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Transcript
PHOTO OF
Dr. Thomas
1
Summary of Guidelines
• JNC VI guidelines focus on:
- Absolute risks and benefits used in
compiling recommendations
- Strong emphasis on risk stratification of
patients including awareness of the
importance of isolated systolic blood
pressure
- Re-emphasis on importance of lifestyle
modification in prevention and treatment
- First line drugs for uncomplicated patient
are diuretics and beta-blockers
2
Blood Pressure Classification
Class
Optimal
Normal
High Normal
Class I HTN
Class II HTN
Class III HTN
Systolic
Diastolic
<120
<80
<130
130-139
140-159
160-179
<=180
<85
85-89
90-99
100-109
>=110
Note: For patients not on anti-hypertensive therapy
and with no acute illnesses. If SBB and DBP
disagree, then use the higher class
4
3
Blood Pressure Follow-Up
Systolic
Diastolic
<130
<85
Recommended
Follow-up
Recheck in 2 years
130-139
85-89
Recheck in 1 year
140-159
90-90
Recheck in 2 months
160-179
100-109
Recheck in 1 month
>=180
>=110
Recheck in 1 week
or admit
4
Ambulatory BP Monitoring
• Correlates more closely with target
organ damage
• Helpful in certain populations:
- Suspected “white coat hypertension”
- Suspected drug resistance
- Hypotensive symptoms on therapy
- Episodic HTN
- Autonomic dysfunction
- NOT for use in basic diagnosis or
screening for HTN
5
Risk-based Treatment Groups
• Risk Group A:
- No risk factors, no target organ disease,
no known cardiovascular disease
• Risk Group B:
- At least one risk factor but NOT diabetes,
no target organ disease or cardiovascular
disease
• Risk group C:
- Target organ disease and / or
cardiovascular disease and / or diabetes,
with or without other risk factors
6
Initial Evaluation
• Assess for target organ damage
at baseline
• Identify any other cardiovascular
risk factors
• Identify any potential secondary
causes
7
Lab Evaluation
• Recommended tests to screen for target
organ damage
- Urinalysis
- Renal function
- CBC
- Electrolytes
- HDL
- 12 lead EKG
• Optional tests to screen for target organ
damage (not all-inclusive):
- Creatinine clearance
- Hemoglobin A1C
- Urine microalbumin
- TSH
- 24 hour urine for protein
- Fasting, full lipid panel
8
Cardiovascular Risk Factors
• Major Risk Factors:
- Smoking
- Dyslipidemia
- Diabetes
- Age >60 years
- All males and postmenopausal
females
- Family history of CAD in women
< 65 or men < 55 years old
9
Target Organ / Cardiovascular Disease
• Heart Disease
- Left ventricular hypertrophy (LVH)
- Angina or prior myocardial infarction
- Prior coronary revascularization
- Heart failure
•
•
•
•
Stroke or transient ischemic attack
Nephropathy
Peripheral Vascular Disease
Hypertensive retinopathy
10
Risk-Based Treatment Options
HTN Class
Risk Gp A
Risk Gp B
Risk Gp C
High Normal
Lifestyle
Mgmt
Lifestyle
Mgmt
Treatment
Class I
Lifestyle
Mgmt for
12 months
Lifestyle
Mgmt for
6 months
Treatment
Class II-III
Treatment
Treatment Treatment
11
Clues for Secondary Causes
• Age, history, severity of HTN do
not correlate with clinical picture
• Poor response to therapy
• Previously well-controlled
• Class III hypertension
• Sudden onset of hypertension
12
Lifestyle Modification
Should be seen as part of both
prevention and treatment
• Diet modification - DASH diet
• Weight reduction
• Increased physical activity
13
Lifestyle Modification
• Moderation of sodium intake
• Maintain appropriate intake of:
- Potassium
- Calcium
- Magnesium
• Improve modifiable CV risk factors
• Questionable benefit - caffeine
reduction, relaxation / biofeedback
14
Treatment Steps
• Step 1: If no other added indication,
start with either diuretic or beta-blocker
• Step 2: If no response, increase dose
• Step 3a: If tolerated at higher dose,
add a second drug
• Step 3b: If not tolerated at higher,
substitute a new drug in its place
15
Treatment Steps
• Step 4: If still not controlled then:
- Continue adding agents from other
classes
- Consider referral to a hypertensive
specialist
• Resistant HTN:
- Defined as BP > 140 / 90 or isolated
systolic > 160 on three drugs (including
a diuretic) at max dose
- Often still related to volume overload
- Consider referral to hypertensive specialist
16
Treatment Steps
• For Stage III hypertensive patient:
- Start pharmacologic therapy sooner
- Increase the dose or add a second agent
sooner
- Look for secondary causes sooner
• Step-down therapy:
- Begin slowly weaning medications after
adequate control for one year
- May be able to accelerate decrease in
medications if also adherent to lifestyle
modifications
17
Special Populations
• African-Americans:
- More effective: diuretics, calcium
antagonists
- Less effective: beta-blockers, ACE
inhibitors as mono-therapies
- Okay to use less effective if have an
additional indication
18
Special Populations
• Children / Adolescents:
- Aggressively identify secondary causes
- Lifestyle modification very important
- Treat with smaller doses of medication
- Avoid ACE and Angiotensin-II receptor
blockers in sexually active / pregnant
women
- Check for use of anabolic steroids
- No need to prohibit from exercise if
asymptomatic
19
Special Populations
• Females:
- Contraceptive use: If BP increase seems
related to OCP use, discontinue OCP and
BP should normalize
- Pregnancy: Defined as essential HTN if
BP elevated before pregnant or before
the 20th week of gestation
- Avoid ACE, A-II receptor blockers
- Use diuretics, alpha-methyl dopa,
beta-blockers (after the 1st trimester)
20
Special Populations
• Elderly:
- Isolated systolic HTN an important, more
common problem
- Pulse pressure (SBP-DBP) a good
predictor of risk in this population
- More effective: thiazide diuretic, thiazide
+ beta-blocker, and long acting
dihydropyridine calcium antagonists
- Avoid postural hypotensive symptoms
- Avoid cognitive symptoms
21
Additional Indications
• Coronary Artery Disease:
- Avoid aggressive, quick lowering of BP
- Added benefit: beta-blocker, long-acting
calcium antagonists
- Avoid: short-acting calcium antagonists
- ACE inhibitors may be useful after
MI with LV function dysfunction
22
Additional Indications
• Heart Failure:
- ACE inhibitors are standard therapy
- May substitute vasodilator and nitrate or
A-II receptor blocker if not tolerated
- Carvedilol and other beta-blockers are
showing more benefit in these patients
- Long-acting dihydropyridines are safe to
use in these patients for the treatment of
angina
23
Additional Indications
• Diabetes:
- Blood pressure control an imperative for
preventing target organ damage from DM
- ACE inhibitors help prevent / reduce
proteinuria
- Avoid beta-blockers only if hypoglycemia
is a significant risk or past history
24
Additional Indications
• Dyslipidemia:
- High dose thiazide and loop diuretics can
induce increases in total cholesterol, LDL
and triglycerides
- Low dose thiazides can be appropriate
- Diet modification can reduce this effect
- Beta-blockers may transiently increase
triglycerides and lower HDL
- Alpha-blockers may slightly reduce total
cholesterol and increase HDL
24 A
Additional Indications
• Reactive / Obstructive Airway Disease:
- Avoid beta-blockers and alpha-betablockers (carvedilol) unless only minimal
lung disease and tolerated well by the
patient
- Check for any OTC remedies for asthma
since may exacerbate blood pressure
24 B
Summary Points
• Focus on risk-adjusting each patient to
better meet that patient’s needs
• Consider additional indications / added
benefits or risks in your choice of
therapy
• Emphasize lifestyle modification
focusing on cardiovascular healthy
habits for both treatment and prevention
• Remember the importance of isolated
systolic hypertension especially in the
elderly
24 C
PHOTO OF
Dr. Dennis
25
Profile
Ms. Barile
• 45 year old female
• Presented 2 years ago with BP 150 / 100
at routine exam
• Previous BP had been in high-normal range
Initial Diagnosis
• Hypertension
• BP 150 / 90
26
Profile
Ms. Barile
Diagnostic Tests
•
•
•
•
Comprehensive history and physical
Urinalysis
EKG
Blood tests for glucose, BUN, creatinine,
electrolytes and cholesterol profile
Diagnosis
• Essential hypertension without diabetes or
target organ abnormalities
26 A
Profile
Ms. Barile
Treatment
• Referred to nutritionist for dietary counseling
• Salt-restricted, low-fat diet with reduced
calories
• Lose weight through increased regular
exercise
• Lisinopril - 10mg daily
26 B
27
Classification of BP for Adults
Age 18 Years and Older
Category
Systolic
(mmHg)
Diastolic
(mmHg)
Optimal
Normal
High normal
<120
<130
130 - 139
<80
<85
85 - 89
Hypertension
Stage I
Stage 2
Stage 3
140 - 159
160 - 179
> 180
90 - 99
100 - 109
> 110
28
Optimal Blood Pressure
Optimal blood pressure is
that value below which further
reduction garners no additional
benefit to morbidity or mortality
29
Mean Systolic and Diastolic BP in
U.S. Adult Population: NHANES III
Adult Population
Mean Blood Pressure (mmHg)
Systolic
Diastolic
All
122
74
Normotensive
117
71
135
144
83
88
Hypertensive
- Treated
- Untreated
30
Office, Home and Ambulatory Blood
Pressure in 1438 Subjects
Age 25-64 Years: PAMELA Study
Blood Pressure (mmHg)
SBP
DBP
Pulse
Rate
Office
127 ± 17
82 ± 9.8
72 ± 8.6
Home
119 ± 17
75 ± 10
73 ± 10
74 ± 7
77 ± 8
123 ± 11
79 ± 8
82 ± 9
Nighttime 108 ± 11
64 ± 8
67 ± 8
24-hr mean 118 ± 11
Daytime
31
Baseline Systolic and Diastolic BP and
Adjusted Relative Risk of Coronary
Heart Disease Death: MRFIT Screens
SBP
DBP (mm Hg)
(mmHg)
<80
80-84
85-89
90-99
>100
< 120
1.00
1.35
1.36
0.98
3.23
120-129
1.19
1.30
1.49
1.49
1.84
130-139
1.67
1.61
1.67
1.91
2.64
140-159
2.52
2.22
2.67
2.56
2.99
> 160
4.19
3.20
3.41
3.41
4.57
33
34
35
TOMHS
n
Acebutolol
132
Active
Amlodipine
131
Treatment
Placebo
Total
(n=234)
Chlorthalidone 136
Doxazosin
134
Enalapril
135
(n=668)
36
Blood Pressure Changes
in TOMHS
Blood Pressure (mmHg)_____
Group
Pre-Treatment
Treatment (4 yrs)
Life style
Modification
+ placebo
141 / 91
132 / 82
Life style
Modification
+ drug
treatment
140 / 91
124 / 79
37
38
Summary
Ms. Barile
Diagnosis
• Stage 1 essential hypertension without
target organ involvement
Currently
• Life-style adjustments: low-fat, low-sodium,
low-calorie diet and increased exercise
• BP is controlled to 134 / 82
Is this adequate?
39