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Hypertension Review Cases By Mayssa Ibrahim Aly Professor of Internal Medicine-Cairo University 2009 A 50-year-old black man has a blood pressure of 160/110 mm Hg on repeated measurements. He is 9 kg overweight, has a family history of hypertension, and smokes one pack of cigarettes daily. Classification according to BP level •Normal <120/80 •Pre-hypertension 129/80—139/89 •Hypertension >140/90 Hypertension Stage I 140-159/90-99 Stage 2 >160/100 Stage II HTN The five-year risk of a major cardiovascular event in a 50-year-old man with a blood pressure of 160/110 mm Hg is 2.5 to 5.0 percent; The risk doubles if the man has a high cholesterol level and triples if he is also a smoker The primary goal of the treatment of hypertension is to prevent cardiovascular disease and death In stage 1 or 2 hypertension lowering systolic pressure by 10 to 12 mm Hg and diastolic pressure by 5 to 6 mm Hg reduces the risk of stroke by 40 %, coronary disease by 16 %, and death from any cardiovascular cause by 20 %. <135/85 Risk Factors • • • • • • • • 1. Smoking 2. Dyslipidemia 3. DM 4.>60ys 5. Men& postmenopausal women 6. Obesity 7. FH of CVD: Men<55ys or Women<65ys Obesity BMI Range Underweight Normal <18.5 Kg/m2 Overweight Obesity grade I Obesity grade II 25-29.9 30-34.9 >35 18.5- 24.9 Patients with stage 1 HTN can be treated with lifestyle modifications alone for up to one year, if they have no other risk factors, or for up to six months, if they have other risk factors. Lifestyle modifications and antihypertensive therapy are indicated for: patients with cardiovascular or other target-organ disease (renal, cardiac, cerebrovascular, or retinal disease) and those with stage 2 Patients with diabetes are at high risk, and drug therapy is indicated in such patients even if BP is at the high end of the normal range Restriction of sodium intake to 2 g /d lowers systolic pressure, on average, by 3.7 to 4.8 mm Hg and lowers diastolic pressure, on average, by 0.9 to 2.5 mm Hg. Salt sensitivity is common in elderly patients with hypertension • Most antihypertensive drugs reduce blood pressure by 10 to 15 percent. • Monotherapy is effective in about 50 percent of unselected patients • Those with stage 2 HTN often need more than one drug. • Evaluation for 2ry HTN should be considered when three or more antihypertensive drugs of different classes do not control blood pressure Step1 Step2 Step3 Step4 Algorithm for Manag. of HTN •Diuretics are appropriate as first-line therapy for patients without coexisting conditions •ACE inhibitors or angiotensin-receptor antagonists are recommended for patients with type 2 diabetes, kidney disease, or both and are also useful in patients with heart failure. •Beta-blockers and ACE inhibitors are recommended in patients with prior myocardial infarction, and •Calcium-channel antagonists benefit elderly patients at risk for stroke Which Stage of HTN? The patient should be advised to: A) lose weight, B) stop smoking, C) engage in regular exercise, and D) modify his diet and He should be screened for vascular disease and other cardiovascular risk factors. • The increase in dietary salt may also have contributed to the growing obesity problem by causing increased intake of fluids, particularly of high-calorie soft drinks If No coexisting disease was detected Hydrochlorothiazide at a dose of 12.5 mg daily. If this dose did not control his blood pressure increase it or add a second drug for example, an ACE inhibitor to prevent the adverse metabolic effects of higher doses of diuretics Use of Diuretics in Patients with Hypertension The upstream portion of the distal convoluted tubule is the major site of action of the thiazides, where they interfere with sodium re-absorption. Sodium is reabsorbed in the distal tubule and collecting ducts through an aldosterone-sensitive sodium channel and by activation of an ATP-dependent sodium–potassium pump. Through both mechanisms, potassium is secreted into the lumen. "K+-sparing agents" collectively refers to the epithelial sodium-channel inhibitors (e.g., amiloride and triamterene) and mineralocorticoidreceptor antagonists (e.g., spironolactone and eplerenone). The onset of action occurs after approximately 2 to 3 hours for most thiazides, with little natriuretic effect beyond 6 hours. Most thiazides have a half-life of approximately 8 to 12 hours, just permitting effective once-daily dosing Initial decreases in blood pressure are attributed to the reductions in extra-cellular fluid and plasma volumes, leading to depressed cardiac preload and output. Activation of the sympathetic NS and the renin–angiotensin–aldosterone system induces a transient rise in peripheral vascular resistance but not sufficient to negate the blood-pressure reduction Combining a Thiazide with (ACE) inhibitor or an angiotensin II– receptor blocker (ARB) can oppose this transient rise in resistance and increase the antihypertensive response. • Thiazides induce a reduction in the systolic and diastolic blood pressures of 10 to 15 mm Hg and 5 to 10 mm Hg, respectively • Hypertension responding preferentially to thiazides is considered to be low-renin or salt-sensitive hypertension. • The elderly, blacks, and patients with characteristics associated with high cardiac output (e.g., obesity) tend to have this type of HTN. Hydrochlorothiazide at a dose of 12.5 to 25 mg /d. Approximately 50% of patients will respond initially to these low doses. Increasing the dose of hydrochlorothiazide from 12.5 to 25 mg /d may result in a response in an additional 20% (approximately) of patients. At 50 mg /d, 80 to 90% of patients should have measurable decreases in blood pressure. Increased electrolyte losses at the higher doses of diuretics may preclude their routine use Case II A 68-year-old man visits his physician • He was told a year earlier that his blood pressure was somewhat elevated and was advised to reduce salt intake and increase physical activity. • Otherwise no history or signs of cardiovascular or renal disease. Examination BP is 178/72 mm Hg, with no clinically significant differences between arms or on standing. Body-mass index is 28.4. The examination is otherwise unremarkable Obesity BMI Range Underweight Normal <18.5 Kg/m2 Overweight Obesity grade I Obesity grade II 25-29.9 30-34.9 >35 18.5- 24.9 Investigation Urinalysis is normal. The non-fasting blood glucose level is 98 mg /dl . Creatinine 1.2 mg /dl. Isolated Systolic HTN Grade 1 140-145/<80 Grade 2 >160/<80 Above 115/75 CVD risk doubles For each of 20/10 Investigation Laboratory Urinalysis, Blood glucose, Estimated GFR, and Lipoprotein profile tests ECG studies should be performed to evaluate cardiovascular risk. • The recommended target level of blood pressure is below 140/90 mm Hg, • except • in diabetes or CRF disease, for whom a lower goal (130/80 mm Hg or lower) is advised. Evaluation Treatment Not at target BP Optimize dosage or Add other drug till Target BP a cigarette within the previous 15 to 30 minutes, can cause an elevation in systolic blood pressure of 5 to 20 mm Hg. Smoking increase in systolic blood pressure occur after one cup of caffeinated coffee is usually only 1 to 2 mm Hg. Long-term smoking or coffee drinking does not cause persistently elevated blood pressure In most older patients, elevation of systolic blood pressure occurs because of reduced elasticity of conduit arteries. Age related changes in BP SBP rises linearly with age: 25 mmHg in men and 23 mmHg in women between 4th and 9th decades. DBP tends to plateau before 60ys and drops after 60ys. Strong predictor of CV complications Lowering SBP is associated with significant reduction in : –CV mortality –Stroke –HF –MI –Dementia The patient described has stage 2 systolic hypertension (160 mm Hg). Non-pharmacologic interventions should be recommended (can reduce the number and dosage of bloodpressure medications required). Therapy : why? Greater benefit than in younger patients. Stroke reduced 30% CV events 20% Dementia 50% Morality 13% Target of therapy in elderly DBP < 90mmHg SBP < 160mmHg Therapy Non pharmacology therapy 1- Life style modification : elderly respond as younger patients . 2- Salt restriction : elderly especially women have increased sensitivity to salt. 3- Moderate exercise. 4- Relaxation therapy. Therapy Pharmacology therapy Started when • Hypertension noted in multiple visits • Non phamocological therapy have not lower BP level into desired range • Evidence of end organ damage AB-CD Trials Step1: Younger A or B Elderly C or D Step2: A or B +C or D Step3: A or B+ C +D Step 4: Add either a blocker or other diuretics A= B= C= D= ACEI B blocker Ca channel blocker Thiazide diuretics Initially treat with a Thiazide-type diuretic. If a second or third drug is required, Second drug of choice : Ca channel blockers. ARBs and ACEIs are effective in preventing complications. The choice will depend on the patient's clinical status Follow up after start of treatment of HTN Low/intermediate Risk Every 2Ms Remains at target level For 2 consecutive visits Every 6Ms High risk Every 1M Remains at target level For 2 consecutive visits Every 3Ms Initial follow-up can be carried out at approximately monthly intervals until the target blood pressure of less than 140/90 mm Hg is achieved. Once the target blood pressure is achieved, follow-up can occur every 3 to 6 months. Serum potassium, Creatinine, and blood glucose levels should be measured at least annually. Low serum potassium levels should be managed with potassium supplementation, use of a potassium-sparing diuretic, or both. Drugs to be avoided Centrally acting drugs : drowsiness depression Impaired cognitive function. Adrenergic antagonists : postural hypotension. NSAID : exacerbate hypertension. Risk of therapy Risk of therapy is increased with age. Drugs Hyponatremia & hypokalemia with diuretics Confusion & depression with drugs affecting CNS as B blocker Postural hypotension which may lead to fall & fracture Cerebral hypoperfusion if BP is acutely lowered Increased glucose intolerance, Creatinine and uric acid with Thiazide treatment Benefit of therapy Greater benefit than in younger patients. Stroke reduced 30% CV events 20% Dementia 50% Morality 13% 1- start with half standard doses. 2- increase dose gradually over several weeks. 3- check BP in both supine and standing position. 4- Adjust dose according to standing position. 5- Monitor renal function and electrolyte status. 6- A adverse drug reaction are 23 times more common. 7- Consider co-morbid condition. When to stop Withdrawal of antihypertensive drugs should be done carefully if : The original level of BP was mild to moderate BP of patient has been in good control for continues period 12 months Follow up for life long with or without medical treatment A 36-Year-Old Man was admitted to the hospital because of seizures and severe hypertension. had an 18-year history of intravenous drug abuse (heroin) One year before admission, he discontinued his use of illicit drugs Three months before admission, tingling developed in the left toes and progressed to numbness in the foot; these symptoms were accompanied by recurrent vomiting, night sweats, intermittent diarrhea, abdominal pain, subjective fever, and a weight loss of 16 kg. He noted erythematous lumps over the shins and ankles Five weeks before admission HTN was diagnosed. Tests for HBV and HCV were +ve. The initial blood pressure was 240/130 mm Hg. Lungs and heart were normal on auscultation. No peripheral edema was found. On neurologic examination the strength was 5/5 except at the left gastrocnemius 2/5 The tone was normal All sensation was normal The deep-tendon reflexes were + in the arms, ++ at the knees and right ankle, and absent at the left ankle; Plantar responses were flexor. Fundus showed optic-disk edema. Investigations Urine was positive (+++) for protein and trace-positive for glucose; the sediment contained 0 to 2 white cells and no red cells/HPF Creatinine was 2.5 and rising to 3.5mg/dl. ECG showed a normal rhythm with voltage criteria for left ventricular hypertrophy ESR was 107mm /hr Imaging A chest radiograph was unremarkable. An U/S of the abdomen showed that the gallbladder was distended and contained gallstones, without evidence of cholecystitis. The liver was normal, and the spleen unremarkable; the kidneys were unchanged. What will you do with our case? REFER intensive care unit for control of his hypertension. Hypertensive Urgencies and Emergencies Hypertensive crisis •BP > 220/120 mmHg + acute TOD (encephalopathy or cereberal hemorrhage). –Emergency, refer to hospital. –Reduce BP to 160/100 over several hours IV diuretics should not be used as initial therapy in hypertensive crisis unless acute pulmonary edema. Sublingual nifedipine plus IV loop diuretic should be avoided it as it may result in organ hypoperfusion. A single dose of sublingual captopril 12.5 mg can be used until the patient transfer to hospital. BP > 220/120 mmHg but no acute TOD. – Urgency, refer to hospital –Treatment by combination of rapidly acting oral antihypertensive drugs. The distinction depends upon the clinical assessment of the degree , the rate of rise of blood pressure and the presence of potential for end-organ damage Management of Rapid Severe HTN Rapid BP>220/130 Severe S of acute TOD YES CAPTOPRIL SL(½ tab) NO Retinal He/exudates/ papilloedema (malignant HTN) YES Refer Combination of rapid Acting oral anti-HTN NO Start oral anti-HTN Assessment of end organ damage Examination of retina for hypertensive changes Examination of peripheral pulses Chest x-ray & ECG for signs of LVH Kidney function tests • This patient had involvement of the NS, the skin, kidneys, the liver, and the heart, and • He also had malignant hypertension, as evidenced by the headache and opticdisk edema • ESR was 107mm /hr • positive tests for hepatitis C & B virus Ab. Management Refer