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Review Of Management Of Hypertension By Professor

Dr Intekhab Alam

Department of Medicine Lady Reading Hospital, Peshawar

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Management of Hypertension

Lecture Objectives

• Define Hypertension (HTN) • Learn how to measure blood pressure • Understand initial clinical evaluation • Identify causes of secondary HTN • Describe lifestyle modifications that lower blood pressure • Select appropriate anti-HTN medications • Provide appropriate follow-up care 4

What is Blood Pressure?

The primary reason most of us are awake and breathing at this very moment in this lecture! BP = CO x TPR

(CO = HR x SV) – Stroke volume – affected by contractility and venous return – TPR is regulated by Norepinephrine, Epinephrine, Angiotensin II.

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Hypertension Defined

“ Hypertension (HTN) is defined as sustained abnormal elevation of the arterial blood pressure.” (Brashers, 2006, p.1).

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Hypertension

“It is an abnormal and persistent elevation of BP.”

BP limits are different in children and pregnancy.

BP goal is different if you have diabetes or chronic kidney disease.

Primary (“essential”) 95% of cases.

Secondary 5% of cases.

Starting at 115/75 mmHg, CVD risk doubles with each increment of 20/10 mmHg throughout the BP range.

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JNC-7 Classification

BP Classification Normal Prehypertension Stage I hypertension Stage II hypertension SBP (mmHg) < 120 120-139 140-159 > 160 and or or or DBP (mmHg) < 80 80-89 90-99 > 100

Diagnosis of HTN

Repeated abnormal elevation of BP using proper technique/cuff on 3 separate occasions over at least 6 weeks A single blood pressure >200/120 Keep in mind: – Risk factors – Evidence of end-organ disease 9

Epidemiology !

The most common primary diagnosis in the United States, 50 million American affected.

Only 70% are aware they have HTN Of those aware of their HTN, only 50% are being treated.

Only 25% of all hypertensive patients have their BP under control In the year 2000, 16·7 million people died from cardiovascular disease, accounting for 30·3% of all deaths worldwide HTN is a risk factor for coronary artery disease (CAD), congestive heart failure (CHF), stroke, and renal failure 10

Prevalence of Hypertension in South Asia

More than half of the cardiovascular deaths take place in developing countries.

South Asia (Pakistan, India, Bangladesh, Nepal, and Sri Lanka) represents more than a quarter of the developing world, and is likely to be strongly affected by the increase in cardiovascular disease, for several reasons. First, people from south Asia are known to have a high coronary risk; this tendency has been well recorded in studies of expatriate south Asians and has also been shown in native settings.

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Prevalence of Hypertension in South Asia

Sex Men

15-30 Years

Women

15-30 Years

Pakistan 1 India 2,3 Bangladesh 4 Nepal 6 Sri Lanka 5 17% … 36.4% 37.5% 9.8

15.6% ..

..

17% ..

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Hypertension classified according to WHO Criteria

References:

1.

Pakistan Medical Research Council. National Health Survey of Pakistan 1990-94: health profile of the people of Pakistan. Islamabad: Network publication service, 1998.

2.

Gupta R, Gupta VP, Sarna M, et al. Prevalence of coronary heart disease and risk factors in an urban Indian population: Jaipur Heart Watch-2.

Indian Heart J

2002; 54: 59-66.

3.

Fernandes VL, Kottke TE, Nicholas JJ. Tobacco consumption and coronary artery disease. In: Rao GHR, Kakkar VV, eds. Coronary artery disease in South Asians., New Dehli: Jaypee Brothers, 2001: 147-64.

4.

Zaman MM, Yoshiike N, Rouf MA, et al. Cardiovascular risk factors: distribution and prevalence in a rural population of Bangladesh.

J Cardiovasc Risk

2001;

5.

103-08. 5.Mendis S, Ekanayake EM. Prevalence of coronary heart disease and its risk factors in middle aged males in a defined population in central Sri Lanka.

Int J Cardiol

1994; 46: 135-42.

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.Pandey MR, Neupane RP, Gautam A. Epidemiological study of tobacco smoking among adults in a rural community of the hill region of Nepal with special reference to attitudes and beliefs.

Int J Cardiol

1988; 17: 535-41. 12

The CVD Situation in Pakistan

Pakistan's Hypertension Statistics (NHS)

Hypertension is the most common cardiovascular disease in Pakistan.

There are an estimated 12 million hypertensives in the country.

Hypertension affects one in three individuals over the age of 45 years in Pakistan. Only 3% of the hypertensive population in Pakistan is adequately controlled.

(The National Health Survey of Pakistan, jointly conducted by the Pakistan Medical Research Council in collaboration with the Federal Bureau of statistics, Pakistan and the Department of Health ad Human Services, Washington, USA )

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Historical Trends in HTN

National Health and Nutrition Examination Survey Trends in awareness, treatment, and control of high blood pressure in adults ages 18-74 Awareness Treatment Control 1976-1980 51% 31% 10% 1988-1991 73% 55% 29% 1991-1994 68% 54% 27% 1994-2000 70% 59% 34% SBP < 140 mmHg and DBP < 90 mmHg

Benefits of Lowering BP

Sustaining a 12 mmHg reduction in SBP over 10 years will prevent one death for every 11 patients treated with Stage I HTN with additional CVD risk factors Why to treat HTN? “The relationship between BP and CVD is positive and continuous.” – 35-40%  in stroke morbidity and mortality – 20-25%  – 21%  CAD events vascular mortality – 52%  – 35%  in CHF in LVH 15

Method

In-office

BP Measurement Techniques

Ambulatory BP monitoring Self-measurement

Brief Description

Two readings, 5 minutes apart, sitting in chair. Confirm elevated reading in contra lateral arm.

Indicated for evaluation of “white-coat” HTN. Absence of 10 –20% BP decrease during sleep may indicate increased CVD risk.

Provides information on response to therapy. May help improve adherence to therapy and evaluate “white-coat” HTN.

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Patient Evaluation

Evaluation of patients with documented HTN has three objectives:

1. Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guides treatment. 2. Reveal identifiable causes of high BP.

3. Assess the presence or absence of target organ damage and CVD.

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Patient Evaluation

Assess lifestyle and identify other CV risk factors or concomitant disorders Hypertension Smoking Obesity Physical inactivity Dyslipidemia Diabetes Microalbuminuria or est GFR < 60 ml/min Age – Males > 55 yrs – Females > 65 yrs Family history of CVD – Males < 55 yrs – Females < 65 yrs 18

Identifiable Causes of Hypertension

 Sleep apnea  Drug-induced or related causes   Primary aldosteronism  Chronic kidney disease Renovascular disease   Pheochromocytoma  Chronic steroid therapy and Cushing’s syndrome Coarctation of the aorta  Thyroid or parathyroid disease 19

Target Organ Damage

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Heart

• Left ventricular hypertrophy • Angina or prior myocardial infarction • Prior coronary revascularization • Heart failure 

Brain

• Stroke or transient ischemic attack 

Chronic kidney disease

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Peripheral arterial disease

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Retinopathy

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Laboratory Tests

      

Routine Tests

Electrocardiogram ( Look for LVH, CAD, arrhythmia) Urinalysis ( Look for protein/blood) Blood glucose, and hematocrit Serum potassium, creatinine, or the corresponding estimated GFR, and calcium Lipid profile, after 9- to 12-hour fast, that includes high-density and low-density lipoprotein cholesterol, and triglycerides. Alb:Cr ratio: Look for microscopic albuminuria.

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Optional tests

• Measurement of urinary albumin excretion or albumin/creatinine ratio 

Specialized investigations:

indicated.

for secondary hypertension not generally indicated unless BP control is not achieved or clinically 21

Treatment Outline

Goals of Therapy Lifestyle modification Classification and management of BP for adults Pharmacologic treatment Compelling indications for individual drug classes Follow-up and monitoring

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Goals of Therapy

 Reduce CVD and renal morbidity and mortality.  Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients with diabetes or chronic kidney disease.  Achieve SBP goal especially in persons >50 years of age.

• Maintain QOL and Minimize side effects.

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Lifestyle Modification

Works best in motivated individuals Initiate at prehypertension classification Obesity  risk for HTN and DM Sodium “ restriction” and other diet aids: – Usual salt intake 10 gm/d = 4 gm Na+ – Reduce to 2.4 gm Na+/day – Caution – salt substitutes contain K+ Discourage excessive consumption of coffee and other caffeine-rich products. Stop smoking and Alcohol consumption.

Exercise/Activity: – 30-40 minutes 3-4x/wk, optimal 5x/wk – Stress reduction 24

Lifestyle Modification

Modification

Weight reduction Adopt DASH eating plan Dietary sodium reduction Physical activity Stopping alcohol consumption

Approximate SBP reduction (range)

5 – 20 mmHg/10 kg weight loss 8 – 14 mmHg 2 – 8 mmHg 4 – 9 mmHg 2 – 4 mmHg 25

Pharmacologic Treatment

Antihypertensive Drug Classes

– Diuretics – Angiotensin Converting Enzyme Inhibitors (ACEI) – Angiotensin II Receptor Blockers (ARB) – Beta blockers – Calcium Channel Blockers (CCB) – Direct Vasodilators 26

JNC-7 Management of BP for Adults

BP classification Normal < 120/80 Prehypertension 120-139 / 80-89 Stage I HTN 140-159 / 90-99 Stage II HTN > 160 / > 100 Lifestyle  Encourage Yes Yes Yes No compelling indication Compelling indication No drug tx Drugs targeted for the compelling indications Thiazide for most Drugs targeted for the compelling indications 2 drugs combination including thiazide Drugs targeted for the compelling indications 27

National Institute for Health and Clinical Excellence (NICE)

NICE is an independent UK based organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.

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Pharmacological interventions:

In hypertensive patients aged 55 or older or black patients of any age, the first choice for initial therapy should either be a calcium-channel blocker or a thiazide type diuretic. For this recommendation,

black patients are considered to be those of African or Caribbean descent, not mixed-race, Asian or Chinese.

In hypertensive patients younger than 55, the first choice for initial therapy should be an angiotensin-converting enzyme (ACE) inhibitor (or an angiotensin-II receptor antagonist if an ACE inhibitor is not tolerated). 29

Pharmacological interventions:

If initial therapy was with a calcium-channel blocker or a thiazide-type diuretic and a second drug is required, add an ACE inhibitor (or an angiotensin-II receptor antagonist if an ACE inhibitor is not tolerated). If therapy was initiated with an ACE inhibitor (or angiotensin-II receptor antagonist), add a calcium-channel blocker or a thiazide-type diuretic. If treatment with three drugs is required, the combination of ACE inhibitor (or angiotensin-II receptor antagonist), calcium-channel blocker and thiazide-type diuretic should be used. 30

Pharmacological interventions:

If blood pressure remains uncontrolled on adequate doses of three drugs, consider adding a fourth and/or seeking expert advice. If a fourth drug is required, one of the following should be considered: – a higher dose of a thiazide-type diuretic or the addition of another diuretic (careful monitoring is recommended) or – beta-blockers or – selective alpha-blockers. 31

Pharmacological interventions:

If blood pressure remains uncontrolled on adequate doses of four drugs, and expert advice has not yet been obtained, this should now be sought. “Beta-blockers are not a preferred initial therapy for hypertension.” However, beta-blockers may be considered in younger people, particularly: – those with an intolerance or contraindication to ACE inhibitors and angiotensin-II receptor antagonists or – women of child-bearing potential or – people with evidence of increased sympathetic drive.

In these circumstances, if therapy is initiated with a beta-blocker and a second drug is required, add a calcium-channel blocker rather than a thiazide type diuretic to reduce the patient’s risk of developing diabetes. 32

Pharmacological interventions:

When a beta-blocker is withdrawn, the dose should be stepped down gradually. Beta-blockers should not be withdrawn in patients who have compelling indications for beta-blockade, for example those who have symptomatic angina or who have had a myocardial infarction. Offer patients with isolated systolic hypertension (systolic BP 160 mmHg or more) the same treatment as patients with both raised systolic and diastolic blood pressure. Offer patients over 80 years of age the same treatment as other patients over 55, taking account of any comorbidity and their existing burden of drug use. 33

The Atenolol Debate

Meta-analysis of 8 randomized, controlled, clinical studies involving atenolol Atenolol vs. placebo (6825) – No outcome difference for all-cause mortality, CV mortality, or MI – Trend for lower risk of stroke (outlier HEP?) Atenolol vs. other antihypertensive (17,671) – No major differences with respect to BP control –  mortality,  trend CV mortality,  risk of stroke 34

The Atenolol Debate

Authors suggestion for findings – Perhaps all B-blockers are not created equal?

Atenolol – hydrophilic, lacks penetration into CNS Atenolol – no benefit in remodeling, endothelial dysfunction More doom for Atenolol?

– ASCOT Trial was halted early > 19,000 patients Atenolol + Thiazide vs. Amlodipine + Perindopril Results due in March – implication thus far for greater CV mortality and stroke 35

Pharmacological interventions:

Where possible, recommend treatment with drugs taken only once a day.

Prescribe non-proprietary drugs where these are appropriate and minimise cost. 36

Special Considerations

 Compelling Indications • Compelling Populations •Blacks • Diabetics • Elderly • Renovascular disease • Pregnancy 37

Compelling Indications

Compelling Indication Initial Therapy Options Heart failure MI High CAD risk Diabetes CRF Recurrent Stroke Prevention Clinical Trial Basis Thiazide, BB, ACEI, ARB, ALDO-Ant BB, ACEI, ALDO-Ant Thiazide, BB, ACEI, CCB BB, ACE, ARB, CCB ACE, ARB Thaizide, ACEI ACC/AHA HF Guidelines, Merit HF, Copernicus, CIBIS, SOLVD, AIRE, TRACE, ValHeft, Rales ACC/AHA Guidelines, BHAT, SAVE, Capricorn, Ephesus ALLHAT, HOPE, LIFE, Convince NKF-ADA Guideline, UKPDS, ALLHAT NKF Guideline, Captopril trial, RENAAL, IDNT, REIN, AASK PROGRESS 38

Compelling Populations High-Risk Hypertensives:

– Blacks – Diabetics – Elderly – Renovascular disease – Pregnancy 39

Blacks

The single most at risk population with HTN – Disproportionately higher rate and more severe Lower plasma renin activity, more Na+ and volume-dependent hypertension Initial tx – DIURETICS – Second line CCB > ACEI =ARB, B-blockers 40

Diabetics

Direct correlation between systolic BP and decline in GFR As little as a 2 mmHg  BP results in significant reductions in CVD (HOT study) Preferred agents – ACEI or ARBs 41

Elderly

Population with the lowest BP control, yet the most to gain! ”

Isolated systolic hypertension is common”

Issues – polypharmacy, altered drug metabolism, physiological changes > 50% of these patients will require combination therapy to achieve goal BP Susceptible to volume depletion – orthostatic hypotension Cognitive impairment Fixed incomes Low-dose thiazide is drug of choice – Additional agent should include – CCB or B-blocker “Start low and go slow” 42

Renal vascular Disease

ACEI and ARBs In patients with RAS or RA hyperplasia – ACEI and ARBs – particularly advantageous –  plasma renin and angiotensin activity

Caution

– Rapid and profound drop in BP as well as renal failure Avoid in bilateral RAS 43

Pregnancy

Almost all cardiovascular drugs are either risk category C or D.

Chronic/transient hypertension vs. preeclampsia Treatment warranted with DBP > 100mmHg Problem – not much data from controlled clinical studies Methyldopa, Hydralazine, Diuretics Caution?

– BB, CCB Avoid – ACEI, ARB 44

Causes of Resistant HTN

Improper BP measurement Excess sodium intake Inadequate diuretic therapy Medication – Inadequate doses – Compliance – Drug interactions – OTC/herbals/dietary supplements Excess alcohol intake Identifiable causes of HTN 45

Public Health Challenges and Community Programs

 Public health approaches (e.g. reducing calories, saturated fat, and salt in processed foods and increasing community/school opportunities for physical activity) can achieve a downward shift in the distribution of a population’s BP, thus potentially reducing morbidity, mortality, and the lifetime risk of an individual’s becoming hypertensive.

 These public health approaches can provide an attractive opportunity to interrupt and prevent the continuing costly cycle of managing HTN and its complications.

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Population-Based Strategy

SBP Distributions

After Intervention Before Intervention Reduction in SBP mmHg 2 3 5 Reduction in BP % Reduction in Mortality Stroke CHD Total –6 –8 –14 –4 –5 –9 –3 –4 –7 47

Which is the Best Strategy Polypill vs. Polymeal

CVD Reduction by 80%. Wald et al. BMJ 2003

CVD Reduction by 75%. Franco et al. BMJ 2004

Enalapril 10 mg Thiazide 25 mg Atenolol 25 mg Aspirin 75 mg Atorvastatin 10 mg Folic acid 5 mg Fish 114 g. Walk, 4 times/week Dark chocolate 100 g Fruits and vegetables 400 g Garlic 2.7 g Almonds 68 g 48

Follow-up and Monitoring

– Patients should return for follow-up and adjustment of medications until the BP goal is reached. – More frequent visits for stage 2 HTN or with complicating comorbid conditions. – Serum potassium and creatinine monitored 1–2 times per year. – After BP at goal and stable, follow-up visits at 3- to 6-month.

– Comorbidities, such as heart failure, associated diseases, such as diabetes, and the need for laboratory tests influence the frequency of visits.

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Continuing treatment

The aim of medication is to reduce blood pressure to 140/90 mmHg or below. However, patients not achieving this target, or for whom further treatment is inappropriate or declined, will still receive worthwhile benefit from the drug(s) if these lower blood pressure. Patients may become motivated to make lifestyle changes and want to reduce or stop using antihypertensive drugs. If at low cardiovascular risk and with well controlled blood pressure, these patients should be offered a trial reduction or withdrawal of therapy with appropriate lifestyle guidance and ongoing review. 50

Questions?