Download Management of Hypertension

Management of
Hypertension:
An Overview & Update
11/12/11
Marcus Weiser, DO
PGY3
Chief Resident
Via Christi Family Medicine
Outline
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Classification
Causes
History, PE, initial testing
Antihypertensive agents
Monotherapy & combination therapy
Hypertension
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Sustained elevation of arterial systemic
blood pressure
Single most common diagnosis at US
family physician office visits (coded at
11.1%)
Age 20-50 usually affected
29% of US adults
Prevalence increases with age
Hypertension
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Baseline high blood pressure at age 50
reduces life expectancy by about 5 years.1
Associations
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Erectile dysfunction, ophthalmologic
conditions, osteoporosis, anxiety, chronic
kidney disease, obstructive sleep apnea,
coronary artery disease, cerebrovascular
disease, peripheral arterial disease,
congestive heart failure, dementia
Types
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Prehypertension (SBP 120-139 or DBP 80-89)
Stage I (SBP 140-159 or DBP 90-99)
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Stage II (SBP > 159 or DBP > 99)
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Evaluate within 1 month (within 1 week if > 180/110)
Type I (vasoconstriction, high renin, high SBP)
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Confirm within 2 months
Treat with ACE, ARB, BB
Type II (Na dependent, low renin, high DBP)
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Treat with diuretics, CCB
ICD-10 codes
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I10 essential (primary) hypertension
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ICD-10-CA modification in Canada
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I11 hypertensive heart disease
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I12.0 hypertensive renal disease with renal failure
I12.9 hypertensive renal disease without renal failure
ICD-10-CA modification in Canada - 4th character extensions were deleted to allow for use of dual classification for added
specificity
I13 hypertensive heart and renal disease
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I11.0 hypertensive heart disease with (congestive) heart failure
I11.9 hypertensive heart disease without (congestive) heart failure
ICD-10-CA modification in Canada - 4th character extensions were deleted to allow for use of dual classification for added
specificity
I12 hypertensive renal disease
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I10.0 benign hypertension
I10.1 malignant hypertension
I13.0 hypertensive heart and renal disease with (congestive) heart failure
I13.1 hypertensive heart and renal disease with renal failure
I13.2 hypertensive heart and renal disease with both (congestive) heart failure and renal failure
I13.9 hypertensive heart and renal disease, unspecified
ICD-10-CA modification in Canada - 4th character extensions were deleted to allow for use of dual classification for added
specificity
I15 secondary hypertension
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I15.0 renovascular hypertension
I15.1 hypertension secondary to other renal disorders
I15.2 hypertension secondary to endocrine disorders
I15.8 other secondary hypertension
I15.9 secondary hypertension, unspecified
ICD-10-CA modification in Canada
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5th digits assigned to specify
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0 benign or unspecified
1 malignant
R03.0 elevated blood-pressure reading, without diagnosis of hypertension
Causes
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CKD (any cause)
Renal Artery Stenosis
Cushing Syndrome
Primary
Hyperaldosteronism
Hyper/Hypothyroidism
Hyperparathyroidism
Pheochromocytoma
Obstructive Sleep Apnea
Coarctation of the Aorta
Black Licorice
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Medications
BP Cuff too small
Arm position
Caffeine
Nicotine
Substance
Abuse/Intoxication
Short sleep duration
Alcohol Use
Salt intake?
Impatience, hostility
History
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Symptoms
Medications
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Past Medical History
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Corticosteroids, OCPs, NSAIDs, venlafaxine,
buspirone, carbamazepine, clozapine, bromocriptine,
cyclosporin, tacrolimus, EPO
DM, CAD, CHF, DSLD, Thyroid/Renal Dz
Social History
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Dietary sodium, stress, smoking, alcohol intake,
activity level, St. John’s wort, ergot-containing herbal
preparations, cocaine, anabolic steroids, narcotic
withdrawal, meth, PCP
Physical Exam
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Proper blood pressure measurement
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Seated in chair with back in calm, quiet, warm room
for at least 5 minutes. Bare arm elevated so elbow is
level with heart. No smoking or caffeine 1 hour prior
Cuff width > 2/3 arm diameter
Cuff length > 2/3 arm circumference
Average of 2 measurements
Carotid bruits
Cardiac auscultation
Abdomen
Extremities
Initial Testing
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Serum Potassium
Serum Creatinine
Fasting Blood Glucose
Fasting Lipid Panel
Urinalysis
Electrocardiogram
- Uniformly recommended by 4
expert panels (CHEP, ESH/ESC,
ICSI, JNC7)
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Hematocrit
Serum Calcium
Serum Sodium
Serum Uric Acid
Urine Albumin/Creatinine Ratio
- Recommended by some, not all
4 panels
Additional Testing to Consider
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PTH
TSH
24 hour urine metanephrine
Plasma Aldosterone
Plasma Renin
Dexamethasone supression test
Sleep study
RAS imaging
Agents
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Ace-inhibitors (ACEs)
Angiotensin Receptor Blockers (ARBs)
Calcium Channel Blockers (CCBs)
Beta Blockers (BBs)
Thiazide Diuretics (TZD)
Loop Diuretics (Loops)
Aldosterone Antagonists
Alpha Blockers
Other agents
ACEs & ARBs
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Special Indications
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ACE
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CHF (SOLVD, AIRE, TRACE)
Post-MI (SAVE)
Diabetes (UKPDS, HOPE)
CKD (REIN, AASK, CAPTOPRIL)
Recurrent Stroke Prevention (PROGRESS)
High CAD Risk (ALLHAT, HOPE, ANBP2)
ARB
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CHF (Val-HeFT)
Diabetes
CKD (RENAAL, IDNT, CAPTOPRIL)
ACEs & ARBs
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Contraindications
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Monitor
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Pregnancy, Angioedema, Renovascular Disease,
Hyperkalemia, Acute Renal Failure
Creatinine, Potassium
Agents
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Benazepril or Lisinopril (20mg to 40mg PO daily)
Enalapril, Ramipril
Losartan, Olmesartan, Valsartan
Calcium Channel Blockers
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Special Indications
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High CAD risk (ALLHAT, CONVINCE)
Migraines
Raynaud’s
Angina (non-dihydropyridine)
Atrial Fibrillation (non-dihydropyridine)
Atrial Flutter (non-dihydropyridine)
Calcium Channel Blockers
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Contraindications
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2nd or 3rd degree heart block
Agents
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Amlodipine (5mg to 10mg PO daily)
Nifedipine, Nicardipine, Felodipine
Beta Blockers
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Special Indications
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Contraindications
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CHF (MERIT-HF, COPERNICUS, CIBIS)
Post-MI (BHAT, CAPRICORN)
Angina, Atrial Fibrillation, Atrial Flutter, Tremor, Migraine
Asthma, COPD, 2nd or 3rd degree heart block, Depression, Acute
CHF
Avoid abrupt cessation
Agents
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Metoprolol (50mg to 200mg PO BID)
Carvedilol (3.125mg to 25mg PO BID)
Atenolol, Nebivolol, Labetalol, Esmolol, Propranolol, Timolol
Beta Blockers
Inappropriate first-line treatment
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JNC8
Worse BP control (LIFE)
Worse CV outcome prevention (LIFE)
Increased mortality (ASCOT)
Higher risk of stroke 2
More side effects 2
Increased risk of type II diabetes 3
Thiazide Diuretics
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Special Indications
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High CAD risk (ALLHAT)
Recurrent stroke prevention (PROGRESS)
DM without proteinuria (ALLHAT)
Edema
Osteoporosis
Thiazide Diuretics
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Contraindications
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Monitor
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Stage IV CKD, Gout, Hyponatremia, Acute
Renal Failure
Creatinine, Potassium, Sodium
Agents
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Chlorthalidone (12.5mg to 25mg PO daily)
Hydrochlorothiazide, Indapamide, Metolazone
Thiazide equivalence?
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Chlorthalidone vs HCTZ
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Chlorthalidone use has sharply declined over
the last 20 years for reasons unknown 4
ACCOMPLISH
Chlorthalidone vs HCTZ
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Amlodipine appears superior to HCTZ
ALLHAT
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Secondary
Outcome
12.00%
10.00%
8.00%
6.00%
6 year CHF
rate
4.00%
2.00%
0.00%
Amlodipine
Chlorthalidone
Chlorthalidone vs HCTZ
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Amlodipine appears superior to HCTZ
Chlorthalidone appears superior to Amlodipine
ALLHAT
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Secondary
Outcome
9.00%
8.00%
7.00%
6.00%
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Lower rate of
combined CVD
with Chlorthalidone
5.00%
4.00%
Stroke rate
CHF rate
3.00%
2.00%
1.00%
0.00%
Lisinopril
Chlorthalidone
Chlorthalidone vs HCTZ
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Amlodipine appears superior to HCTZ
Chlorthalidone appears superior to Amlodipine
Chlorthalidone appears superior to Lisinopril
ACE-I Beats Diuretic (ANBP2)
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Rate of events per
year
1.40%
1.20%
1.00%
MI
0.80%
CHF
0.60%
TIA or
Stroke
0.40%
0.20%
0.00%
Enalapril
HCTZ
Chlorthalidone vs HCTZ
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Amlodipine appears superior to HCTZ
Chlorthalidone appears superior to Amlodipine
Chlorthalidone appears superior to Lisinopril
Enalapril appears superior to HCTZ
Thiazide equivalence?
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Chlorthalidone vs HCTZ
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Chlorthalidone use has sharply declined over the last 20
years for reasons unknown 4
No evidence that HCTZ improves cardiovascular
outcomes
Large body of evidence in major trials (ALLHAT)
showing cardiovascular event reduction and outcome
benefit with chlorthalidone
Chlorthalidone has much longer half-life, is 1.5-2.0
times more potent, and has slightly more hypokalemia
(7-8% patients require treatment 5,6)
Thiazide Diuretics
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Chlorthalidone superior reduction of
nighttime BP, compared to HCTZ 7
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13.5 mmHg vs 6.4 mmHg
Chlorthalidone (12.5-25mg) vs HCTZ (2550mg)
Agents
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Chlorthalidone (12.5mg to 25mg PO daily)
Hydrochlorothiazide, Indapamide, Metolazone
Loop Diuretics
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Special Indications
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Contraindications
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Gout, Acute Renal Failure
Monitor
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CHF, Edema
Creatinine, Electrolytes
Agents
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Torsemide (5mg to 10mg PO daily)
Furosemide, Bumetanide
Aldosterone Antagonists
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Special Indications
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Contraindications
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Gout, Hyperkalemia, Acute Renal Failure
Monitor
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CHF (RALES)
Post-MI (EPHESUS)
Creatinine, Potassium
Agents (ASCOT)
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Spironolactone (25mg to 50mg once daily)
Amiloride, Triamterene
ASCOT
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Patients with uncontrolled hypertension on
3 antihypertensive agents
Spironolactone 25mg once daily added as
4th agent
Mean BP drop of 22/10 at one year followup
Alpha Blockers
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Special Indications
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Contraindications
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BPH
High CV risk (ALLHAT)
Agents
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Doxazosin, Prazosin, Terazosin
Other Agents
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Clonidine
Methyldopa
Hydralazine
Tekturna
Minoxidil
Isosorbide dinitrate/mononitrate
Low . . . but how low is too low?
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Treatment goal < 140/90
< 130/80 in diabetics per JNC7
recommendation
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ACCORD, INVEST
BP targets below 140/90 overall do not
improve morbidity or mortality
DBP < 70 increases risk of death, MI,
stroke
Lifestyle Modifications
First-Line Treatment
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Sodium Restriction (2-8 mmHg)
DASH (8-14 mmHg)
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Aerobic physical activity (4-9 mmHg)
Weight Reduction
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Fruits, vegetables, low-fat dairy, reduced fat
(5-20 mmHg per 10 kg lost)
Moderate alcohol (2-4 mmHg)
Smoking Cessation
*From JNC7 Express Report, 2003
Monotherapy vs Multi-Drug Therapy
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Sequential treatment
Avoid excessive
dosing
First-line agents
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Avoid similar agents
Avoid excessive
dosing
Other agents
Monotherapy – 1st line agents
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1. Thiazide
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2. ACE/ARB
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Chlorthalidone 12.5mg daily, titrate to 25mg?
Benazepril or Lisinopril 20mg daily
Titrate up to 40mg, possibly beyond
3. Calcium Channel Blocker
(dihydropyridine)
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Amlodipine 5mg daily
Titrate up to 10mg once daily
Monotherapy
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Sequential treatment
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If inadequate control, switch instead of add
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Try one agent, titrate up
Each first-line agent will normalize BP in 30-50% of
patients 8,9
49.1% chance a different agent will control Stage I
Hypertension following failure of initial agent 10
May prevent unnecessary multi-drug treatment
JNC7 recommendation for uncontrolled stage I
hypertension on monotherapy is to optimize
dose or add 2nd medication
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Addition of a second drug from a different class
should be initiated when use of a single drug in
adequate doses fails to achieve the BP goal
Combination Therapy
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Consider combination for Stage 2
Add if sequential monotherapy fails
Drugs for each compelling indication
ACCOMPLISH
Include a diuretic
Consider Spironolactone as 4th agent
(ASCOT)
First-line agents
ACCOMPLISH
ACCOMPLISH
ACCOMPLISH
Combination Therapy
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Drugs for each compelling indication
ACCOMPLISH
Include a diuretic
First-line agents
Consider Spironolactone as 4th agent
(ASCOT)
Resistant Hypertension
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Uncontrolled on 3 medications
Controlled on 4 or more medications
Must include a diuretic
Causes
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CKD (any cause)
Renal Artery Stenosis
Cushing Syndrome
Primary
Hyperaldosteronism
Hyper/Hypothyroidism
Hyperparathyroidism
Pheochromocytoma
Obstructive Sleep Apnea
Coarctation of the Aorta
Licorice
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Medications
BP Cuff too small
Arm position
Caffeine
Nicotine
Substance
Abuse/Intoxication
Short sleep duration
Alcohol Use
Salt intake?
Impatience, hostility
Who do I screen for secondary
causes of hypertension?
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Resistant Hypertension
Early or Late onset
History & Physical Exam
Abnormal initial labs
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Low potassium
High calcium
Abnormal subsequent monitoring
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Increase Cr > 20% after starting ACE/ARB
Additional Testing to Consider
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PTH
TSH
24 hour urine metanephrine
Plasma Aldosterone
Plasma Renin
Dexamethasone supression test
Sleep study
RAS imaging
Cases
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31 yo healthy AAM, BMI 31, BP 132/99
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Benazepril
Chlorthalidone
Losartan
Metoprolol
Cases
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77 yo 100 lb WF with hyperlipidemia
BP 159/82
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Benazepril
Metoprolol
HCTZ
Spironolactone
Cases
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58 yo M, GFR 48, proteinuria, BP 150/95
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Lisinopril
HCTZ
Torsemide
Amlodipine
Cases
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47 yo M with depression/gout, BP 162/96
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Chlorthalidone
Benazepril
Amlodipine
Metoprolol
Sources
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10.
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cardiovascular disease in men and women. Life course analysis. Hypertension 2005; 46:280-286.
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hypertension. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD002003. DOI:
10.1002/14651858.CD002003.pub2
Risk/benefit assessment of beta-blockers and diuretics precludes their use for first-line therapy in
hypertension. Messerli FH, Bangalore S, Julius S. Circulation. 2008;117(20):2706.
Carter BL, Malone DC, Ellis SL, Dombrowski RC. Antihypertensive drug utilization in hypertensive veterans
with complex medication profiles. J Clin Hypertens. 2000; 2: 172–180.
Hypokalemia associated with diuretic use and cardiovascular events in the Systolic Hypertension in the
Elderly Program. Franse LV, Pahor M, Di Bari M, Somes GW, Cushman WC, Applegate WB. Hypertension.
2000;35(5):1025.
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Heritier S, Li N, Perkovic V, Woodward M, MacMahon S. BMJ. 2008;336(7653):1121.
Ernst ME, Carter BC, Goerdt CJ, Steffensmeier JJG, Bryles Phillips B, Zimmerman MB, Bergus GR.
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blood pressure. Hypertension. 2006; 47: 352–358.
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or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent
Heart Attack Trial (ALLHAT). JAMA. 2002;288(23):2981.
Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147
randomised trials in the context of expectations from prospective epidemiological studies. Law MR, Morris
JK, Wald NJ. BMJ. 2009;338:b1665.
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the initial drug. Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents.
Materson BJ, Reda DJ, Preston RA, Cushman WC, Massie BM, Freis ED, Kochar MS, Hamburger RJ, Fye C,
Lakshman R. Arch Intern Med. 1995;155(16):1757.