cure pathologic fear of hypertension create rational approach to drug choice complement rational...
TRANSCRIPT
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Cure Pathologic Fear of Hypertension
Create Rational Approach to Drug Choice
Complement Rational Choice with Pearls
Consolidate new information with cases
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• Those who do not have high blood pressure at age 55 face a 90 percent chance of developing it during their lifetimes.
• So high blood pressure is a condition that most people have at some point in their lives.
• 90% of Americans over 65 have hypertension or Prehypertension
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You can at least cause Dys-Ease
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Your Blood pressure is 128/84While drug treatment is recommended if your BP is at or above 140/90,
new medical guidelines state that a normal BP for most adults is less than 120/80. Ask your doctor what is right for you.
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The risk of cardiovascular disease begins at 115/75In individuals aged 40 to 70 years, each 20/10 mm Hg increase in blood pressure doubles the risk of cardiovascular disease, including heart attack, stroke or kidney disease
This program includes: A free 30 day trial of Diovan, Diovan HCT and Lotrel, 3 medications proven to help lower blood pressure.
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115/75
180/100
Low Risk High Risk
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115/75
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We’re Doomed, We’re Doomed
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The Silent Killer
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69% of people who have a heart attack, 77% of people who have a first stroke,
and 74% of people with chronic CHF
have high blood pressure.
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95% of people who have a heart attack, 95% of people who have a first stroke,
and 95% of people with chronic CHF
Have eaten pickles in the previous 10 years
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http://cybersmokeblog.blogspot.com/2013/03/do-you-agree-to-tell-whole-truth-and.html
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Disease Low Dose Diuretic
Ace Inhibitors BetaBlockers
Death 28% 27% 27%
Stroke 37% 35% 11%
Coronary Heart Disease
28% 19% NS
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45 Year Old Female Cholesterol 200 Non-Smoker Systolic of 190 10 Year Risk?
2% Risk of Heart Attack 1.4% if treated
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65 Year Old Male Cholesterol 200 Non-Smoker Systolic of 155 10 Year Risk?
10% Risk of Heart Attack 7.2% if treated
90% Chance of Going 10 years with NO heart attack
92.8% If they Are Treated
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65 Year Old Male Cholesterol 200 Smoker Systolic of 180 10 Year Risk?
25% Risk of Heart Attack 18% if treated
75% Chance of Going 10 years with NO heart attack
82% If they Are Treated
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Accord Trial NEJM 2010;362:17
Diabetes PLUS◦ Heart Disease◦ OR◦ Albuminuria◦ OR◦ Hypertrophy◦ OR ◦ Two Risk Factors
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Accord Trial NEJM 2010;362:17
Systolic of <120 vs Systolic of <140
Achieved 119 vs 133
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Accord Trial NEJM 2010;362:17
Outcome: nonfatal myocardial infarction, nonfatal
stroke, or death from cardiovascular causes
Followed Almost 5 years
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Accord Trial NEJM 2010;362:17
Composite Outcome:
1.87 vs 2.09 p=0.2
Death
1.28 vs 1.19
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Accord Trial NEJM 2010;362:17
Stroke:
0.32 vs 0.53 p=0.01
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Seven trials (22,089 subjects) -4/-3 better
…at present there is no evidence to support aiming for a blood pressure target lower than 140/90 mmHg in any hypertensive patient.
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Fear of
Hypertension
Fear Of
Hypertension
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Rational Approach to Treat HTN
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High ReninLow Renin
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IntuitiveRenin AngiotensinAldosterone
Sympathetic Nervous SystemAngiotensin VasoconstrictionAldosterone Sodium and Water
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Characteristics Systolic and Diastolic Equally Elevated
Higher Hemoglobin Younger High Stress? White?
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Not IntuitiveWhy is Renin Low?Flaws in Sodium Excretion VolumeParadoxical Aldosterone
Stiff Arteries & Volume Excess
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Characteristics Isolated Systolic Hypertension Older Women African American Diabetes
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So What?
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Stimulate RAA Inhibit RAA
Diuretics
CCB’s
ACE’s / ARB’s
Beta Blockers?
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Salt retaining Steroids◦ Corticosteroids◦ Anabolic Steroids◦ Oral contraceptives◦ Estrogens
NSAIDS
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Weight 276 pounds BP 170/90 Blood sugars run 200-250
◦ Glucophage 500mg BID◦ Micronase 5mg qd◦ Zestril 20mg qd
Complaining of palpitations.
HCTZChlorthalidone
OrIndapamide
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Transition
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0 12.5 25 50 1000 12.5 25 50 100
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Lasix for Hypertension
Only if:◦ Serious Edema◦ CrCl < 30◦ Torsemide probably better
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Women: Only the ones with Prostate Glands
Men: only the ones with BIG Prostate Glands
When in Doubt, Cut It Out.
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All the outcomes data are on the next slide
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https://www.toledoblade.com/image/2013/01/09/670x_b1_a4-3_cCM_z_cT/Cedar-
Point-GateKeeper.jpg
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Causes
Drugs Street Drugs Sleep Apnea Renal Artery Stenosis
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The Situation
All 4 Classes added Still No Joy Add Spironolactone Especially if the potassium is on the low
side
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The number one cause of Resistant Hypertension
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A Couple Stories
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67 years old Norvasc 5 Lisinopril 40 Carvedilol 25 BID Chlorthalidone 25mg Blood Pressure is 192/105
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Assess Compliance Assess Compliance Assess Compliance Consider Sleep Apnea Consider Spironolactone
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52 year old female Non-smoker Blood Pressure 152/94 Which drug should be started?
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Leave the Poor Woman Alone !!
Take away her home blood pressure machine
Exercise, Salt and Healthy Food
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Cured Pathologic Fear of Hypertension
Created a Rational Approach to Drug Choice
Complemented Rational Choice with Pearls
Consolidated new information with cases