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FOLLOW UP OF HTN

DR. SHAHRZAD SHAHIDI

PROFESSOR OF NEPHROLOGY

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THE ALMIGHTYPardons & Grants me heaven

Even if I don't know a single letter about:

Crutz Feld Jacob’s Disease

Tsutsugamushi Fever

Crigler-Najjar Syndrome

South American equine encephalitis &

Many & much more rarer topics

BUT …….

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Will drag me to hell and will not pardon

My ignorance of even the minute details of HTN

My indifference to apply the current knowledge

My negligence in screening for HTN, TOD

My despondency about preventing TOD

My inadequacy in maintaining my patients

as normo-tensive as possible –

(This is applicable to all common diseases)

THE ALMIGHTY

RESULTS OF BP SCREENINGS

Recheck in 2 yrs if nml

Recheck in 1 yr if Pre–HTN

Stage 1 - Confirm in 2 mos

Stage 2 - Confirm in 1 mo

If > 180 / 110, treat now

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GOALS OF THERAPY

Reduce CVD & renal morbidity & mortality.

Achieve SBP goal especially in persons >50 years of age.

NEXT SLIDE

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"THE GOAL IS TO GET TO GOAL!”

HTN-PLUS-

Proteinuria (Microalbuminuria or more)

< 140/90 mmHg ≤ 130/80 mmHg

Measurements & goals should be provided to the

patient verbally & in writing at each office visit

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BP CONTROL RATESTrends in awareness, treatment, and

control of high BP in adults ages 18–74

National Health and Nutrition Examination Survey, Percent

II1976–80

II(Phase 1)1988–91

II(Phase 2)1991–94 1999–2000

Awareness 51 73 68 70

Treatment 31 55 54 59

Control 10 29 27 34

Sources: Unpublished data for 1999–2000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6.

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PATIENT EVALUATIONEvaluation of patients with documented HTN has three

objectives:1. Assess lifestyle and identify other CV risk factors or

concomitant disorders that affects prognosis and guides treatment.

2. Reveal identifiable causes of high BP.

3. Assess the presence or absence of target organ damage and CVD.

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LABORATORY TESTS

Routine Tests ECG Urinalysis Blood glucose, & hematocrit Serum K, Cr, or the corresponding estimated GFR, Ca Lipid profile, after 9- to 12-hour fast, that includes HDL & LDL

& TG Optional tests Measurement of urinary albumin excretion or Alb/Cr ratio More extensive testing for identifiable causes is not

generally indicated unless BP control is not achieved

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LIFESTYLE MODIFICATION:EFFECT ON BP

Modification Approximate SBP reduction(range)

Weight reduction 5 –20 mmHg/10 kg weight loss

Dietary sodium reduction 2–8 mmHg

Physical Activity 4–9 mmHg

Moderation of alcohol consumption

2–4 mmHg

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Algorithm for Treatment of Hypertension

Not at goal blood pressure (<140/90) (<130/80 for those with DM or CKD)

Lifestyle modifications

Initial drug choices

Without compelling indications

Stage 1 hypertension(SBP 140–159 or DBP 90–99 ) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB or combination.

Stage 2 hypertension (SBP >160 or DBP >100 ) 2-drug combination for most (usually thiazide-type diuretic & ACEI, or ARB, or BB, or CCB)

With compelling indications

Drugs for the compelling indications

Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed.

Not at goal BP

Optimize dosages or add additional drugs until goal blood pressure is achieved.

Consider consultation with hypertension specialist

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BETA-BLOCKERS

• Are not a preferred initial therapy for HTN.

• May be considered in younger people, particularly:

• Intolerance or contraindication to ACEI & ARB• Women of child-bearing potential• People with evidence of increased sympathetic drive

• If therapy is initiated with a beta-blocker & a second drug is required, add a calcium-channel blocker rather than a thiazide-like diuretic to reduce the person’s risk of developing DM.

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DIURETICS

• When using further diuretic therapy for resistant HTN:

Monitor blood Na, K & renal function within 1 month & repeat as required

thereafter.

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FOR ADEQUATE CONTROL OF B.P.

Do you think we can control most of the

patients of HTN with: One drugTwo drugsThree drugsCan’t control

In most of the patients Two drugs are required for adequate control

More so if the initial BP is 20/10 above the goal

OK NOW WHAT?

2/3 of patients with HTN will need at least 2 medicines for BP control

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HTN – Why Combinations ?

If goal BP is not achieved by a single drug in full dose

Then adding another agent will help achieve the goal BP

Two agents sometimes nullify each others side effects

Fixed dose combinations will reduce the no. of tablets

Once daily formulations are good for compliance

Sustained release or LA formulations for 24 h BP control

If 3 drugs can’t achieve goal BP : Resistant HTN

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2013 ESH/ESC Guidelines for the management of HTN

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• Green continuous : preferred combinations• Green dashed: useful combination • Black dashed lines: possible but less well tested combinations• Red : not recommended combination.

In patients with resistant HTN, adding drugs to drugs should be done with attention to results & any compound

overtly ineffective or minimally effective should be replaced, rather

than retained in an automatic step-up multiple-drug approach

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Osterberg, L. et al. N Engl J Med 2005

Adherence to Medication According to

Frequency of Doses

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PEARLSFor resistant HTN – sit down & take a good Hx:

• How much water, coffee, milk, juice, tea, ice – anything liquid do you drink daily.

• Food preferences & salt intake• Drugs/Alcohol• Compliance

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CAUSES OF RESISTANT HTN Improper BP measurement Excess Na intake Inadequate diuretic therapy Medication

• Inadequate doses

• Drug actions & interactions: NSAIDs, illicit drugs, sympathomimetics, OCP

• OTC drugs & herbal supplements Excess alcohol intake Identifiable causes of HTN

JNC 7 Express. JAMA. 2003 25

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DRUG-INDUCED HTN: PRESCRIPTION MEDICATIONS

•Steroids

•Estrogens

•NSAIDS

•Phenylpropanolamines

•Cyclosporine/Tacrolimus

•Erythropoietin

•Sibutramine

•Methylphenidate

•Ergotamine

•Ketamine

•Desflurane

•Carbamazepine

•Bromocryptine

•Metoclopramide

•Antidepressants

• Venlafaxine•Buspirone

•Clonidine

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DRUG-INDUCED HTN: STREET DRUGS & HERBAL PRODUCTS

• Cocaine

• Ma huang “herbal ecstasy”

• Nicotine

• Anabolic steroids

• Narcotic withdrawal

• Methylphenidate

• Phencyclidine

• Ketamine

• Ergot-containing herbal products

• St John’s wort

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SUBSTANCES ASSOCIATED WITH HTN

Food Substances

•Sodium Chloride

•Ethanol

•Licorice•Tyramine-containing foods (with MAOI)

Chemicals

•Lead

•Mercury

•Thallium & other heavy metals

•Lithium salts

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FOLLOW-UP & MONITORING

Patients should return for follow-up & adjustment of medications every 1-2 months until the BP goal is reached

After BP at goal & stable, follow-up visits at 3- to 6-month intervals More frequent visits for stage 2 HTN or with

complicating comorbid conditions Continue to encourage self BP monitoring

Serum K & Cr monitored 1–2 times per year

JNC 7 Express. JAMA. 2003 30

NON - ADHERENCE Misunderstanding of Condition Denial of illness / Asymptomatic Lack of patient involvement in care plan Unexpected adverse effects of medicine Too many f / u visits, lab requests

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KEYS TO ACHIEVING BP CONTROL • BP checks at every patient care encounter

–Including optometry, OB-GYN, etc

• BP clinic (Non-MD clinic)

–Free & frequent visits, walk ins welcome

–Removing all barriers for patients

• Simple algorithm – easy for providers & patients

–One BP goal (<140/90) for all patients

–Emphasis on combination pills (lisinopril / HCTZ)

–Emphasis on getting to target BP control quickly

• Feedback on Performance / Transparency

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NEW FEATURES AND KEY MESSAGES

The most effective therapy prescribed by the careful clinician will control HTN only if patients are motivated.

Motivation improves when patients have positive experiences with, & trust in, the clinician.

Empathy builds trust & is a potent motivator.

The responsible physician’s judgment remains paramount.

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THE CORRECT APPROACH TO HTN

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CASES

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CASE 1: DIAGNOSIS

AB is a 56 yo female with no significant PMH.

Her BMI is 26 & she has a FHx positive for Type 2 DM.

Her BP measured on 2 consecutive clinic visits is 132/84.

What is AB’s BP classification?

1. Normal2. Prehypertensive3. Stage 1 Hypertension4. Stage 2 Hypertension

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CASE 1: THERAPY

What therapy should be initiated for AB?

1. Enalapril 5 mg PO daily

2. Hydrochlorothiazide 25 mg PO daily

3. No therapy is indicated

4. Lifestyle modifications including weight loss & DASH eating plan should be encouraged

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CASE 1: GOAL OF THERAPY

What is the goal of lifestyle modification in AB?

1. Goal BP < 140/90, the goal is to get to goal

2. Goal BP < 130/80, the goal is to get to goal

3. Improve patients quality of life

4. Prevent onset of hypertension

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CASE 1: 5 YEARS LATER

AB, now 59 y, returns to clinic with marginal success at lifestyle changes. Her BP has repeatedly measured around 146/92. What is AB’s BP classification?

1. Normal

2. Prehypertensive

3. Stage 1 Hypertension

4. Stage 2 Hypertension

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CASE 1: 5 YEARS LATER

AB, now 59, Her BP has repeatedly measured around 146/92. What should be done?

1. Enalapril 5 mg PO daily2. Hydrochlorothiazide 25 mg PO daily3. No therapy is indicated4. Reinforce lifestyle modifications

including weight loss and the DASH eating plan.

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CASE 2: GOAL OF THERAPY

CD is a 50 yo black male with diet controlled type 2 diabetes. Consecutive BP measurements during recent clinic visits are 162/98 and 158/96. He is diagnosed with Stage 2 Hypertension. What is the goal of therapy for CD?

1. Goal BP <140/90

2. Goal BP <130/80

3. Slow the progression of diabetic renal disease by reducing BP to <125/80

4. Improve patients quality of life

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When do you D/C or taper the antihypertensive drugs?

(Is it possible)

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