Cure Pathologic Fear of Hypertension Create Rational Approach to Drug Choice Complement Rational...
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Transcript of Cure Pathologic Fear of Hypertension Create Rational Approach to Drug Choice Complement Rational...
Cure Pathologic Fear of Hypertension
Create Rational Approach to Drug Choice
Complement Rational Choice with Pearls
Consolidate new information with cases
• Those who do not have high blood pressure at age 55 face a 90 percent chance of developing it during their lifetimes.
• So high blood pressure is a condition that most people have at some point in their lives.
• 90% of Americans over 65 have hypertension or Prehypertension
You can at least cause Dys-Ease
Your Blood pressure is 128/84While drug treatment is recommended if your BP is at or above 140/90,
new medical guidelines state that a normal BP for most adults is less than 120/80. Ask your doctor what is right for you.
The risk of cardiovascular disease begins at 115/75In individuals aged 40 to 70 years, each 20/10 mm Hg increase in blood pressure doubles the risk of cardiovascular disease, including heart attack, stroke or kidney disease
This program includes: A free 30 day trial of Diovan, Diovan HCT and Lotrel, 3 medications proven to help lower blood pressure.
115/75
180/100
Low Risk High Risk
115/75
We’re Doomed, We’re Doomed
The Silent Killer
69% of people who have a heart attack, 77% of people who have a first stroke,
and 74% of people with chronic CHF
have high blood pressure.
95% of people who have a heart attack, 95% of people who have a first stroke,
and 95% of people with chronic CHF
Have eaten pickles in the previous 10 years
http://cybersmokeblog.blogspot.com/2013/03/do-you-agree-to-tell-whole-truth-and.html
Disease Low Dose Diuretic
Ace Inhibitors BetaBlockers
Death 28% 27% 27%
Stroke 37% 35% 11%
Coronary Heart Disease
28% 19% NS
45 Year Old Female Cholesterol 200 Non-Smoker Systolic of 190 10 Year Risk?
2% Risk of Heart Attack 1.4% if treated
65 Year Old Male Cholesterol 200 Non-Smoker Systolic of 155 10 Year Risk?
10% Risk of Heart Attack 7.2% if treated
90% Chance of Going 10 years with NO heart attack
92.8% If they Are Treated
65 Year Old Male Cholesterol 200 Smoker Systolic of 180 10 Year Risk?
25% Risk of Heart Attack 18% if treated
75% Chance of Going 10 years with NO heart attack
82% If they Are Treated
Accord Trial NEJM 2010;362:17
Diabetes PLUS◦ Heart Disease◦ OR◦ Albuminuria◦ OR◦ Hypertrophy◦ OR ◦ Two Risk Factors
Accord Trial NEJM 2010;362:17
Systolic of <120 vs Systolic of <140
Achieved 119 vs 133
Accord Trial NEJM 2010;362:17
Outcome: nonfatal myocardial infarction, nonfatal
stroke, or death from cardiovascular causes
Followed Almost 5 years
Accord Trial NEJM 2010;362:17
Composite Outcome:
1.87 vs 2.09 p=0.2
Death
1.28 vs 1.19
Accord Trial NEJM 2010;362:17
Stroke:
0.32 vs 0.53 p=0.01
Seven trials (22,089 subjects) -4/-3 better
…at present there is no evidence to support aiming for a blood pressure target lower than 140/90 mmHg in any hypertensive patient.
Fear of
Hypertension
Fear Of
Hypertension
Rational Approach to Treat HTN
High ReninLow Renin
IntuitiveRenin AngiotensinAldosterone
Sympathetic Nervous SystemAngiotensin VasoconstrictionAldosterone Sodium and Water
Characteristics Systolic and Diastolic Equally Elevated
Higher Hemoglobin Younger High Stress? White?
Not IntuitiveWhy is Renin Low?Flaws in Sodium Excretion VolumeParadoxical Aldosterone
Stiff Arteries & Volume Excess
Characteristics Isolated Systolic Hypertension Older Women African American Diabetes
So What?
Stimulate RAA Inhibit RAA
Diuretics
CCB’s
ACE’s / ARB’s
Beta Blockers?
Salt retaining Steroids◦ Corticosteroids◦ Anabolic Steroids◦ Oral contraceptives◦ Estrogens
NSAIDS
Weight 276 pounds BP 170/90 Blood sugars run 200-250
◦ Glucophage 500mg BID◦ Micronase 5mg qd◦ Zestril 20mg qd
Complaining of palpitations.
HCTZChlorthalidone
OrIndapamide
Transition
https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcSZnyeB7hSiohvoaUK2XPf8I3RkGhJcnxmgTzAxVstB5KyIxXmC
https://encrypted-tbn3.gstatic.com/images?q=tbn:ANd9GcRJ9hLG9bZqehwMhM3Au6sq1xi4x8gb1LY-PnnvCiqbwv7HJeJW
0 12.5 25 50 1000 12.5 25 50 100
Lasix for Hypertension
Only if:◦ Serious Edema◦ CrCl < 30◦ Torsemide probably better
Women: Only the ones with Prostate Glands
Men: only the ones with BIG Prostate Glands
When in Doubt, Cut It Out.
All the outcomes data are on the next slide
https://www.toledoblade.com/image/2013/01/09/670x_b1_a4-3_cCM_z_cT/Cedar-
Point-GateKeeper.jpg
Causes
Drugs Street Drugs Sleep Apnea Renal Artery Stenosis
The Situation
All 4 Classes added Still No Joy Add Spironolactone Especially if the potassium is on the low
side
The number one cause of Resistant Hypertension
https://encrypted-tbn3.gstatic.com/images?q=tbn:ANd9GcR7w6eOwm6ymMSLZxuF_7PpZ-oCCQo8xh_oJKrxhdtC4PfFtYWr
A Couple Stories
67 years old Norvasc 5 Lisinopril 40 Carvedilol 25 BID Chlorthalidone 25mg Blood Pressure is 192/105
Assess Compliance Assess Compliance Assess Compliance Consider Sleep Apnea Consider Spironolactone
52 year old female Non-smoker Blood Pressure 152/94 Which drug should be started?
Leave the Poor Woman Alone !!
Take away her home blood pressure machine
Exercise, Salt and Healthy Food
Cured Pathologic Fear of Hypertension
Created a Rational Approach to Drug Choice
Complemented Rational Choice with Pearls
Consolidated new information with cases