Transcript Control of HTN in special groups.ppt

CONTROL OF HYPERTENTION
IN SPECIAL GROUPS
HYPERTENTION IN PREGNANCY
Etiology & Definition
Complicates 10-20% of pregnancies
Elevation of BP ≥140 mmHg systolic and/or ≥90
mmHg diastolic, on two occasions at least 6
hours apart.
Categories
Chronic Hypertension
Gestational Hypertension
Preeclampsia
Preeclampsia superimposed on Chronic
Hypertension
Chronic Hypertension
“Preexisting Hypertension”
Definition
Systolic pressure ≥ 140 mmHg, diastolic pressure
≥90 mmHg, or both.
Presents before 20th week of pregnancy or persists
longer then 12 weeks postpartum.
Causes
Primary = “Essential Hypertension”
Secondary = Result of other medical condition (ie:
renal disease)
Prenatal Care for Chronic
Hypertensives
Electrocardiogram should be obtained in women with
long-standing hypertension.
Baseline laboratory tests
Urinalysis, urine culture, and serum creatinine,
glucose, and electrolytes
Tests will rule out renal disease, and identify
comorbidities such as diabetes mellitus.
Women with proteinuria on a urine dipstick should
have a quantitative test for urine protein.
Treatment for Chronic
Hypertension
Avoid treatment in women with uncomplicated mild
essential HTN as blood pressure may decrease
as pregnancy progresses.
May taper or discontinue meds for women with
blood pressures less than 120/80 in 1st
trimester.
Reinstitute or initiate therapy for persistent
diastolic pressures >95 mmHg, systolic
pressures >150 mmHg, or signs of hypertensive
end-organ damage.
Medication choices = Oral methyldopa and
labetalol.
Preeclampsia
Definition = New onset of hypertension and
proteinuria after 20 weeks gestation.
Systolic blood pressure ≥140 mmHg OR diastolic blood
pressure ≥90 mmHg
Proteinuria of 0.3 g or greater in a 24-hour urine
specimen
Preeclampsia before 20 weeks, think MOLAR
PREGNANCY!
Categories
Mild Preeclampsia
Severe Preeclampsia
Eclampsia
Occurrence of generalized convulsion and/or coma in
the setting of preeclampsia, with no other
neurological condition.
Preeclampsia
Severe Preeclampsia must have one of the
following:
Symptoms of central nervous system dysfunction = Blurred vision,
scotomata, altered mental status, severe headache
Symptoms of liver capsule distention = Right upper quadrant or
epigastric pain
Nausea, vomiting
Hepatocellular injury = Serum transaminase concentration at least
twice normal
Systolic blood pressure ≥160 mm Hg or diastolic ≥110 mm Hg on
two occasions at least six hours apart
Thrombocytopenia = <100,000 platelets per cubic milimeter
Proteinuria = 5 or more grams in 24 hours
Oliguria = <500 mL in 24 hours
Severe fetal growth restriction
Pulmonary edema or cyanosis
Cerebrovascular accident
Preeclampsia superimposed on
Chronic Hypertension
Affects 10-25% of patients with chronic HTN
Preexisting Hypertension with the following
additional signs/symptoms:
New onset proteinuria
Hypertension and proteinuria beginning prior to 20
weeks of gestation.
A sudden increase in blood pressure.
Thrombocytopenia.
Elevated aminotransferases.
Treatment of Preeclampsia
Definitive Treatment = Delivery
Major indication for antihypertensive therapy is
prevention of stroke.
Diastolic pressure ≥105-110 mmHg or systolic
pressure ≥160 mmHg
Choice of drug therapy:
Acute – IV labetalol, IV hydralazine, SR Nifedipine
Long-term – Oral methyldopa or labetalol
Gestational Hypertension
Mild hypertension without proteinuria or other
signs of preeclampsia.
Develops in late pregnancy, after 20 weeks
gestation.
Resolves by 12 weeks postpartum.
Can progress onto preeclampsia.
Often when hypertension develops <30 weeks gestation.
Indications for and choice of antihypertensive
therapy are the same as for women with
preeclampsia.
Risk Factors for
Hypertension in Pregnancy
Nulliparity
Preeclampsia in a previous pregnancy
Age >40 years or <18 years
Family history of pregnancy-induced hypertension
Chronic hypertension
Chronic renal disease
Antiphospholipid antibody syndrome or inherited thrombophilia
Vascular or connective tissue disease
Diabetes mellitus (pregestational and gestational)
Multifetal gestation
High body mass index
Male partner whose previous partner had preeclampsia
Hydrops fetalis
Unexplained fetal growth restriction
Evaluation of Hypertension in
Pregnancy
History
Physical
ID and Complaint
Vitals
HPI (S/S of Preeclampsia)
HEENT = Vision
Past Medical Hx, Past Family
Hx
Cardiovascular
Past Obstetrical Hx, Past
Gyne Hx
Abdominal = Epigastric pain,
RUQ pain
Social Hx
Neuromuscular and
Extremities = Reflex, Clonus,
Edema
Medications, Allergies
Prenatal serology, blood
work
Assess for Hypertension in
Pregnancy risk factors
Respiratory
Fetus = Leopold’s, FM, NST
Evaluation of Hypertension in
Pregnancy
Laboratory Tests
CBC (Hgb, Plts)
Renal Function (Cr, UA, Albumin)
Liver Function (AST, ALT, ALP, LD)
Coagulation (PT, PTT, INR, Fibrinogen)
Urine Protein (Dipstick, 24 hour)
Management of Hypertension in
Pregnancy
Depends on severity of hypertension and
gestational age!!!!
Observational Management
Restricted activity
Close Maternal and Fetal Monitoring
BP Monitoring
S/S of preeclampsia
Fetal growth and well being (NST, and U/S)
Routine weekly or biweekly blood work
Management of Hypertension in
Pregnancy
Medical Management
Acute Therapy = IV Labetalol, IV Hydralazine, SR
Nifedipine
Expectant Therapy = Oral Labetalol, Methyldopa,
Nifedipine
Eclampsia prevention = MgSO4
Contraindicated antihypertensive drugs
ACE inhibitors
Angiotensin receptor antagonists
Management of Hypertension in
Pregnancy
Proceed with Delivery
Vaginal Delivery VS Cesarean Section
Depends on severity of hypertension!
May need to administer antenatal corticosteroids
depending on gestation!
Only cure is DELIVERY!!!
2013 ESH/ESC Guidelines for the management of arterial hypertension
Definitions and classification of office BP levels (mmHg)*
Hypertension:
SBP >140 mmHg ± DBP >90 mmHg
Category
Systolic
Diastolic
Optimal
<120
and
<80
Normal
120–129
and/or
80–84
High normal
130–139
and/or
85–89
Grade 1 hypertension
140–159
and/or
90–99
Grade 2 hypertension
160–179
and/or
100–109
Grade 3 hypertension
≥180
and/or
≥110
Isolated systolic hypertension
≥140
and
<90
* The blood pressure (BP) category is defined by the highest level of BP, whether systolic or diastolic. Isolated systolic
hypertension should be graded 1, 2, or 3 according to systolic BP values in the ranges indicated.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281Medical Education & Information – for all Media, all Disciplines, from all over the World
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JNC 8: Graded Recommendations
A – Strong evidence
B – Moderate evidence
C – Weak evidence
D – Against
E – Expert Opinion
N – No recommendation
JNC 8: Drug Treatment
Thresholds and Goals
Age > 60 yo
Systolic:
Threshold > 150 mmHg
Goal < 150 mmHg
LOE: Grade A
Diastolic:
Threshold > 90 mmHg
Goal < 90 mmHg
LOE: Grade A
JNC 8: Drug Treatment
Thresholds and Goals
Age < 60 yo
Systolic:
Threshold > 140 mmHg
Goal < 140 mmHg
LOE: Grade E
Diastolic:
Threshold > 90 mmHg
Goal < 90 mmHg
LOE: Grade A for ages 40-59; Grade E for ages 18-39
JNC 8: Drug Treatment
Thresholds and Goals
Age > 18 yo with CKD or DM
JNC 7: < 130/80 (MDRD NEJM 1994)
Systolic:
Threshold > 140 mmHg
Goal < 140 mmHg
LOE: Grade E
Diastolic:
Threshold > 90 mmHg
Goal < 90 mmHg
LOE: Grade E
JNC 8: Initial Drug Choice
Nonblack, including DM
Thiazide diuretic, CCB, ACEI, ARB
LOE: Grade B
Black, including DM
Thiazide diuretic, CCB
LOE: Grade B (Grade C for diabetics)
JNC 8: Initial Drug Choice
Age > 18 yo with CKD and HTN (regardless of
race or diabetes)
Initial (or add-on) therapy should include an ACEI or
ARB to improve kidney outcomes
LOE: Grade B
Blacks w/ or w/o proteinuria
ACEI or ARB as initial therapy (LOE: Grade E)
No evidence for RAS-blockers > 75 yo
Diuretic is an option for initial therapy
JNC 8: Subsequent Management
Reassess treatment monthly
Avoid ACEI/ARB combination
Consider 2-drug initial therapy for Stage 2 HTN
(> 160/100)
Goal BP not reached with 3 drugs, use drugs
from other classes
Consider referral to HTN specialist
LOE: Grade E
2013 ESH/ESC Guidelines for the management of arterial hypertension
Blood pressure goals in hypertensive patients
Recommendations
SBP goal for “most”
•Patients at low–moderate CV risk
•Patients with diabetes
•Consider with previous stroke or TIA
•Consider with CHD
•Consider with diabetic or non-diabetic CKD
<140 mmHg
SBP goal for elderly
•Ages <80 years
•Initial SBP ≥160 mmHg
140-150 mmHg
SBP goal for fit elderly
Aged <80 years
<140 mmHg
SBP goal for elderly >80 years with SBP
•≥160 mmHg
140-150 mmHg
DBP goal for “most”
<90 mmHg
DB goal for patients with diabetes
<85 mmHg
SBP, systolic blood pressure; CV, cardiovascular; TIA, transient ischaemic attack; CHD, coronary heart disease; CKD, chronic kidney disease;
DBP, diastolic blood pressure.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281Medical Education & Information – for all Media, all Disciplines, from all over the World
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2013 ESH/ESC Guidelines for the management of arterial hypertension
Hypertension treatment for people with diabetes
Recommendations
Additonal considerations
Mandatory: initiate drug treatment in patients
with SBP ≥160 mmHg
• Strongly recommended: start drug treatment
when SBP ≥140 mmHg
SBP goals for patients with diabetes: <140 mmHg
DBP goals for patients with diabetes: <85 mmHg
All hypertension treatment agents are
recommended and may be used in patients with
diabetes
• RAS blockers may be preferred
• Especially in presence of preoteinuria or
microalbuminuria
Choice of hypertension treatment must take comorbidities into account
• Avoid in patients with diabetes
Coadministration of RAS blockers not
recommended
SBP, systolic blood pressure; DBP, diastolic blood pressure; RAS, renin–angiotensin system.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281Medical Education & Information – for all Media, all Disciplines, from all over the World
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2013 ESH/ESC Guidelines for the management of arterial hypertension
Hypertension treatment for people with nephropathy
Recommendations
Additonal considerations
Consider lowering SBP to <140 mmHg
Consider SBP <130 mmHg with overt
proteinuria
• Monitor changes in eGFR
RAS blockers more effective to reduce
albuminuria than other agents
• Indicated in presence of microalbuminuria or
overt proteinuria
Combination therapy usually required to reach
BP goals
• Combine RAS blockers with other agents
Combination of two RAS blockers
• Not recommended
Aldosterone antagonist not recommended in
CKD
• Especially in combination with a RAS blocker
• Risk of excessive reduction in renal function,
hyperkalemia
SBP, systolic blood pressure; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; RAS, renin–angiotensin system.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281Medical Education & Information – for all Media, all Disciplines, from all over the World
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Comparison of Recent
Guideline Statements
JNC 8
ESH/ESC
AHA/ACC
ASH/ISH
>140/90
>140/90 <80 yr
>150/90 >80 yr
>140/90
Threshold
for Drug Rx
>140/90 < 60 yr Eldery SBP >160
>150/90 >60 yr Consider SBP
140-150 if <80 yr
B-blocker
First line Rx
No
Yes
No
No
Initiate Therapy
w/ 2 drugs
>160/100
"Markedly
elevated BP"
>160/100
>160/100
Comparison of Recent
Guideline Statements
JNC 8
ESH/ESC
AHA/ACC
ASH/ISH
>140/90
>140/90 <80 yr
>150/90 >80 yr
>140/90
Threshold
for Drug Rx
>140/90 < 60 yr Eldery SBP >160
>150/90 >60 yr Consider SBP
140-150 if <80 yr
B-blocker
First line Rx
No
Yes
No
No
Initiate Therapy
w/ 2 drugs
>160/100
"Markedly
elevated BP"
>160/100
>160/100
Goal BP
Group
BP Goal (mm Hg)
General
DM*
CKD**
JNC 8:
<60 yr: <140/90
>60 yr: <150/90
< 140/90
< 140/90
ESH/ESC:
< 140/90
< 140/85
< 140/90
Elderly
140-150/90
(<80 yr: SBP<140)
ASH/ISH
< 140/90
>80 yr: <150/90
AHA/ACC
< 140/90
*ADA: < 140/80 or lower
(SBP < 130 if proteinuria)
< 140/90
< 140/90
(Consider < 130/80 if proteinuria)
< 140/90
< 140/90
**KDIGO: <140/90 w/o
albuminuria
2013 ESH/ESC Guidelines for the management of arterial hypertension
Lifestyle changes for hypertensive patients
Recommendations to reduce BP and/or CV risk factors
Salt intake
Restrict 5-6 g/day
Moderate alcohol intake
Limit to 20-30 g/day men,
10-20 g/day women
Increase vegetable, fruit, low-fat dairy intake
25 kg/m2
BMI goal
Waist circumference goal
Men: <102 cm (40 in.)*
Women: <88 cm (34 in.)*
≥30 min/day, 5-7 days/week
(moderate, dynamic exercise)
Exercise goals
Quit smoking
* Unless contraindicated. BMI, body mass index.
The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31:1281Medical Education & Information – for all Media, all Disciplines, from all over the World
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Hypertension in the Elderly
Fastest growing segment of the population
Prevalence of hypertension is very high
Several issues make managing HTN unique:
Often present with isolated systolic HTN
More likely to present with comorbidities
Many clinical trials in HTN have excluded these patients
(particularly for those 80 years and older)
Elderly are more susceptible to certain adverse effects
(orthostatic hypotension)
Hypertension in the Elderly
HYVET demonstrated that treatment of HTN to goal
BP less than 150/80 mm Hg in patients >80 years old
was safe and effective
But…what about a lower BP goal?
And…what about the patients age 60-80?
Hypertension in the Elderly
Two “treat-to-target” trials in this age group
Japanese Trial to Assess Optimal SBP (JATOS)
4416 patients aged 65-85 (average age of 74)
Randomized to SBP<140 vs. SBP 140-160
Achieved BP of 136/75 vs. 146/78
No difference in CV events or renal failure (p=0.99)
VALISH trial
3079 patients aged 70-84 (average age of 76)
Randomized to SBP<140 or SBP 140-149
No significant reductions in stroke, CV events, or renal failure
Overall event rates were lower than anticipated in both of
these studies
JATOS Study Group. Hypertens Res 2008;31:2115-27.
Ogihara T et al. Hypertension 2010;56:196-202.
Hypertension in the Elderly
The opposing arguments:
The Japanese trials had low event rates and may not
represent the risks in other populations
Data from other studies suggests a goal SBP closer to
140mm Hg may be more appropriate for ages 60-80
Methodology may have prevented JNC-8 panel from considering
the results in their analysis
The “Speed Limit” effect
Wright JT Jr et al. Ann Intern Med 2014;160:499-504.
Hypertension in Diabetics
Action to Control CV Risk in Diabetes (ACCORD)
Randomized, double-blind trial
Included patients with T2DM and high CV risk
Randomized to SBP<120 or SBP<140
Primary outcome of CV death, MI, or stroke
Results
Mean SBP of 119 mm Hg vs. 133 mm Hg
No significant difference in primary outcome
(HR=0.88, p=0.2)
Incidence of stroke was lower with intensive treatment
(HR 0.59, p=0.01)
Significant increase in serious adverse events
The ACCORD Study Group. N Engl J Med 2010;362:1575-85.
Comparisons to Other Guidelines
BP Goal JNC-7
JNC-8
ASH/ISH ESC/ES
H
CHEP
Age < 60 <140/90
<140/90
<140/90
<140/90
<140/90
Age 6079
<140/90
<150/90
<140/90
<140/90
<140/90
Age 80+
<140/90
<150/90
<150/90
<150/90
<150/90
Diabetes <130/80
<140/90
<140/90
<140/85
<130/80
CKD
<140/90
<140/90
<130/90
<140/90
<130/80
Adapted from Salvo M et al. Ann Pharmacother 2014;48:1242-8.
Comparisons to Other Guidelines
JNC-7
JNC-8
ASH/ISH ESC/ES
H
CHEP
NonThiazide
black (no
DM or
CKD)
Thiazide,
ACEI,
ARB,
CCB
<60:ACE
I,ARB
>60:CCB
, thiazide
Thiazide,
ACEI,
ARB (BB
if <60)
Black (no Thiazide
DM or
CKD)
Thiazide, Thiazide, Thiazide, Thiazide,
CCB
CCB
ACEI,
ARB (BB
ARB,
if <60)
CCB, BB
Thiazide,
ACEI,
ARB,
CCB, BB
Diabetes ACEI,
CCB,
ACEI,
ACEI,
ARB,
thiazide ARB,
ARB
CCB,
CCB,
BB,
thiazide
Adapted from Salvo M et al. Ann Pharmacother 2014;48:1242-8.
thiazide
ACEI,
ARB,
CCB,
thiazide
Hypertension and The Kidney
Update: Clinical Trials
Paul J. Scheel, Jr., M.D.
Director, Division of Nephrology
The Johns Hopkins University School of
Medicine
Primary Diagnosis in Patients With
Kidney Disease
Patient Primary Diagnosis
Other
20%
8%
Glomerulonephritis
Diabetes
45%
27%
Hypertension
USRDS 2010Annual Data Report. The data reported here have been supplied by the USRDS. The interpretation
and reporting of these data are the responsibility of the author(s) and in no way should be seen as an official
policy or interpretation of the U.S. government. Available at: www.usrds.org. Accessed 3/28/05.
Combination Therapy for BP Control:
Rule Rather Than Exception
Trial/Systolic Blood Pressure Achieved
ALLHAT
138
mm Hg
IDNT
138 mm Hg
RENAAL
141 mm Hg
UKPDS
144 mm Hg
ABCD
132 mm Hg
MDRD
132 mm Hg
HOT
138 mm Hg
AASK
128 mm Hg
1
2
3
4
Number of BP Medications
Adapted from Bakris et al. Am J Kidney Dis. 2000;36:646-661.
43
Lower BP Slows Decline in GFR
MAP (mmHg)
95
0
98
101
104
107
110
113
116
119
GFR (mL/min/year)
-2
-4
-6
Untreated
HTN
-8
-10
-12
130/85
140/90
-14
Bakris GL et al. Am J Kidney Dis. 2000; 36(3):646-661.
Hypertension and The Kidney
Significant Publications 2013
The Coral Trial
Symplicity HTN I, II, III Study
JNC VIII
Atherosclerotic Narrowing of
Proximal Renal Artery
CORAL Trial
947 Patients
Radomized
Medical Therapy
Medical Therapy plus Stent
Systolic HTN despite 2 or more
drugs or CKD
Endpoints: Death,MI, Stroke,
CHF, Progressive CKD or
Need for Dialysis
Kaplan–Meier Curves for the Primary Outcome.
Cooper CJ et al. N Engl J Med 2014;370:13-22.
Cooper et al.NEJM. 2014;370(1):13-22
The Coral Trial
Results:
- No difference in composite end point between
the treatment groups.
- No difference in individual components of
primary endpoint between the treatment
groups.
- Modest difference in control of systolic BP in
patients treated with stents ( -2.3 mm Hg, P= 0.03)
Percutaneous Renal Denervation
Symplicity HTN Study
Symplicity I, II, III HTN study designed to study
efficacy of radiofrequency ablation of renal
artery in patients with resistant HTN
Renal Denervation
Symplicity
Renal Artery Denervation
Percutaneous renal denervation in patients with
treatment-resistant hypertension: final 3-year
report of the Symplicity HTN-1 study
- Open- Label Study of 153 patients with
resistant HTN
- Eligible Patients: BP > 160 mm Hg on 3 or
more anti-hypertensives at “optimum dose”
- End Point: Safety and Changes in BP over
time.
ww.thelancet.com Published online November 7, 2013
Percutaneous renal denervation in patients with
treatment-resistant hypertension: final 3-year
report of the Symplicity HTN-1 study
ww.thelancet.com Published online November 7, 2013
Renal Sympathetic Denervation for Treatment of DrugResistant Hypertension: One Year Results From the
Symplicity HTN-2 Randomized Controlled Trial
- RCT of Medical Therapy vs Renal Denervation with Cross
Over
- 106 Patients with > Drug Hypertension Randomized
- Patients Randomized To Medical Therapy were Crossed Over
to Renal Denervation at 6 months.
- Patients Followed for 12 months
- Primary Endpoint = Control of BP
Esler et al. Circulation 2012; 18 (25): 2976-2982
Renal Sympathetic Denervation for Treatment of DrugResistant Hypertension: One Year Results From the
Symplicity HTN-2 Randomized Controlled Trial
Esler et al. Circulation 2012; 18 (25): 2976-2982
Symplicity 3 HTN Trial
- 535 patients with resistant HTN in 87 US
medical centers
- Intervention: Radiofrequency ablation vs sham
control.
- Radomization: 2/3 intervention, 1/3 Sham
- Endpoints: safety and efficacy at 6 months
- Results: Not published. Press release. Study
failed to meet efficacy endpoint at 6 months.
2014 Evidence-Based Guidelines for the Management
of High Blood Pressure in Adults
Report From the Panel Members Appointed to the Eight Joint
National Committee ( JNC 8)
Three Questions Answered:
1) In adults with HTN, does initiating antihypertensive
pharmacologic therapy at specific thresholds improve health
outcomes ?
2) In adults with HTN, does treatment with antihypertensive
pharmacologic therapy to a specific BP goal lead to
improvements in health outcomes ?
3) In adults with HTN, do various antihypertensive drug or drug
classes differ in comparative benefits and harms on specific
health outcomes ?
James et al. JAMA published online December 18, 2013
2014 Evidence-Based Guidelines for the Management of High
Blood Pressure in Adults
Report From the Panel Members Appointed to the Eight Joint
National Committee ( JNC 8)
Evidence Review:
1) Mortality, CVD-related mortality,CKD-related mortality
2) MI, CHF, hospitalization for CHF or CVA
3) Need for coronary revascularizaton, PTA or stent placement
(coronary, carotid,renal or lower extremities)
4) ESRD, or doubling of serum creatinine or 50% reduction in
measured GFR
5) Included only RCT
James et al. JAMA published online December 18, 2013
2014 Evidence-Based Guidelines for the Management of High Blood Pressure in
Adults Report From the Panel Members Appointed to the Eight Joint National
Committee ( JNC 8)
James et al. JAMA published online December 18, 2013
Conclusions
- PTA and endovascular stenting of the renal
artery for atherosclerotic disease should not
be routine practice
- Renal artery denervation for resistant
hypertension has shown initial promise and we
will have to await publication of Simplicity 3 to
determine its place in management of severe
hypertension
- JNC 8 has raised goal BP for most patients
with HTN. Jury is still out for patients with
CKD or CKD plus proteinuria