Clinical Aspects of Hypertension
Anna Maio, M.D.
Incidence and Prevalence58-65 million Americans
30% incidence in the 18 and older age group
1/2 of people over 65 are hypertensive 15% of whites and 25% of African
Americans--reason unknown More common in men than in women up to
the age of 50.
JNC 7 Report-JAMA-May, 2003 Classification of BP
Systolic Diastolic
Normal <120 and <80
Prehyper-
tension
120-139 or 80-99
Stage 1 140-159 or 90-99
Stage 2 >160 or >100
Definition of Isolated Systolic Hypertension
Systolic blood pressure>160 mmHg Diastolic blood pressure< or = 90 mmHg Prevalence increases with age 11.7% of individuals >80 years of age 50% higher prevalence in women and
African Americans
Emergent/Urgent Hypertension
DBP>120 mmHg and papilledema (malignant)
Usually renal failure or stroke or chest pain or confusion or hemolytic anemia is present
Requires admission to an ICU, arterial line and parenteral treatment
Risk Factors for Essential HTN
More common and more severe in blacks Relationship between sodium intake and
hypertension Association between excess alcohol and
HTN Increased prevalence of obesity More common among those with hostile
attitudes
Identifiable Causes of Hypertension
Chronic kidney disease and renovascular disease (5-10%)
Sleep apnea Chronic steroid therapy/Cushing syndrome Primary aldosteronism Pheochromocytoma Coarctation of the aorta Thyroid or parathyroid disease
Identifiable CausesDrug-Induced or Drug-Related
NSAIDS/COX-2 inhibitors Cocaine, amphetamines, other illicit drugs Sympathomimetics OCPs Adrenal steroids Cyclosporine and tacrolimus Erythropoietin Licorice
History
Duration of disease Prior treatment including drugs, doses, side
effects Use of estrogens, steroids, sympathomimetics,
etc. (drugs taken are essential) Family history of HTN, early cardiac death,
pheo, renal disease ROS focuses on the target organs
Physical Exam
Measurement of BP in both arms, BMI Fundi Auscultation for carotid, abdominal, and
femoral bruits Palpation of the thyroid Heart, lungs, abdomen Edema and pulses Neuro assessment
Laboratory and Other Studies
Urinalysis Glucose, serum potassium, creatinine, calcium Hematocrit? TSH? Pregnancy test? EKG? Lipids?
Essential vs.. Secondary Causes
Use clues in the history and physical to order other testing
Acute BP rise over stable baseline Age<20 or >50 years of age Severe HTN with retinal involvement Unexplained hypokalemia No family history Abdominal bruit
Complication Associated With Untreated Hypertension
Coronary Artery Disease Cerebrovascular Disease Left ventricular hypertrophy with
congestive heart failure Renal failure Aortic dissection Retinal hemorrhages/papilledema
Cardiovascular Disease Risk
Relationship is independent of other risk factors
The higher the BP the greater the chance of MI, HF, stroke, and kidney disease
Stage 1 and risk factors--12 mmHg decrease in systolic BP for 10 years will prevent 1 death for every 11 treated patients
Benefits of Treatment
35-40% mean reduction in stroke 20-25% in myocardial infarction 50% reduction in heart failure
Initial Drug Therapy
Without CI With CI
Prehyper-tension
No drugtreatment
Drug Tx forCI
Stage 1 Thiazidediuretics formost
Drug Tx forCI//Others asneeded
Stage 2 2 DrugCombinationsfor most
Drug Tx forCI//Others asneeded
Treatment
Lifestyle changes Treatment of
hypertension with and without CI
Initiating therapy with 2 drugs if > 20/10 mmHg over goal/side effect problems
Use thiazide diuretics
Lifestyle Modifications
Weight reduction BMI=18.5-24.9 Adopt DASH eating plan Consume diet rich
in fruits, veggies, and low-fat dairy Dietary sodium reduction Physical activity Regular aerobic activity at
least 30 minutes/day most days/week Moderation of alcohol consumption No more
than 2/day
Compelling Indications
HF-diuretic, beta-blocker, ACEI, ARB, aldosterone antagonist
Post-MI-beta-blocker, ACEI, aldosterone antagonist
High coronary disease risk-diuretic, beta-blocker, ACEI, CCB
Diabetes-diuretic, beta-blocker, ACEI, ARB, CCB
Compelling Indications
Chronic kidney disease-ACEI, ARB Recurrent stroke prevention-diuretic, ACEI
Favorable Drug Effects
Thiazides are useful in slowing the demineralization in osteoporosis
Beta-blockers can be used to treat arrhythmias, migraine, thyrotoxicosis, tremor, or stage fright
CCBs can be used in Raynaud’s and some arrhythmias
Alpha-blockers may be useful in prostatic hypertrophy
Unfavorable Drug Effects
Pregnancy--methyldopa, beta-blockers, and vasodilators; ACEI and ARBs are contraindicated because of fetal defects and should be avoided in women who are likely to get pregnant
Thiazides should be used with caution in gout or a history of hyponatremia
Avoid beta-blockers in reactive airway disease or heart block
Creating a Drug Regimen
Choose first drug very carefully; often a thiazide Bring patient back in 1-2 weeks Add second drug if needed; if first drug is not a
diuretic the second one should be Third drug is often a CCB or an alpha2 agonist If the patient requires a 4th drug it is usually a
potent vasodilator
Drug Regimen for Isolated Systolic Hypertension
Drugs shown to be of benefit (>33% reduction in stroke) are thiazide diuretics and beta-blockers
Always check orthostatic blood pressure since this can effect quality of life
Drug Regimens for Accelerated Hypertension
All drugs should be given in a monitered setting-CCU or ICU; consider an arterial line
Drugs should be given parenterally Volume overload is common; assess need for
loop diuretic Nitroprusside, Enalapril, Esmolol, Cardizem
are just a few of the drugs available IV now
Physicians’ Role
Strive for optimal blood pressure control Look for identifiable causes and
treat/eliminate when possible Partner with the patient to choose the best
drug regimen considering cost, convenience, side effects
Follow-up and education
Improving Hypertension Control
Clinical inertia
Questions?????