HYPERTENSIONNon Pharmacologic Management

Mohammad Ilyas, M.D.

Assistant Clinical Professor

University of Florida / Health Sciences Center

Jacksonville, Florida USA

6/24/2014

1

Outline

1. Definition, Regulation and Pathophysiology

2. Measurement of Blood Pressure, Staging of Hypertension and Ambulatory

Blood Pressure Monitoring

3. Evaluation of Primary Versus Secondary

4. Sequel of Hypertension and Hypertension Emergencies

5. Management of Hypertension (Non-Pharmacology versus Drug Therapy)

6. The Relation Between Hypertension: Obesity, Drugs, Stress and Sleep

Disorders.

7. Hypertension in Renal diseases and Pregnancies

8. Pediatric, Neonatal and Genetic Hypertension

6/24/2014

2

0

10

20

30

40

50

60

70

80

Hypertension Awareness, Treatment,

and Control: US 1976 to 2000*

NHANES III

(Phase 2)

1991-1994

NHANES III

(Phase 1)

1988-1991

51%

73% 68%

31%

55% 54%

10%

29% 27%

% A

du

lts

NHANES II

1976-1980

NHANES

1999-2000

70%

59%

34%

Healthy People

2000/2010 Control

Target = 50%

Control

Awareness

Treated

Chobanian et al. JAMA. 2003;289:2560-2572.

6/24/2014

3

CV Mortality* Risk Doubles with

Each 20/10 mm Hg BP Increment*

Age 40-70 yearsRef: Lancet. 2002; 60:1903-1913.

JNC 7 Express. JAMA. 2003;289:2560-2572.

CV

mortality

risk

SBP/DBP (mm Hg)

0

1

2

3

4

5

6

7

8

115/75 135/85 155/95 175/105

6/24/2014

4

0

1

2

3

4

5

6

7

8

9

120/80 140/90 160/100 180/110

HTN leads to an increased risk of death from stroke and heart disease

Systolic BP / Diastolic BP (mmHg)

8x

4x

2x

CV mortality risk doubles for every 20 mmHg increase in systolic blood pressure.1,2

Card

iovascu

lar

Mo

rtality

Ris

k

Chobanian et al. Hypertension 2003;42:1206-1252; 2Lancet 2002;360:1903-1913

6/24/2014

5

Benefits of Treatment

Reductions in Stroke about 35–40 %

Reductions in MI, about 20–25 %

Reductions in HF, about >50 %

6/24/2014

6

Goals of Treatment

Treating SBP and DBP to targets that are <140/90 mmHg

Patients with diabetes or renal disease, the BP goal is <130/80 mmHg

The primary focus should be on attaining the SBP goal.

To reduce cardiovascular and renal morbidity and mortality

6/24/2014

7

Goal Blood Pressure

Below 140/90 mmHg uncomplicated

Below 150/90 mmHg in patients 60 years and older

Individuals over age 65 years with isolated systolic

hypertension caution is needed not to reduce the

diastolic blood pressure to less 60 mmHg to attain a goal

systolic pressure less than 150 mmHg since such low

diastolic pressures have been associated with an

increased risk of myocardial infarction and stroke.

6/24/2014

8

JNC 7/8 Emphasizes Importance of Low BP

OPTIMAL<120 and <80

HIGH NORMAL130-139 or 85-89

STAGE 1140-159 or 90-99

STAGE 2 160-179 or 100-109

STAGE 3≥180 or ≥110

NORMAL<130 and <85

NORMAL<120 and <80

PREHYPERTENSION120-139 OR 80-89

STAGE 2≥160 or ≥100

STAGE 1140-159 or 90-99

JNC 7 (2003) JNC 8 (2013)JNC VI (1997)

Hy

pe

rte

nsi

on

JNC VI. Arch Intern Med. 1997;157:2413-2446 JNC 7. JAMA. 2003;289(19):2560-2572. 6/24/2014

9

2014 Hypertension Guideline Management Algorithm SBP indicates systolic blood pressure; DBP, diastolic blood pressure; ACEI,

angiotensin-converting enzyme; ARB, angiotensin receptor blocker; and CCB, calcium channel blocker.aACEIs and ARBs should not

be used in combination.bIf blood pressure fails to be maintained at goal, reenter the algorithm where appropriate based on the

current individual therapeutic plan.

JNC 8 (2014 Hypertension Guideline Management Algorithm)

JAMA. 2013;():. doi:10.1001/jama.2013.284427

1

6/24/2014

10

Adapted from the JNC 7 Slide Deck. Available at: http://www.nhlbi.nih.gov.

JNC 7: Guidelines for Hypertension

Goal: To reduce cardiovascular and renal morbidity and

mortality through prevention and management of hypertension

Classification of Blood Pressure

DBP (mm Hg)SBP (mm Hg)Category

80

80-89

90-99

100

120

120-139

140-159

160

Normal

Prehypertension

Hypertension, Stage 1

Hypertension, Stage 2

and

or

or

or

JNC 7, the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High

Blood Pressure; SBP, systolic blood pressure; DBP, diastolic blood pressure.

6/24/2014

11

6/24/2014

12

JAMA. 2013;():. doi:10.1001/jama.2013.284427

2014 Hypertension Guideline Management Algorithm SBP indicates systolic blood pressure; DBP, diastolic blood pressure; ACEI,

angiotensin-converting enzyme; ARB, angiotensin receptor blocker; and CCB, calcium channel blocker.aACEIs and ARBs should not

be used in combination.bIf blood pressure fails to be maintained at goal, reenter the algorithm where appropriate based on the

current individual therapeutic plan.

JNC 8 (2014 Hypertension Guideline Management Algorithm)

2

6/24/2014

13

Non-pharmacologic therapy (life style modification)

1. Weight loss

2. DASH Plan

3. Dietary salt restriction

4. Exercise

5. Limited alcohol intake

6. Patient education

7. Other non-pharmacologic therapies

Vitamin D supplementation, adequate potassium intake,

cessation of smoking, and limiting the use of non-steroidal anti-

inflammatory drugs and acetaminophen6/24/2014

14

6/24/2014

15

Reducing Weight

Decrease time in sedentary behaviors such as watching television, playing video games, or spending time online.

Increase physical activity such as walking, biking, aerobic exercise, tennis, soccer, basketball, etc.

Decrease portion sizes for meals and snacks.

Reduce portion sizes or frequency of consumption of calorie containing beverages.

6/24/2014

16

6/24/2014

17

Creeping Obesity

Physical activity

decreases and

leads to a decreaseIn metabolic rate.

If energy expenditure

drops more than

energy intake, weight

gain will occur.

6/24/2014

18

What is The DASH Diet?

The Dietary Approaches to Stop Hypertension

clinical trial (DASH)

Diet rich in fruits, vegetables, and low fat dairy foods,

can substantially lower blood pressure in individuals with

hypertension and high normal blood pressure.

As effective as one medication

6/24/2014

19

Dash Study

Control:

Ca, Mg, & K ~ 25% of US diet

Macronutrients and fiber ~ US average

Fruits and Vegetables

Fruits and vegetables increased to 8.5 servings

K and Mg to 75%

Combination:

Add 2-3 servings low-fat dairy to fruit & vegetable diet.

Ca, K and Mg increased to 75%6/24/2014

20

Dash Study Outcomes

Fruit and Vegetable Diet:

Decrease in systolic and diastolic blood pressure in

entire study group and in the hypertensive subgroup.

Combination Diet:

Significant decrease in both systolic and diastolic

blood pressure in both groups.

Greatest drop was in systolic BP in hypertensive group

(11.4 mmHg)

6/24/2014

21

Dash Diet Implications

Combination diet affects comparable to pharmacological trails in mild hypertension.

Population wide reductions in blood pressure similar to DASH results would reduce CHD by ~ 15% and stroke by ~27%

Great potential in susceptible groups: African Americans and elderly.

6/24/2014

22

The DASH Diet

The DASH Diet includes:7-8 servings of grains and grain products

4-5 servings of vegetables

4-5 servings of fruits

2-3 servings of low fat dairy products

2 or less servings of meat, poultry and fish

2-3 servings of fats and oils

Nuts, seeds and dry beans 4-5 times /week

Limited ‘sweets’ low in fat. 6/24/2014

23

6/24/2014

24

Effects of increasing Calcium-Rich Dairy

Food in Black Hypertensives

Increases urinary sodium excretion

Decreases volume

Decreases peripheral vascular resistance

Decrease blood pressure

Reduces left ventricular mass and risk of left ventricular

hypertrophy

Effects sustained for one-year period of study

6/24/2014

25

Sodium in Foods

Conversion of milligrams to milliequivalents

(mEq):

mg/atomic weight x valence = mEq.

Atomic weight sodium = 23, valence = 1

The U.S. Food and Drug Administration

recommends 2,300 mgs of sodium per day

2300 mg/23 x 1 = 100 mEq sodium

6/24/2014

26

Reducing Sodium in the Diet

Use fresh poultry, fish and lean meat, rather than canned or processed.

Buy fresh, plain frozen or canned with “no salt added” vegetables.

Use herbs, spices and salt-free seasoning blends in cooking and at the table; decrease or eliminate use of table salt.

Choose ‘convenience’ foods that are lower in sodium.

6/24/2014

27

Reducing Sodium in the Diet

When available, buy low- or reduced-sodium or ‘no-salt-added’ versions of foods like:

Canned soup, canned vegetables, vegetable juices

cheeses, lower in fat

condiments like soy sauce

crackers and snack foods like nuts

processed lean meats

6/24/2014

28

Food Labels

Claim Amount

Low Sodium >140 mg/serving

Very Low Sodium >35 mg/serving

Sodium Free >5 mg/serving

Reduced Sodium 25% less than original

6/24/2014

29

6/24/2014

30

Other non-pharmacologic therapies

1. Patient education

2. Vitamin D supplementation,

3. Adequate potassium intake,

4. Cessation of smoking, and

5. Limiting the use of non-steroidal anti-

inflammatory drugs and acetaminophen

6/24/2014

31