Hypertension Diagnosis and

TreatmentOctober 2, 2014

Joshua M. Crasner,DO,FACC,FACOI

Incidence

50 million people USA SBP>115 incr risk CAD/CVA Q 20mm incr=2X risk JNC-8 has changed aggressive Tx Pseudo-HTN

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ESSENTIAL HYPERTENSION

Most common HBP( > 90 %)--multifactorial increased peripheral resistance perpetuates

the process of high blood pressure and all of its secondary effects

structural hypertrophy giving rise to smooth muscle hypercontractility

pressure varies throughout the day major risk factor for coronary, renal, and

cerebrovascular disease (50% of all USA deaths)

leading cause of doctor’s visit carries prognostic value: 16X increased risk

40 y.o. smokes

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BP MEASUREMENT

Patient seated/back supported/feet on floor

Should rest 5 minutes prior Arm at heart level No recent caffeine, tobacco, cocaine Take medications as directed Cuff size important orthostatics

Hypertension Focus

Determine lifestyle/CV risk factors ID and Tx secondary causes ID target end organ damage

brain, heart, kidney, eyes, arteries

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Lifestyle/CV risk factors Cigarette smoking Obesity Inactivity Dyslipidemia Diabetes mellitus Microalbuminuria Male>55; Female>65 Fam Hx: male<55; female<65 Metabolic syndrome

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Secondary Causes

Endocrine Cardiac Renal

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Secondary CausesEndocrine

Pheochromocytoma Primary Aldosteronism Cushing’s disease

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Pheochromocytoma

5 P’s: pressure,pain,palps,perspiration,pallor Adrenal tumor or sympth ganglia 2-8 cases/million/year 0.5% in hypertensive patients Usually sustained HBP,sometimes paroxysmal Associated with MEN-2 a/b Plasma metanephrines most sensitive CT after plasma, then surgery

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Primary Aldosteronism

Adrenal oversecretion Hypertension,hypokalemia,alkalosis,hyper-

glycemia 2-15% incidence Screen w/aldo-renin ratio Unusual hypokalemia,adrenal mass, early HTN,

primary relative w/same Tx w/spironolactone,eplerenone,surgery

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Cushing disease

Hyperglycemia, hypokalemia,HTN 24hr cortisol Obese, moon facies, purple striae

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Secondary CausesCardiac

Coarctation Obstructive sleep apnea

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Coarctation

Constriction beyond subclavian Weak,delayed,absent FA pulse Rib notching on CXR Childhood Tx surgical

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Obstructive Sleep Apnea

Obese, retrognathia,large neck Loud snoring Daytime hypersomnolence, morning

headache Polysomnography test

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Secondary CausesRenal

Renal parenchymal disease Renovascular HTN

Renal artery stenosis Fibromuscular dysplasia

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Renal parenchymal disease

Common cause secondary HTN Rapid loss renal fxn if HTN-ive Creat,urine analysis,protein Decr elimination of salt and water,incr

renin, decr vasodilation all lead to incr volume/fluid retention

Dihydropyridine CCB help decr proteinuria

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Renovascular HTNRAS FMD

Atherosclerotic, e.g.CAD Smokers>50, new HTNSystolic/diastolic high pitched abd bruitSuspect B/L if decr renal fxn w/ use of ACEi/ARBPTA but higher restenosisRx

White female<30No family Hx HTNPTA treatment of choice

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RED FLAGS FOR SECONDARYHYPERTENSION

Abdominal bruit: renal artery stenosis Palps,HA,pallor,perspiration:

pheochromocytoma Obesity,moon face,purple striae: Cushing’s Abd mass: polycystic kidney,hydroneph Obesity,hypersomnolence: OSAS Agitation, sweating: cocaine, ethanol,narc

w/d Hypokalemia: hyperaldosteronism Hypercalcemia: hyperparathyroidism

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Simple Guide to work up secondary causes of HTN

Pregnancy

Alpha methyldopa first DOC Hydralazine,some BB ok, diuretics Avoid ACEi/ARB/renin inhibitors

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Drugs that raise BP

BCPs EtOH Decongestants,diet pills NSAIDs MOA Cocaine Marijuana Licorice cyclosporine

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JNC-7 Definition of HTNCATEGORY SYSTOLIC BP DIASTOLIC BP

normal < 120 and < 80

Pre-HTN 120-139 or 80-89

Hypertension

Stage 1 140-159 or 90-99

Stage 2 ≥ 160 or ≥ 100

JAMA 289; 2560-72: 2003

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JNC-8 1. In the general population aged ≥60 years, initiate pharmacologic treatment to lower blood pressure (BP) at systolic blood pressure (SBP) ≥150 mm Hg or diastolic

blood pressure (DBP) ≥90 mm Hg and treat to a goal SBP <150 mm Hg and goal DBP <90 mm Hg. (Strong Recommendation – Grade A) In the general population aged ≥60 years, if pharmacologic treatment for high BP results in lower achieved SBP (e.g., <140 mm Hg) and treatment is well tolerated and without adverse effects on health or quality of life, treatment does not need to be adjusted. (Expert Opinion – Grade E)

2. In the general population <60 years, initiate pharmacologic treatment to lower BP at DBP ≥90 mm Hg and treat to a goal DBP <90 mm Hg. (For ages 30-59 years, Strong Recommendation – Grade A; for ages 18-29 years, Expert Opinion – Grade E)

3. In the general population <60 years, initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg and treat to a goal SBP <140 mm Hg. (Expert Opinion – Grade E)

4. In the population aged ≥18 years with chronic kidney disease (CKD), initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg and treat to goal SBP <140 mm Hg and goal DBP <90 mm Hg. (Expert Opinion – Grade E)

5. In the population aged ≥18 years with diabetes, initiate pharmacological treatment to lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg and treat to a goal SBP <140 mm Hg and goal DBP <90 mm Hg. (Expert Opinion – Grade E)

6. In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin-receptor blocker (ARB). (Moderate Recommendation – Grade B)

7. In the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or CCB. (For general black population: Moderate Recommendation – Grade B; for black patients with diabetes: Weak Recommendation – Grade C)

8. In the population aged ≥18 years with CKD, initial (or add-on) antihypertensive treatment should include an ACEI or ARB to improve kidney outcomes. This applies to all CKD patients with hypertension regardless of race or diabetes status. (Moderate Recommendation – Grade B)

9. The main objective of hypertension treatment is to attain and maintain goal BP. If goal BP is not reached within a month of treatment, increase the dose of the initial drug or add a second drug from one of the classes in recommendation 6 (thiazide-type diuretic, CCB, ACEI, or ARB). The clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached. If goal BP cannot be reached with two drugs, add and titrate a third drug from the list provided. Do not use an ACEI and an ARB together in the same patient. If goal BP cannot be reached using only the drugs in recommendation 6 because of a contraindication or the need to use more than three drugs to reach goal BP, antihypertensive drugs from other classes can be used. Referral to a hypertension specialist may be indicated for patients in whom goal BP cannot be attained using the above strategy or for the management of complicated patients for whom additional clinical consultation is needed. (Expert Opinion – Grade E)

10. Although this guideline provides evidence-based recommendations for the management of high BP and should meet the clinical needs of most patients, these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient. Future guidelines should cover the full range of cardiovascular care topics, to develop an integrated approach for prevention, detection, and evaluation, along with treatment goals. Individual recommendations from discrete guidelines—such as for hypertension, cholesterol, and obesity—may not reflect the integrated care needed for many patients seen in practice. There is also a need to harmonize the hypertension guideline with other cardiovascular risk guidelines and recommendations, thereby resulting in a more coherent overall cardiovascular prevention strategy. Author(s):

Debabrata Mukherjee, M.D., F.A.C.C. (Disclosure

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Summary JNC 8

Patient Subgroup Target SBP Target DBP

> 60 years <150 <90

<60 years <140 <90

>18 years w CKD <140 <90

>18 years w DM <140 <90

Hypertension 2014 26James PA, et al.,JAMA,2013 Dec18

JNC 8 recommendations

General non-African population Thiazides, CCB,ACEi,or ARB initially

General African population Thiazides or CCB initially

CKD Include ACEi or ARB

Uptitrate/add RX after 1mo.if not at goal Don’t use ACEi and ARB jointly If >3 Rx needed refer to specialist

Hypertension 2014 27James PA, et al.,JAMA, 2013 Dec 18

5 of 17 JNC 8 authors disagree!!!

ANSWER??

FOLLOW THE AHA/ACC BP guidelines Start lifestyle changes and then Rx at 140/90 up to

age 80, then at 150/90 Position paper of JACC July 2014 refutes, citing

placement of mostly elderly African-American women at incr. risk for CVD mortality**

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**Krakoff, et al; JACC, July 29,2014;394-402

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LAB TESTING

Urine analysis Chemistry panel Cholesterol CBC Endocrine Drug screen

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PHARMACOLOGIC TREATMENT

Heart failure: ACEi, ARB, diuretics, BB Diabetes: ACEi, ARB CAD/post-MI: BB, ACEi,(CCB for intol.) Systolic HTN: ACEi/ARB with diuretic, BB,

CCB Pregnancy: labetalol, methyldopa, CCB Prostate enlargement: alpha blocker Renal disease: ACEi or ARB

Summary--BP Goals

<140/90 Diabetics/CKD/High risk CAD <130/80 Reduced EF; proteinuria <120/80 Stay tuned for AHA/ACC update 2015

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REVIEW POINTS

Familiarity with target end-organ damage

What is ideal BP? Causes of secondary hypertension Ideal agents for condition(s) Familiarity with treatment options