Download Appearance Of Seasonal Allergens

PHOTO OF
Dr. Thomas
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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
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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
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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
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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
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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
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Initial Evaluation
• Assess for target organ damage
at baseline
• Identify any other cardiovascular
risk factors
• Identify any potential secondary
causes
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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
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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
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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
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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
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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
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Lifestyle Modification
Should be seen as part of both
prevention and treatment
• Diet modification - DASH diet
• Weight reduction
• Increased physical activity
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Lifestyle Modification
• Moderation of sodium intake
• Maintain appropriate intake of:
- Potassium
- Calcium
- Magnesium
• Improve modifiable CV risk factors
• Questionable benefit - caffeine
reduction, relaxation / biofeedback
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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
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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
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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
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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
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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
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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)
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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
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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
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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
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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
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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
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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
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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
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PHOTO OF
Dr. Dennis
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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
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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
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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
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Optimal Blood Pressure
Optimal blood pressure is
that value below which further
reduction garners no additional
benefit to morbidity or mortality
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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
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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
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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
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TOMHS
n
Acebutolol
132
Active
Amlodipine
131
Treatment
Placebo
Total
(n=234)
Chlorthalidone 136
Doxazosin
134
Enalapril
135
(n=668)
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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
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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?
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