1. Hypertension Catherine Florio Pipas, MD Community & Family Medicine 2007

2. An Approach to Hypertension ( JNC 7 Report JAMA 2003;289:2560-2572) An Approach to Hypertension ( JNC 7 Report JAMA 2003;289:2560-2572) Accurate diagnosis Accurate diagnosis Classification Classification Evaluation ( Initial and follow up) Evaluation ( Initial and follow up) Risk factors and target organ diseaseRisk factors and target organ disease Treatment Treatment Lifestyle Modification Drug treatments Co-Morbid conditions Co-Morbid conditions

3. Hypertension - Facts n 50 million adult Americans have hypertension (60%>60), (80% >80), (90%> 90) –95% is primary (idiopathic) –5% of adult HTN is secondary »Renal (parenchymal/vascular) »Endocrine (adrenal/parathyroid) »Pregnancy related »Result of drug therapy »Coarctation of aorta »Sleep apnea

4. Hypertension - Trends National Health and Nutrition Examination Survey Trials (NHANES) demonstrate that since 1976-1994: -More patients are aware they have HTN -More patients are under therapy for HTN -More patients under therapy are in control -However since 1991 these increases have leveled off Age-adjusted mortality rates for strokes and CHD have decreased since 1976 but since 1991 the rates are leveling off The frequency of end-stage renal disease and heart failure is increasing

5. CC: Mr Charlie Bont is a 44- year old, black male who presents for a comprehensive health assessment required by his new employer. SH: Mr Bont, an electrician, offered a substantial increase in salary, benefits, and supervisory responsibility. ROS: No current complaints Hypertension Case 1 of 15

6. Hypertension Case - Cont. PMH: Last visit to a physician was a pre-employment evaluation prior to his previous job 11 years ago. Reported as normal. PE: Vital signs - BP 156/98 right arm sitting; respirations 14/min; pulse 68 and regular; temp 98.6; weight 223 lbs; height 5 feet 7 inches. BMI 34.6 2 of 15

7. Hypertension Case - Cont. 1. Considering only this preliminary data, List three “medical concerns” that warrant further evaluation. 3 of 15

8. Hypertension Case - Cont. 2. Give four conditions required of the patient, the measurement and/or the instrument needed to accurately confirm the “diagnosis of hypertension” versus “ elevated BP” “ elevated BP” 4 of 15

9. Hypertension - Diagnosis Measurement in the office Measurement in the office –BP evaluated on two separate visits –Bare arm in seated position –No smoking or caffeine for at least thirty minutes prior –Cuff bladder should nearly encircle the arm (at least 80%) –BP measured after at least 5 minutes of rest –Two or more readings should be repeated (at least 2 minutes apart)

10. JNC-7* Adult BP Classification * Joint National Commision on Prevention, Detection, Evaluation and Treatment of High Blood Pressure * For adults ≥18 years old * If SBP and DBP in different classes, choose the highest class

11. JNC-6 Classification Hypertension - Age < 18 years * Lifestyle modifications recommended ** Pharmacologic therapy recommended

12. You have established the presence of “stage 1 hypertension” in Mr Bont. What history that would be important in defining other cardiovascular risk factors or the presence of target organ disease. Include the specifics, if necessary to define increased risk. Ex. Hypercholesterolemia (chol >200) Component of History: Past medical historyROS Social habitsNutritional history Psychosocial/environmental historyFamily history Hypertension Case - Cont. 7 of 15

13. Hypertension Evaluation Additional Major CV Risk Factors n Smoking Dyslipidemia Dyslipidemia Diabetes Diabetes Obesity (BMI>30) Obesity (BMI>30) Physical inactivity Physical inactivity Microalbuminuria or GFR < 60ml/min Microalbuminuria or GFR < 60ml/min Age >55 men, >65women Age >55 men, >65women FH of premature CVD FH of premature CVD Men <55 yo Men <55 yo Women <65 yo Women <65 yo Target-organ damage Heart disease - LVH - Angina or prior MI - Prior CABG - Heart failure Stroke or TIA Nephropathy Peripheral arterial disease Retinopathy

14. Hypertension Case- PE Describe components of the PHYSICAL EXAM that alert you to the presence of target organ disease, other CV risk factors or secondary hypertension. Component of physical exam: VS- Wght, BP, EyesNeck HeartLungs AbdomenExtremities Neurologic 8 of 15

15. PE COMPONENTS History/Physical Exam: BP both arms, BMI Fundoscopic exam Thyroid Exam Carotid, femoral & abdominal bruits Pulmonary and Cardiac exam LV apex - (S3 &S4 gallop) Abdominal Exam (kidneys, masses, AAA) Peripheral vascular pulses and edema Neurologic exam

16. Hypertension Case - Cont. What initial lab tests or studies would you perform on Mr Bont. Give rationale for choosing the test and the findings that might alert you. 9 of 15

17. Hypertension – Initial Lab and Test Evaluation* Labs: Electrolytes – K+/ Na+ –BUN/Creatinine – Fasting blood glucose n Fasting Lipid panel Urinalysis (GFR) EKG NEW JNC 7- Hct and Ca

18. Hypertension - Additional Testing Consider further evaluation if any of the following are present: Abdominal trauma Abdominal trauma Sudden onset of severe HTN Sudden onset of severe HTN History of abnormal urinalysis History of abnormal urinalysis Elevated creatinine Elevated creatinine Hypokalemia Hypokalemia Hypercalcemia Hypercalcemia Consider secondary causes of hypertension: Resistant HTN Paroxysmal HTN Abdominal mass or bruit Cushing Syndrome

19. Hypertension Case - Cont. Mr Bont has n STAGE 1 HTN n Negative History and PE n Normal Labs and EKG Describe your initial approach to his treatment. 10 of 15

20. JNC-7* Adult BP Classification and Treatment Recommendations * Joint National Commision on Prevention, Detection, Evaluation and Treatment of High Blood Pressure * For adults ≥18 years old * If SBP and DBP in different classes, choose the highest class

21. Lifestyle Modifications PREVENTION for all !!!!!!!!!!! Weight loss (10lb wght loss reduces SBP 5-20mm Hg ) Weight loss (10lb wght loss reduces SBP 5-20mm Hg ) BMI 18.5-24.9 BMI 18.5-24.9 Limit ETOH (reduces SBP 2-4 mm HG) Limit ETOH (reduces SBP 2-4 mm HG) - Men 1-2/daily(1 oz ethanol, 24 oz beer, 10 oz wine or 3.0 oz whiskey) - Men 1-2/daily(1 oz ethanol, 24 oz beer, 10 oz wine or 3.0 oz whiskey) - Women 1 daily(0.5 oz ethanol) - Women 1 daily(0.5 oz ethanol) Increase aerobic physical activity (reduces SBP 4-9mm HG) Increase aerobic physical activity (reduces SBP 4-9mm HG) 30-45 minutes most days of week 30-45 minutes most days of week Reduce sodium intake (reduces SBP 2-8mm HG) Reduce sodium intake (reduces SBP 2-8mm HG) 2.4 g sodium or 6 g salt (1 teaspoon table salt)) 2.4 g sodium or 6 g salt (1 teaspoon table salt)) Stop smoking Stop smoking Improve diet (reduces SBP 8-14 mm HG) Improve diet (reduces SBP 8-14 mm HG) Decrease intake of saturated fat and cholesterol Decrease intake of saturated fat and cholesterol Increase fruits, vegetables and lowfat dairy Increase fruits, vegetables and lowfat dairy

22. Hypertension Case - Cont. BP 156/98 BP 156/98 You have decided to initiate drug treatment for Mr. Bont, what drug did you initiate and why? 11 of 15

23. Hypertension - Drug Therapy JNC-7 recommends drug therapy be pushed to achieve goal BP of < 140/90 or <130/80 if DM or Nephropathy JNC-7 recommends drug therapy be pushed to achieve goal BP of < 140/90 or <130/80 if DM or Nephropathy Thiazides are best choice for most with Stage 1 Thiazides are best choice for most with Stage 1 Use long-acting formulations that provide total 24- hour coverage with QD dosing when possible Use long-acting formulations that provide total 24- hour coverage with QD dosing when possible Pts with BP >160/100 likely need two medications (thiazide plus another) Pts with BP >160/100 likely need two medications (thiazide plus another) Patients with Co-Morbidities should have appropriate medications used Patients with Co-Morbidities should have appropriate medications used

24. Hypertension Case - Cont. Briefly state the class and describe the mechanism of action for each of the following drugs: PRIMARYSECONDARY HydrochlorothiazidePropanolol BenazeprilHydralazine DiltiazemClonidine Losartan Doxazosin 12 of 15

25. Individualize the pharmacologic treatment that you might initiate for hypertensive patients with CO-MORBIDITIES: 1. 82-year old man with congestive heart failure 2. 61-year old man post myocardial infarction 3. 40 year old with multiple CV risk factors 4. 42-year old man with Type II diabetes 5. 62-year old woman with chronic renal disease 6. 79 -yr old with Recurrent Stroke Hypertension Case - Cont. 13 of 15

26. Mr Bont returns after being on an antihypertensive agent for six weeks. His blood pressure is now 154/98. List possible reasons for his lack of response to pharmacologic therapy. Hypertension Case - Cont. 14 of 15

27. REFRACTORY HTN n 40% Non compliance n 40% Sub Optimal Therapy n 10% Exogenous causes n 10% Secondary HTN

28. What potential strategies would increase adherence and improve responsiveness to treatment? Hypertension Case - Cont. 15 of 15

29. JNC 7 REPORTS :“Motivation improves when patients have positive experiences with and trust in their clinicians. Empathy builds trust and is a potent motivator” n Patients previous knowledge and experiences n Patients cultural beliefs, concerns and fears n Verbal and written confirmation of goals n Ambulatory monitoring n Identify barriers

30. Summary:Approach to HTN n Accurate Diagnosis n Staging –Classification via JNC 7 2003 »Remember PREHYPERTENSIVES (120-139 or 80-89) –Assess H, PE, Labs and CV Risk factors n Treatment –Life Style Modifications/ Prevention for all –Thiazide Diuretics as first line –Consider Co-Morbid conditions n Consider your causes if refractory(40.40.10.10)