Management of Hypertension

Information about Management of Hypertension

Published on August 11, 2014

Author: toufiqurrahman52

Source: authorstream.com

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Management of Hypertension: Management of Hypertension Dr. Md. Toufiqur Rahman MBBS, FCPS, MD, FACC, FESC, FRCPE, FRCPG, FAHA, FSCAI, FAPSC, FAPSIC Associate Professor of Cardiology National Institute of Cardiovascular Diseases(NICVD), Dhaka [email protected] Key Messages: Key Messages Above 115/75 mmHg, CVD risk doubles with each BP increase of 20/10 mmHg Prehypertension SBP 120–139 mmHg DBP 80–89 mmHg Require health-promoting lifestyle modifications to prevent CVD Patient involvement is key [email protected] Key Messages: Key Messages Thiazide-type diuretics should be included in initial drug therapy for most Compelling indications for other drug classes remain in the guideline Most patients require two or more drugs to achieve goal BP If BP is >20/10 mmHg above goal, initiate therapy with two agents [email protected] Patient Evaluation: Patient Evaluation Two consecutive blood pressure measurements Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guides treatment Reveal identifiable causes of high BP Assess the presence or absence of target organ damage and CVD [email protected] BP Measurement Techniques: BP Measurement Techniques Method Brief Description In-office Two readings, 5 minutes apart Sitting in chair, not on exam table Confirm elevated reading in contralateral arm Self-measurement Provides information on response to therapy May help improve adherence to therapy Evaluate “white-coat” HTN [email protected] BP Measurement Techniques: BP Measurement Techniques Method Brief Description In-office Two readings, 5 minutes apart. Sitting in chair, not on exam table. Confirm elevated reading in contralateral arm. Self-measurement Provides information on response to therapy. May help improve adherence to therapy and evaluate “white-coat” HTN. Ambulatory BP monitoring Indicated for evaluation of “white-coat” HTN. Can be used to confirm self-measurement when inconsistent with in-office measurement. Reimbursable. http://hin.nhlbi.nih.gov/nhbpep_slds/menu.htm; Accessed October 20, 2003; 8:15AM [email protected] Self-Measurement of BP: Self-Measurement of BP Improves awareness and adherence Instruction on proper use and technique should be provided Home measurement devices should: Have an arm cuff Be checked in office regularly Validated meters: BMJ 2001;322:531-536. omronhealthcare.com Daily Logs Self-Measurement of BP: Self-Measurement of BP Home measurements of >135/85 mmHg (or 125/75 in diabetes or renal disease) are considered hypertensive At least 50% of measurements should be at or below goal [email protected] Blood Pressure Classification: Blood Pressure Classification BP Classification SBP mmHg* DBP mmHg Lifestyle Modification Drug Therapy** Normal <120 and <80 Encourage No Prehypertension 120-139 or 80-89 Yes No Stage 1 Hypertension 140-159 or 90-99 Yes Single Agent Stage 2 Hypertension ≥ 160 or ≥ 100 Yes Combo JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314 *Treatment determined by highest BP category; **Consider treatment for compelling indications regardless of BP [email protected] Why Prehypertension?: Why Prehypertension? Patients normotensive at age 55 have a 90% lifetime risk to develop HTN Joint National Committee on Prevention , Detection, Evaluation, and Treatment of High Blood Pressure Prehypertensive: 120–139 / 80–89 mmHg Require health-promoting lifestyle modifications to prevent CVD Public health goal: Prevent hypertension and cardiovascular disease before it happens [email protected] Causal Factors for Hypertension: Causal Factors for Hypertension Excess body weight 122 million Americans are overweight or obese Excess dietary sodium Mean intake: Men 4100 mg; Women 2750 mg 75% from processed foods Reduced physical activity Inadequate fruit, vegetable and potassium intake Excess alcohol consumption Hypertension 2003;289:2560-2572 . [email protected] Lifestyle Modification: Lifestyle Modification Modification Approximate SBP Reduction (range) Weight reduction 5-20 mmHg/ 10 kg weight loss Adopt DASH eating plan 8-14 mmHg Dietary sodium reduction 2-8 mmHg Physical activity 4-9 mmHg Moderation of alcohol consumption 2-4 mmHg JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314 [email protected] Impact of a 5 mmHg Reduction: Impact of a 5 mmHg Reduction Overall Reduction Stroke 14% Coronary Heart Disease 9% All Cause Mortality 7% Hypertension 2003;289:2560-2572 . [email protected] Public Health Strategy: Lower Sodium: Public Health Strategy: Lower Sodium Healthy eating options are less available Foods with lower sodium and calories are higher in cost American Public Health Association and National High Blood Pressure Education Program Food industry including manufacturers and restaurants should reduce sodium in the food supply by 50% over the next 10 years [email protected] PowerPoint Presentation: D ietary A pproaches to S top H ypertension Lowers systolic BP in normotensive patients by an average of 3.5 mm Hg In hypertensive patients by 11.4 mm Hg Copies available from NHLBI website / [email protected] DASH Eating Plan: DASH Eating Plan Low in saturated fat, cholesterol, and total fat Emphasizes fruits, vegetables, and low fat diary products Reduced red meat, sweets, and sugar containing beverages Rich in magnesium, potassium, calcium, protein, and fiber 3 -1.5 g sodium per day Can reduce BP in 2 weeks Sacks FM. NEJM. 2001; 344:3-10. [email protected] Changes in BP Classification: Changes in BP Classification Hypertension 2003;289:2560-2572 . [email protected] Blood Pressure Classification: Blood Pressure Classification BP Classification SBP mmHg* DBP mmHg Lifestyle Modification Drug Therapy** Normal <120 and <80 Encourage No Prehypertension 120-139 or 80-89 Yes No Stage 1 Hypertension 140-159 or 90-99 Yes Single Agent Stage 2 Hypertension ≥ 160 or ≥ 100 Yes Combo JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314 *Treatment determined by highest BP category; **Consider treatment for compelling indications regardless of BP [email protected] "The Goal is to Get to Goal!”: "The Goal is to Get to Goal!” Hypertension -PLUS- Diabetes or Renal Disease < 140/90 mmHg < 130/80 mmHg [email protected] "The Goal is to Get to Goal!”: "The Goal is to Get to Goal!” Hypertension -PLUS- Diabetes or Renal Disease < 140/90 mmHg < 130/80 mmHg Measurements and goals should be provided to the patient verbally and in writing at each office visit [email protected] Treatment Overview: Treatment Overview Lifestyle modification Same as for prevention Pharmacologic treatment Initial therapy Combination therapy What to do when a patient is still not at goal? Follow-up and monitoring [email protected] Algorithm for Treatment of Hypertension: Algorithm for Treatment of Hypertension Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. With Compelling Indications Lifestyle Modifications Stage 2 HTN (SBP > 160 or DBP > 100 mm Hg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) Stage 1 HTN (SBP 140 –159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Without Compelling Indications JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314 Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist. [email protected] Is it appropriate to start 2 agents?: Is it appropriate to start 2 agents? In ALLHAT, 60% of patients achieved SBP control The mean number of drugs to achieve BP control was 1.6 Inadequate titration of drug regimens is a primary reason patients do not reach BP goal Patients and providers should be educated that more than one antihypertensive is the norm not the exception [email protected] Low Dose Combinations: Low Dose Combinations Meta-analysis of 354 randomized trials of antihypertensives: BB, ACEI, ARB, & CCB Dose of each agent expressed as a multiple of a standard dose n=56,000 patients Placebo adjusted reductions in SBP and DBP Prevalence in adverse effects based on dose Law MR et al. BMJ. 2003; 326:1427 [email protected] Low Dose Combinations: Low Dose Combinations All five drug categories produced similar BP reductions Blood pressure reduction achieved with half standard dose was only 20% lower than standard dose Law MR et al. BMJ. 2003; 326:1427 [email protected] Low Dose Combinations: Low Dose Combinations BP lowering effects from different drug categories were additive Law MR et al. BMJ. 2003; 326:1427 19.9 [email protected] Low Dose Combinations: Low Dose Combinations Adverse effects in all drug categories, except ACEI, were dose related Prevalence of adverse effects in combination was less than additive Conclusion: Utilization of low dose combination therapy can effectively reduce blood pressure while limiting the incidence of side effects Law MR et al. BMJ. 2003; 326:1427 [email protected] Algorithm for Treatment of Hypertension: Algorithm for Treatment of Hypertension Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. With Compelling Indications Lifestyle Modifications Stage 2 HTN (SBP > 160 or DBP > 100 mm Hg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) Stage 1 HTN (SBP 140 –159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Without Compelling Indications JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314 Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist. [email protected] Compelling Indications for Individual Drug Classes: Compelling Indications for Individual Drug Classes Compelling Indication Initial Therapy Options Clinical Trial Basis Heart failure THIAZ, BB, ACEI, ARB, ARA ACC/AHA Heart Failure Guideline, MERIT-HF, COPERNICUS, CIBIS, SOLVD, AIRE, TRACE, ValHEFT, RALES Postmyocardial infarction BB, ACEI ACC/AHA Post-MI Guideline, BHAT, SAVE, Capricorn, EPHESUS High CAD risk THIAZ, BB, ACEI, CCB ALLHAT, HOPE, ANBP2, LIFE, CONVINCE [email protected] Compelling Indications for Individual Drug Classes: Compelling Indications for Individual Drug Classes Compelling Indication Initial Therapy Options Clinical Trial Basis Diabetes ACEI, ARB, CCB, THIAZ, BB, NKF-ADA Guideline, UKPDS, ALLHAT Chronic kidney disease ACEI, ARB NKF Guideline, Captopril Trial, RENAAL, IDNT, REIN, AASK Recurrent stroke prevention THIAZ, ACEI PROGRESS [email protected] "The Goal is to Get to Goal!”: "The Goal is to Get to Goal!” Hypertension -PLUS- Diabetes or Renal Disease < 140/90 mmHg < 130/80 mmHg Patients should return for follow-up and adjustment of medications every 1-2 months until the BP goal is reached [email protected] When a Patient is Still Not at Goal?: When a Patient is Still Not at Goal? Optimize dosages or add additional drugs until goal blood pressure is achieved What do you do when you are using several effective medications? Consider causes of resistant hypertension Assure drug therapy is rational “Tricks of the trade” [email protected] Identifiable Causes of Hypertension: Identifiable Causes of Hypertension Sleep apnea Drug-induced or related causes Chronic kidney disease Primary aldosteronism Renovascular disease Chronic steroid therapy and Cushing’s syndrome Pheochromocytoma Coarctation of the aorta Thyroid or parathyroid disease JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314 [email protected] Causes of Resistant Hypertension: Causes of Resistant Hypertension Improper BP measurement Excess sodium intake Inadequate diuretic therapy Medication Inadequate doses Drug actions and interactions: Nonsteroidal antiinflammatory drugs (NSAIDs), illicit drugs, sympathomimetics, oral contraceptives Over-the-counter ( OTC) drugs and herbal supplements Excess alcohol intake Identifiable causes of HTN JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314 [email protected] Drug-Induced Hypertension: Prescription Medications: Drug-Induced Hypertension: Prescription Medications Steroids Estrogens NSAIDS Phenylpropanolamines Cyclosporine/tacrolimus Erythropoietin Sibutramine Methylphenidate Ergotamine Ketamine Desflurane Carbamazepine Bromocryptine Metoclopramide Antidepressants Venlafaxine Buspirone Clonidine [email protected] COX-2 Inhibitors and NSAIDs: COX-2 Inhibitors and NSAIDs Inhibition of cyclooxygenase, inhibits prostaglandin synthesis that normally maintains afferent arteriole vasodilatation Afferent vasoconstriction decreases renal perfusion → increased BP Increasing salt and water retention Increasing rennin release COX-1 is thought to be primary enzyme responsible for renal vasodilatory prostaglandins [email protected] COX-2 Inhibitors and NSAIDs: COX-2 Inhibitors and NSAIDs However, COX-2 inhibitors are no less likely to increase BP than other NSAIDS Case reports of severe increases in BP exists in patients after one dose or more typically after 4 weeks for regular usage Consider scheduled acetaminophen as an alternative to NSAIDs in patients with difficult to manage hypertension Drugs Aging. 2004; 21:479-84; JAMA. 2001; 286:954-59 [email protected] Drug-Induced Hypertension: Street Drugs and Herbal Products: Drug-Induced Hypertension: Street Drugs and Herbal Products Cocaine Ma huang “herbal ecstasy” Nicotine Anabolic steroids Narcotic withdrawal Methylphenidate Phencyclidine Ketamine Ergot-containing herbal products St John’s wort [email protected] Substances Associated with HTN : Substances Associated with HTN Food Substances Sodium Chloride Ethanol Licorice Tyramine-containing foods (with MAOI) Chemicals Lead Mercury Thallium and other heavy metals Lithium salts [email protected] Rational Combination Therapy: Chinese Menu Approach: Rational Combination Therapy: Chinese Menu Approach [email protected] Algebra of Blood Pressure: Algebra of Blood Pressure BP = Cardiac Output x SVR CO = HR x Stroke Volume ↓ BP = HR x Stroke Volume x SVR [email protected] Physiologic Components of BP: Heart HR Arteries SVR Veins Stroke Volume Physiologic Components of BP [email protected] Thiazide Diuretics: Thiazide Diuretics Thiazides Veins Mechanism: inhibit Na/K pumps in the distal tubule Examples: Hydrocholorthiazide 12.5-25 mg daily Chlorthalidone 12.5-50 mg daily Effective first line agent and provides synergistic benefit As single agent more effective if CrCl >30 ml/min Compelling indications: HF, High CAD risk, Diabetes, Stroke, ISH [email protected] Loop Diuretics: Loop Diuretics Thiazides Loops Veins Mechanism: Inhibit Na/K/Cl ATPase in ascending loop of henle Examples: Furosemide 20 mg BID Typically only beneficial in patients with resistant HTN and evidence of fluid; effective if CrCl <30 ml/min MUST be dosed at least twice daily (Lasix = Lasts six hours) Administer AM and lunch time to avoid nocturia [email protected] Aldosterone Receptor Antagonists: Aldosterone Receptor Antagonists Thiazides Loops Aldosterone Ant. Veins Mechanism: inhibit aldosterone’s effect at the receptor, reducing Na and water retention Examples: Spironolactone 25 mg daily Can provide as much as 25 mmHg BP reduction on top of 4 drug regimen in resistant hypertension Monitor SCr and K Compelling indications: HF Am J Hypertension. 2003; 16:925-930. [email protected] Nitrates: Nitrates Thiazides Loops Aldosterone Ant. Nitrates Veins Mechanism: Direct venodilation by release of nitric oxide Examples: Isosorbide dinitrate 10 mg TID IMDUR 30 mg daily In renal patients with resistant hypertension addition to 3-4 drug regimen may help get patient to goal Provide 8h nitrate free interval daily Compelling indications: Angina [email protected] ACEI & ARB’s: ACEI & ARB’s Thiazides Loops Aldosterone Ant. Nitrates ACEI ARB Veins Mechanism: Inhibit vasoconstriction by inhibiting synthesis or blocking action of angiotensin II; provides balanced vasdilation Examples: Enalapril 2.5-40 mg daily –BID Lisinopril 5 – 40 mg daily Irbesartan 150-300 mg daily Losartan 25-100 mg Daily - BID Monitor: SCr, K Compelling indications: HF, post-MI, High CAD risk, Diabetes, CKD, Stroke [email protected] Beta Blockers: Beta Blockers Beta Blockers Heart Mechanism: Competitively inhibit the binding of catecholamines to beta-adrenergic receptors Examples: Atenolol 25-100 mg PO daily Metoprolol 25 -100 mg PO daily or BID Carvedilol 6.25-25 mg PO BID Monitor: HR, Blood Glucose in DM Not contraindicated in asthma or COPD but use caution Compelling indications: HF, post-MI, High CAD risk, Diabetes [email protected] Diltiazem and Verapamil: Diltiazem and Verapamil Beta Blockers Diltiazem Verapamil Heart Mechanism: Decrease calcium influx into cells of vascular smooth muscle and myocardium Examples: Diltiazem 60-480mg q6h to daily Verapamil 60-480 q8h to daily Monitor: HR Verapamil causes constipation Relatively contraindicated in heart failure Compelling indications: Diabetes, High CAD risk [email protected] Alpha2 Agonists: Central Acting Agents: Alpha 2 Agonists: Central Acting Agents Beta Blockers Diltiazem Verapamil Via Central Mechanism: Clonidine Heart Mechanism: false neurotransmitters reduce sympathetic outflow reducing sympathetic tone Examples: Clonidine 0.1-0.6 mg PO BID-TID; patch Methyldopa, Guanabenz, Guanfacine Monitor: HR Side effects often limiting: Dry mouth, orthostasis, sedation Clonidine patch can be useful in elderly patients with labile blood pressure Withdrawal: real at doses > 0.3 mg [email protected] Dihydropyridine Calcium Channel Blockers: Dihydropyridine Calcium Channel Blockers Dihydropyridine CCBs Arteries Mechanism: Decrease calcium influx into cells of vascular smooth muscle Examples: Amlodipine 2.5-10 mg PO daily Felodipine2.5-10 mg PO daily Do not use immediate release nifedipine Monitor: Peripheral edema, HR (can cause reflex tachycardia) Good add on agent if cost is not an issue [email protected] Vasodilators: Vasodilators Dihydropyridine CCBs Hydralazine Minoxidil Arteries Mechanism: Direct vasodilation of arterioles via increased intracellular cAMP Examples: Hydralazine 20-400 mg BID-QID Minoxidil 2.5-40 mg PO daily-BID Monitor: HR (can cause reflex tachycardia), Na/Water retention Hydralazine is an alternative in HF if ACEI contraindicated Consider minoxidil in refractory patients on multi-drug regimens [email protected] Alpha1 Blockers: Alpha 1 Blockers Dihydropyridine CCBs Hydralazine Minoxidil Alpha 1 Blockers Arteries Mechanism: Inhibit peripheral post-synaptic alpha1 receptors causing vasodilation Examples: Terazosin 1 – 20 mg daily Doxazosin 1 – 16 mg daily Cause marked orthostatic hypotension, give dose at bedtime Consider only as add on therapy Can be beneficial in patients with BPH [email protected] ACEI & ARB’s: ACEI & ARB’s Dihydropyridine CCBs Hydralazine Minoxidil Alpha 1 Blockers ACEI ARB Arteries Mechanism: Inhibit vasoconstriction by inhibiting synthesis or blocking action of angiotensin II; provides balanced vasdilation Examples: Enalapril 2.5-40 mg daily –BID Lisinopril 5 – 40 mg daily Irbesartan 150-300 mg daily Losartan 25-100 mg Daily - BID Monitor: SCr , K Compelling indications: HF, post-MI, High CAD risk, Diabetes, CKD, Stroke [email protected] Pharmacologic Sites of Action: Pharmacologic Sites of Action Thiazides Loops Aldosterone Ant. Nitrates ACEI ARB Beta Blockers Diltiazem Verapamil Via Central Mechanism: Clonidine Dihydropyridine CCBs Hydralazine Minoxidil Alpha 1 Blockers ACEI ARB Heart Arteries Veins [email protected] Chinese Menu Approach: Chinese Menu Approach Thiazides Loops Aldosterone Ant. Nitrates ACEI ARB Beta Blockers Diltiazem Verapamil Via Central Mechanism: Clonidine Dihydropyridines Hydralazine Minoxidil Alpha 1 Blockers ACEI ARB Heart Arteries Veins Choose one agent from each category [email protected] Algorithm for Treatment of Hypertension: Algorithm for Treatment of Hypertension Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. With Compelling Indications Lifestyle Modifications Stage 2 HTN (SBP > 160 or DBP > 100 m mHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) Stage 1 HTN (SBP 140 –159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Without Compelling Indications Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist. JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314 [email protected] Summary: Summary Lifestyle modifications are important for the prevention of hypertension The goal is to get to goal: Initial therapy with a thiazide is indicated for most Consider compelling indications Initiate low dose combination therapy if BP >20/10 mmHg above goal Consider the physiologic site of action of agents when choosing combination therapy [email protected]

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