Instrumentation;
BHS=British Hypertension Society; IP: International Protocol.
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Recommended Technique
for Measuring Blood Pressure (cont.)
Select a
cuff with the
appropriate size
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Cuff size
Arm circumference (cm)
Size of Cuff (cm)
From 18 to 26
9 x 18 (child)
From 26 to 33
12 x 23 (standard
adult model)
From 33 to 41
15 x 33 (large, obese)
More than 41
18 x 36 (extra large,
obese)
Tehran Arrhythmia Center
Recommended Technique
for Measuring Blood Pressure (cont.)
– Locate brachial and
radial pulse
– Position cuff at the
heart level
– Arm should be
supported
Tehran Arrhythmia Center
Recommended Technique
for Measuring Blood Pressure
(cont.)
– To exclude possibility of
auscultatory gap,
increase cuff pressure
rapidly to 20-30 mmHg
above level of
disappearance of radial
pulse
– Place stethoscope over
the brachial artery
Tehran Arrhythmia Center
Recommended Technique
for Measuring Blood Pressure
–
Drop pressure by 2 mmHg /
sec
•
Appearance of sound (phase I
Korotkoff) = systolic pressure
–
Record measurement
–
Drop pressure by 2 mmHg /
beat
•
–
–
(cont.)
Disappearance of sound (phase V
Korotkoff) = diastolic pressure
Record measurement
Take 2 blood pressure
measurements, 1 minute apart
Tehran Arrhythmia Center
Recommended Technique
for Measuring Blood Pressure (cont.)
Korotkoff sounds
200
180
160
No sound
Clear sound
Phase 1
Muffling
140
No sound
Phase 2
Auscultato
ry gap
120
Muffled sound
Phase 3
Muffled sound
Phase 4
No sound
Phase 5
100
80
Systolic BP
Diastolic BP
60
40
20
0
Possible readings:
184 / 100
136 / 100
184 / 86 = correct
136 / 86
mm Hg
Tehran Arrhythmia Center
Recommended Technique
for Measuring Blood Pressure
Standardized technique:
• For initial readings, take
the blood pressure in both
arms and subsequently
measure it in the arm with
the highest reading.
• Thereafter, take two
measurements on the side
where BP is highest.
Tehran Arrhythmia Center
Recommended Technique
for Measuring Blood Pressure (cont.)
Record the blood pressure
to the closest 2 mmHg on
the manometer
as well as the arm used
and whether the patient
was supine, sitting or
standing.
Tehran Arrhythmia Center
Recommended Technique
for Measuring Blood Pressure (cont.)
• Avoid digit
preference for
five (5) or zeros
(0) by not
rounding up or
down.
• Record the heart
rate.
Tehran Arrhythmia Center
Blood pressure measurement with specific
devices
• Mercury Blood Pressure Monitor
• Aneroid Blood Pressure Monitor
• Electronic Blood Pressure Monitor
Tehran Arrhythmia Center
Blood Pressure Measurement with Mercury
Blood Pressure Monitor
• The patient should be calmly seated for at least 5 minutes,
with his or her back well supported and arm supported at
the level of the heart. His or her feet should touch the floor
and legs should not be crossed. The patient should be
instructed not to talk prior and during the procedure.
• The column of mercury must be vertical, and at the
observers eye level
• Use a cuff with the appropriate size
• Estimate the systolic beforehand:
a) Palpate the brachial artery
b) Inflate cuff until pulsation disappears
c) Deflate cuff
d) Estimate systolic pressure
• Inflate to 30mmHg above the estimated systolic level
needed to occlude the pulse
• Place the stethoscope diaphragm over the brachial artery
and deflate at a rate of 2-3mm/sec until you hear regular
tapping sounds. Measure systolic (first sound) to nearest
2mmHg
• Deflate at a rate of 2-3mm/heart beat until disappearance.
Measure diastolic blood pressure to nearest 2mmHg.
Tehran Arrhythmia Center
Blood Pressure Measurement with Aneroid
Blood Pressure Monitor
Aneroid devices should
not be used
if there is not
an established
calibration check
every 6-12 months.
Tehran Arrhythmia Center
Blood Pressure Measurement with
Electronic Blood Pressure Monitor
• The patient should be calmly seated for at least 5
minutes, with his or her back well supported and
arm supported at the level of the heart. His or her
feet should touch the floor and legs should not be
crossed. The patient should be instructed not to
talk prior and during the procedure.
• The arm must be supported
• Ensure no tight clothing constricts the arm
• Use a cuff with the appropriate size
• Place the cuff on neatly with the indicator mark
on the cuff over the brachial artery
• Most monitors will automatically inflate and reinflate at the appropriate level
• Take two blood pressure measurements one
minute apart
• Record measurement as displayed
Tehran Arrhythmia Center
Recommended Technique
for Measuring Blood Pressure (cont.)
The seated blood pressure
is used to determine
and monitor treatment
decisions.
The standing blood
pressure is used to test
for postural
hypotension, if present,
which may modify the
treatment.
Tehran Arrhythmia Center
Blood Pressure Assessment:
Patient preparation and posture
Standing position
For patients over age 65, diabetics
and patients being treated with
antihypertensives, check if there are
postural changes while taking blood
pressure reading, i.e. after one to
five minutes in the standing position
and under circumstances when the
patients complains of symptoms
suggestive of hypotension.
Tehran Arrhythmia Center
Home/Self measurement of blood pressure
Beyond diagnosis, Home/Self BP measurement may also be
considered for selected patients for the management of
hypertension
Which patients?
• Non adherence
• Hypertension and diabetes
• Office-induced blood pressure elevation
(white coat effect)
If office BP measurement
is elevated and Home BP
is normal
Further assess
using
24-h ambulatory
blood pressure
monitoring
Daytime average BP over 135/85 mm Hg should be considered elevated
Tehran Arrhythmia Center
Suggested Protocol for Home (Self)
Measurement of Blood Pressure
Home blood pressure values should be based on:
- duplicate measures,
- morning and evening,
- for an initial 7-day period.
Singular and first day home BP values should not
be considered.
For patients treated for hypertension
Morning measurement should be
done before medication taking
Tehran Arrhythmia Center
BP MEASUREMENT
• Self measurement of
BP
– Avg BP > 135/85
at home = HTN
– Wrist and finger
manometers are not
recommended
http://www.familymedshop.com/prod_img/pc0007.jpg
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Ambulatory BP Monitoring:
Specific Role in Selected Patients
Which patients?
Those with suspected office-induced BP elevation
Untreated
• Mild to moderate clinic BP elevation and without target
organ damage
Treated patients
• Blood pressure that is not below target values despite
receiving appropriate chronic antihypertensive therapy
• Symptoms suggestive of hypotension
• Fluctuating office blood pressure readings
Tehran Arrhythmia Center
Ambulatory BP Monitoring
Specific Role in Selected Patients
How to ?
Use validated devices
How to interpret?
Average daytime ambulatory blood pressure
>135/85 mmHg is considered elevated
A drop in nocturnal BP of <10% is associated
with increased risk of CV events
Tehran Arrhythmia Center
BP MEASUREMENT
• Ambulatory Blood Pressure Monitor (ABPM)
– Warranted for “white-coat” HTN if no target organ
injury
– apparent drug resistance
– hypotensive symptoms with antihypertensives
– episodic HTN
– autonomic dysfunction
Correlates better than office measurements with
target organ injury
BP should drop 10 to 20% during the night
• No Drop = increased risk for CV events
Tehran Arrhythmia Center
Clinic, Home/Self, Ambulatory (ABP) Blood
Pressure Measurement equivalence
numbers
A clinic blood pressure of 140/90 mmHg
has the equivalent risk of a:
Description
Blood Pressure mmHg
Home/Self pressure
average
135 / 85
Daytime average ABP
135 / 85
24-hour average ABP
130 / 80
Tehran Arrhythmia Center
Tehran Arrhythmia Center
CLASSIFICATION
JNC VI
Category
•
•
•
•
Optimal
Normal
High-normal
HTN
-Stage 1
(67%)
-Stage 2
(22%)
-Stage 3
(11%)
Systolic BP
Diastolic BP
<120
<130
130-139
and
and
or
<80
<85
85-89
140-159
or
90-99
160-179
or
100-109
>180
or
>110
Tehran Arrhythmia Center
CLASSIFICATION
JNC VII
Category
•
•
•
Normal
PREHTN
Hypertension
-Stage 1
-Stage 2
Systolic BP
Diastolic BP
<120
120-139
and
or
<80
80-90
140-159
>160
or
or
90-99
>100
Tehran Arrhythmia Center
Overview: Diagnostic algorithm for high Blood Pressure
including Office, ABPM and Self/Home Blood Pressure
Measurement
Hypertension Visit 1
BP Measurement,
History and Physical
examination
Hypertension
Visit 2
Target Organ Damage
or Diabetes
or Chronic Kidney Disease
or BP ≥ 180/110?
Hypertensive
Urgency /
Emergency
Yes
Diagnosis
of HTN
No
BP: 140-179 / 90-109
Clinic BPM
ABPM (If available)
S/H BPM (If available)
Tehran Arrhythmia Center
Diagnostic algorithm for high Blood Pressure including
Office, ABPM and Self/Home Blood Pressure Measurement
Elevated Out of
the Office BP
measurement
Elevated Random
Office BP
Measurement
Hypertension
Visit 1
Hypertensive
Urgency /
Emergency
BP Measurement,
History and Physical
examination
Diagnostic tests ordering
at visit 1 or 2
Hypertension Visit 2
within 1 month
BP ≥ 140/90 mmHg
and
Target organ damage
or Diabetes or Chronic
Kidney Disease or BP ≥
180/110?
Yes
Diagnosis
of HTN
No
BP: 140-179 / 90109
Tehran Arrhythmia Center
Diagnostic algorithm for high Blood Pressure
including Office, ABPM and Self/Home Blood Pressure
Measurement
BP: 140-179 / 90-109
Clinic BP
Hypertension visit 3
≥ 160 SBP
or ≥ 100
DBP
< 160 /
100
Diagnosis
of HTN
or
ABPM or S/H
BPM if
available
24-h ABPM (If
available)
Awake BP
< 135/85
24-hour
< 130/80
Awake BP
≥ 135 SBP or
≥ 85 DBP or
24-hour
≥ 130 SBP or
≥ 80 DBP
Continue to
follow-up
Diagnosis
of HTN
Hypertension visit 4-5
≥ 140 SBP
or
≥ 90 DBP
< 140 /
90
Diagnosis
of HTN
S/H BPM (If
available)
<
135/85
≥
135/85
or
Continue to
follow-up
Diagnosis
of HTN
Continue to
follow-up
Tehran Arrhythmia Center
Threshold for Initiation of Treatment and
Target Values
Condition
Initiation
SBP
/ DBP
mmHg
Diastolic ± systolic
hypertension
Isolated systolic
hypertension
Diabetes
Renal disease
Target
SBP
/ DBP
mmHg
 140/90
<140/90
SBP >160
<140
 130/80
<130/80
( 130/80)
<130/80
Tehran Arrhythmia Center
CLINICAL EVALUATION
Which one of the following would be most likely to
have secondary HTN?
A)
B)
C)
D)
E)
39 y/o male who weighs 119 kg and BP=142/94
48 y/o female with LVH on echo and BP=162/98
62 y/o female with a strong FH of HTN
78 y/o male with abdominal bruits BP=182/102
88 y/o male with hemiparesis from prior stroke
BP=192/88
Tehran Arrhythmia Center
CLINICAL EVALUATION
Answer:
D) 78 y/o WF with abdominal bruits and BP is
182/102 mm Hg
Objective of the clinical evaluation:
1) Identify other CV risk factors
- assess lifestyle and concomitant disorders
that may affect prognosis and guide treatment
2) Reveal identifiable causes of high BP
3) Assess the presence/absence of target organ damage
(TOD) and CVD
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CLINICAL EVALUATION
•Other historical factors that may affect
treatment decisions
•Gout, sexual dysfunction, bronchospasm,
migraine, heart block, pregnancy plans in female
•Physical Examination
•Goal is to assess for target organ damage and
clues to secondary causes
Tehran Arrhythmia Center
Laboratory Tests
 Routine Tests
• Electrocardiogram
• Urinalysis
• Blood glucose, and hematocrit
• Serum potassium, creatinine, or the corresponding estimated GFR,
and calcium
• Lipid profile, after 9- to 12-hour fast, that includes high-density and
low-density lipoprotein cholesterol, and triglycerides
 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
Tehran Arrhythmia Center
The Role of Echocardiography:
Specific Roles
Echocardiography is useful for:
Assessment of Left ventricular dysfunction
Suspicion of Left ventricular hypertrophy may
influence management
Echocardiography is not useful for:
• Routine Evaluation
• Tracking of the therapeutic regression
Tehran Arrhythmia Center
Major Risk Factors
JNC VI
JNC VII
•
•
•
•
•
•HTN
•Smoking
•Dyslipidemia
•Diabetes mellitus
•FH of *premature CAD
(women < 65 or men < 55)
•Age (> 55 for men, >65 for women)
•*Obesity (BMI >30 kg/m2)
•*Physical inactivity
•*Microalbuminuria or estimated
GFR <60 mL/min
HTN
Smoking
Dyslipidemia
Diabetes mellitus
FH of CAD
– women < age 65
–
men < age 55
• Age > 60 years
• Sex (men and
postmenopausal
women)
*HOPE trial N Engl J Med. 2000
Tehran Arrhythmia Center
TARGET 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
Tehran Arrhythmia Center
SECONDARY HYPERTENSION
•
•
•
•
•
Sleep apnea
Chronic kidney disease
Primary aldosteronism
Renovascular disease
Chronic steroid therapy / Cushing’s
syndrome
• Pheochromocytoma
• Coarctation of the aorta
• Thyroid or parathyroid disease
Tehran Arrhythmia Center
SECONDARY HYPERTENSION
• Drug-induced or related causes
– NSAIDs
– Cocaine, amphetamines, other illicit
drugs
– Sympathomimetics, oral contraceptives,
steroids
– Cyclosporine and tacrolimus
– Erythropoietin
– Selected OTC supplements/medicines
(e.g., ephedra, bitter orange)
Tehran Arrhythmia Center
Renovascular Disease
• Most common correctable secondary cause
• 10-45% of white patients w/ severe HTN
–
–
–
–
–
–
Acute rise in BP after stable baseline
Proven onset before puberty or after age 50
Acute elevation in creatinine, especially w/ ACE
Asymmetric renal disease
Systolic/diastolic bruit (Sens. 40%, spec. 99%)
Negative family history
Tehran Arrhythmia Center
Tehran Arrhythmia Center
LIFESTYLE MANAGEMENT
Tehran Arrhythmia Center
Lifestyle Recommendations for Prevention of
Hypertension for NON-Hypertensive Individuals.
To reduce the possibility of becoming hypertensive,
1.
2.
3.
Healthy diet; High in fresh fruits, vegetables and low fat dairy
products, low in saturated fat and salt
Regular physical activity: accumulation of 30-60 minutes of
moderate intensity dynamic exercise 4-7/week at least 4/week
Low risk alcohol consumption (≤2 drinks/day or less than
14/week for men and less than 9/week for women)
4.
Maintenance of ideal body weight (BMI 18.5-24.9 kg/m2)
5.
Waist Circumference
< 102 cm for men
< 88 cm for women
6.
Restriction of salt intake to less than 100 mmol/day in
individuals considered salt-sensitive, such as: African descent,
age over 45, individuals with impaired renal function or with
diabetes.
7.
Smoke free environment
Tehran Arrhythmia Center
Lifestyle Recommendations for the Treatment of
Hypertension
1.
2.
3.
4.
5.
Healthy diet; High in fresh fruits, vegetables and low fat dairy products,
low in saturated fat and salt in accordance with the DASH diet
Regular physical activity: optimum 30-60 minutes of moderate
cardio-respiratory activity 4/week or more
Reduction in alcohol consumption in those who drink excessively
Weight loss ( ≥ 5 Kg) in those who are over weight (BMI>25)
Waist Circumference
< 102 cm for men
< 88 cm for women
6.
In individuals considered salt-sensitive, such as: African descent,
age over 45, individuals with impaired renal function or with diabetes.
Restrict salt intake to less than 100 mmol/day
7.
Smoke free environment
Tehran Arrhythmia Center
Lifestyle Recommendations for Hypertension:
Dietary
Dietary Sodium
• Fresh Fruits
• Vegetables
• Low Fat dairy
products
• Low fat diet in
accordance with the
DASH diet
(Dietary Approaches
to Stop
Hypertension)
Restrict to target range of 65-100
mmol/day
(Most of the salt in food is hidden and
comes from processed food)
Dietary Potassium
If required, daily dietary
intake >80 mmol
Calcium supplementation
No conclusive studies for hypertension
Magnesium supplementation
No conclusive studies for hypertension
http://www.hc-sc.gc.ca/hpfb-dgpsa/onpp-bppn/food_guide_rainbow_e.html
Tehran Arrhythmia Center
Lifestyle Recommendations for Hypertension:
Physical Activity
Should be prescribed to reduce blood pressure
F
Frequency - Four or more days per week
I
Intensity
- Moderate
T
Time
- 30-60 minutes
Type
Dynamic exercise
- Walking, jogging
- Cycling
- Non-competitive swimming
T
For patients who are prescribed pharmacological therapy: Exercise should be prescribed as adjunctive
therapy
Tehran Arrhythmia Center
Lifestyle Recommendations for
Hypertension: Alcohol
Low risk alcohol consumption
• 0-2 drinks/day
• Men: maximum of 14 drinks/week
• Women: maximum of 9 drinks/week
1 drink = one beer, or 1 glass of wine or 1 ounce of 40% spirit
Tehran Arrhythmia Center
Lifestyle Recommendations for
Hypertension: Stress Management
Stress management
Hypertensive patients
in whom stress appears to be an important issue
Behavior Modification
Individualized cognitive behavioral interventions are
more likely to be effective when relaxation
techniques are employed
Tehran Arrhythmia Center
Lifestyle Recommendations for
Hypertension: Weight Loss
Hypertensive and all patients
BMI over 25 for hypertension
- Encourage weight reduction
- Healthy BMI: 18.5-24.9 kg/m2
Waist Circumference
< 102 cm for men
< 88 cm for women
For patients prescribed pharmacological therapy:
weight loss has additional antihypertensive effects.
Weight loss strategies should employ a multidisciplinary
approach and include dietary education, increased
physical activity and behavioural modification.
Tehran Arrhythmia Center
Lifestyle Therapies in Hypertensive
Adults: Summary
Intervention
Sodium restriction
Weight loss
Waist Circumference
Alcohol restriction
Exercise
Dietary patterns
Smoking cessation
Target
65-100 mmol/day
BMI <25 kg/m2
< 102 cm for men
< 88 cm for women
Less or equal to 2 drinks/day
at least 4 times/week
DASH diet
Smoke free environment
Tehran Arrhythmia Center
Lifestyle Modifications
• Modification
Recommendation
SBP
Reduction
Weight
reduction
BMI 18.5–24.9
5–20 mmHg/
10 kg wt loss
Adopt DASH
eating plan
-diet rich in fruits,
vegetables, and lowfat
dairy products
-reduced saturated and
total fat
8–14 mmHg
Dietary sodium
reduction
No more than 2.4 g
sodium/day
2–8 mmHg
Tehran Arrhythmia Center
Lifestyle Modifications
• Modification
Physical
activity
Moderation
of alcohol
consumption
Recommendation
Regular aerobic physical
activity > 30 min/day,
most days of the week
No more than 2
drinks/day in most men
and
No more than 1
drink/day in women.
SBP
Reduction
4–9 mmHg
2–8 mmHg
Tehran Arrhythmia Center
Tehran Arrhythmia Center
Hypertension
PHARMACOTHERAPY
Tehran Arrhythmia Center
Indications for Pharmacotherapy
Strongly consider prescription if:
• Average DBP equal or over 90 mmHg and:
• Hypertensive Target-organ damage (or CVD) or
• Independent cardiovascular risk factors
• Elevated systolic BP
• Cigarette smoking
• Abnormal lipid profile
• Strong family history of premature CV disease
• Truncal obesity
• Sedentary Lifestyle
• Average DBP equal or over 80 mmHg in a patient
with diabetes or chronic renal disease
Tehran Arrhythmia Center
GOALS OF THERAPY
JNC VI
JNC VII
• Goal BP:
• Goal BP:
– HTN: <140/90
– Diabetics:
<130/85
– Renal failure:
<130/85
– Proteinuria (>1
gm/24 hrs):
<125/75
– HTN: <140/90
– Diabetics:
<130/80
– Renal failure:
<130/80
Tehran Arrhythmia Center
Goals of Therapy
 Reduce CVD and renal morbidity and mortality.
 Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients
with diabetes or chronic kidney disease.
 Achieve SBP goal especially in persons >50 years of age.
 Since most persons with hypertension, especially those over 50,
will reach the DBP goal once the SBP goal is achieved, the
primary focus should be on attaining the SBP goal.
Tehran Arrhythmia Center
Antihypertensive Drug Class
• Diuretics
– Thiazides
• Hydrochlorothiazide
• Chlorthalidone
– Loop diuretics
• Furosemide
– Aldosterone antagonists (K sparing)
• Triamteren
• Spironolactone
Tehran Arrhythmia Center
Antihypertensive Drug Class
• Beta-blockers (BB)
– Selective
• Atenolol
• Metoprolol
– Non-selective
• Propranolol
– Combined beta- and alpha-blockers
• Carvedilol
Tehran Arrhythmia Center
Antihypertensive Drug Class
• Angiotensin Converting Enzyme Inhibitors
(ACEI)
– Captopril
– Enalapril
• Angiotensin Receptor Blockers (ARB)
– Losartan
– Valsartan
Tehran Arrhythmia Center
Antihypertensive Drug Class
• Calcium Channel Blockers (CCB)
– Dihydropyridines
• Nifedipine
• Amlodipine
– Non-dihydropyridines
• Diltiazem
• Verapamil
Tehran Arrhythmia Center
Antihypertensive Drug Class
• Alpha-blockers
– Prazocin
• Central alpha-2 agonists
– Clonidine
– Methldopa
– Reserpine
• Direct Vasodilators
– Hydralazine
– Minoxidil
Tehran Arrhythmia Center
Choice of Therapy
• Medication decisions based on:
– compelling indications
– comorbid conditions
– drug interactions
– side effect profile
– cost
• Always favor the long-acting formulations
Tehran Arrhythmia Center
Choice of Pharmacological Treatment
Associated risk factors?
or
Target organ damage/complications?
or
Concomitant diseases/conditions?
NO
Treatment in the
absence of compelling
indication
YES
Individualized
Treatment
(with compelling
indications)
Tehran Arrhythmia Center
Choice of pharmacological treatment
for hypertensive patients without other
compelling indications:
• Treatment of Systolic Diastolic hypertension
• Treatment of Isolated Systolic hypertension
Tehran Arrhythmia Center
ANTIHYPERTENSIVE MEDICATIONS
JNC VI
• Uncomplicated
HTN
– Diuretics
– -blockers
JNC VII
• Uncomplicated
HTN
– Thiazide diuretics
– Either alone or in
combination with
an ACE-I, ARB,
 -blocker, or CCB
Tehran Arrhythmia Center
Treatment of Adults with Systolic-Diastolic
Hypertension without Other Compelling
Indications
TARGET <140 mm Hg systolic and < 90 mmHg diastolic
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification
therapy
Thiazide
ACE-I
ARB
Longacting
CCB
Betablocker*
* Not indicated as first line therapy over 60
Tehran Arrhythmia Center
Considerations Regarding the Choice
of First-Line Therapy
• Diuretic-induced hypokalemia should be avoided through
the use of potassium sparing agent
• Beta adrenergic blockers are not recommended for patients
over 60 years without another compelling indication
• ACE-I are not recommended (as monotherapy)
for black patients without another compelling indication
Tehran Arrhythmia Center
Combination Therapy for Systolic-Diastolic
Hypertension without Other Compelling Indications
If partial response to monotherapy
1. Dual Combination Therapy
CONSIDER
2. Triple or Quadruple Therapy
• Nonadherence?
• Secondary HTN?
• Interfering drugs or
lifestyle?
• White coat effect?
• Resistant Hypertension?
If blood pressure is still not controlled, or there are adverse
effects, other classes of antihypertensive drugs may be
combined (such as alpha blockers, centrally acting agents, or
nondihydropyridine calcium channel blocker).
Tehran Arrhythmia Center
Useful Dual Combinations
For additive hypotensive effect in dual therapy
Combine an agent from
Column 1 with any in Column 2
Column 1
Column 2
• Thiazide diuretic
• Beta adrenergic blocker
• Long-acting calcium
channel blocker*
• ACE Inhibitor
• ARB
* Caution should be exercised when using a non DHP-CCB and a beta-blocker
Tehran Arrhythmia Center
Useful Triple Therapy Combinations
For additive hypotensive effect in triple therapy
Combine 2 agents from one Column with any in the
other Column
Column 1
Column 2
• Thiazide diuretic
• Beta adrenergic blocker
• Long-acting calcium
channel blocker*
• ACE Inhibitor
• ARB
* Caution should be exercised when using a non DHP-CCB and a beta-blocker
Tehran Arrhythmia Center
Summary: Treatment of Systolic-Diastolic
Hypertension without Other Compelling Indications
TARGET <140 mm Hg systolic and < 90 mmHg diastolic
Lifestyle modification
therapy
Thiazide
diuretic
CONSIDER
•Nonadherence?
•Secondary HTN?
•Interfering drugs
or lifestyle?
•White coat effect?
ACE-I
ARB
Long-acting
CCB
Betablocker*
Dual Combination
Triple or Quadruple
Therapy
* Not indicated as first line therapy over 60
Tehran Arrhythmia Center
Treatment Algorithm for Isolated Systolic
Hypertension without Other Compelling
Indications
TARGET <140 mmHg Systolic BP
INITIAL TREATMENT AND MONOTHERAPY
Lifestyle modification
therapy
Thiazide
diuretic
ARB
Long-acting
DHP CCB
Tehran Arrhythmia Center
Combination therapy for Isolated Systolic
Hypertension without Other Compelling Indications
If partial response to monotherapy
Dual combination
Combine agents from two adjacent classes
Thiazide
diuretic
CONSIDER
•Nonadherence?
•Secondary HTN?
•Interfering drugs
or lifestyle?
•White coat effect?
ARB
Long-acting
DHP CCB
Triple or quadruple
therapy
If blood pressure is still not controlled, or there are adverse effects,
other classes of antihypertensive drugs may be combined (such as
alpha adrenergic blockers, centrally acting agents, or
nondihydropyridine calcium channel blocker).
Tehran Arrhythmia Center
Summary: Treatment of Isolated Systolic
Hypertension without Other Compelling Indications
TARGET <140 mmHg Systolic BP
Lifestyle modification
therapy
Thiazide
diuretic
CONSIDER
•Nonadherence?
•Secondary HTN?
•Interfering drugs
or lifestyle?
•White coat effect?
ARB
Dual combination
Triple or Quadruple*
combination
Long-acting
DHP CCB
*If blood pressure is still
not controlled, or there
are adverse effects,
other classes of
antihypertensive drugs
may be combined (such
as alpha blockers,
centrally acting agents,
or nondihydropyridine
calcium channel
blocker).
Tehran Arrhythmia Center
Choice of pharmacological treatment
for hypertensive patients with other
compelling indications
• Treatment of diastolic-systolic hypertension
• Treatment of isolated systolic hypertension
Tehran Arrhythmia Center
Choice of pharmacological treatment for
hypertensive patients with other compelling
indications
Individualized treatment
•
Compelling indications:
• Smoking
• Ischemic Heart Disease
• Recent ST Segment Elevation-MI or non-ST Segment ElevationMI
• Left Ventricular Systolic Dysfunction
• Cerebrovascular Disease
• Left Ventricular Hypertrophy
• Non Diabetic Chronic Kidney Disease
• Renovascular Disease
•
Diabetes Mellitus
• With Diabetic Nephropathy
• Without Diabetic Nephropathy
•
Global Vascular Protection for Hypertensive Patients
• Statins
• Aspirin
Tehran Arrhythmia Center
Special Considerations
 Compelling Indications
 Other Special Situations
• Minority populations
• Obesity and the metabolic syndrome
• Left ventricular hypertrophy
• Peripheral arterial disease
• Hypertension in older persons
• Postural hypotension
• Dementia
• Hypertension in women
• Hypertension in children and adolescents
• Hypertension urgencies and emergencies
Tehran Arrhythmia Center
Coronary Artery Disease
 One caveat: The finding in some studies of an apparent increase
in coronary risk at low levels of DBP.
 SHEP study; lowering DBP to 55 or 60 mm Hg was associated
with an increase in cardiovascular events, including MI.
 No similar J-shaped curve has been observed with SBP.
 Patients with occlusive CAD and/or LVH are put at risk of
coronary events if DBP is low.
 Overall, however, many more events are prevented than caused
if BP is aggressively treated.
Tehran Arrhythmia Center
Treatment of Hypertension in Patients with
Ischemic Heart Disease
Stable angina
1. Beta-blocker
2. Long-acting CCB
ACE-I are recommended in ALL
patients with established CAD
• Caution should be exercised when combining a non DHP-CCB and a
beta-blocker
• If abnormal systolic left ventricular function: avoid non DHP-CCB
(Verapamil or Diltiazem)
Short-acting
nifedipine
Tehran Arrhythmia Center
Treatment of Hypertension
in Patients with Recent ST Segment
Elevation-MI
or non-ST Segment Elevation-MI
Recent
myocardial
infarction
Beta-blocker
and ACE-I
If beta-blocker
contraindicated
or not effective
Heart
Failure
?
YES
Long-acting
DHP CCB
(Amlodipine,
Felodipine)
NO
Long-acting CCB
Tehran Arrhythmia Center
Heart Failure
 Hypertension precedes the development of HF in approximately
90% of patients and increases risk for HF by 2- to 3-fold.
 CAD is the cause of HF in approximately two-thirds of HF
patients.
 BP targets in HF have not been firmly established, but lowering
SBP is almost uniformly beneficial.
 In most successful trials, systolic blood pressures were lowered
to the range of 110 to 130 mm Hg.
 Forty to 50% of patients with symptoms of HF may have
preserved systolic function.
Tehran Arrhythmia Center
Treatment of Hypertension
with Left Ventricular Systolic
Dysfunction
Systolic
cardiac
Dysfunction
• ACE-I
• if ACE-I intolerant: ARB
and Beta-Blocker
If additional therapy is needed:
• Diuretic
• for CHF class III-IV: Aldosterone
Antagonist
If ACE-I and ARB are contraindicated: Hydralazine and
Isosorbide dinitrate in combination
If additional antihypertensive therapy is needed:
Non
dihydropyridine
CCB
• ACE-I / ARB Combination
• Long-acting DHP-CCB (Amlodipine or Felodipine)
Beta-blockers used in clinical were bisoprolol, carvedilol and metoprolol. Physicians who are not yet
experienced in the use of beta-blockers should consider initiation of treatment in conjunction with a
physician experienced in heart failure management particularly for NYHA Class III-IV patients
Tehran Arrhythmia Center
Patients with Cerebrovascular
Disease
 Given the population distribution of BP, most ischemic
strokes occur in individuals with pre-hypertension or
stage 1 hypertension.
 The incidence of ischemic or hemorrhagic stroke is
reduced substantially with the treatment of
hypertension.
Tehran Arrhythmia Center
Patients with Cerebrovascular
Disease
 No specific agent has proven to be clearly superior to all others
for stroke protection.
 In the LIFE study, there were fewer strokes in the losartantreated group than in the group treated with atenolol.
 In the ALLHAT study, the stroke incidence was 15% greater with
ACEI than with thiazide-type diuretic or dihydropyridine CCB, but
the BP reduction in the lisinopril group was also less than with
chlorthalidone or amlodipine.
Tehran Arrhythmia Center
Treatment of Hypertension
for Patients with Cerebrovascular
Disease
Strongly consider blood pressure reduction
in all patients after the acute phase of non
disabling stroke or TIA .
Stroke
TIA
An ACE-I / diuretic
combination may be
preferred
Tehran Arrhythmia Center
Hypertension and Acute Stroke
 The management of BP during an acute stroke remains
controversial.
 American Stroke Association guidelines: In patients with
recent ischemic stroke whose SBP is 220 mm Hg or
DBP 120 to 140 mm Hg, cautious reduction of BP by
about 10% to 15% is suggested
• If the DBP is 140 mm Hg, carefully monitored
infusion of sodium nitroprusside should be used to
reduce the BP by 10 to 15%
Tehran Arrhythmia Center
Left Ventricular Hypertrophy
 LVH is an independent risk factor that increases the risk of CVD.
 Individuals with LVH are more than twice as likely to suffer premature
cardiovascular events or death.
 Regression of LVH occurs with aggressive BP management: weight
loss, sodium restriction, and treatment with all classes of drugs
except the direct vasodilators hydralazine and minoxidil.
 The most consistent reduction in LV mass was achieved with ACEIs,
the least reduction occurred with BBs, and intermediate benefits
occurred for diuretics and calcium antagonists
Tehran Arrhythmia Center
Treatment of Hypertension in Patients
with Left Ventricular Hypertrophy
Hypertensive patients with left ventricular hypertrophy should be
treated with antihypertensive therapy to lower the rate of subsequent
cardiovascular events.
Left ventricular
ventricular
Left
hypertrophy
hypertrophy
ACE-I
-- ACE-I
ARB
-- ARB,
CCB
-- CCB
Diuretic
-- Diuretic
BB (below
(below age
age 60)*
60)
-- BB
Vasodilators:
Vasodilators:
Hydralazine, Minoxidil
Minoxidil Can
Can
Hydralazine,
Increase LVH
LVH
Increase
Tehran Arrhythmia Center
Chronic Kidney Disease
 CVD is the most common cause of death in individuals
with CKD, and CKD is itself an independent risk factor
for CVD.
 CVD risk also exhibits a continuous relationship with
albuminuria; the presence of microalbuminuria confers
a 50% increase in risk and the presence of
macroalbuminuria, a 350% increase.
Tehran Arrhythmia Center
Chronic Kidney Disease
 NHANES III data indicated that about 3% (5.6 million
people) of adults in the United States had elevated
serum creatinine values and 70% of these had
hypertension.
 While 75% of individuals received treatment, only 11%
with hypertension and elevated serum creatinine had
BP 130/85 mm Hg and only 27% had BP 140/90 mm
Hg.
Tehran Arrhythmia Center
Chronic Kidney Disease
 Many studies demonstrate that antihypertensive
regimens that include an ACEI or ARB are more
effective in slowing progression of CKD than other
antihypertensive regimens.
 Most patients with CKD should receive an ACEI or an
ARB in combination with a diuretic and that many will
require a loop diuretic rather than a thiazide.
Tehran Arrhythmia Center
Treatment of Hypertension in Patients
with chronic kidney disease
Target BP:
< 130 mmHg systolic and
< 80 mmHg diastolic
Renal disease
1. ACE-I
2. Alternate if ACE-I not tolerated: ARB
Additive therapy: Diuretic.
Usually a loop diuretic
Combination with other agents
ACE-I/ARB:
Bilateral renal
artery stenosis
Tehran Arrhythmia Center
Treatment of
Hypertension for
Patients
with Diabetes Mellitus
Tehran Arrhythmia Center
Concordance of Diabetes and
Hypertension
 The combined unadjusted prevalence of total diabetes
and impaired fasting glucose in those over 20 years old
is 14.4%.
 The leading cause of blindness, ESRD, and nontraumatic amputations.
 Hypertension is disproportionately higher in diabetics,
while persons with elevated BP are 2.5 times more
likely to develop diabetes within 5 years.
Tehran Arrhythmia Center
Concordance of Diabetes and
Hypertension
 The coexistence of hypertension in diabetes is
particularly Pernicious.
 The United Kingdom Prospective Diabetes Study
(UKPDS)
• Each 10 mm Hg decrease in SBP was associated
with average reductions in rates of diabetes-related
mortality of 15%; myocardial infarction, 11%; and the
microvascular complications of retinopathy or
nephropathy,13%.
Tehran Arrhythmia Center
Drug Choices in Diabetes
 Regarding the selection of medications, clinical trials
with diuretics, ACEIs, BBs, ARBs, and calcium
antagonists have demonstrated benefit in the treatment
of hypertension in both type 1 and type 2 diabetics.
 The question of which agent class is superior for
lowering BP is somewhat moot because the majority of
diabetic patients will require 2 or more drugs to achieve
BP control.
Tehran Arrhythmia Center
Drug Choices in Diabetes
Diuretics
 Thiazide-type diuretics are beneficial in diabetics, either
alone or as part of a combined regimen.
 Of potential concern is the tendency for thiazide type
diuretics to worsen hyperglycemia, but this effect
tended to be small and did not produce more CV events
compared with the other drug classes.
Tehran Arrhythmia Center
Drug Choices in Diabetes
ACEI / ARB
 Therapy with an ACEI also is an important component of most
regimens to control BP in diabetic patients.
 Much more effective when combined with a thiazide-type diuretic or
other antihypertensive drugs.
 The ADA has recommended ACEIs for diabetic patients over 55
years old at high risk for CVD and BBs for those with known CAD.
 With respect to microvascular complications, the ADA has
recommended both ACEIs and ARBs for use in Type 2 diabetic
patients with chronic kidney disease.
Tehran Arrhythmia Center
Drug Choices in Diabetes
Beta-blockers
 BBs, especially beta1-selective agents, are beneficial in diabetics
as part of multi-drug therapy, but their value as monotherapy is
less clear.
 A BB is indicated in a diabetic with ischemic heart disease but
may be less effective in preventing stroke than an ARB, as was
found in the LIFE study.
 Although BBs can cause adverse effects on glucose
homeostasis in diabetics, including worsening of insulin
sensitivity and potential masking of the epinephrine-mediated
symptoms of hypoglycemia, these problems are usually easily
managed and are not absolute contraindications.
Tehran Arrhythmia Center
Treatment of Hypertension in
Association with Diabetic Nephropathy
Threshold ≥ 130/80 mmHg and TARGET < 130 mmHg
systolic and < 80 mmHg diastolic
Urinary albumin excretion rate over 30 mg/day
DIABETES
with
Nephropathy
ACE Inhibitor
or ARB
IF ACE-I and ARB are
contraindicated or
not tolerated,
SUBSTITUTE
• Cardioselective BB
or
• Long-acting CCB or
• Thiazide diuretic
Addition of one or more
of
Thiazide diuretic or
Long-acting CCB
3 - 4 drugs combination
may be needed
If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic
should be substituted for a thiazide diuretic if control of volume is desired
Tehran Arrhythmia Center
Treatment of Systolic-Diastolic Hypertension
without Diabetic Nephropathy
Threshold ≥ 130/80 mmHg and
TARGET < 130 mmHg systolic and < 80 mmHg diastolic
Urinary albumin excretion rate less than 30 mg/day
Diabetes
without
Nephropathy
With
Systolic
diastolic
Hypertension
ACE-Inhibitor or
ARB or
Thiazide diuretic
Combination of first line
agents
IF ACE-I and ARB and
Thiazide are
contraindicated or not
tolerated,
SUBSTITUTE
• Cardioselective BB* or
• Long-acting CCB
Addition of one or more
of:
Cardioselective BB or
Long-acting CCB
* Cardioselective BB: Acebutolol, Atenolol, Bisoprolol , Metoprolol
More than 3 drugs may be needed to reach target values for diabetic patients
Tehran Arrhythmia Center
Treatment of Hypertension
in association with Renovascular
Disease
Renovascular
disease
Does not imply specific
treatment choice
Caution in the use of ACE-I/ARB in
Bilateral renal artery stenosis or
unilateral disease with solitary kidney
Close follow-up and early intervention (angioplasty and stenting or surgery)
should be considered for patients with: uncontrolled hypertension despite
therapy with three or more drugs, or deteriorating renal function, or bilateral
atherosclerotic renal artery lesions (or tight atherosclerotic stenosis in a single
kidney), or recurrent episodes of flash pulmonary edema.
Tehran Arrhythmia Center
Peripheral Arterial Disease
 PAD is equivalent in risk to ischemic heart disease.
 Any class of drugs can be used in most PAD patients.
 BBs may cause peripheral vasoconstriction and have the potential to
increase the frequency of intermittent claudication in individuals with
PAD. However, recent studies have shown that BBs have little effect
on walking distance.
 Other risk factors should be managed aggressively.
 Aspirin should be used.
Tehran Arrhythmia Center
Hypertension in Older
Persons
 More than two-thirds of people over 65 have HTN.
 This population has the lowest rates of BP control.
 BP is more variable in the older patient, often due to stiff large arteries
and age-related decreases in baroreflex buffering.
 Exaggerated BP drops may occur in the elderly during postural
change, after meals, and after exercise.
 Pseudo-hypertension should be strongly considered if usual treatment
does not reduce BP, especially in those patients who complain of
symptoms consistent with postural hypotension.
Tehran Arrhythmia Center
Hypertension in Older
Persons
 SBP should be the primary target for the diagnosis and
management of older people with hypertension.
 Pulse pressure is only marginally stronger than SBP for risk
stratification in individuals over age 60, but under age 60, PP is
not useful as a CVD risk predictor.
 Treatment, including those who with isolated systolic HTN,
should follow same principles outlined for general care of HTN.
 Lower initial drug doses may be indicated to avoid symptoms;
standard doses and multiple drugs will be needed to reach BP
targets.
Tehran Arrhythmia Center
Orthostatic Hypotension
 Decrease in standing SBP >20 mmHg or DBP > 10mmHg, when
associated with dizziness/fainting.
 More frequent in older SBP patients with diabetes.
 There is a strong correlation between the severity of OH and
premature death as well as increased numbers of falls and fractures.
 The causes include severe volume depletion, baroreflex dysfunction,
autonomic insufficiency, and certain venodilator antihypertensive
drugs, especially Alpha-blockers.
 Diuretics and nitrates may further aggravate OH.
Tehran Arrhythmia Center
Orthostatic Hypotension
 OH is a common barrier to intensive BP control.
 Avoid volume depletion and excessively rapid dose titration of drugs.
 Lying and standing BPs should be obtained periodically in all
hypertensive individuals over 50 years old.
Tehran Arrhythmia Center
Dementia
 Dementia and cognitive impairment occur more commonly in people
with HTN.
 Reduced progression of cognitive impairment occurs with effective
antihypertensive therapy.
Tehran Arrhythmia Center
Hypertension in Women
 Oral contraceptives may increase BP, and BP should be checked
regularly. In contrast, HRT does not raise BP.
Development of HTN—consider other forms of contraception.
 Pregnant women with HTN should be followed carefully. Methyldopa,
BBs, and vasodilators, preferred for the safety of the fetus.
 ACEI and ARBs contraindicated in pregnancy.
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Children and Adolescents
 HTN defined as BP—95th percentile or greater, adjusted for age,
height, and gender.
 Use lifestyle interventions first, then drug therapy for higher levels of
BP or if insufficient response to lifestyle modifications.
 Drug choices similar in children and adults, but effective doses are
often smaller.
 Uncomplicated HTN not a reason to restrict physical activity.
Tehran Arrhythmia Center
ANTIHYPERTENSIVE
MEDICATIONS
JNC VII
Compelling Indications
• Diabetes mellitus (type 1)
with proteinuria
Diuretic,  -blocker,
ACE-I, ARB, CCB
• Heart failure
Diuretic,  -blocker,
ACE-I, ARB, and Aldo
antagonist
• High coronary disease risk
Diuretic,  -blocker,
ACE-I, CCB
Tehran Arrhythmia Center
ANTIHYPERTENSIVE
MEDICATIONS
JNC VII
Compelling Indications
• Post Myocardial infarction
 -blockers, ACE-I
• Chronic kidney disease
ACE-I, ARB
• Recurrent stroke
prevention
Diuretic, ACE-I
Tehran Arrhythmia Center
Drug Classes and Guideline Basis
Recommended Drugs
Indications
Diuretic
BB
ACEI
ARB
CCB
Aldo Ant
Trials
Heart Failure
ACC/AHA Heart Failure
Guideline, MERIT-HF,
COPERNICUS, CIBIS,
SOLVD, AIRE, TRACE,
ValHEFT, RALES, CHARM
Post- MI
ACC/AHA Post-MI
Guideline, BHAT,
SAVE, Capricorn,
EPHESUS
High CAD Risk
ALLHAT, HOPE, ANBP2,
LIFE,
CONVINCE, EUROPA,
INVEST
Diabetes
NKF-ADA Guideline,
UKPDS, ALLHAT
Chronic Kidney
Disease
NKF Guideline, Captopril
Trial,
RENAAL, IDNT, REIN,
AASK
Stroke
Prevention
PROGRESS
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Additional Considerations in
Antihypertensive Drug Choices
Potential favorable effects
 Thiazide-type diuretics useful in slowing demineralization in
osteoporosis.
 BBs useful in the treatment of atrial tachyarrhythmias/fibrillation,
migraine, thyrotoxicosis (short-term), essential tremor, or perioperative
HTN.
 CCBs useful in Raynaud’s syndrome and certain arrhythmias.
 Alpha-blockers useful in prostatism.
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Additional Considerations in
Antihypertensive Drug Choices
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.
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Resistant HTN
• Failure of a 3-drug regimen including a diuretic
• Pseudo-hypertension
– Marked HTN without end-organ damage
– Therapy produces symptoms of hypoperfusion
without significant BP reduction
– Consider Home or Ambulatory BP monitoring
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Causes of
Resistant Hypertension
 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
Tehran Arrhythmia Center
Resistant Hypertension
• If resistant hypertension persists after
remediable causes are identified and corrected,
then a concerted search for a cause of
secondary hypertension should be conducted.
• Try minoxidil
• Refer to HTN specialist.
• The prevalence of truly resistant hypertension is
small.
Tehran Arrhythmia Center
Interventions that Can Help Improve
Adherence
• Educate patients and families on the consequences of
hypertension and the benefits of lifestyle and drug therapy
• Counsel on side effects
• Tailor pill-taking to fit patients’ daily habits (same
time/place/situation)
• Simplify drug and lifestyle regime (e.g., once daily dosing)
• Ensure regime is affordable
• Involve family and friends in lifestyle and medication adherence
• Maintain regular BP follow-up
• Encourage patient responsibility/autonomy in monitoring BP and
adjusting prescriptions
Tehran Arrhythmia Center
Tehran Arrhythmia Center
ANTIHYPERTENSIVE
MEDICATIONS
• Diuretics
– Compelling indications: DM, HF, high CAD risk,
recurrent stroke prevention (5 of 7)
– May have favorable effects on: osteoporosis
(thiazides)
– May have unfavorable effects on: DM
(hyperglycemia at higher doses), Dyslipidemia
(high dose), gout (> in men), hyponatremia (> in
women)
• HCTZ: decreased benefit > 25mg, increased side
effects - anecdotal
Tehran Arrhythmia Center
QUESTION
The following are statements about the use of
diuretics for the treatment of HTN:
True or False
A) Diuretic therapy has been demonstrated to decrease
mortality rates in patients with HTN
True
B) Thiazide diuretics have been shown to reduce the
incidence of stroke in elderly individuals with isolated
systolic HTN
True
From: AAFP Core Content Review of Family Medicine 2003
Tehran Arrhythmia Center
QUESTION
C) Thiazide diuretics have been demonstrated to be as
effective as the CCB amlodipine or ACE-I lisinopril in
preventing nonfatal MI
True
D) When combined with other classes of HTN meds, lowdose diuretics can improve BP control
True
E)
In patients with HTN and normal renal function, loop
diuretics, such as furosemide, are generally more
effectice than thiazide diuretics
False
From: AAFP Core Content Review of Family Medicine 2003
Tehran Arrhythmia Center
TREATMENT
•
ALLHAT trial
– chlorthalidone was as effective as
amlodipine or lisinopril in preventing fatal
CAD and nonfatal MI
•
Diuretics have been shown to:
– decrease mortality in patients with HTN
– reduce incidence of CV events and stroke in
the elderly with isolated systolic HTN
Tehran Arrhythmia Center
ALLHAT
The Antihypertensive and Lipid Lowering
Treatment to Prevent Heart Attack Trial
• Study design: randomized, prospective, doubleblinded over ~five years
• Population: 42,418 individuals > 55 y/o with mild
(Stage 1 or 2) HTN with at least one other CV
risk factor - randomized to one of four arms
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ALLHAT
• Intervention: 3 arms
1) CCB - amlodipine
2) Alpha-blocker –
doxazosin
3) ACE-I – lisinopril
• Control:
Diuretic –
chlorthalidone
A second
drug could be
added to
achieve BP
control
(atenolol,
clonidine, or
reserpine)
Tehran Arrhythmia Center
ALLHAT
• Outcomes measured:
– Primary outcomes:
• fatal coronary heart disease
• nonfatal MI
No difference between the drug groups
Simple message: treated patients do
better
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Diuretics
• Thiazide diuretics  less effective in
patients with creatinine clearances below
30 – 50 ml/min
• Loop diuretics  less effective for HTN in
patients with normal renal function
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Diuretics
•
•
•
•
Cheap
Daily dosing
Tolerable side effects
No drug reps pushing them
• USE THEM!
Tehran Arrhythmia Center
Additional Considerations
•  -blockers
• Compelling indications: DM, HF, post-MI, high
CAD risk
• May have favorable effects on: atrial tachycardia
and a-fib, essential tremor, thyrotoxicosis,
migraine, peri-operative hypertension
• May have unfavorable effects on: asthma, 2nd or
3rd degree heart block
Tehran Arrhythmia Center
Additional Considerations
• ACE-I
• Compelling indications: DM, HF, post-MI, high
risk CAD, chronic kidney disease, recurrent
stroke prevention (6 of 7)
• May have unfavorable effects on: hyperkalemia
• Contraindicated in pregnancy
Tehran Arrhythmia Center
Additional Considerations
• Angiotensin Receptor Blockers
•Compelling indications: DM, HF,
chronic kidney disease
• Contraindicated in pregnancy
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MORE QUESTIONS
Which one of the following antihypertensive
agents can be given to diabetic patients
without adversely affecting glucose
metabolism?
A)
B)
C)
D)
E)
Hydrochlorothiazide
Chlorthalidone
Prazosin
Propranolol
Diazoxide
Tehran Arrhythmia Center
Answer:
C) Prazosin
• Prazosin, a peripheral alpha blocker, has no
known adverse effects on glucose tolerance
• Thiazide diuretics and Diazoxide (European) can
worsen hyperglycemia
•  -blockers may induce or mask hypoglycemia
Tehran Arrhythmia Center
MORE QUESTIONS
A 50 y/o man with elevated cholesterol requires
medication for HTN. Which one of the
following can adversely affect the lipid profile?
A)
B)
C)
D)
ACE inhibitors
Calcium channel blockers
Alpha blockers
 -blockers
Tehran Arrhythmia Center
Answer:
D)  -blockers
•  -blockers can raise triglycerides and
lower HDL
• The other drugs listed have no adverse
effects on lipids
Tehran Arrhythmia Center
MORE QUESTIONS
A 40 y/o man currently being treated for HTN
abruptly stops his medication. He presents to
your office with significantly elevated BP,
palpitations, anxiety, and headache.
The patient was most likely taking
A) prazosin
B) clonidine
C) hydrochlorothiazide
D) hydralazine
E) captopril
Tehran Arrhythmia Center
Answer:
B) Clonidine
• Withdrawal of clonidine may produce a
hypertensive crisis
– Accompanied by signs and symptoms
consistent with sympathetic overactivity
– Good med to include in travel and
deployment kits
Tehran Arrhythmia Center
Tehran Arrhythmia Center
Follow-up and Monitoring
 Patients should return for follow-up and adjustment of
medications until the BP goal is reached, usually monthly.
 More frequent visits for stage 2 HTN or with complicating
comorbid conditions.
 Serum potassium and creatinine monitored 1–2 times per
year.
Tehran Arrhythmia Center
Follow-up and Monitoring
(continued)
 After BP at goal and stable, follow-up visits at 3- to 6-month
intervals.
 Co-morbidities, such as heart failure, associated diseases,
such as diabetes, and the need for laboratory tests influence
the frequency
of visits
Tehran Arrhythmia Center
Recommendations for Follow-up
Diagnosis of hypertension
Non Pharmacological treatment
With or without Pharmacological treatment
Are BP readings below target during 2 consecutive visits?
Yes
Follow-up at 3-6
month intervals
No
Symptoms, Severe
hypertension, Intolerance
to anti-hypertensive
treatment or Target Organ
Damage
Yes
More frequent
visits
No
Visits every 1
to 2 months
Tehran Arrhythmia Center
Public Health Challenges
and Community Programs
 Public health approaches (e.g. reducing calories, saturated fat, and salt
in processed foods and increasing community/school opportunities for
physical activity) can achieve a downward shift in the distribution of a
population’s BP, thus potentially reducing morbidity, mortality, and the
lifetime risk of an individual’s becoming hypertensive.
 These public health approaches can provide an attractive opportunity to
interrupt and prevent the continuing costly cycle of managing HTN and
its complications.
Tehran Arrhythmia Center
Population-Based Strategy
SBP Distributions
After
Intervention
Before
Intervention
Reduction
in BP
Reduction in SBP
mmHg
2
3
5
% Reduction in Mortality
Stroke CHD Total
–6
–8
–14
–4
–5
–9
–3
–4
–7
Tehran Arrhythmia Center
Go Air Force
Tehran Arrhythmia Center
Important Messages for the
Management of Hypertension



Expedite the diagnosis of hypertension
Assess the risk
Treat to target
• Lifestyle
• Combination therapy

Promote adherence
Tehran Arrhythmia Center
NEW FEATURES AND KEY MESSAGES
of JNC VII
• Hypertension (HTN) affects 50 million in U.S
and one billion worldwide
• If normotensive at age 55 
– 90 % lifetime risk for developing HTN
• BP and risk of CVD events is continuous,
consistent, and independent of other risk
factors
– CVD risk doubles with each 20/10
increment above 115/75 mmHg
Tehran Arrhythmia Center
NEW FEATURES AND KEY MESSAGES
• SBP is a more important CVD risk factor than
DBP except < 50y
• If BP is >20/10 mmHg above goal, drug
therapy should be initiated with two agents
– One usually should be a Thiazide-type diuretic
• Motivation improves compliance
– Motivation improves with trust in the clinician
– Empathy builds trust  potent motivator
Tehran Arrhythmia Center
New Features and Key Messages
 For persons over age 50, SBP is a more important than DBP as CVD risk
factor.
 Starting at 115/75 mmHg, CVD risk doubles with each increment of
20/10 mmHg throughout the BP range.
 Persons who are normotensive at age 55 have a 90% lifetime risk for
developing HTN.
 Those with SBP 120–139 mmHg or DBP 80–89 mmHg should be
considered prehypertensive who require health-promoting lifestyle
modifications to prevent CVD.
Tehran Arrhythmia Center
New Features and Key Messages
(Continued)
 Thiazide-type diuretics should be initial drug therapy for most, either
alone or combined with other drug classes.
 Certain high-risk conditions are compelling indications for other drug
classes.
 Most patients will require two or more antihypertensive drugs to
achieve goal BP.
 If BP is >20/10 mmHg above goal, initiate therapy with two agents,
one usually should be a thiazide-type diuretic.
Tehran Arrhythmia Center
New Features and Key Messages
(Continued)
 The most effective therapy prescribed by the careful clinician will control
HTN only if patients are motivated.
 Motivation improves when patients have positive experiences with, and
trust in, the clinician.
 Empathy builds trust and is a potent motivator.
 The responsible physician’s judgment remains paramount.
Tehran Arrhythmia Center
Hypertensive Urgencies
and Emergencies
 Patients with marked BP elevations and acute TOD (e.g.,
encephalopathy, myocardial infarction, unstable angina, pulmonary
edema, eclampsia, stroke, head trauma, life-threatening arterial
bleeding, or aortic dissection) require hospitalization and parenteral
drug therapy.
 Patients with markedly elevated BP but without acute TOD usually do
not require hospitalization, but should receive immediate combination
oral antihypertensive therapy.
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Global Vascular Protection for Patients
with Hypertension
Tehran Arrhythmia Center
Beyond Hypertension
 The evidence that blood pressure is a potent risk factor for CVD across the full
range of blood pressure, extending from 115/75 mm Hg, questions the logic of
thresholds for “normotension,” “pre-hypertension,” and “hypertension”.
 In people at high CVD risk, lowering their blood pressure will produce a benefit
irrespective of whether they are hypertensive by any of the current definitions.
The Heart Outcomes Prevention Evaluation Study Investigators. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on
cardiovascular events in high-risk patients. N Engl J Med 2000;342: 145–53.
EURopean trial On reduction of cardiac events with Perindopril in stable coronary Artery disease Investigators. Efficacy of
perindopril in reduction of cardiovascular events among patients with stable coronary artery disease: randomised, double-blind,
placebo-controlled, multicentre trial (the EUROPA study). Lancet 2003;362:782– 88.
Tehran Arrhythmia Center
GOING BEYOND BLOOD PRESSURE?
ADD A STATIN
 Just as it is not necessary to be “hypertensive” to benefit from
blood pressure lowering, it is also not necessary to have a high
blood cholesterol level to benefit from statin therapy.
 Most people with treated hypertension, especially males over the
age of 50 years, are at sufficient CVD risk to benefit from the
addition of statin therapy.
 Statins may further substantially reduce their risk of CHD by an
additional 30% and stroke by an additional 25%.
Tehran Arrhythmia Center
Vascular Protection for
Hypertensive Patients: Statins
Statins are specially recommended in high-risk hypertensive
patients with established atherosclerotic disease or with at
least 3 cardiovascular risks such as :
•
•
•
•
•
Male
55 y or older
Smoking
Type 2 Diabetes
Total-C/HDL-C ratio of 6 or
higher
• Premature Family History of CV
disease
•
•
•
•
•
Previous Stroke or TIA
LVH
ECG abnormalities
Microalbuminuria or Proteinuria
Peripheral Vascular Disease
ASCOT-LLA Lancet 2003;361:1149-58
Tehran Arrhythmia Center
Vascular Protection for
Hypertensive Patients : ASA
Consider low dose ASA
Caution should be exercised if BP is not controlled.
Tehran Arrhythmia Center
Supporting Materials
 Web site www.nhlbi.nih.gov/
 For patients and the general public
• “Facts About the DASH Eating Plan” (Revised May 2003)
• “Your Guide to Lowering Blood Pressure”
 For health professionals
• Reference Card
• Slide Show
Tehran Arrhythmia Center
Web site
www.nhlbi.nih.gov/
Tehran Arrhythmia Center
DASH Fact Sheet
Tehran Arrhythmia Center
Tehran Arrhythmia Center
WWW.IranEP.org
[email protected]
Tehran Arrhythmia Center