HypertensionMark Thel

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In the next 20 minutes

• Prevalence

• First visit

• When to begin medications

• Which medicines to use

• BP goal

• Resistant HTN

What’s more important than HTN?• #1 modifiable risk factor for: MI, stroke, CHF, atrial fibrillation, aortic dissection, PAD, cognitive

decline1

• #2 modifiable risk factor causing death (smoking)– 2/3 of strokes– ½ of ischemic heart disease3

• US 80 million, worldwide 1 billion (140/90)– 46% of all American adults– 1/3 total population by 2025 (aging + obesity)

• Adults > 45 yo without HTN, over 40 years– 93% African-Americans– 92% Hispanic– 86% white– 84% Chinese

• African-Americans: earlier onset, more severe ☛ increased disability and death• Increase of SBP 20 mm Hg and DBP 10 mm Hg each doubled risk of:

– Death from stroke, heart disease, PAD2

1Lancet 2016;388:530-5322 JAMA 2017;317:165-823 Lancet 2015;386:801-812

Definitions

1 Lancet 2015;386:801-812

SBP (mm Hg) DBP (mm Hg)

Normal <120 <80

Elevated 120-129 <80

HTN Stage 1 130-139 80-89

HTN Stage 2 ≥140 ≥90

Initial Office Visit

1.Accurate measurement of BP (cuff, automated, home, ambulatory)

2.Assessment of global cardiovascular disease

3.Detection of secondary HTN

Cardiovascular Risk

RISK FACTORS• SBP + DBP

• Pulse pressure

• Age

• Smoking

• Physical inactivity

• Diet

• Male gender

• Dyslipidemia

• Impaired fasting glucose (102-125)

• DM

• Family history

• Abdominal obesity

TARGET ORGAN DAMAGE• LVH

• Renal impairment

• Microalbuminuria

• PAD

• Presence of CVD: prior CVA, TIA, ICH

• PAF

• HFpEF, HFrEF

• CAD

• Retinopathy

http://tools.acc.org/ASCVDRisk-Estimator 10 year risk of: CAD, CHF, & stroke

Initial Evaluation: Labs• Fasting BMP

• TSH, Free T4

• Lipids (to calculate CVD risk)

• Urinalysis (proteinuria)

• EKG – LVH, LAE

• ?Coronary calcium score

• ? Echocardiogram

Secondary HTNWhen to be suspicious:

• Age onset < 30 or > 65• Abrupt onset• Drug induced/resistant• Acute rise in BP• Disproportionate TOD• Unprovoked, excessive hypokalemia• BP > 180/110• Exacerbation when previously controlled• Accelerated/malignant HTN• DBP in older patients (>65)

Secondary HTNWhat to consider:

• Sleep apnea

• Renal disease (U/A, BMP)

• Renovascular disease (duplex doppler sonography)

• Coarctation of the aorta (BP in legs)

• Primary aldosteronism (plasma renin, serum aldosterone)

• Pheochromocytoma (plasma-free metanephrines

When to initiate medications

• 1. Known CVD or primary in adults with (high)10 year ASCVD risk of 10% ASCVD= first CHD death, non-fatal MI, fatal or non-fatal stroke >130/80

• 2. Primary Prevention-no history of CVD and (low) estimated 10 year ASCVD risk < 10% >140/90

http://tools.acc.org/ASCVD-Risk-Estimator

CVD=CHD, CHF, stroke

2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A

Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, Volume: 71, Issue: 6, Pages: e13-e115, DOI:

(10.1161/HYP.0000000000000065)

Challenges for BP Control

• Frequent check ups

• Usually requires 3 medications

• Compromised by:– Pill burden

– Costs

– Side effects

– Drug interactions

– Compliance

– Insufficient time for patient education

• Less than ½ patients achieve BP < 140/90

• 12% patients with HTN have SBP > 160

Try These Medications First

• Thiazide diuretics

• ARB/ACEI

• CCB

Medication Caveats• Thiazide diuretics (particularly chlorthalidone) first line• Beta blockers only for specific CV comorbidities• Low threshold for using combinations• Second agent may block a compensatory response or effect a different pressor mechanism

– Thiazides stimulate RAAS• Combinations improve:

– Effectiveness– Affordability– Compliance

• Chlorthalidone more effective c/w amlodipine or lisinopril in preventing CHF1

• Thiazides + CCB better than ACEI for preventing stoke• AA patients-ACEI markedly less powerful c/w CCB for preventing stoke and CHF• ARB better tolerated than ACEI (particularly in AA patients) possibly less angioedema as well• Triple therapy meds (ARB, amlodipine, HCTZ) typically limited by HCTZ dose• For stroke prevention beta blockers less effective than CCB and thiazide diuretics

1 NEJM 2008;359:2417-28

Preferred antihypertensive drugs for specific conditions

Eur Heart J 2013;34:2159-2219

Compelling and possible contraindications for specific medications

Eur Heart J 2013;34:2159-2219

Lancet 2014;384:591-598

The greater the risk & higher the SBP, the greater the benefit

BP Goal

• < 130/80• Class I for known CAD + 10 year ASCVD risk > 10%

• Class IIb for patients without additional risk markers

Hypertension 2018;71:e13-e115Lancet 2016;387:435-43Am J Med 2017;30:707-19

BP goal for everyone is:

130/80

Guidelines are Not Commandments

SPRINT TRIAL

Inclusion Criteria

• 9361 patients

• No DM (ACCORD Trial)

• 50

• SBP 130-180

• Clinical or subclinical CAD other than stroke

• CKD eGFR 20-59

• 10 year ASCVD 15% based on Framingham Risk Score

• Or 75 yo

SPRINT Results• Target 120 mm Hg vs 140 mm Hg

• Stopped early (3.2 years)

Primary outcome: MI, ACS, stoke, CHF, death from CV cause

HR p

All cause mortality 0.73 0.003

Primary outcome 0.75 <0.001

CHF 0.62 0.002

CV death 0.43 0.005

Resistant HTN• BP > 130/80 on maximum dose of 3 meds (CCB, ARB/ACEI, diuretic)

• BP at goal on 4 meds

• Prognosis

• > 200,000 patients

• 47% higher risk of death, MI, CHF, stroke, CKD2

• Consider

– White coat

– Compliance (50-80%)

– Life style changes (dietary Na, obesity, alcohol, inactivity, diet)

– Medications (NSAIDs, oral contraceptives, HRT)

1Hypertension 2018;72:e53-e902Circulation 2012;125:1635-1642

Etiology of Resistant HTN

• OSA (70-90%)1

• Primary aldosteronism

• Renal Parenchymal disease

• RAS

• Pheochromocytoma

• Cushing syndrome

• Coarctation of aorta

1 J Sleep Res 2010;19:597-602

Treatment of Resistant HTN– Weight loss

– Dietary salt restriction

– DASH diet

– Exercise

– Chlorthalidone or indapamide (↓ 8 mm Hg c/w HCTZ)

– Spironolactone or eplerenone

• Avoid if eGFR < 45 mL/min

– Nocturnal dosing

– Divided dosing

– 5th agent: beta blockers, ⍺-2 agonists, hydralazine (drug induced lupus)

– Treat the sleep apnea!

Summary• 1. Initiate medications when:

– 130/80 known CVD or high risk

– 140/90 no CVD, lower risk

• 2. chlorthalidone → ARB/ACEI → CCB

• 3. Goal 130/80, SPRINT 120/80

• 4. 4th drug: spironolactone, chlorthalidone, beta blockers

• 5. References– Eur Heart J 2013;34:2159-2219

– http://tools.acc.org/ASCVD

– Hypertension 2018;71:e13-e115

– NEJM 2015;373:2103-2116