Transcript Hypertension

My doctor thought that blood
pressure of 150/95was pretty
good
I have
hypertension
My doctor thought I was OK,
because I was asymptomatic
My doctor would not
treat me because I was
an unassigned patient
My doctor maintained
hypertension in the
elderly to prevent
orthostatic hypotension
My doctor gave me the latest
medication recommended by
a drug rep
My doctor thought that
hypertension is a part of aging
because of stiff arteryies
Myocardial infarction and
congestive heart failure
Cerebral Vascular Accident
Renal Insufficiency & Failure
Why Do We Have To Talk
About Hypertension again?
Prevent
Black Out
Goals
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What is hypertension?
Why we do what we do?
Joint National Committee on
Prevention, Detection,
Evaluation, and Treatment of
High Blood Pressure
JNC 6 in 1997
Recall
JNC 7
Candidates
Intimidator
Sybaritor
Eliminator
Hypertension is weapons of
mass destruction, and we
need to take a preemptive
strike against this terrorist.
Hypertension affect:
 50
million people in the U.S
 1 billion people in the world
Hypertension is a part of the
normal aging process?
Myth
Facts

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Two-third of patients with hypertension
are over age 65
Normotensive patients age 55 have a 90%
lifetime risk of developing hypertension
What is hypertension?
Blood pressure
≥ 140/90 mmHg
On ≥ 2 different occasions
Prehypertension
Systolic blood pressure 120-139 mmHg
Diastolic blood pressure 80-89 mmHg
Risk of Prehypertension

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For patients age 40-70 with blood
pressure range 115-185/75-115 mmHg
With each incremental increase of 20
mmHg in systolic blood pressure and 10
mmHg in diastolic blood pressure, risk of
cardiovascular disease doubles
Moral of the story
How Blood Pressure is
Measured?
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Sit & Relax for at least 5
minutes
Arm bared and at heart
level
Bladder within the cuff at
least 80% of arm
circumference
Average of  2 readings 2
minutes apart
Ambulatory vs. Office
Measurement?


Lower than office
measurement
Consider hypertension if
mean blood pressure
>135/85 mmHg
Work-up Goals


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Identify secondary causes of hypertension
Identify cardiovascular risk factors and
concomitant disorders
Assess target-organ damage and
cardiovascular disease
Secondary Causes of Hypertension?
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Drugs
Sleep apnea
Chronic renal disease
Primary aldosteronism
Cushing syndrome
Pheochromocytoma
Coarctation of the aorta
Thyroid or parathyroid disease
Major Cardiovascular Risk Factors?
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Cigarette smoking
Obesity (BMI ≥ 30)
Physical inactivity
Dyslipidemia
Diabetes mellitus
Microalbuminuria or estimated GFR <60 mL/min
Age: >55 for men and >65 for women
Family history of premature cardiovascular disease:
men <55 years or women <65 years
Target-Organ Damage?
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Cardiac: LVH, MI, CHF
Stroke
Chronic kidney disease
Peripheral arterial disease
Retinopathy
What is the most common
cause of hypertension?
Essential hypertension
What Is The Most Common
Presentation?
Asymptomatic
History: What Could Cause
Elevated Blood Pressure?
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Medications: OCP, pseudoephrine, NSAID
Diet: High sodium, alcohol
Illicit drugs
Smoking
Psychosocial: Stress, work
Axis of Evil

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Hypertension
Diabetes
mellitus
Hyperlipidemia
History: What are the
cardiovascular risk factors?
Metabolic syndrome
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Blood pressure ≥ 130/85
Glucose intolerance with FBS ≥ 110 mg/dL
Triglyceride >150 mg/dL or HDL <40 mg/dL in males and <50
mg/dL in females
Abdominal obesity with waist circumference >102 cm for males and
>89 cm for female
Past Medical History
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Coronary or cerebral vascular diseases
Renal disease
History: What are the symptoms of
target organ damage?
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Increased intracranial pressure:
headache, blurry vision, confusion
Heart: chest pain
Physical Exam?
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Fundoscopic: Hypertensive retinopathy
Carotid bruit: Atherosclerosis
JVD: Congestive Heart Failure
Thyroid gland: Hyperthyroidism
Heart: S3S4 in congestive heart failure
Lungs: Rales in congestive heart failure
Abdominal bruit: Renovascular stenosis
Extremities: Edema in congestive heart failure,
decreased femoral pulse in aortic coarctation
Diagnostic Tests?
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Chemistry
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Sodium and potassium – high cortisol or
aldosterone
Bun and creatinine – kidney function
Glucose – diabetes mellitus
Calcium - hyperparathyroidism
Fasting lipid panel
Diagnostic Tests
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CBC
Urinalysis
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Proteinuria
Hematuria: glomerulonephritis
EKG
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Cardiomegaly
Blood Pressure Goal?
General <140/90 mm Hg
Diabetes mellitus and renal disease < 130/80
How Hypertension Is Treated?
I would audit the PDR
and get rid of wasteful
medications
How hypertension should be
managed?
Lifestyle modification
Medications
Lifestyle Modification
BMI < 27
Lifestyle Modification: Weight
Reduction
Exercise, Exercise, Exercise
Lifestyle Modification: Diet
DASH: Dietary Approach to Stop
Hypertension
High in fruits, vegetables, low-fat dairy foods,
protein, fiber, potassium, calcium, and magnesium
Low in fat and cholesterol
Lifestyle Modification: Diet
Limit the salt to < 2.5 gm
sodium or < 6 gm sodium
chloride per day
Lifestyle Modification: Alcohol
Beer: 2 oz or 2 cans
Wine: 10 oz or 1 glass
Which Medication Should Be
Started?
Viagra
How do we pick medications?
Recurrent Themes:
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Target organ damage
Cardiovascular risk factors and
concomitant disorders
Which medications should be
used for uncomplicated
hypertension?
Diuretics
Beta-Blockers
Diuretics
FOR????
 Gout
 Potassium
Side Note:
Minimal effects on
dyslipidemia and
glucose intolerance
Beta-blockers
No, no….
•Asthma/COPD
•Depression
•Peripheral vascular disease
•Class IV congestive heart failure
Side Note:
Minimal effects on dyslipidemia
and glucose intolerance
Which medication should be
used in diabetics?
Pick one….
ce-Inhibitors or ARB
ACE-inhibitors
Side Effect?
Hyperkalemia
Renovascular stenosis
Which Medications Should Be
Used In Ischemic Heart Disease?
ce-Inhibitors
Beta-Blockers
Calcium-channel blockers
Calcium-channel Blockers
In what condition????
•Angina pectoris
•Non Q-wave MI
•MI without left
ventricular
dysfunction
Only
nondihydropyridines:
diltiazem & verapamil
Calcium-channel Blocker:
Cautions
Side Effect?
Pitting edema
Impotence (no
illustration)
Do not use short-acting calciumchannel blockers
Which medications should be
used in CHF?
ce-Inhibitors
Beta-Blockers
Angiotensin receptor
blockers
Loop
diuretics ±
aldosterone
blockers
Which medication should be
used in renal insufficiency?
ce-Inhibitors
Limitation:
Hyperkalemia
Which medication should be
used in BPH?
Alpha-blockers
Combination Therapy
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Most patients need ≥ 2 drugs
If blood pressure >20 mmHg systolic or
10 mmHg diastolic, initiate 2 drugs
Combination drugs
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ACE-I and CCB
ACE-I and diuretics
ARB and diruetics
Β-blockers and diuretics
Central acting drug and diuretics
Diuretics and diuretics
Hypertensive Emergency &
Urgency
Emergency:
 Encephalopathy: Headache, nausea,
vomiting, intracranial hemorrhage
 Heart: Acute MI or left ventricular
dysfunction, dissecting aortic aneurysm
Urgency:
 No acute target organ damage
Hypertensive Emergency
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Control blood pressure within minutes to 2
hours
Gradual reduction in blood pressure to avoid
MI and CVA: 25% or 20 mm Hg initially and
slowly to 160/100 mm Hg
Medications: Sodium nitroprusside & esmolol
because of quick onset of action and short
duration (minutes)
Hypertensive Urgency
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Control blood pressure within 24 hours
Gradual reduction of blood pressure
Medications: Oral (not sublingual)
calcium-blockers, beta-blockers, aceinhibitors,
2-blockers
Hypertension
Why hypertension again?
Confusion
?????????
MD, BS, MS, DDS, OCP
Hypertension
Basic and Practical Approach to
Hypertension
Remember this basic dictum
cold turkey
Blood pressure  140/90 mmHg is
NOT
Stable or controlled
Sophisticated Classification
Category
Optimal
Normal
High-normal
Hypertension
Stage 1
Stage 2
Stage 3
Systolic
(mm Hg)
<120
<130
130-139
140-159
160-179
180
Diastolic
(mm Hg)
< 80
<85
85-89
90-99
100-109
110