Hypertension

Prof.Dr.Medhat Ashmawy Professor of Cardiology, Tanta University Hypertension

Blood Pressure Classification JNC7 Normal <120 and <80 Prehypertension 120 – 139 or 80 – 89 Stage 1 Hypertension 140 – 159 or 90 – 99 Stage 2 Hypertension > 160 or > 100 BP Classification SBP mmHg DBP mmHg Diabetes/Kidney Dz > 130 or > 80

HTN is a real burden !!! 50 million hypertensive patients in the U.S.A. 30% of the population (> 25 years) are hypertensives in Egypt So the challenge is big

Why Hyp. Is a Risk Factor ? 1- Hyp. Increases workload over the heart. 2- LVH. 3- Increase shear and tear forces over the arterial wall increase the chance for deposition of lipids & Ca in aterial wall leading to atherosclerosis.

Patient Evaluation Evaluation of patients with documented HTN has three objectives : 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.

CVD Risk Factors Hypertension* Cigarette smoking Obesity* (BMI > 30 kg/m 2 ) Physical inactivity Dyslipidemia* Diabetes mellitus* Microalbuminuria or estimated GFR <60 ml/min Age (older than 55 for men, 65 for women) Family history of premature CVD (men under age 55 or women under age 65) *Components of the metabolic syndrome.

Target Organ Damage Heart Left ventricular hypertrophy Angina or prior myocardial infarction Prior coronary revascularization Heart failure Brain Stroke or transient ischemic attack Chronic kidney disease Peripheral arterial disease Retinopathy

Physical Exam BP in both arms Funduscopic Thyroid Cardiovascular - Auscultation, Carotids, Pulses Pulmonary Abdomen - Bruits, AAA, masses Extremities Neurological

Laboratory Tests Routine ECG Urinalysis Blood Glucose Hematocrit, potassium, calcium, creatinine (or eGFR) Lipid profile (9-12 hour fast) Optional Urine albumin excretion or albumin/creatinine ratio More extensive testing not generally indicated unless BP control not obtained or secondary HTN suspected

European guidelines 2007 Journal of Hypertension 2007, Vol 25 No 6

Stratification of CV Risk in four categories Journal of Hypertension 2007, Vol 25 No 6

Factors influencing prognosis 1- Risk factors Electrocardiographic LVH (Sokolow-Lyon ) Levels of pulse pressure (in the elderly) LVMI by echo Age (M>55 years; W>65 years) . Carotid wall thickening (IMT>0.9 mm) or plaque Carotid-femoral pulse wave velocity >12 m/s Dyslipidaemia Journal of Hypertension 2007, Vol 25 No 6

Low estimated glomerular filtration ratey (<60 ml/min/1.73m2) or creatinine clearance^ (<- TG>1.7 mmol/l (150 mg/dl) 60 ml/min) Fasting plasma glucose 5.6–6.9 mmol/L (102–125 mg/dl) Microalbuminuria 30–300 mg/24 h or albumin-creatinine ratio: Abnormal glucose tolerance test 22 (M); or 31(W) mg/g creatinine Abdominal obesity (Waist circumference>102cm (M), >88cm (W)) Family history of premature CV disease (M at age <55 years; W at age<65 years) Journal of Hypertension 2007, Vol 25 No 6

Established CV or renal disease Cerebrovascular disease: ischaemic stroke; cerebral haemorrhage; transient ischaemic attack. Heart disease: myocardial infarction; angina; coronary Revascularization. Heart failure Renal disease “proteinuria” > 300 mg/24 h. Peripheral artery disease Advanced retinopathy. Journal of Hypertension 2007, Vol 25 No 6

Physical examination for secondary hypertension, organ damage and visceral obesity Signs suggesting secondary hypertension and organ damage Features of Cushing syndrome Skin stigmata of neurofibromatosis (phaeochromocytoma) Palpation of enlarged kidneys (polycystic kidney) Auscultation of abdominal murmurs (renovascular hypertension) Auscultation of precordial or chest murmurs (aortic coarctation or aortic disease) Diminished and delayed femoral pulses and reduced femoral BP (aortic coarctation, aortic disease) Journal of Hypertension 2007, Vol 25 No 6

Signs of organ damage Brain: murmurs over neck arteries, motor or sensory defects Retina: fundoscopic abnormalities Heart: location and characteristics of apical impulse, abnormal cardiac rhythms, ventricular gallop, pulmonary rales, peripheral oedema Peripheral arteries: absence, reduction, or asymmetry of pulses, cold extremities, ischaemic skin lesions Carotid arteries: systolic murmurs Journal of Hypertension 2007, Vol 25 No 6

Evidence of visceral obesity Body weight Increased waist circumference (standing position) M: > 102 cm; F: > 88 cm Increased body mass index [body weight (kg)/ height (m)2] Overweight 25 kg/m2; Obesity 30 kg/m2 Journal of Hypertension 2007, Vol 25 No 6

Laboratory investigations Routine tests Fasting plasma glucose Serum total cholesterol, Serum LDL- cholesterol, Serum HDL-cholesterol, Fasting serum triglycerides. Serum potassium, Serum uric acid. Haemoglobin and haematocrit Journal of Hypertension 2007, Vol 25 No 6

Initiation of antihypertensive treatment Journal of Hypertension 2007, Vol 25 No 6

Despite use of combination treatment, reducing systolic BP to < 140mmHg may be difficult and more so if the target is a reduction to < 130mmHg. Additional difficulties should be expected in elderly and diabetic patients, and, in general, in patients with cardiovascular damage. Journal of Hypertension 2007, Vol 25 No 6

Causes of resistant hypertension Poor adherence to therapeutic plan Failure to modify lifestyle. Continued intake of drugs that raise blood pressure(liquorice, cocaine, glucocorticoids, non-steroid anti-inflammatory drugs, etc.) Obstructive sleep apnea Unsuspected secondary cause Irreversible or scarcely reversible organ damage Volume overload due to: inadequate diuretic therapy, progressive renal insufficiency ,high sodium intake, hyperaldosteronism Journal of Hypertension 2007, Vol 25 No 6

Patients’ follow-up Titration to BP control requires frequent visits in order to timely modify the treatment regimen in relation to BP changes and appearance of side effects. Once target BP has been obtained, the frequency of visits can be considerably reduced. However, excessively wide intervals between visits are not advisable because they interfere with a good doctor-patient relationship, which is crucial for patient’s compliance. Journal of Hypertension 2007, Vol 25 No 6

Patients’ follow-up Patients at low risk or with grade 1 hypertension may be seen every 6 months . Follow-up visits should aim at maintaining control of all reversible risk factors as well as at checking the status of organ damage. Journal of Hypertension 2007, Vol 25 No 6

Goal of Hypertension Prevention and Management To reduce morbidity and mortality by the least intrusive means possible. This may be accomplished by achieving and maintaining: SBP < 140 mm Hg DBP < 90 mm Hg controlling other cardiovascular risk factors

Algorithm forTreatment of Hypertension Continue adding agents from other classes. Consider referral to a hypertension specialist. Not at Goal Blood Pressure Substitute drug from different class Not at Goal Blood Pressure Initial Drug Choices Not at Goal Blood Pressure Begin or Continue Lifestyle Modifications No response or troublesome side effects Inadequate response but well tolerated Add agent from different class

Algorithm for Treatment of Hypertension (continued) Not at Goal Blood Pressure Begin or Continue Lifestyle Modifications Lose weight Limit alcohol Increase physical activity Reduce Sodium Maintain potassium Maintain calcium and magnesium Stop smoking Reduce saturated fat, cholesterol

Algorithm for Treatment of Hypertension (continued) Initial Drug Choices Not at Goal Blood Pressure (< 140/90 mm Hg) lower goals for patients with diabetes or renal disease Begin or Continue Lifestyle Modifications

Not at Goal Blood Pressure Initial Drug Choices Uncomplicated Compelling Indications Not at Goal Blood Pressure Algorithm for Treatment of Hypertension (continued) Start at low dose and titrate upward. Low-dose combinations may be appropriate. Specific Indications

Initial Drug Choices* Uncomplicated Diuretics  -blockers Algorithm for Treatment of Hypertension (continued) *Based on randomized controlle ۽

Initial Drug Choices* Algorithm for Treatment of Hypertension (continued) Compelling Indications Heart failure ACE inhibitors Diuretics Myocardial infarction  -blockers (non-ISA) ACE inhibitors (with systolic dysfunction) Diabetes mellitus (type 1) with proteinuria ACE inhibitors Isolated systolic hypertension (older persons) Diuretics preferred Long-acting dihydropyridine calcium antagonists *Based on randomized controlled trials .

Initial Drug Choices Specific indications for the following drugs: Algorithm for Treatment of Hypertension (continued) ACE inhibitors Angiotensin II receptor blockers  -blockers  -  -blockers  -blockers Calcium antagonists Diuretics

Specific Drug Indications Angina  -blockers Calcium antagonists Atrial tachycardia and fibrillation  -blockers Nondihydropyridine calcium antagonists Heart failure Carvedilol Losartan Myocardial infarction Diltiazem Verapamil Some antihypertensive drugs may have favorable effects on comorbid conditions:

Specific Indications (continued) Cyclosporine-induced hypertension Calcium antagonists Diabetes mellitus (1 and 2) with proteinuria ACE inhibitors (preferred) Calcium antagonists Diabetes mellitus (type 2) Low-dose diuretics Dyslipidemia  -blockers Prostatism (benign prostatic hyperplasia)  -blockers Renal insufficiency (caution in renovascular hypertension and creatinine  3 mg/dL [  265.2  mol/L]) ACE inhibitors Some antihypertensive drugs may have favorable effects on comorbid conditions:

Specific Indications (continued) Essential tremor Noncardioselective  -blockers Hyperthyroidism  -blockers Migraine Noncardioselective  -blockers Nondihydropyridine calcium antagonists Osteoporosis Thiazides Perioperative hypertension  -blockers Some antihypertensive drugs may have favorable effects on comorbid conditions:

Not at Goal Blood Pressure (< 140/90 mm Hg) No response or troublesome side effects Inadequate response but well tolerated Substitute another drug from different class Add second agent from different class (diuretic if not already used) Not at Goal Blood Pressure (<140/90 mmHg) Initial Drug Choices Algorithm for Treatment of Hypertension (continued)

Algorithm for Treatment of Hypertension (continued) Not at Goal Blood Pressure (< 140/90 mm Hg) Continue adding agents from other classes. Consider referral to a hypertension specialist. Substitute drug from different class Add second agent from different class

Algorithm for Treatment of Hypertension Continue adding agents from other classes. Consider referral to a hypertension specialist. Not at Goal Blood Pressure Substitute drug from different class Not at Goal Blood Pressure Initial Drug Choices Not at Goal Blood Pressure Begin or Continue Lifestyle Modifications No response or troublesome side effects Inadequate response but well tolerated Add agent from different class

Lifestyle Modifications For Prevention and Management Lose weight if overweight. Limit alcohol intake. Increase aerobic physical activity. Reduce sodium intake. Maintain adequate intake of potassium. For Overall and Cardiovascular Health Maintain adequate intake of calcium and magnesium. Stop smoking. Reduce dietary saturated fat and cholesterol.

Pharmacologic Treatment Decreases cardiovascular morbidity and mortality based on randomized controlled trials. Protects against stroke, coronary events, heart failure, progression of renal disease, progression to more severe hypertension, and all-cause mortality.

Special Considerations in Selecting Drug Therapy Demographics Coexisting diseases and therapies Quality of life Physiological and biochemical measurements Drug interactions Economic considerations

Drug Therapy A low dose of initial drug should be used, slowly titrating upward. Optimal formulation should provide 24-hour efficacy with once-daily dose with at least 50% of peak effect remaining at end of 24 hours. Combination therapies may provide additional efficacy with fewer adverse effects.

Classes of Antihypertensive Drugs ACE inhibitors Adrenergic inhibitors Angiotensin II receptor blockers Calcium antagonists Direct vasodilators Diuretics

Combination Therapies  -adrenergic blockers and diuretics ACE inhibitors and diuretics Angiotensin II receptor antagonists and diuretics Calcium antagonists and ACE inhibitors Other combinations

Followup Follow up within 1-2 months after initiating therapy. Recognize that high-risk patients often require high dose or combination therapies and shorter intervals between changes in medications. Consider reasons for lack of responsiveness if blood pressure is uncontrolled after reaching full dose. Consider reducing dose and number of agents after 1 year at or below goal.

Causes for Inadequate Response to Drug Therapy Pseudoresistance Nonadherence to therapy Volume overload Drug-related causes Associated conditions Identifiable causes of hypertension

Guidelines for Improving Adherence to Therapy Be aware of signs of nonadherence. Establish goal of therapy. Encourage a positive attitude about achieving goals. Educate patients about the disease and therapy. Maintain contact with patients. Encourage lifestyle modifications. Keep care inexpensive and simple.

Guidelines for Improving Adherence to Therapy (continued) Integrate therapy into daily routine. Prescribe long-acting drugs. Adjust therapy to minimize adverse affects. Continue to add drugs systematically to meet goal. Consider using nurse case management. Utilize other health professionals. Try a new approach if current regime is inadequate.

Hypertensive Emergencies and Urgencies Emergencies require immediate blood pressure reduction to prevent or limit target organ damage. Urgencies benefit from reducing blood pressure within a few hours. Elevated blood pressure alone rarely requires emergency therapy. Fast-acting drugs are available.

Drugs Available for Hypertensive Emergencies Vasodilators Nitroprusside Nicardipine Fenoldopam Nitroglycerin Enalaprilat Hydralazine Adrenergic Inhibitors Labetalol Esmolol Phentolamine

Summary of Chapter 3 Modifying lifestyles in populations can have a major protective effect against high blood pressure and cardiovascular disease. Lowering blood pressure decreases death from stroke, coronary events, and heart failure; slows progression of renal failure; prevents progression to more severe hypertension; and reduces all-cause mortality. A diuretic and/or a  -blocker should be chosen as initial therapy unless there are compelling or specific indications for another drug.

Summary of Chapter 3 (continued) Management strategies can improve adherence through the use of multidisciplinary teams. The reductions in cardiovascular events demonstrated in randomized controlled trials have important implications for managed care organizations. Management of hypertensive emergencies requires immediate action whereas urgencies benefit from reducing blood pressure within a few hours.

Special Populations Racial and ethnic groups Children and adolescents Women Older persons

Children and Adolescents Blood pressure at 95th or higher percentile is considered elevated. Lifestyle modifications should be recommended. Drug therapy should be prescribed for higher levels of blood pressure. Attempts should be made to determine other causes of high blood pressure and other cardiovascular risk factors.

95th Percentile of Blood Pressure by Selected Ages and Height in Girls

95th Percentile of Blood Pressure by Selected Ages and Height in Boys

Women Clinical trials have not demonstrated significant differences between men and women in treatment response and outcomes. Some women using oral contraceptives may have significant increases in blood pressure. High blood pressure in not a contraindication to hormone replacement therapy.

Pregnant Women Chronic hypertension is high blood pressure present before pregnancy or diagnosed before 20th week of gestation. Preeclampsia is increased blood pressure that occurs in pregnancy (generally after the 20th week) and is accompanied by edema, proteinuria, or both. ACE inhibitors and angiotensin II receptor blockers are contraindicated for pregnant women. Methyldopa is recommended for women diagnosed during pregnancy.

Antihypertensive Drugs Used in Pregnancy

Antihypertensive Drugs Used in Pregnancy (continued)

Older Persons Hypertension is common. SBP is better predictor of events than DBP. Pseudohypertension and “white-coat hypertension” may indicate need for readings outside office. Primary hypertension is most common cause, but common identifiable causes (e.g., renovascular hypertension) should be considered.

Older Persons (continued) Therapy should begin with lifestyle modifications. Starting doses for drug therapy should be lower than those used in younger adults. Goal of therapy is the same (< 140/90 mm Hg) although an interim goal of SBP < 160 mm Hg may be necessary.

Special Situations Cardiovascular diseases Renal disease Diabetes mellitus Dyslipidemia Sleep apnea Bronchial asthma Gout Surgery Various chemical agents

Cardiovascular Diseases Cerebrovascular disease Indication for treatment, except immediately after ischemic cerebral infarction Coronary artery disease Benefits of therapy well established Left ventricular hypertrophy Antihypertensive agents (except direct vasodilators) indicated Reduced weight and decreased sodium intake beneficial

Cardiovascular Diseases (continued) Cardiac failure ACE inhibitors, especially with digoxin or diuretics, shown to prevent subsequent heart failure Peripheral arterial disease Limited or no data available

Renal Disease Hypertension may result from renal disease that reduces functioning nephrons. Evidence shows a clear relationship between high blood pressure and end-stage renal disease. Blood pressure should be controlled to < 130/85 mm Hg  or lower (< 125/75 mm Hg) in patients with proteinuria in excess of 1 gram per 24 hours. ACE inhibitors work well to control blood pressure and slow progression of renal failure.

Diabetes Mellitus Drug therapy should begin along with lifestyle modifications to reduce blood pressure to < 130/85 mm Hg. ACE inhibitors,  -blockers, calcium antagonists, and low dose-diuretics are preferred. Insulin resistance or high peripheral insulin levels may cause hypertension, which can be treated with lifestyle changes, insulin-sensitizing agents, vasodilating antihypertensive drugs, and lipid-lowering agents.

Dyslipidemia Coexistence of hypertension and dyslipidemia requires aggressive management. Emphasis should be on weight loss; reduced intake of saturated fat, cholesterol, sodium, and alcohol; and increased physical activity. Lifestyle changes and hypolipidemic agents should be used to reach appropriate goals.

Sleep Apnea Obstructive sleep apnea is more common in patients with hypertension and is associated with several adverse clinical consequences. Improved hypertension control has been reported following treatment of sleep apnea.

Bronchial Asthma or Chronic Airway Disease Elevated blood pressure is common in acute asthma and is possibly related to treatment with systemic corticosteroids or  -agonists.  -blockers and  -  -blockers may exacerbate asthma. ACE inhibitors only rarely induce bronchospasm. Over-the-counter medications are generally safe in limited doses for patients on drug therapy.

Gout Diuretics can increase serum uric acid levels. Diuretics should be avoided in patients with gout. Diuretic-induced hyperuricemia does not require treatment in the absence of gout or urate stones.

Patients Undergoing Surgery When possible, surgery should be delayed until blood pressure is < 180/110 mm Hg. Those not on prior drug therapy may be best treated with cardioselective  -blockers before and after surgery. Those with controlled blood pressure should continue medication until surgery and begin as soon after surgery as possible.

Cocaine and Amphetamines Cocaine abuse must be considered in patients presenting to the emergency department with hypertension-related problems. Nitroglycerin is indicated to reverse cocaine-related coronary vasoconstriction. Acute amphetamine toxicity is similar to that of cocaine but longer in duration. Ongoing cocaine abuse does not appear to cause chronic hypertension.

Immunosuppressive Agents Immunosuppressive regimens produce widespread vasoconstriction in both transplant and nontransplant situations. Treatment is based on vasodilation including dihydropyridine calcium antagonists.

Erythropoietin Erythropoietin often increases blood pressure in treatment of patients with end-stage renal disease. Management includes optimal volume control, antihypertensive agents, and reducing erythopoietin dose or changing method of administration.

Other Chemical Agents That May Induce Hypertension Mineralocorticoids and derivatives Anabolic steroids Monoamine oxidase inhibitors Lead Cadmium Bromocriptine

Hypertension

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