Hypertension

Evidence Based Treatment of HypertensionHarleen Singh, Pharm.D.Ted D. Williams, Pharm.D. CandidateOSU/OHSU College of PharmacyP4 Year Investing in your Education

LectureLabLearning ObjectivesDemonstrate an understanding of the different roles of pharmacology, pathophysiology, and evidence based medicine as they apply to patient therapyDemonstrate understanding of pathological disorders caused by chronic, poorly controlled hypertensionIdentify signs and symptoms of end-organ damage due to hypertensionDemonstrate an understanding of sites of action and most likely side effects of various antihypertensive drug classes and differences between drugs in the same classClassify patients by JNC-7 Hypertension levelsAssign blood pressure goals according to AHA 2007 Scientific Statement for patients based on comorbiditiesSelect most appropriate therapy for patients based on Evidence Based Medicine Compelling IndicationsApply outcomes of landmark hypertension studies to selecting patient therapyThe Road AheadEvidence Based Medicine (EBM) PrimerHypertension Defined, Epidemiology, ComplicationsGoals of Hypertension TherapyHypertension Treatment GuidelinesNon-Pharmacological Treaments of Hypertension Pharmacology ReviewBy Drug ClassAssessing Drug InteractionsEBM for pharmacological treatment selectionTypes of SignificanceStatistical SignificanceCan we detect any differenceClinical SignificanceDo we care if there is a differencePatient SignificanceBlood Glucose level differences with Thiazide Diuretics are significantly higher vs. placeboIncrease in Blood Glucose 3-5mg/dL in non-diabeticsIs this clinically significant?EBM In Real LifeQuestion for PharmD: Recommend a therapy for a patient on 25mg HCTZ QDay with BP 140/95Answer from PharmD: Continue HCTZ 25mg Q Day and add Lisinopril 10mg Q Day, titrating to 40mg Q DayResponse: Why not increase HCTZ to 50mg Q Day. Micromedex says the max daily dose is 100mgPharmD: ???JNC-7The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood PressureGold Standard EBM in Hypertension diagnosis and treatmentCaseMore CasesHypertension DefinedElevated Blood Pressure (BP)Systolic Blood Pressure (SBP) >=140mmHgDiastolic Blood Pressure (DBP) >=90mmHgEpidemiology of HypertensionApproximately 50 million people in the U.S. have hypertension.The incidence of hypertension increases steadily with age and prevalence is higher in blacks than in whites. Prevalence exceeds 60% in people over age 60.There is a strong correlation between blood pressure and cardiovascular morbidity and mortality.Systolic BP has a stronger correlation than diastolic BP, but both are importantEpidemiology of HypertensionThe higher the pressure, the greater the risk of myocardial infarction, angina, stroke, heart failure, renal failure, peripheral vascular disease and retinopathy.For each 20mm increase in SBP or 10mm increase in DBP over 115/75, risk doublesComplication rates increase with each additional CVD risk factor that is presentHypertension accounts for 2/3 of strokes and about 25% of MIsPreventing and controlling hypertension is a major strategy for reducing CVD morbidity and mortality.While 70% of hypertensives are aware of their condition and 59% are being treated; only 34% are controlled.Determinants of Blood PressureArterial blood pressure is generated by the interplay of cardiac output and total peripheral resistance: BP = CO x TPRIt reaches a peak during cardiac contraction (systolic pressure) and a nadir at the end of cardiac relaxation (diastolic pressure).Blood pressure is measured in millimeters of mercury and recorded as systolic (SBP) over diastolic pressure (DBP).The difference between the systolic and the diastolic pressure is the pulse pressure (PP)Mean arterial pressure (MAP) = 1/3 PP + DBP.Pathophysiology of HypertensionSympathetic ActivationPeripheral ResistanceCardiac OutputHRStrokeVolumeReninAT IIAldosteroneBlood PressurePlasmaVolumeAdapted from APhAs Completed Review for Pharmacy. Gourley, DR. 2004Pathophysiology of Hypertension(HTN)Increased Sympathetic ActivationExcessive vascular volumeActivation of the Renin Anginotensin Aldosterone SystemPeripheral ResistanceCauses of HypertensionIdiopathic90-95% of cases have no known etiologySecondaryRenal InsufficiencyCoarcation of the aortaPrimary AldosteronismThyroid/parathyroid diseaseCushings SyndromePheochromocytomaSleep ApneaIncreased Intracranial pressureLook for secondary causes, but dont expect to find them

Hypertension as a Risk FactorHTNRetinopathyHeart FailureIschemic Heart DiseaseCerebrovascular DiseasePeripheral Vascular DiseaseChronic Kidney DiseaseWhenever working with a patient, check for signs of end organ damage (e.g. Retinopathy, Heart sounds, Chest Pain, unilateral weakness, Edema, increased urniation)Run baseline labs (Chem 7, EKG, Lipid Panel, Uric Acid)19Hypertension as a Risk FactorHypertension is a primary risk factor for multiple co-morbiditiesIschemic Heart Disease (IHD)aka Carotid Artery Disease (CAD), Coronary Heart Disease(CHD)Myocardial Infarction (MI)AnginaHeart Failure (HF)Left Ventricular Hypertrophy or Dysfunction (LVH, LVD)Cerebrovascular DiseaseStrokeTransient Ischemic Attack (TIA)Chronic Kidney Disease (CKD)RetinopathyTypes of HypertensionChronicWhat we will focus on today and what we will call HypertensionHypertensive CrisisHypertensive EmergencyHypertensive UrgencyDr Marrs will discuss this in detail in subsequent lecturesHypertensive CrisisLess than 1% of all hypertensives will ever have a hypertensive crisis.Hypertensive crisis is defined as a diastolic pressure above 120mm Hg.There are 2 types of hypertensive crisis: hypertensive emergency hypertensive urgencyGoals of Hypertensive TherapyLong TermShort TermLong Term Goals of Hypertension TherapyDirect MeasuresReduced MortalityReduced incidence of end organ damageCardiovascularCerebrovascularRenalRetinopathyTrailing indicatorsShort Term Goals of Hypertension TherapySurrogate markersBlood PressureLeading indicatorWhy is blood pressure a good surrogate marker?

Hypertension and Ischemic Heart DiseaseThe Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. 2004Hypertension and Stroke

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. 2004Hypertension and Cardiovascular DiseaseHigh Normal = 130-139/85-89mmHgNormal = 120-129/80-84mmHgOptimal