prime summit 2016 - dr. ona slide deck (2)

8/16/2019 PRIME Summit 2016 - Dr. Ona Slide Deck (2)

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Dyslipidemia Management

Deborah David-Ona, MD, FPCPClinical Associate Professor, Section of Hypertension,

Department of MedicineUniversity of the Philippines-Philippine General Hospital

St. Luke’s Medical Center, Global City


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Meet Amor

• 47 year old, teacher, consulted for headaches and nape pains.

• She is a non smoker, non alcoholic drinker.

– Family History: Father and Mother (+) HPN, (+) DM

– G2P2 with regular menstruation.

• On PE, her BMI was 24 kg/m2. BP of 140/100. Other systems unremarkable.

•Laboratory: – FBS 120 mg/dl,

– Crea 0.73 mg/dl,

– TC = 258mg/dl, TG=181.73 mg/dl, LDL=165.76 mg/dl, HDL=55.83 mg/dl,

ALT 35 u/l

– HBA1C= 6.3%

– 12 lead ECG Normal, CXR No Significant Chest Findings.

• She was given Losartan 100 mg OD


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How will you manage Amor’s cholesterol levels?

A. Start patient with statin therapy

B. Focus on lifestyle modification first before starting any

lipid lowering medication

C. Lifestyle modification and start on low dose statin

therapy

D. No intervention, repeat lipid profile after 1 month


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PRIMARY PREVENTION

Statement 2• For non-diabetic individuals aged ≥ 45 years with LDL-C ≥ 130

mg/dL and ≥ 2 risk factors*, without ASCVD, statins are

RECOMMENDED for the prevention of cardiovascular events.

• *Risk factors are:

– Male, postmenopausal women, smoker, hypertension, BMI > 25 kg/m2, family

history of premature CHD, familial hypercholesterolemia, microalbuminuria,

proteinuria, and left ventricular hypertrophy

• *Patients who fulfill the criteria for Familial Hypercholesterolemia should beinitiated therapy for aggressive LDL-C lowering


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Applicability to our Filipino Patient

ASCVD RISK ESTIMATOR

• Estimates of 10-year risk for ASCVD are based on data from multiple

community-based populations and are applicable to African-American andnon-Hispanic white men and women 40 through 79 years of age.

• For other ethnic groups, ATP 4 recommends using the equations for non-

Hispanic whites as well. These estimates may underestimate the risk for

persons from some race/ethnic groups.


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Risk Factor Counting vs

ASCVD Risk Estimator

• Unfortunately, there is no local risk scoring that has beendeveloped for Filipinos to determine the risk for development

of ASCVD, and studies on the applicability of other risk scoring

systems on Filipinos have not been done.

• There are no POOLED COHORT POPULATIONS of similar

proportion in the Philippines for us to make a similar Risk

Estimator

• More practical to use even in the rural setting

RISK FACTOR COUNTING IS ADVOCATED FOR ESTIMATION OF LEVEL OF

RISK FOR CV EVENTS IN FILIPINO DYSLIPIDEMIC PATIENTS


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Meet Amor

• 47 year old, teacher, consulted for headaches and nape pains.

• She is a non smoker, non alcoholic drinker.

• G2P2 with regular menstruation. On PE, her BMI was 24 kg/m2.

• BP of 140/100. Other systems unremarkable.

• FMHx = Father and Mother (+) HPN, (+) DM

• Laboratory: FBS 120 mg/dl, creat 0.73 mg/dl, TC = 258mg/dl,

TG=181.73 mg/dl, LDL=165.76 mg/dl, HDL=55.83 mg/dl, ALT 35 u/l,HBA1C= 6.3%

• 12 lead ECG Normal, CXR: No Significant Chest Findings

Assessment: Hypertension, Stage 2, Pre Diabetes, Dyslipidemia

Recommendation:

• She was given Losartan 100 mg OD

• Advised to lose weight through diet and exercise with close follow up

PRIMARY PREVENTION OF CARDIOVASCULAR EVENTS IN THE GENERAL POPULATION


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PRIMARY PREVENTION

Statement 2• For non-diabetic individuals aged ≥ 45 years with LDL-C ≥ 130

mg/dL and ≥ 2 risk factors*, without ASCVD, statins are

RECOMMENDED for the prevention of cardiovascular events.

•*Risk factors are: – Male, postmenopausal women, smoker, hypertension, BMI > 25 kg/m2, family

history of premature CHD, familial hypercholesterolemia, microalbuminuria,

proteinuria, and left ventricular hypertrophy

• *Patients who fulfill the criteria for FamilialHypercholesterolemia should be initiated therapy for aggressive

LDL-C lowering


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r er a or e erozygousFamilial Hypercholesterolemia


11/76


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• Amor was lost to follow-up

• She came back at age 58 and she consulted for chest pain on

effort.

– BP 130/80 on Losartan 100 mg OD, Metformin 500 mg OD.

– BMI 30 kg/m2

Labs: – HBA1C = 11%

– TC 246 mg/dl, TG 312.15 mg/dl, LDL 138.13 mg/dl, HDL 44.66 mg/dl

– Creatinine 1.04 mg%, ALT 20 u/l (nv < 85)


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How should you address Amor’s high cholesterol levels?

A. Start her on Low Intensity statin therapy

B. Start patient with Moderate Intensity statin therapyC. Start patient with High Intensity statin therapy

D. Focus on lifestyle modification first before starting any

lipid lowering medication


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PRIMARY PREVENTION

Statement 3

For diabetic individuals without evidence of ASCVD,

statins are RECOMMENDED for primary prevention of

cardiovascular events.

ALL DIABETICS, regardless of age or

duration (new-onset or long standing)


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Applicability to our Filipino Patient(Primary Prevention of ASCVD in DM)


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Applicability to our Filipino Patient

(Primary Prevention of ASCVD in DM)

CANDI MANILA 2009


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PRIMARY PREVENTION of ASCVD in

DMRECOMMEND:

DIABETIC FILIPINO PATIENTS, REGARDLESS OF AGE, SHOULD

BE GIVEN STATIN THERAPY FOR PRIMARY PREVENTION OF

ASCVD

Appropriate Statin Treatment Goal:

30% or greater reduction of LDL-C from baseline or less than 70 mg/dL

for very high risk patients

(trials on moderate- vs high-intensity statin therapy have shown a

dose-dependent response in terms of benefit in the reduction of

adverse outcomes)


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• You started Amor on Atorvastatin 10 mg once aday.

• On follow up, the following were Amor’s lab

results: – HBA1c: 9.0

– Total chol: 220mg/dl

– LDL: 102 mg/dl

– HDL: 48 mg/dl

– Trig: 250 mg/dl

– AST: 112 ( normal


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• You noted that the AST was elevated from

baseline, but Amor remains asymptomatic.

What will you do?

A. Continue with statin treatment

B. Continue with statin treatment and recheck LFTs

C. Stop statin treatment

D. Lower the dose of the statin


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Further investigation showed the following

regarding Amor’s condition:

– 2DECHO = Concentric LVH with good systolic

function – Treadmill Exercise Test = (+) for ischemia at 6

mets

•

She was advised to undergo coronaryangiography but she refused


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How will you manage the cholesterol levels of Amor at this

point?

A. Start patient with High Intensity Statin Therapy

B. Continue on previous statin dose (moderate intensity

statin therapy)

C. Give Fenofibrate as medication for the lipid level

D. Add Fenofibrate on top of statin therapy


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SECONDARY PREVENTION

Statement 5

For individuals with ASCVD, statin therapy is

RECOMMENDED

ASCVD – are patients with prior Coronary Heart Disease, transient

ischemic attack, stroke, carotid artery disease and clinical PeripheralArtery Disease


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STATIN TREATMENT GOAL


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Intensity of Statin Therapy


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• Amor was given the following meds:

– Atorvastatin 40 mg OD

– Losartan was shifted to Irbesartan 150 mg +

Amlodipine 5 mg OD

– Metformin 1000 mg BID and Glimepiride 2 mg OD

– ASA 80 mg OD and Metoprolol 50 mg BID


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• After 3 months, Amor followed up with muscle aches over the

shoulders and hips, upper arms and thighs of 1 week duration.

• (-) tea colored urine

• Her laboratory results showed:

– Creatinine 1.37 mg% (NV


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• Amor was admitted and given IV hydration.

Atorvastatin was withheld.

• Repeat Creatinine after 3 days was 1.0 mg%.

• She was discharged on ASA, Amlodipine 5 mg

OD, Glimepiride 2 mg OD, and Metoprolol 50

mg BID.

• Irbesartan and statins were withheld.


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• What would be your next step after discontinuing

statins?

A. Repeat lipid profile after 1 month

B. Restart combination therapy with low dose statin

and ezetemibe after 6 weeksC. Restart low dose rosuvastatin as alternate dosing or

weekly dosing

D. Use non statin therapies such as ezetemibe or

fibrates


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Statin + Lipid Effect Outcome Information

Ezetimibe LDL↓↓ IMPROVE-IT showed significant

reduction in the composite CV endpoint

Fibrates TG↓↓ HDL↑↑

LDL(↓)

Negative outcome trials in diabetic

patient; subgroup with elevated Tg and

low HDL-C may benefit

Omega-3 FAs Tg↓↓ HDL↑ Negative outcome trials in patients with

IFG, IGT or early T2DM; limitation: low

dose of omega-3 FAs was used

Bile acid sequestrants LDL↓↓ Tg↑ No outcome trial with concomitant

statin therapy; older trials suggestbenefit in patients not on statins

Niacin Tg↓↓ HDL↑↑

LDL↓↓

Lp(a)↓↓

Negative outcome trials in diabetic and

non-diabetic patients; limitation: very

low baseline levels (on statin therapy)

Wu L et al. Metabolism clinical and Experimental 2014;63:1469-1479.


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Should addressing high triglyceride value or low HDL level be

a primary concern in managing dyslipidemia?

A. YES

B. NO


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•Treatment goals for LDL-C and non-HDL-C are no longer recommended

• High- and moderate-intensity statin treatment emphasized; low-intensity statin treatment eliminated.

• “ASCVD” now includes stroke in addition to ischemic heart disease andperipheral arterial disease.

• Four groups are targeted for treatment.

• Non-statin treatments de-emphasized.

• No guidelines provided for treating high triglycerides.

Stone NJ et al. Circulation 2013; 00: 000-000.


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Hypertension

Management:

Deborah David-Ona, MD, FPCPClinical Associate Profession

Section of Hypertension , Department of Medicine

University of the Philippines-Philippine General Hospital


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• 45-yo , Executive

• Chief complaint: intermittent headache and nape pain (6/10in pain scale) 3 days PTC

–

PMHX: unremarkable – 10 pack-years smoking history

– Occasional alcohol drinker

– No blurring of vision, vomiting, chest pain, shortness of breath,numbness or weakness

• BP 190/110 HR 110 RR 22

• PE findings unremarkable


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Daniel reported increased work load over the past 6 months. He

had a few similar episodes of headache partially relieved by pain

medication and/or rest. What is your clinical impression?

A. Hypertensive emergency

B. Hypertensive urgency

C. Malignant Hypertension

D. Resistant Hypertension


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Daniel’s repeat BP after 5 minutes was 185/95, both arms. Which

of the following will be your immediate course of action?

A. Send to ER for rapid BP reduction.

B. Treat with oral antihypertensive and closely follow-up asout patient.

C. Offer ambulatory BP monitoring or home BP monitoring.

D. Request for laboratory and other relevant tests and make

a formal assessment of CV risk.


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Progressive endorgan damage

SBP ≥180 mm Hgand/or

DBP ≥120 mm Hg

HypertensiveCrisis

YES

HypertensiveEmergency

(24%)

NO

HypertensiveUrgency

(76%)

1. Ramos AP et al. Curr Hypertens Rep 2014;16:450. 2. Papadopoulos DP et al. Blood Pressure 2010;19:328. 3. Chobianan

AV et al. Hypertension 2003;41:1178.


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• Symptoms: chest pain (myocardial ischemia), dyspnea (pulmonary edema),

back pain (aortic dissection), headache (encephalopathy, subarachnoid

hemorrhage), visual disturbances (retinopathy)

• Past medical hx: HTN, CAD, renal disease, peripheral vascular disease, cerebral

vascular disease

• Prescribed meds: assess compliance especially if known hypertensive

• Meds that can raise BP: liquorice, nasal drops, oral contraceptives, steroids,

non-steroidal anti-inflammatory drugs, erythropoietin, cyclosporine)

• Illicit drugs: amphetamines, cocaine

1. Ramos AP et al. Curr Hypertens Rep 2014;16:450. 2. Papadopoulos DP et al. Blood Pressure 2010;19:328. 3. Vidt DG.

Journal of Clinical Hypertension 2001;3:158. 4.


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Altered mental status(HTN encephalopathy)

Papilledema (↑ICP) ,retinal hemorrhages,

exudates (retinopathy)

Inspiratory crackles

(pulmonary edema)

S3 (heart failure), mitral

regurgitation (papillary

muscle rupture)

Bruit (partial occlusion

of renal artery)

Peripheral edema

(LV failure)Absent arterial pulse

(aortic dissection)




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Group 1 – High BP Group 2 – Urgency Group 3 – Emergency

BP >180/110 >180/110 Usually >220/140

Symptoms Headache

Anxiety

Asymptomatic

Severe headache

Shortness of breath

Edema

Shortness of breath

Chest pain

NocturiaDysarthria

Weakness

Altered mental status

Exam No end organ

damage

No clinical CVD

End organ damage

Clinical CVD

present/Stable CVD

Encephalopathy

Pulmonary edema

Renal insufficiency

Stroke

ACS




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Group 1 – Urgency Group 2 – Urgency Group 3 – Emergency

Goal Reduce BP over 24 to 48 hours Reduce BP by 10 to

15% over 30 –60 min*

Therapy • Initiate /resume

medication

• Increase dosage ofinadequate agent

• Observe 1-3 hrs

• Lower BP with

short-acting oral

agents• Adjust current

therapy

• Observe 3-6 hrs

• Baseline labs

• IV line

• Monitor BP• Parenteral therapy

in ER

Plan • Arrange follow-up

evaluation in


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Overall Approach for Hypertensive Urgency

(Severe Asymptomatic Hypertension)

– How quickly should the BP be reduced?

• Over a period of hours to days

• Slower reductions may be needed in older adult patients at

high risk for cerebral and myocardial ischemia

– What is the BP target?

• BP


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1. Ramos AP et al. Curr Hypertens Rep 2014;16:450. 2. Papadopoulos DP et al. Blood Pressure 2010;19:328. 3. Handler J. .

Journal of Clinical Hypertension 2006;8:61. 4. Vidt DG. Journal of Clinical Hypertension 2001;3:158.

Agent Dose Onset/

Duration of

Action

Precautions

Catopril 25 mg p.o., repeat as

needed

15 –30 min/

2 –6 hr

Hypotension, renal failure in

bilateral renal artery stenosis

Clonidine 0.1 –0.2 mg p.o., repeathourly as required to

total dose of 0.6 mg

30 –60 min/8 –16 hr

Hypotension, drowsiness,dry mouth

Labetalol 200 –400 mg p.o.,

repeat every 2 –3 hr

30 min –2hr/

2 –12 hr

Bronchoconstriction, heart

block, orthostatic

hypotensionPrazosin 1 –2 mg p.o., repeat

hourly as needed

1 –2 hr/

8 –12 hr

Syncope (first dose),

palpitations, tachycardia,

orthostatic hypotension


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Hypertensive urgency

• In general, treatment is:

– Resumption of antihypertensive therapy (in non-

adherent patients)

– Initiation of antihypertensive therapy (intreatment naïve patients)

– Addition of another antihypertensive drug (in

currently treated patients)


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After oral antihypertensive and 30-minute rest, Daniel’s BP

decreased to 170/95 and his headache improved. After

another hour of rest, BP reading was 165/90. If you are to

start him on antihypertensive regimen, what BP goal will you

set?

A.


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JNC 72004

JNC 82014

ASH/ISH2013

ESH/ESC2013

CHEP2013

ADA2016

BP goals in general population without diabetes or CKD


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Population: 9,361 patients with SBP ≥130 mm Hg and an increased CV

risk but without diabetes or prior stroke

Intervention: SBP target of


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110

120

130

140

150

0 1 2 3 4 5

Standard Treatment

Average # of meds: 1.9

Intensive TreatmentAverage # of meds: 3.0

S y s t o l i c B P ( m m H

g )

YearsSPRINT Research Group. N Engl J Med 2015; DOI:10.1056/NEJMoa1511939.


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SPRINT Research Group. N Engl J Med 2015; DOI:10.1056/NEJMoa1511939.

↓ 25%

NNT 62


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Outcome Intensive Tx Standard Tx Hazard Ratio p-value

# of patients

(%)

# of patients

(%)

n = 4678 n = 4683

MI 97 (2.1) 116 (2.5) 0.83 (0.64 - 1.09) 0.19

ACS 40 (0.9) 40 (0.9) 1.00 (0.64 – 1.55) 0.99

Stroke 62 (1.3) 70 (1.5) 0.89 (0.63 – 1.25) 0.50

Heart Failure 62 (1.3) 100 (2.1) 0.62 (0.45 – 0.84) 0.002

CV Death 37 (0.8) 65 (1.4) 0.57 (0.38 – 0.85) 0.005

All-CauseDeath

155 (3.3) 210 (4.5) 0.73 (0.60 – 0.90) 0.003

1o Outcome

or Death

332 (7.1) 423 (9.0) 0.78 (0.67 – 0.90)


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Adverse Events

• Significantly higher rate of some treatment-related AEs in theintensive treatment group: syncope, hypotension, acute kidneyinjury or failure.

• These need to be weighed against the benefits with respect to CVevents and death.

Limitations

• Generalizability to population not included in the study: personswith diabetes, those with prior stroke, those younger than 50 yearsof age, those at lower CV risk

SPRINT Research Group. N Engl J Med 2015; DOI:10.1056/NEJMoa1511939.

Daniel


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His BP reading before discharge from the clinic was 165/90. His

headache was almost completely relieved. He was given a request

for laboratory tests, advised to monitor BP at home (HMBP) and

follow-up in 1 week. Which of the following medications will you

send him home with?

A. Clonidine as needed for BP >180/120

B. Combination antihypertensive regimen daily

C. BothD. Neither. You will wait for the HMBP results before

prescribing maintenance medications.


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ABPM

• Ensure that at least two measurements

per hour are taken during the patient’s

usual waking hours.

• Use the average value of at least 14

measurements taken during the

patient’s usual waking hours.

HBPM

• For each BP recording, 2 consecutivemeasurements are taken, at least 1minute apart and with the personseated &

• BP is recorded 2x daily, ideally in themorning and evening &

• BP recording continues for at least 4days, ideally for 7 days

• Discard the measurements taken on thefirst day and use the average value of allthe remaining measurements.

NICE Hypertension Guidelines 2011


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• If the clinic blood pressure is 140/90 mmHg or higher, offerambulatory blood pressure monitoring (ABPM) to confirm

the diagnosis of hypertension.

• If a person is unable to tolerate ABPM, home blood pressuremonitoring (HBPM) is a suitable alternative to confirm the

diagnosis of hypertension.

• If the person has severe hypertension, consider startingantihypertensive drug treatment immediately, without

waiting for the results of ABPM or HBPM.

DanielNICE Hypertension Guidelines 2011


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Which of the following treatment will you start Daniel

with?

a. Monotherapy with CCB

b. Monotherapy with ACE or ARB

c. Monotherapy with Diuretics

d. Combination Therapy


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11

2221

28

0

10

20

30

1992 1997 2007 2013

P e r c e n

t o f A d u l t P o p u l a

t i o n ≥ 1 8 y o

Sison J et al. PRESYON 3. 2013 PHA Annual Convention.


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11

22 21

28

51

22

65

75

1310

66

57

11 1013

20

0

10

20

30

40

50

60

70

80

Natl Registry

1992-1993

PRESYON 1

1997-1998

PRESYON 2

2007

PRESYON 3

2012-2013

P e r c e n t a g e ( % )

Prevalence

Treated

Compliant

Controlled


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Copley JB, Rosario R. Dis Mon. 2005;51:548-614.

The ACCORD Study Group. N Engl J Med . 2010 Mar 14.

ALLHAT 138

HOT 138

MDRD 132

ACCORD (intensive)* 119ACCORD (standard)* 133

INVEST 133

IDNT 138

RENAAL 141

ABCD 132UKPDS 144

AASK 128

Hyper-

tension

Diabetes

Kidney

disease

No. of BP medications

1 2 3 4

SBP achieved

(mm Hg)Trial


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James PA et al. JAMA. doi: 10.1001/jama.2013.284427

Daniel


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Description DetailsA Start 1drug, titrate to

max dose, then add a

2nd drug

If goal BP not achieved initial drug, titrate to max

recommended dose.

If goal BP achieved with 1 drug despite titration to max

dose, add a 2nd drug from list (TZD-type, CCB, ACEI, ARB)

and titrate to max recommended dose.

If goal BP not achieved with 2 drugs, add a3rd drug from list

and titrate to max dose. Avoid combined use of ACEI and

ARB

B Start 1 drug and add a2nd drug before

achieving max dose of

the initial drug

Start with 1 drug then add a 2nd drug from list, titrate bothdrugs up to max recommended dose to achieve goal BP.

If goal BP not achieved, add a 3rd drug from list and titrate to

max dose.



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Description Details

C Begin with 2 drugs at

the same time, either

as 2 separate pills or a

single pill combination

Initiate therapy with 2 drugs simultaneously, either as 2

separate drugs or single pill combination.

Start therapy with ≥2 drugs when SBP >160 mm Hg and/or

DBP >100 mm Hg, or if SBP is >20 mm Hg above goal and/or

DBP is >10 mm Hg above goal.

If goal BP is not achieved with 2 drugs, select a third drug

from list and titrate to max recommended dose.


Daniel


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Mild BP elevation

Low/moderate CV risk

Single agent

Marked BP elevation

High/very high CV risk

Previous combination

at full dose

Add a

third drug

Full-dose

monotherapy

Two-drug

combination

at full doses

Three-drug

combination

at full doses

Two-drug combination

Previous agent

at full dose

Switch to

different agent

Choose between

Switch to different

two-drug

combination

Daniel

Mancia G et al. Journal of Hypertension 2013; 31: 1281-1357.


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Thiazide diuretics

ARBs

Calcium

antagonists

ACEIs

Other

Anti-HTN

BBs

Preferred

Useful (w/ some limitations)

Possible (less well-tested)

Not recommendedMancia G et al. Journal of Hypertension 2013; 31: 1281-1357.

• Initiate 2-drug

combination for

patients with markedly

elevated BP or high CV

risk.

• Fixed-dosecombination may be

favored to improve

adherence, which is low

in hypertensive

patients.


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Daniel was started on ARB-CCB combination. He followed-up 1 week later

with his laboratory results which were within acceptable limits. AverageHMBP over the last 3 days was ~150/90. He was advised to continue his

medication with lifestyle modification. He followed up 1 month later with a

BP of 155/90 despite adherence and lifestyle changes. A TZD diuretic was

added in his regimen. 2 weeks later, he followed-up as advised with a BP of

150/90. What will be your next step?

A. Add a low-dose aldosterone receptor antagonist or maximize TZD

diuretic dose

B. Conduct ABPM or HBPM

C. Work up to identify possible secondary causes of HTN

D. Refer to a hypertension specialist


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• Blood pressure that remains above goal in spite of concurrentuse of 3 antihypertensive agents of different classes at

optimal doses, ideally one of which is a diuretic.

• Includes patients whose blood pressure is controlled with useof more than 3 medications.

• Prevalence of 10% to 30% of hypertensive patients.

• Not synonymous to uncontrolled hypertension.

1. Mancia G et al. Journal of Hypertension 2013; 31: 1281-1357 2. Fagard RH et al. Heart 2012;98:254 3. NICE

Hypertension Guidelines 2011 4. Calhoun DA et al. Hypertension 2008;51:1403.


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Confirm Treatment Resistance

Office BP above goal despite treatment with 3 agents from

different classes, ideally including a diuretic

or

Office BP at goal but patient requiring 4 or more medications

Exclude Pseudoresistance

Is patient adherent with the prescribed regimen?

Obtain home or ambulatory blood pressure readings to exclude

white coat effect.




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Identify and Reverse Contributing Lifestyle Factors

Obesity

Physical inactivity

Excessive alcohol ingestion

High salt, low fiber diet

Discontinue or Minimize Interfering Agents

Non-steroidal anti-inflammatory agents

Sympathomimetics (diet pills, decongestants)

Stimulants

Oral contraceptivesLicorice

Ephedra




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Pharmacologic Treatment

Maximize TZD diuretic if serum potassium is ≥ 4.5 mmol

Further diuretic therapy with low-dose spirinolactone if serum

potassium is ≤ 4.5 mmol

Consider alpha- or beta-blocker

Refer to Specialist

For suspected secondary causes of hypertensionor

If blood pressure remains uncontrolled after 6 months of

treatment




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Screen for Secondary Causes of Hypertension

Obstructive sleep apnea (snoring, witnessed apnea, excessive daytime sleepiness)

Primary aldosteronism (elevated aldosterone/renin ratio)

Chronic kidney disease (creatinine clearance


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• Almost 6 months and 4 drugs later (ARB, CCB, TZD diuretic,spironolactone), BP was 150-160/90-100

• Referred to a hypertension specialist.

• Currently being evaluated for secondary hypertension.


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