2017Hypertension - PowerPoint Presentation

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2017Hypertension

Update

J. Paul Martin, MDSlide2
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NC State

Ctr for Hlth Stats

WNC Higher Than the National Ave.

Hypertension

Diabetes

Elevated Cholesterol

ObesitySlide8

Hypertension

WNC Higher Than the National Ave.

1 in 3 Adults in US have HTNOur local HRA’s found >50% HTN in several employee groups

55 YO with normal BP has 90% chance of developing HTN during lifetime

<50% of those treated reach goalSlide9

Joint National Committee

US Dept. of Health and Human Services

National Institutes of Health

National Heart, Lung, and Blood Institute

JNC 1 – 1976 normal diastolic <90

JNC 3 – 1984 normal systolic < 140

isolated systolic

htn

>160

JNC 7 – 2003 normal < 120/80

JNC 8 – December 2013 normal <120/80

On Prevention, Detection, Evaluation

And Treatment of High Blood Pressure (JNCOPDEATOHBP8)Slide10

BP Classification (JNC-8)

Normal < 120/80

Pre-hypertensive – 120-139/80-89Hypertension >140/90Stage 1: 140-159/90-99Stage 2: >

160/100Slide11

Other Advisory Groups

American Diabetes Association

American Society of Hypertension /International Society of Hypertension

European Society of Hypertension/ European Society of CardiologySlide12

Proper BP MeasurementSlide13

Proper BP Measurement

Locate brachial artery on inner upper arm

Place the middle of the cuff over the brachial artery. The lower edge of the cuff should be 1” above the antecubital space.Tell the patient not to talkDetermine the maximum inflation point by palpating the radial artery and rapidly inflating cuff (palpated systolic). To that add 30 mm HgSlide14

Proper BP Measurement

Deflate cuff rapidly and wait 15 – 30 seconds before re-inflating.

Apply the stethoscope bell lightly over the palpated brachial arteryInflate cuff rapidly to palpable systolic pressure + 30 mm Hg

Release the air so pressure drops 3 mm Hg/secSlide15

Proper BP Measurement

Listen for at least two consecutive beats (

Korotkoff sounds Phase 1) i.e. the systolic BP Listen for a muffling of the sounds in children or the absence of the sounds in adults (Korotkoff sounds Phase 4 or 5). This is the diastolic BP

Continue listening for an additional deflation of 10 – 20 mm Hg to confirm findings.

Don’t repeat for 1-2 minutes to allow trapped blood to be released from veins.Slide16

Proper BP Measurement

Total Time:

5 minutes sitting30 seconds to apply & palpate systolic BP30 seconds wait45 seconds to re -inflate & slowly deflate

Total Time approx. 7 minutesSlide17

Treatment of high blood pressure

Decrease risk of stroke 35-40%

Decrease risk of heart attack 20 – 25%Decrease risk of CHF > 50%

WHY?Slide18

Treatment of high blood pressure

In stage 1 HTN and additional CVD risk factors, achieving a sustained 12 mmHg reduction in SBP over 10 years will prevent 1 death for every 11 patients treated.Slide19

Treatment of high blood pressure

>

60 yrs of age systolic BP is major predictor of coronary artery disease50-59 systolic and diastolic BP are equal predictors of coronary artery disease< 50 Y/O diastolic BP is major predictor of coronary artery diseaseSlide20

Treatment of high blood pressure

What is the target?

Slide21

BP Treatment Recommendations

Joint National Committee

Normal < 120/80Pre-hypertensive – 120-139/80-89NOT a disease category

It IS a risk categorySlide22

Treatment of high blood pressure

What is the target?

Slide23

Treatment of high blood pressure

What is the target?

< 140/90 Slide24

Treatment of high blood pressure

What is the target?

< 140/90 …..with some caveats JNC-8

Slide25

Definitions

CVD – Cardiovascular Disease PVD – Peripheral Vascular Disease

CBVD –

Cerebrovascular

Disease

CAD – Coronary Artery Disease RVD – Renal Vascular Di

sease

Slide26

Definitions

Uncontrolled BP (>140/90 mmHg) despite:

the use of 3

antihypertensives

including a diuretic =

Resistant Hypertension

the use of 5

antihypertensives

including long-acting thiazide and mineralocorticoid receptor antagonist =

Refractory Hypertension

Slide27

Joint National Committee

JNC 1 – 1976

Thiazides

for DBP

>

105

JNC 3 – 1984 ß-Blockers added as initial therapy option

JNC 4 – 1988 ACEI and CBB added as initial therapy options (despite no RCT’s)

JNC 5 – 1993 Evidence-based:

Thiazides

and

ß-Blockers preferred initial agents

JNC 6 – 1997 Any of the seven classes could

be appropriate initial option

Slide28

JNC 7 - 2003

Thiazides

as initial therapy for “most”

ACEI, ARBs, CCBs,

ß-Bs appropriate first line in those with compelling indication

Stage 2 hypertensives

(

> 160/100) should be started on two medications (one a thiazide)

BP target for high-risk CVD

<

130/80

Slide29

JNC 7 - 2003

Thiazides

as initial therapy for “most”

ACEI, ARBs, CCBs,

ß-Bs appropriate first line in those with compelling indication

Stage 2 hypertensives

(

> 160/100) should be started on two medications (one a thiazide)

BP target for high-risk CVD

<

130/80

Slide30

JNC 8 - 2013

The JNC-8 guidelines provide practice guidance for patients aged ≥18 years across a number of pre-specified subgroups, such as diabetes, chronic kidney disease, CVD, older adults, sex, racial and ethnic groups, and smokers.

Slide31

What constitutes good care?How important is diet, exercise, weight control?

What medications are available?Which ones actually work?How low should you go?Slide32

Diet, Exercise, & Weight Management Slide33
Slide34

Diet, Exercise, & Weight Management Slide35

Treatment of high blood pressure

Diet 8-14 mmHg

Exercise 4-9 mmHgWeight control 5-20 mmHg/10KgDietary

NaCl

2-8 mmHg

Magnesium 2-3 mmHg

Approx SBP reductionSlide36

Diet, Exercise, Weight ManagementSlide37

Primary Prevention of HTN

Calcium supplementation, fish oil,

reduction of caffeine: Prudent for general health

Minimal effect on lowering BP or preventing HTNSlide38

Primary Prevention of HTN

Drugs which may induce hypertension:

Adrenal SteroidsOral ContraceptivesNSAIDSStimulants

SympathomimeticsSlide39

Primary Prevention of HTN

While caffeine can acutely increase BP, studies have not shown a linear relationship between caffeine intake and incident

morbidity To judge effect of caffeine on your BP, measure BP 30-60 minutes after intake.Slide40

What constitutes good care?

How important is diet, exercise, weight control?What medications are available?Which ones actually work?How low should you go?Slide41

MedicationsSlide42

MedicationsSlide43

Medications

Thiazides

Beta BlockersACEI / ARBsCalcium Channel BlockersMineralocorticoid Receptor Antagonists

Alpha 2 Adrenergic Agonists

Alpha 1 Adrenergic Receptor Blockers

Direct VasodilatorsSlide44

Medications -

Thiazides

JNC-7 - Thiazide Diuretics should be initial hydrochlorothiazide (hctz),

chlorthalidone

,

indapamide

Most patients will require more

than one medication to reach

their BP goalSlide45

Medications -

Thiazides

Hydrochlorothiazide doses > 25mg/d are seldom justifiable based on published evidence of outcomes & adverse effectsLong acting thiazides such as chlorthalidone

and

indapamide

are indicated in resistant or refractory hypertensionSlide46

Medications -

ThiazidesSlide47

Medications -

Thiazides

Thiazides may induce glucose intolerance Keep Potassium > 4.0 mEq/L (consider

KCl

,

ACEI, ARB, triamterene

,

amiloride

, spironolactone)

Prior Stroke –

Thiazide

& ACEI

In HYVET (age >80)

indapamide

+ ACEI

21% decrease in all cause mortality

30% reduction in CVA

64% reduction in CHFSlide48

Medications -

Thiazides

Reduce excretion of:Calcium (fewer Ca++

kidney stones)

Uric Acid ( increasing risk of gout)

Lithium (increasing risk of toxicity)

Increase excretion of

:

Potassium

MagnesiumSlide49

Medications -

Thiazides

NaCl restriction enhances response to thiazides

High Dietary salt intake offsets responseSlide50

Medications – Loop Diuretics

Thiazide diuretics typically considered ineffective when GFR < 30-40 ml/min (except

metolazone-Zaroxyln)Substitute furosemide or torsemide

(loop diuretics)Slide51

Medications – Loop DiureticsSlide52

Beta Blockers have fallen from grace as single agents in HTN except in patients with CAD (?)

Atenolol should be given BIDAvoid Beta Blockers in

Prinzmetal AnginaJAMA Oct 3, 2012 45,000 patient observation – no lower risk of composite CV events with Beta Blockers even in patients s/p MI (distant) – REACH study

Medications – Beta BlockersSlide53

Medications – Beta Blockers

Older beta-blockers (propranolol, atenolol, metoprolol) worsen insulin resistance

The vasodilating beta-blockers (carvedilol, labetolol,

nebivolol

) don’t have this effect

Slide54

Medications – Beta Blockers

Cochrane Database

Syst Rev 2007 RCTs assessing the effectiveness of beta blockers

compared to placebo, no therapy or other drug classes,

as

monotherapy

or first-line therapy for HTN, on

morbidity and mortality endpoints

13 RCTs; 91,561 subjects

Available evidence does not support the use of beta blockers as first-line agents in HTN treatmentSlide55

Medications – Beta Blockers

Bisoprolol

(Zebeta), carvedilol (

Coreg

) and sustained-release

metoprolol

(

ToprolXL

) are specifically indicated as adjuncts to standard ACE inhibitor and diuretic therapy in congestive heart failure.

Slide56

Medications – Beta Blockers

Rebound Hypertension

Short –acting

β

-blockers such as:

Propranolol

Atenolol

Metroprolol

Rapid disappearance of

β-

blockade

-Loss of protection against ischemia

-Loss of antihypertensive effect

-Subsequent enhanced

β-

receptor mediated responsesSlide57

Medications – Beta Blockers

Rebound Hypertension

Short –acting

β

-blockers such as:

Propranolol

Atenolol

Metroprolol

Rapid disappearance of

β-

blockade

-Loss of protection against ischemia

-Loss of antihypertensive effect

-Subsequent enhanced

β-

receptor mediated responses

Partial compliance with

β

-blocker treatment is

Associated with increased risk of sudden death Slide58

Medications ACEI/ARBs

ACE Inhibitors (

benazepril, enalapril, lisinopril)

ARB (losartan,

irbesartan

, candesartan, valsartan)

Cough,

angioedema

,

hyperkalemia

, ARF

ONTARGET – no benefit combining

- led to increased renal impairmentSlide59

Medications ACEI/ARBs

ACE Inhibitors, ARBs and Aldosterone Inhibitors all lessen insulin resistanceSlide60

African Americans & ACEI/ARBs

Htn

is commonly of low renin typeSensitivity of blood pressure to salt intake is often increased

The

ability to excrete ingested salt is impaired (60–70

%)

This leads to an overall expansion of intravascular volume.

Obesity

is especially prevalent in black women and is associated with an increase in total body sodium content

.

Intake of dietary potassium, in the form of fruit and vegetables, is generally lower in blacks than in whites.

Black

patients may also have relatively higher concentrations of intracellular

calcium

Heart. 2005 Aug; 91(8): 1105–1109 “Management of Hypertension in Ethnic Minorities”Slide61

Medications ACEI/ARBsSlide62

Medications ACEI/ARBsSlide63

Medications ACEI/ARBs

Should be use in the population

> 18 yrs with CKD or DM to improve kidney outcomesThis is regardless of race

Do

NOT

use an ACEI and ARB togetherSlide64

Medications ACEI/ARBs

42 YO Asian female with HTN and type 2 DM has baseline serum Cr of 1.7 mg/

dL. Her BP is 147/92. She is started on lisinopril. Two weeks later her BP is 128/78. Her serum Cr = 2.1.

A repeat serum Cr 1 week later is unchanged.

Which is the most appropriate course of action? Slide65

Medications ACEI/ARBs

A.

Continue the lisinopril at the same dosage

B. Reduce the

lisinopril

dosage

C. Discontinue the

lisinopril

D. Switch to an ARB

E. Evaluate the patient for bilateral renal stenosisSlide66

Medications - CCBs

Dihydropyridines

(amlodipine, nifedipine

)

Non-

dihydropyridines

(

verapamil

,

diltiazem

)Slide67

Medications - CCBsSlide68

JNC 7 - 2003

Thiazides

as initial therapy for “most”

ACEI, ARBs, CCBs,

ß-Bs

appropriate first line in those with compelling indication

Stage 2 hypertensives (>160/100) should be started on two medications (one a thiazide)

BP target for high-risk CVD

<

130/80

Slide69

Medications for Compelling Indications

Htn & Stable Angina – beta blocker (?CCB)Htn & CHF – beta blocker & ACEI

Chronic Kidney Disease – ACEI or ARB

Diabetes – ACEI or ARB

Prior Stroke –

Thiazide

& ACEI

Slide70

JNC 8 - 2013

Thiazides ACEI, ARBs, CCBs,

appropriate first line based on physician/patient preference.Thiazides and calcium channel blockers are preferred for black patients because of improved cardiovascular and cerebrovascular outcomes, and more effective blood pressure reduction in this population

.

Slide71

JNC 8 - 2013

If after 30 days BP has not reached goal of <140/90 either the dose should be increased or a second drug added from initial list Slide72

JNC 8 - 2013

54 YO African American female presents for routine evaluation with BP 164/106

. Which antihypertensive meds would you initially consider?

Chlorthalidone

& Amlodipine

Lisinopril & Atenolol

Losartan (

Cozaar

) & Atenolol

Prazosin & Atenolol

Clonidine or

MinoxidilSlide73

Medications

Thiazides

Beta Blockers

ACEI / ARBs

Calcium Channel Blockers

Mineralocorticoid Receptor Antagonists

Alpha 2 Adrenergic Agonists

Alpha 1 Adrenergic Receptor Blockers

Direct VasodilatorsSlide74

Mineralocorticoid Receptor Antagonists

In resistant or refractory HTN consider spironolactone

In HTN associated with Obstructive Sleep Apnea consider spironolactone (

Aldactone

)

Eplerenone

(

Inspra

) is 6X as expensive – reserve for those requiring >50mg

spironolactone

with side effects

Slide75

Medications - SpironolactoneSlide76

Alpha-2 Adrenergic Agonists

Centrally-acting Clonidine (

Catapres

)

Guanfacine

(

Tenex

)

Methyldopa (

Aldomet

)

Dexmedetomidine

(

Precedex

),

Tizanidine

(

Zanaflex

)Slide77

Centrally-acting Alpha-2 Adrenergic Agonists

Slide78

Centrally-acting Alpha-2 Adrenergic Agonists

Slow heart rate / lower BPPotential for rebound HTN (esp. >1.2mg clonidine long term >2 months)Should be avoided in CHF – negative chronotropic and inotropic effects. Slide79

Centrally-acting Alpha-2 Adrenergic Agonists

Off Label

Chronic Pain (neurogenic/hypersensitivity)ADD/ADHDNarcotic WithdrawalBehavioral Issues Slide80

Alpha-1 Adrenergic Receptor Blockers

Peripheral

Doxazosin (Cardura

)

Prazosin

(

Minipress

)

Terazosin

(

Hytrin

)

Slide81

Peripherally-acting Alpha-1

Adrenergic Blockers

Slide82

Potpourri of Medication Updates

Direct Vasodilators

Hydralazine (

Apresoline

)

Minoxidil

Slide83

Medications

Thiazides

Beta Blockers

ACEI / ARBs

Calcium Channel Blockers

Mineralocorticoid Receptor Antagonists

Alpha 2 Adrenergic Agonists

Alpha 1 Adrenergic Receptor Blockers

Direct VasodilatorsSlide84

Treatment of high blood pressure

What is the target?

< 140/90 …..with some caveats

Slide85

JNC-8 Target for Age >60

<150/90

<140/90 if tolerated with no adverse effects and for those with high CV risk

Endorsed by ACP & AAFP 2017Slide86

JNC-8 Target for DM or CKD

<140/90 for all

> 18 yrs of age

Slide87

Treatment of high blood pressure

AHA 2007 guidelines: < 120/80

with LV DysfunctionCAD risk equivalents – PVD, AAA, Carotid Artery Disease

Slide88

Treatment of high blood pressure

ADA 2013 Clinical Practice

Recs:<140 SBP

<130 SBP may be appropriate for younger patients

Based on ACCORD study

Slide89

Can too low be bad?

In the elderly DBP<65 is potentially dangerous

For very elderly patients - Begin with a single drug

- Standing BP should be checked after 5 minutes

- SBP<130 & DBP<65 should be avoided

Slide90

Can too low be bad?

In the elderly DBP<65 is potentially dangerous

For elderly patients - Begin with a single drug

- Standing BP should be checked after 5 minutes

- SBP<130 & DBP<65 should be avoided

YESSlide91

Treatment of high blood pressure

What is the target?

< 140/90 …..with some caveats

Slide92

What constitutes good care?

How important is diet, exercise, weight control?What medications are available?Which ones actually work?

How low should you go?Slide93

JNC - 9

What Should We Expect?Slide94

JNC - 9

What Should We Expect?

It‘s tough to make predictions, especially about the future. Yogi BerraSlide95

JNC - 9

What Should We Expect?

SPRINT trial – target systolic 120 mmHg in nondiabetics

>

50 years.

25% lower HF/CVD & all cause mortality, Stopped due to benefit after 3.26 yrs.

N

Engl

J Med 2015:373:2103-16

Aggressive treatment of individuals with proteinuria to prevent ESRDSlide96

JNC - 9

What Should We Expect?

3. Aggressive treatment of individuals post-stroke & diabetesSlide97

What’s New

Renal Artery Denervation Slide98

Renal

Denervation

4 Trial (Phase III)Slide99

So What Do We Do Today?

Try to get most patients <140/90

Pts > 60 yrs w chronic volume depletion or susceptible to

orthostasis

<150/90 may be acceptable

Patients at high risk of CHF or CVA there appears to be benefit to decrease systolic BP to 120 with NNT of only 61 over 3

yr

period.

Slide100

Questions?Slide101

Hypertension Case Studies #1

39 YO White male with unremarkable PMH. Exam reveals an obese male with a round face and plethoric complexion.

BP 156/98 P=82 R=16/minProminent dorsal cervical and supraclavicular fat pads. Violaceous striae on trunkLab notable only for FBG = 114mg/dL

Slide102

Hypertension Case Studies #1Slide103

Hypertension Case Studies #1

What is most likely diagnosis?

A. Primary hyperaldosteronismB. PheochromocytomaC. HemochromatosisD. Cushing’s syndrome

E. Addison’s disease

Slide104

Hard to Treat Hypertension

Resistant Hypertension

Three or more medications including a diureticConsider switching to long-acting thiazideAdd Spironolactone Slide105

Hard to Treat Hypertension

Refractory Hypertension

Five or more medications including a long acting diuretic AND a mineralocorticoid receptor antagonistIn the context of normal renal perfusion, felt to be a neurogenic cause Slide106

Hypertension Case Studies #2

45 YO Female with

resistant HTN for f/u. Meds: hctz 25mg qd; lisinopril 40 mg BID; amlodipine 7.5 mg

qd

; simvastatin 40 mg

qd

PMHx

– chronic

htn

; prediabetes, LDL, 1-2 beers/d. Hypokalemia.

BP 156/98 P=82 R=16/min BMI 29.5

Serum aldosterone/plasma renin activity ratio of 31ng/

dL

per ng/mL/

hr

(

nl

<23.6)

Slide107

Hypertension Case Studies #2

What is most likely diagnosis?

A. Primary hyperaldosteronismB. PheochromocytomaC. HemochromatosisD. Alcohol Induced hypertension

E. Addison’s disease

Slide108

Resistant Hypertension Case Studies #2

Initially consider:

Nonadherence to medicationsDrug induced hypertensionWhite coat hypertensionInaccurate BP measurementsLifestyle issues (weight, Na, alcohol)Missed medical diagnoses

Slide109

Hypertension Case Studies #2

What is most likely to help?

A. Candesartan (Atacand)B. Diltiazem (Cardizem)C. Spironolactone (

Aldactone

)

D. Alcohol abstinence

E. Discontinuing simvastatin

Slide110

Hypertension Case Studies #3

52 YO White female avid scuba diver presents with stage 1 hypertension.

152/94 P=65 R=16/min BMI-23Regular exercise and history of mild hypercholesterolemia treated with diet.Given the following EKG which meds would be safe to use?Slide111

Hypertension Case Studies #3Slide112

Hypertension Case Studies #3

Amlodipine

DiltiazemAtenololClonidineChlorthalidoneACE-I / ARBSlide113

Hypertension Case Studies #4

68 YO African American male with presents with refractory hypertension presents with a history of slowly progressive confusion, irritability and forgetfulness over the last few weeks. He is otherwise active, walks his dog daily and has had no other health issues.

146/88 P=78 R=16/min BMI-27His labs including glucose, electrolytes, LFTs, CBC, are normal. Neurologic exam normal except cognitive slowing and poor short term memory.Which three of the following drugs

most likely

are contributing to his altered mental status?Slide114

Hypertension Case Studies #4

Methyldopa (

Aldomet)Propranolol (Inderal LA)

Nifedipine

(short acting)

Spironolactone

Chlorthalidone

Lisinopril

Slide115

Hypertension Case Studies #5

69 YO white female with BP 160/84.

Medical Hx notable for osteoporosis and calcium oxalate kidney stones. Which of the following drugs would be most appropriate for managing this patient’s hypertension?Slide116

Hypertension Case Studies #5

A. An ACE Inhibitor

B. An alpha-1 agonist C. A β-blockerD. A calcium channel blocker

E. A Thiazide diuretic

F. A mineralocorticoid receptor blocker

Slide117

2017Hypertension

Update

J. Paul Martin, MDSlide118

Studies

ACCORD

: Action to Control Cardiovascular Risk in Diabetes Trial 2008

– intensive BP management in diabetics didn’t improve outcome of nonfatal CV events

ALLHAT

:

Antihypertensive Lipid Lowering Treatment to Prevent Heart Attack Trial 2002

demonstrated that

chlorthalidone

is superior to ACEI, CCB, Alpha –blocker Slide119

Studies

3. HYVET

: HYpertension in the Very Elderly Trial 2008

– All cause mortality reduction 21%;

using

indapamide

/perindopril

3845 patients >80

yrs

w systolic BP

> 160

4. PROGRESS

:

Perindopril

pROtection

aGainst

REcurrent

Stroke Study 2001

demonstrated benefit of ACEI and a

thiazide

(

indapamide

).Slide120

Studies

REACH

: REduction of

Atherothrombosis

for Continued Health registry 45,000 patients:

JAMA

. 2012;308[13]:1340-1349

Among patients with either coronary artery disease (CAD) risk factors only, known prior heart attack, or known CAD without heart attack, the use of beta-blockers was not associated with a lower risk of a composite of cardiovascular events that included cardiovascular death, nonfatal heart attack or nonfatal stroke. Slide121

Studies

ONTARGET

: ONgoing

Telmisartan

Alone and in combination with

Ramipril

Global Endpoint Trial 2008:

Telmisartan

(

Micardis

) was equivalent to

ramipril

(

Altace

) with less

angioedema

. The combination provided no benefit, but more adverse effects.Slide122

Studies

ACCOMPLISH trial

: Avoiding Cardiovascular Events in Combination Therapy in Patients Living with Systolic Hypertension 2008

The

benazepril–amlodipine

combination was superior to the

benazepril

–hydrochlorothiazide combination in reducing cardiovascular events in patients with hypertension who were at high risk for such events. Slide123

Studies

COMMIT

: ClOpidogrel and Metoprolol

in Myocardial Infarction

Trial 2005 (China: 46,000

patients)

No benefit of

Metoprolol

over placebo to composite

of death,

cardiac arrest or

death from any cause during the scheduled treatment

period.