Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes. Case studies in Hypertension (pearls for achieving control) 2019 KAROL E. WATSON, MD, PHD, FACC PROFESSOR OF MEDICINE/CARDIOLOGY DAVID GEFFEN SCHOOL OF MEDICINE AT UCLA CO‐DIRECTOR, UCLA PROGRAM IN PREVENTIVE CARDIOLOGY Brachial blood pressure is a strong predictor of clinical outcomes in people with hypertension and it is assumed that brachial blood pressure accurately reflects pressures in the central aorta and thus left ventricular load This assumption may not be valid in all circumstances The gold standard for measuring central aortic pressure is invasive, however, noninvasive methods exist as well Case #1: Difficult to control BP in an elderly patient 52-year-Old Normal Pressure Wave 81-year-Old Early Pulse Wave Reflection Elderly Patients have Stiffer Blood Vessels Average Blood Pressure Waveform Notch Notch Shoulder Time (sec) Time (sec) Average Blood Pressure Waveform www.lejacq.com/Symposia_Info/UMH_DC-0504/Pickering.ppt 140 70 Radial Transfer function Central Aortic 140 70
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Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes.
Case studies in Hypertension(pearls for achieving control) 2019
KARO L E . W A T S O N , MD , P H D , F A C C
P R O F E S S O R O F M E D I C I N E / C A R D I O L O G Y
D A V I D G E F F E N S C HOO L O F M ED I C I N E A T U C L A
CO ‐ D I R E C T O R , U C L A P R O G R AM I N P R E V E N T I V E C A R D I O L O G Y
Brachial blood pressure is a strong predictor of clinical outcomes in people with hypertension and it is assumed that brachial blood pressure accurately reflects pressures in the central aorta and thus left ventricular load
This assumption may not be valid in all circumstances
The gold standard for measuring central aortic pressure is invasive, however, noninvasive methods exist as well
Case #1: Difficult to control BP in an elderly patient
52-year-OldNormal Pressure Wave
81-year-Old Early Pulse Wave Reflection
Elderly Patients have Stiffer Blood VesselsAverage Blood Pressure Waveform
Serum Creatinine increase with ACE inhibitors and ARBs
Starting an ACE inhibitor or ARB can result in a small, non‐progressive increase in serum creatinine that reflects decreased glomerular filtration rate from the favorable hemodynamic effect of reducing intra‐glomerular pressure
A 30% increase in serum creatinine is generally acceptable
Creatinine will usually peak within a week, then stabilize
If > 30% increase in creatinine occurs, stop the drug
ACE/ARB dilate here
CapillaryAfferent arteriole Efferent arteriole
Intraglomerular pressure decreases
Filtration gradient decreases
Less creatinine is filteredSerum creatinine rises
Intraglomerular pressure decreases
Nephrons are sparedRenal function is
preservedOutcomes are improved
Changes in GFR with ACE‐I or ARB therapy
Aimun K. Ahmed et al. Nephrol. Dial. Transplant. 2010;25:3977-3982
Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes.
Case #2: Patient with creatinine increase on ACE inhibitor
Follow up: 0.9 to 1.17 is a 30% increase in creatinine
Follow up Medications: No change
Follow up Physical Exam: BP 125/80 mm Hg
Labs/studies: Creatinine stable at 1.12
A 30% increase in serum Creatinine after addition of an ACE inhibitor or ARB is acceptable.
Case #3: 33 year old patient with new onset hypertension
Chief complaint: 33 year old male referred by PCP for new onset hypertension. Has been following this patient for over 10 years but for the last 3 visits his BP has suddenly jumped up. Patient’s only complaint is back pain from an occupational injury
PMH: back strain, current smoker
Medications: Amlodipine 10 mg, Ibuprofen prn
Physical Exam: BP 148/92 mm Hg
Labs/studies: Unremarkable
Renin‐Angiotensin‐Aldosterone Regulation of Blood Pressure
http://vasoactivetherapy.com/files/CORLOPAM.PPT
Blood Pressure
Vasoconstriction
Angiotensin IRenin Substrate
Angiotensin IIRenin
Sodium & Water Reabsorption
Aldosterone
The role of aldosterone is to retain sodium in the face of deficiency
Adrenal Cortex
Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes.
Sympathetic Nervous System Regulation of Blood Pressure
http://vasoactivetherapy.com/files/CORLOPAM.PPT
Adrenergic Tone
Angiotensin
Cardiac Output
CatecholaminesAdrenal Gland
CNS
ArteriesResistance
Afterload
Blood Pressure
Reninsecretion
Aldosterone
Most cases of Resistant Hypertension are caused by:Sodium excess
Extracellular volume expansion
Sympathetic overactivation
Too Much Salt
Too Much Water
Too Much Sympathetic Activity
Interfering SubstancesSteroids
Pain Relievers (e.g., NSAIDs and COX‐2 inhibitors)
•Several pharmaceutical companies have announced recalls of generic versions of valsartan, irbesartan and losartan.
•This is due to the contaminants NDMA and NDEA being found in certain lots
•The Food and Drug Administration has traced the contaminated products to a large factory in China and later a second factory in India. Both used a similar manufacturing process to make and supply generic drug companies worldwide.
•Only generic versions are affected. Not all makers of genetic versions are affected.
•Check FDA website for most up‐to‐date information on recalls
Case #4: 58 year old with hypertension, worried about cancer scare
Follow up: Patient called his pharmacy and checked the FDA website. There is no recall of his medication lot. He is reassured
Follow up Medications: No change
Follow up Physical Exam: BP 120/78 mm Hg
Labs/studies: Unremarkable
Case #4: 58 year old with hypertension, worried about cancer scare
Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes.
Case #5: 68 year old with difficult to control hypertension
Chief complaint: 68 year old male referred by PCP for resistant hypertension. Blood pressure has been slowly increasing over the past several years and now has become resistant to prescribed therapies.
Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes.
Somers et al. J Clin Invest. 1995;96:1897.
Sympathetic Activity in Sleep Apnea Blood Pressure in OSA
Effect of CPAP on Blood Pressure
Becker et al, 2003
15
10
5
0
-5
-10
-15
-20
-25
MAP systolic diastolic
mm
Hg
* * *
Active CPAP Control CPAP
OSA is a common cause of resistant HTN. Effective treatment can decrease mean BP by 10mmHg.
Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes.
Follow up: Patient underwent sleep study and found to have severe obstructive sleep apnea (apnea: hypopnea index of 32). CPAP begun
Follow up Medications: No change
Follow up Physical Exam: BP 129/80 mm Hg
Labs/studies: Unremarkable
Case #5: 68 year old with difficult to control hypertension
Case #6: 58 year old who complains about amlodipine
Chief complaint: 58 year old female referred by PCP for complaints about amlodipine. PCP has tried multiple antihypertensive regimens and the only time she was able to gain control was when amlodipine was added. Patient complains of lower extremity edema
PMH: hypertension, metabolic syndrome
Medications: Amlodipine 10 mg, HCTZ 12.5 mg daily
Physical Exam: BP 118/78 mm Hg, 1‐2+ ankle edema
Labs/studies: Unremarkable
Calcium Channel Blockers and Edema
CCBs dilate here
ACE/ARB dilate here
CapillaryAfferent arteriole Efferent arteriole
Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes.
Adding an ACE inhibitor or an ARB to a CCB can decrease edema
Follow up: Amlodipine dose lowered; An ARB was added to the regimen
Follow up Physical Exam: BP 125/65 mm Hg, NO ankle edema
Labs/studies: Unremarkable
Case #6: 58 year old who complains about amlodipine
Case #7: Young man referred by PCP for elevated BPChief complaint: 21 year old male track star referred by PCP for elevated BP. Secondary causes have been ruled out. Patient states “I won’t take medications”
PMH: Elevated BP
FH: Severe hypertension (early onset) in multiple family members. Father died at age 44 of MI, mother suffered TIA last year
Medications: None
Physical Exam: BP 128/88 mm Hg
Labs/studies: Unremarkable
Categories of BP in Adults
BP Category SBP DBP
Normal <120 mm Hg and <80mm Hg
Elevated 120–129 mm Hg and <80 mm Hg
Hypertension
Stage 1 130–139 mm Hg or 80–89 mm Hg
Stage 2 ≥140 mm Hg or ≥90 mm Hg
J Am Coll Cardiol. 2017 Nov
130 is the new 140
Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes.
Trajectories of BP elevation preceding diagnosis of HTN: Framingham
Whelton PK et al. JAMA. 1997;277:1624-1632.
Nonpharmacologic Interventionsand BP Reduction
BP
Dec
reas
e(m
m H
g)
SBP DBP
ExerciseLow-Salt
DietAlcohol
ReductionPotassiumRepletion
5
4
3
2
1
0
6
7
Weight Loss(19.4 lb)
The Role of Potassium in Hypertension
Potassium deficit is critical in hypertension
Recent evidence as well as classic studies point to the interaction of sodium and potassium, as compared with an isolated abnormality of either alone, as a dominant factor in hypertension
Processed foods are high in sodium and low in potassium; Conversely, fruits and vegetables are sodium‐poor and potassium‐rich
The Institute of Medicine (IOM) recommendations: 4.7 grams K+ per day (4 ½ cups, 9‐10 servings)
‐Whelton PK. Potassium and blood pressure. In: Izzo JL Jr, Black HR, eds. Hypertension primer. 3rd ed. Dallas: American Heart Association/Council on HighBlood Pressure Research, 2003:280‐.;He FJ, MacGregor GA. Beneficial effects of potassium. BMJ 2001;323:497‐501; Dietary reference intakes for water,potassium, sodium, chloride, and sulfate. National Academies Press, 2005.
Salt Sensitivity related to potassium intake
J Am Coll Nutr June 2006 vol. 25 no. suppl 3 262S‐270S
• Black and White men were maintained on diets of varying Potassium levels.
• Then given 7‐days of salt loading and salt sensitivity measured
• On the low K+ diet, 80% of Black and 35% of White men were salt sensitive
• As potassium intake INCREASED, salt sensitivity DECREASED.
• On the high K+ diet, only 20% of the Black men, and none of the White men remained salt sensitive
African American White
Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes.
DASH diet is rich in potassium
DASH = Dietary Approaches to Stop Hypertension
The diet is rich in fruits, vegetables (high K+), low fat dairy foods, and low in fat, total fat, cholesterol and salt
Appel, et al. Circulation, 102:852, 2000
Follow up: Dietary history reviewed. Patient admits to eating out most nights (high salt) and rarely, if ever, eating fruits and vegetables. Dietary counseling given and patient adopted recommendations
Follow up Medications: No medications
Follow up Physical Exam: BP 118/70 mm Hg
Labs/studies: Unremarkable
Case #7: Young man referred by PCP for elevated BP
Chief complaint: 68 year old female referred by PCP for resistant HTN. Secondary causes have been ruled out.
PMH: Severe hypertension, rheumatoid arthritis, CKD
Nishizaka MK, et al. Am J Hypertens 2003;16;925-930
Spironolactone (Aldosterone antagonist)
-21
-10
-23
-10
-25
-12
-30-25-20-15-10
-50
BP
resp
onse
(mm
Hg) 6wk 3mo 6mo
Systolic BP Diastolic BP
Patients with resistant hypertension who were documented to have normalaldosterone levels. Treated with a diuretic and ACE inhibitor or ARB In patients with resistant hypertension, it
is reasonable to give a trial of Spironolactone
But watch K+ carefully
Syllabi/Slides for this program are a supplement to the live CME session and are not intended for other purposes.