Hypertension

HypertensionHypertension

Catherine Florio Pipas, MDCatherine Florio Pipas, MD

Community & Family MedicineCommunity & Family Medicine

20072007

An Approach to An Approach to HypertensionHypertension

( JNC 7 Report JAMA 2003;289:2560-2572)( JNC 7 Report JAMA 2003;289:2560-2572) • Accurate diagnosis Accurate diagnosis

• Classification Classification • Evaluation ( Initial and follow up)Evaluation ( Initial and follow up)

• Risk factors and target organ diseaseRisk factors and target organ disease• TreatmentTreatment

Lifestyle ModificationLifestyle Modification

Drug treatmentsDrug treatments Co-Morbid conditionsCo-Morbid conditions

Hypertension - FactsHypertension - Facts

50 million adult Americans have hypertension 50 million adult Americans have hypertension (60%>60), (80% >80) , (90%> 90)(60%>60), (80% >80) , (90%> 90)– 95% is primary (idiopathic)95% is primary (idiopathic)– 5% of adult HTN is secondary 5% of adult HTN is secondary

» Renal (parenchymal/vascular)Renal (parenchymal/vascular)

» Endocrine (adrenal/parathyroid)Endocrine (adrenal/parathyroid)

» Pregnancy relatedPregnancy related

» Result of drug therapyResult of drug therapy

» Coarctation of aortaCoarctation of aorta

» Sleep apneaSleep apnea

Hypertension - TrendsHypertension - Trends

National Health and Nutrition Examination Survey Trials National Health and Nutrition Examination Survey Trials (NHANES) demonstrate that since 1976-1994:(NHANES) demonstrate that since 1976-1994:

-More patients are aware they have HTN-More patients are aware they have HTN

-More patients are under therapy for HTN-More patients are under therapy for HTN

-More patients under therapy are in control-More patients under therapy are in control

-However since 1991 these increases have leveled off-However since 1991 these increases have leveled off

Age-adjusted mortality rates for strokes and CHD have decreased Age-adjusted mortality rates for strokes and CHD have decreased since 1976 but since 1991 the rates are leveling offsince 1976 but since 1991 the rates are leveling off

The frequency of end-stage renal disease and heart failure is The frequency of end-stage renal disease and heart failure is increasingincreasing

CC: Mr Charlie Bont is a 44- year old, black male CC: Mr Charlie Bont is a 44- year old, black male who presents for a comprehensive health who presents for a comprehensive health assessment required by his new employer.assessment required by his new employer.

SH: Mr Bont, an electrician, offered a substantial SH: Mr Bont, an electrician, offered a substantial increase in salary, benefits, and supervisory increase in salary, benefits, and supervisory responsibility . responsibility .

ROS: No current complaintsROS: No current complaints

Hypertension CaseHypertension Case

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Hypertension Case - Cont.Hypertension Case - Cont.

PMH: Last visit to a physician was a pre-employment PMH: Last visit to a physician was a pre-employment evaluation prior to his previous job 11 years ago. Reported evaluation prior to his previous job 11 years ago. Reported as normal.as normal.

PE: Vital signs - BP 156/98 right arm sitting; respirations PE: Vital signs - BP 156/98 right arm sitting; respirations 14/min; pulse 68 and regular; temp 98.6; weight 223 lbs; 14/min; pulse 68 and regular; temp 98.6; weight 223 lbs;

height 5 feet 7 inches . BMI 34.6height 5 feet 7 inches . BMI 34.6

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Hypertension Case - Cont. Hypertension Case - Cont.

1. Considering only this preliminary data, List three 1. Considering only this preliminary data, List three ““medical concernsmedical concerns” that warrant further evaluation.” that warrant further evaluation.

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Hypertension Case - Cont. Hypertension Case - Cont.

2. Give four conditions required of the 2. Give four conditions required of the patient, the measurement and/or the patient, the measurement and/or the instrument needed to accurately confirm instrument needed to accurately confirm the “the “diagnosis of hypertensiondiagnosis of hypertension””

versusversus

“ “ elevated BP”elevated BP”

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Hypertension - DiagnosisHypertension - Diagnosis• Measurement in the officeMeasurement in the office

– BP evaluated on two separate visitsBP evaluated on two separate visits

– Bare arm in seated positionBare arm in seated position

– No smoking or caffeine for at least thirty minutes priorNo smoking or caffeine for at least thirty minutes prior

– Cuff bladder should nearly encircle the arm (at least 80%)Cuff bladder should nearly encircle the arm (at least 80%)

– BP measured after at least 5 minutes of restBP measured after at least 5 minutes of rest

– Two or more readings should be repeated (at least 2 minutes Two or more readings should be repeated (at least 2 minutes apart)apart)

JNC-7* Adult BP ClassificationJNC-7* Adult BP Classification

Category BP (mm/Hg)

Follow-up protocol

Normal < 120 / 80 Lifestyle modification (LM)

Prehypertension 120-139 or 80-89 Lifestyle modification

Stage 1 140-159 or 90-99 LM and BEGIN ONE drug TREATMENT

Stage 2 >160 or >100 LM and BEGIN TWO drug Tx.

* Joint National Commision on Prevention, Detection, Evaluation and Treatment of High Blood Pressure * For adults ≥18 years old* If SBP and DBP in different classes, choose the highest class

JNC-6 ClassificationJNC-6 ClassificationHypertension - Age < 18 yearsHypertension - Age < 18 years

Age

(yrs)

Significant HTN

(95-99%) *

Severe HTN

(>99%) **

3-5 116-123 / 76-84 > 124/ >84

6-9 122-129 / 78-85 > 130/ >86

10-12 126-133 / 82-89 > 134 / >90

13-15 136-143 / 86-91 >144 / >92

16-18 142-149 / 92-97 >150 / >98

* Lifestyle modifications recommended* Lifestyle modifications recommended** Pharmacologic therapy recommended** Pharmacologic therapy recommended

You have established the presence of “You have established the presence of “stage 1 hypertensionstage 1 hypertension” in ” in Mr Bont. What Mr Bont. What historyhistory that would be important in defining that would be important in defining other other cardiovascular risk factorscardiovascular risk factors or the presence of or the presence of target target organ diseaseorgan disease. Include the specifics, if necessary to define . Include the specifics, if necessary to define increased risk. Ex. Hypercholesterolemia (chol >200)increased risk. Ex. Hypercholesterolemia (chol >200)

Component of History:Component of History:

Past medical historyPast medical history ROSROS

Social habitsSocial habits Nutritional historyNutritional history

Psychosocial/environmental historyPsychosocial/environmental history Family historyFamily history


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Hypertension EvaluationHypertension Evaluation

Additional Major CV Risk Additional Major CV Risk Factors Factors

SmokingSmoking• DyslipidemiaDyslipidemia• DiabetesDiabetes• Obesity (BMI>30)Obesity (BMI>30)• Physical inactivityPhysical inactivity• Microalbuminuria or GFR < Microalbuminuria or GFR <

60ml/min60ml/min• Age >55 men, >65womenAge >55 men, >65women• FH of premature CVDFH of premature CVD

• Men <55 yoMen <55 yo

• Women <65 yoWomen <65 yo

Target-organ damageTarget-organ damage

• Heart diseaseHeart disease

- LVH- LVH

- Angina or prior MI- Angina or prior MI

- Prior CABG- Prior CABG

- Heart failure- Heart failure• Stroke or TIAStroke or TIA• NephropathyNephropathy• Peripheral arterial diseasePeripheral arterial disease• RetinopathyRetinopathy

Hypertension Case- PEHypertension Case- PE

Describe components of the PHYSICAL EXAM that alert you Describe components of the PHYSICAL EXAM that alert you to the presence of to the presence of target organ disease, other CV risk factors target organ disease, other CV risk factors or secondary hypertensionor secondary hypertension..

Component of physical exam:Component of physical exam:

VS- Wght, BP,VS- Wght, BP,

EyesEyes NeckNeck

HeartHeart LungsLungs

AbdomenAbdomen ExtremitiesExtremities

NeurologicNeurologic

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PE COMPONENTSPE COMPONENTS

History/Physical Exam:• BP both arms, BMI• Fundoscopic exam• Thyroid Exam• Carotid , femoral & abdominal bruits• Pulmonary and Cardiac exam

• LV apex - (S3 &S4 gallop)

• Abdominal Exam (kidneys, masses, AAA)• Peripheral vascular pulses and edema• Neurologic exam


What initial lab tests or studiesWhat initial lab tests or studies would would you perform on Mr Bont. you perform on Mr Bont.

Give rationale for choosing the test and the findings that might alert you.Give rationale for choosing the test and the findings that might alert you.

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Hypertension – Initial Lab and Hypertension – Initial Lab and Test Evaluation*Test Evaluation*

Labs:

• Electrolytes– K+/ Na+

– BUN/Creatinine

– Fasting blood glucose

Fasting Lipid panel• Urinalysis (GFR)• EKG

• NEW JNC 7- Hct and CaNEW JNC 7- Hct and Ca

Hypertension - Additional Hypertension - Additional Testing Testing

Consider further Consider further evaluation if any of evaluation if any of the following are the following are present:present:

• Abdominal traumaAbdominal trauma• Sudden onset of severe Sudden onset of severe

HTNHTN• History of abnormal History of abnormal

urinalysisurinalysis• Elevated creatinine Elevated creatinine • HypokalemiaHypokalemia• HypercalcemiaHypercalcemia

Consider secondary Consider secondary causes of causes of hypertension:hypertension:

• Resistant HTNResistant HTN• Paroxysmal HTNParoxysmal HTN• Abdominal mass or Abdominal mass or

bruitbruit• Cushing SyndromeCushing Syndrome


Mr Bont has Mr Bont has STAGE 1 HTN STAGE 1 HTN Negative History and PENegative History and PE Normal Labs and EKGNormal Labs and EKG

Describe your Describe your initial approach to his initial approach to his treatment.treatment.

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JNC-7* Adult BP Classification and JNC-7* Adult BP Classification and Treatment RecommendationsTreatment RecommendationsCategory BP (mm/Hg)

Follow-up protocol

Normal < 120 / 80 Lifestyle modification (LM)

Prehypertension 120-139 or 80-89 Lifestyle modification

Stage 1 (Mild) 140-159 or 90-99 LM and BEGIN ONE drug TREATMENT

Stage 2 (Mod) >160 or >100 LM and BEGIN TWO drug Tx.

* Joint National Commision on Prevention, Detection, Evaluation and Treatment of High Blood Pressure * For adults ≥18 years old* If SBP and DBP in different classes, choose the highest class

Lifestyle ModificationsLifestyle ModificationsPREVENTION for all !!!!!!!!!!!PREVENTION for all !!!!!!!!!!!

• Weight loss (10lb wght loss reduces SBP 5-20mm Hg )Weight loss (10lb wght loss reduces SBP 5-20mm Hg )• BMI 18.5-24.9BMI 18.5-24.9

• Limit ETOH (reduces SBP 2-4 mm HG)Limit ETOH (reduces SBP 2-4 mm HG) - Men 1-2/daily(1 oz ethanol, 24 oz beer, 10 oz wine or 3.0 oz - Men 1-2/daily(1 oz ethanol, 24 oz beer, 10 oz wine or 3.0 oz

whiskey)whiskey) - Women 1 daily(0.5 oz ethanol)- Women 1 daily(0.5 oz ethanol)

• Increase aerobic physical activity (reduces SBP 4-9mm HG)Increase aerobic physical activity (reduces SBP 4-9mm HG)• 30-45 minutes most days of week30-45 minutes most days of week

• Reduce sodium intake (reduces SBP 2-8mm HG)Reduce sodium intake (reduces SBP 2-8mm HG)• 2.4 g sodium or 6 g salt (1 teaspoon table salt))2.4 g sodium or 6 g salt (1 teaspoon table salt))

• Stop smokingStop smoking• Improve diet (reduces SBP 8-14 mm HG)Improve diet (reduces SBP 8-14 mm HG)

• Decrease intake of saturated fat and cholesterolDecrease intake of saturated fat and cholesterol• Increase fruits, vegetables and lowfat dairyIncrease fruits, vegetables and lowfat dairy


BP 156/98 BP 156/98

You have decided to initiate You have decided to initiate drug drug treatmenttreatment for Mr. Bont, what drug for Mr. Bont, what drug did you initiate and why?did you initiate and why?

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Hypertension - Drug TherapyHypertension - Drug Therapy

• JNC-7 recommends drug therapy be pushed to JNC-7 recommends drug therapy be pushed to achieve goal BP of < 140/90 or <130/80 if DM or achieve goal BP of < 140/90 or <130/80 if DM or NephropathyNephropathy

• Thiazides are best choice for most with Stage 1 Thiazides are best choice for most with Stage 1 • Use long-acting formulations that provide total 24-Use long-acting formulations that provide total 24-

hour coverage with QD dosing when possiblehour coverage with QD dosing when possible• Pts with BP >160/100 likely need two medications Pts with BP >160/100 likely need two medications

(thiazide plus another) (thiazide plus another) • Patients with Co-Morbidities should have appropriate Patients with Co-Morbidities should have appropriate

medications usedmedications used

Hypertension Case - Cont.Hypertension Case - Cont.Briefly state the Briefly state the classclass and describe the and describe the mechanismmechanism of action for of action for

each of the following drugs:each of the following drugs:

PRIMARYPRIMARY SECONDARYSECONDARYHydrochlorothiazideHydrochlorothiazide

PropanololPropanolol

BenazeprilBenazepril HydralazineHydralazine

DiltiazemDiltiazem ClonidineClonidine

Losartan Losartan DoxazosinDoxazosin

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Individualize the Individualize the pharmacologic treatmentpharmacologic treatment that that you might initiate for hypertensive patients you might initiate for hypertensive patients with CO-MORBIDITIES:with CO-MORBIDITIES:

1.1. 82-year old man with congestive heart failure 82-year old man with congestive heart failure 2.2. 61-year old man post myocardial infarction61-year old man post myocardial infarction3. 40 year old with multiple CV risk factors 3. 40 year old with multiple CV risk factors 4. 42-year old man with Type II diabetes4. 42-year old man with Type II diabetes5. 62-year old woman with chronic renal disease5. 62-year old woman with chronic renal disease6. 79 -yr old with Recurrent Stroke6. 79 -yr old with Recurrent Stroke


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Mr Bont returns after being on an antihypertensive agent for Mr Bont returns after being on an antihypertensive agent for six weeks. His blood pressure is now 154/98. six weeks. His blood pressure is now 154/98.

List possible reasons for his List possible reasons for his lack of response to pharmacologic lack of response to pharmacologic therapytherapy..


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REFRACTORY HTNREFRACTORY HTN

40% Non compliance40% Non compliance 40% Sub Optimal Therapy40% Sub Optimal Therapy 10% Exogenous causes10% Exogenous causes 10% Secondary HTN10% Secondary HTN

What potential strategies would What potential strategies would increase adherence and increase adherence and improve responsiveness to treatmentimprove responsiveness to treatment??


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JNC 7 REPORTS JNC 7 REPORTS :“Motivation improves when patients have :“Motivation improves when patients have positive experiences with and trust in their clinicians. positive experiences with and trust in their clinicians.

Empathy builds trust and is a potent motivator”Empathy builds trust and is a potent motivator”

Patients previous knowledge and Patients previous knowledge and experiencesexperiences

Patients cultural beliefs, concerns and fearsPatients cultural beliefs, concerns and fears Verbal and written confirmation of goalsVerbal and written confirmation of goals Ambulatory monitoringAmbulatory monitoring Identify barriersIdentify barriers

Summary:Approach to HTNSummary:Approach to HTN

Accurate DiagnosisAccurate Diagnosis StagingStaging

– Classification via JNC 7 2003Classification via JNC 7 2003» Remember PREHYPERTENSIVES (120-139 or 80-89)Remember PREHYPERTENSIVES (120-139 or 80-89)

– Assess H, PE, Labs and CV Risk factors Assess H, PE, Labs and CV Risk factors TreatmentTreatment

– Life Style Modifications/ Prevention for allLife Style Modifications/ Prevention for all– Thiazide Diuretics as first lineThiazide Diuretics as first line– Consider Co-Morbid conditionsConsider Co-Morbid conditions

Consider your causes if refractory(40.40.10.10)Consider your causes if refractory(40.40.10.10)

Hypertension

Health & Medicine

Transcript of Hypertension