Presentation on theme: "Changing Strategies Of Treatment Of Hypertension Dr Sunita Dodani Family Medicine Department The Aga Khan University Karachi, Pakistan."— Presentation transcript:
Changing Strategies Of Treatment Of Hypertension Dr Sunita Dodani Family Medicine Department The Aga Khan University Karachi, Pakistan
Objectives: At the end of this presentation, we should be able to: Learn about recent guidelines of hypertension management. Define hypertension by the JNC-VI guidelines. Discuss the management steps recommended by JNC VI. Define the provider’s role in patient compliance. Controversies of stepped care therapy.
New Guidelines: Joint National Committee (JNC) sixth report on prevention, detection, evaluation and treatment of high blood pressure(JNC-VI) WHO/International Society of Hypertension (ISH), Guidelines of Hypertension Management for Primary Care Physicians British Hypertension Society Guidelines for Hypertension Management Local: First report of National Task Force on Hypertension, Pakistan Hypertension League
JNC-VI Guidelines : JNC-VI Guidelines : ( Drawn from consensus and evidence - based findings) ( Drawn from consensus and evidence - based findings) Discuss hypertension treatment in step- wise-manner. Cover treatment strategies in special population like Black Americans, pregnancy and patients with co-morbid conditions.
Definition: Normal pressure into 3 categories. Abnormal pressure into 3 stages for adults > 18 and older.
Classification of Blood Pressure for Adults Age 18 and Olders: Classification of Blood Pressure for Adults Age 18 and Olders: CategorySystolic Diastolic (mm Hg)(mm Hg) Optimal<120and<80 Normal<130and<85 High-normal or85-89 Hypertension Stage or90-99 Stage or Stage 3> 180or> 110
Changing Strategies Of Treatment Of Hypertension (Cont’d) Elevated BP (>140/90) on 2 or more visits with BP taken 2 or more times on each visit and then averaged. Seated in a chair with arm supported at heart level. Must not smoke or drink caffeine for 30 minutes prior to measuring the BP. Cuff size should encircle 80% of the patient’s arm.
Changing Strategies Of Treatment Of Hypertension (Cont’d) BP measurements should be attempted only after 5 minutes of rest. BP should be at least 2 minutes apart, averaged, and then repeated if 2 measurements differ by more than 5 mmHg. Anxious patient may falsely give high reading (white coat hypertension).
Changing Strategies Of Treatment Of Hypertension(Cont’d) BP rises in most people as they age, BP is not considered a normal part of aging. Isolated systolic hypertension is considered in patients with systolic BP >140 mmHg and diastolic BP 140 mmHg and diastolic BP <90 mmHg
Management: Three-pronged approach: Lifestyle modifications. Appropriate medications (based on the patient’s demographic and medical profile). Professional health care support to foster compliance.
Life Style Modification: Lifestyle modifications for all stages of hypertension and are the initial recommendations for both high normal and stage 1 hypertension.
Life Style Modifications (Cont’d): Weight reduction also cholesterol and DM also cholesterol and DM Patients with abdominal obesity waist size>34 cms Females >39 cms Males Hypertension risk
Exercise: Brisk walking. minutes at 40% - 60% of maximal activity determined by pulse rate (220 - age x 0.4 & 0.6).
Changing Strategies Of Treatment Of Hypertension (Cont’d) DASH: Dietary approaches to stop hypertension. Like DM diet, DASH diet includes a specific number of servings and the weight of servings. Unlike DM Diet, DASH diet does not offer the option of food exchanges. Plant food sources Only animal protein servings/day
Changing Strategies Of Treatment Of Hypertension (Cont’d) in Dietary sodium. Esp. for African Americans Elderly DM 75 meq/day of dietary sodium or less ( 5 mmHg systolic & 2.6 mm diastolic). Cessation of smoking. alcohol intake. < 10 oz wine < 2 oz whisky < 24 oz beer
Initial Drug Therapy: Step-wise approach: 1. First line - Diuretic or -blocker. 2. New agents - Ca channel blocker, ACE inhibitor, vasodilator etc. should be considered if patient is not responsive to initial therapy or has co-morbid conditions. 3. Adrenergic agents should only be used as a last choice b/c of their side effect profile.
Choosing the right medication for your patient: Choosing the right medication for your patient: Choice of the treatment regimen depends on: Choice of the treatment regimen depends on: Degree of BP elevation. Number of associated & concurrent risk factors. Presence of TOD. Clinical CVD or associated clinical conditions (ACC).
Risk Stratification: Risk Factors for Cardiovascular Diseases Target Organ Damage (TOD) Associated Clinical Conditions (ACC) 1. Used for risk stratification : Levels of systolic and diastolic BP (Stages 1-3) Men > 55 years Women > 65 years Smoking TotalCholestrol > 6.5 mmol/L Diabetes FH of premature CVD LVH (ECG, Echo, XR) Proteinuria & / or slight elevation of plasma creatinine 1. 2 – 2 mg/dl ( mmol/L) Ultrasound or radiological evidence ofatherosclerotic plaques (carotid,illiac & femoral arteries, aorta) Cerebrovascular Disease Ischemic stroke Cerebralhemorhage Transientischemic attack Heart Disease: Myocardial Infarction Angina Pectoris Coronary revascularization Congestive Heart failure
Risk Stratification (Cont’d): Risk Factors For Cardiovascular Diseases Target Organ Damage (TOD) Associated Clinical Conditions (ACC) 2. Other factors adversely influencing the prognosis Reduced HDL Raised LDL Microalbuminuria in diabetes Impaired GTT Obesity Sedentary life style Raised fibrinogen High risk socioeconomic & ethnic group High risk geographic region Generalized or focal narrowing of the retinal arteries ( retinopathy) Renal Diseases: Diabetic nephropathy
Dosage & Combination Therapy Single daily dose interval of weeks to observe the full response, unless it is necessary to lower BP more urgently. If drug well tolerated but response is small, the dose or add drugs stepwise until BP control is attained. Treatment can be stepped down later if BP falls substantially below the optimal level. Most hypertensives require a combinations of antihypertensive therapy to achieve optimal control.
Drugs from different classes generally have additive effect on BP. Submaximal doses of 2 drugs results in larger response of BP & fewer side effects eg:Diuretic + B-blocker Diuretic + ACE inhibitor Ca-channel blocker + ACE inhibitor Fixed dose combination may be convenient and are acceptable when monotherapy is ineffective Dosage & Combination Therapy (Cont’d):
Dosage & Combination Therapy (Cont’d) In Elderly: 1.Initial drug therapy: Diuretics Ca channel blockers
Specific Medication Recommendations For Concurrent Medical Problems: Concurrent Conditions/ Charactersticks Recommended Drug Therapy Intermediate Drug Therapy Usually Not Used or Contra- indicated Medications Diabetes with proteinuria ACE Inhibitors Ca antagonists (both types) ACE Inhibitors Angiotensin ReceptorBlockers Diuretics with care BBlockers Heart Failure ACE Inhibitors Diuretics Carvadilol Losartin BBlockers Ca Antagonists Isolated Systolic Hypertension Diuretics Ca Antagonists (non-DHP central effects), long acting forms ACE Inhibitors Angiotensin ReceptorBlockers B
Specific Medication Recommendations For Concurrent Medical Problems: Concurrent Conditions/ Characteristics Recommended Drug Therapy Intermediate Drug Therapy Usually Not Contraindicated Myocardial Infarction BBlockers (non-ISA) ACE Inhibitors; reduce mortality after MI Diuretics ACE Inhibitors ReceptorBlockers NonDHP,CaAntago- nists, (Diltiazem, Verapamil) DHP Ca Antagonistseg nifedipine (immediate release can worsen myocardial ischemia) African American race Diuretics Calcium Antagonists (both types) Angiotensin ReceptorBlockers B ACE Inhibitors Atrial Tachycardia/ Fibrillation BBlockers Ca Antagonists (Both Types) Diuretics ACE Inhibitors Angiotensin. ReceptorBlockers
Specific Medication Recommendations For Concurrent Medical Problems:
Specific Medication Recommendations For Concurrent Medical Problems (Cont’d): Concurrent Conditions/ Characteristics Recommended Drug Therapy Intermediate Drug Therapy Usually not used Contraindicated Medications Essential or senile tremors BBlockersACE Inhibitors ReceptorBlocker Ca Antagonists Diuretics HyperthyroidismBBlockers MigraineBBlockers (Non ISA) Calcium Antagonist (non DHP) Diuretics ACE Inhibitors ReceptorBlocker DHP Calcium Antagonists
Specific Medication Recommendations For Concurrent Medical Problems (Cont’d): Concurrent Conditions/ Characteristics Recommended Drug Therapy Intermediate Drug Therapy Usually Not Used/ Contraindicated Medications OsteoporosisThiazides Pre-operative Hypertension BBlockers Prostatism Angiotensin Receptor Blockers Diuretics ACE Inhibitors ( can’t be given with severe renal impairment) Renal Insufficiency Angiotensin Receptor Blockers Ca Antagonists (both types) B Blockers
WHO/ISH Guidelines for Hypertension Management Summary Points: Use of Grades rather than stages, otherwise values choosen are same as JNC-VI. Mild, moderate and severe are not used in the WHO-ISH guidelines - they correspond to grades 1,2 & 3. Term borderline hypertension is subgroup of Grade 1 i.e. Systolic Diastolic Diastolic 90-94
British Hypertension Society Guidelines for Hypertension Management: Summary Points: Grades rather than stages are used to classify hypertension. Uses coronary heart disease risk accessors or risk charts. Isolated systolic hypertension defined as systolic > 160 and diastolic 160 and diastolic < 90. Use of aspirin (primary prevention ) in hypertension patients. Use of statins in patients with hypertension.
Indications for specialist referral: Urgent treatment indicated: Malignant hypertension, impending complications. To investigate potential underlying causes of hypertension when initial evaluation suggests this possibility. To evaluate therapeutic problems or failures. Special circumstances: Unusually variable blood pressure, possible white coat hypertension, pregnancy.
New guidelines like JNC-VI, unlike previous guidelines, has introduced the concept of aggressive blood pressure control at optimal levels. For elderly patients, the achievement of at least 140/90 mm Hg or below blood pressure is acceptable. Life style modification alone for those patients at relatively low overall risk for cardiovascular diseases and with drugs for those at higher risk. Conclusion :
Diuretics or B-blockers for those as first choice with uncomplicated hypertension. ACE inhibitors for Diabetic patients with proteinuria. ACE inhibitors &/ 0r diuretics for patients with heart failure & systolic dysfunction. Long-acting dihydropyridine Ca antagonist for systolic hypertension in the elderly. Follow-up during evaluation & stabilization of treatment should be frequent to monitor BP and other risk factors. Follow-up is important to establish good relationship with patient and to educate the patient. Conclusion : (Contd…)
Life style modification,Reduce wt Quit smoking,Regular exc., Decrease sodium and alcohol Inadequate response Continue lifestyle modifica- tion,Initiate pharmacotherapy Inadequate response Increase daily doseSubstitute another drug Add 2 nd drug from diff.class Inadequate response Add 2 nd or 3 rd Drug Inadeq, response Refer Figure 1: Stepped Care Algorithm for treatment of Hypertension:
Changing Strategies Of Treatment Of Hypertension (Cont’d) Goal: JNC-VI uses a lower goal BP (<140/90 mmHg) for hypertension in the elderly.
Changing Strategies Of Treatment Of Hypertension (Cont’d) Diuretics: plasma volume. cause peripheral vasodilation. potentiate the effect of other anti-hypertensive drugs. Caution: Renal disease, Gout, DM, Dyslipidemia. Start low dose. -blockers: 1 selective : start low dose & gradually-increase. Should not be used in COPD, CHF or left ventricular function. ACE inhibitors: DM with proteinuria. CHF or myocardial infarction.
Stratifying risk and quantifying prognosis:
Which Drug treatment should be used? b Dyslipidemia b Athletes b Physically active patients b Peripheral vascular. disease b Asthma b COPD b Heart Blocks b Heart failure b Pregnancy b Diabetes b Angina b Post MI b Tachy- arrythmias B Blockers b Dyslipidemias b Sexually active males b Gout b Diabetes b Heart failure b Elderly b Systolic Hypertension Diuretics Possible Contra- indications Compelling contra- indications Possible Indications Compelling Indications Class of Drug
Which Drug treatment should be used Congestive Heart Failure Peripheral Vascular Disease b Angina b Elderly b Systolic Hypertension CalciumAntagonists b Pregnancy b Bilateral Renal artery Stenosis b Hyperkalemia b Heart Blocks b Heart Failure b LV. Dysfunction b After MI b Diabetic neph- ropathy ACE Inhibitors Possible Contra- indications Compelling contra- indications Possible Indications Compelling Indications Class of Drug
Which Drug treatment should be used Possible Contra- indications Compelling contra- indications Possible indications Compelling Indiacations Class of Drug Pregnancy b Bilateral Renal artery Stenosis b Hyperkalemia b Heart Blocks Heart Failure Side Effects with other drugs e.g. ACE inhibitors (cough) Angiotensin II Antagonists Orthostatichypotension b Glucose Intolerance b Dyslipidemias Prostrate Hypertrophy Alpha Blockers
References: BMJ 1999 Sep 4; 319: British Hypertension Society guidelines for Hypertension management 1999; Summary NEW: Editorial - British guidelines on managing hypertension World Health Organization- International Society of Hypertension WHO-ISH Guidelines for the management of Hypertension - Journal of Hypertension (see on line articles, Volume 17, Issue 2, pages , February 1999). The Sixth Report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure JNC-V1- PDF format from the National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health (NIH) NEW updated URL 2-11
References (Cont’d): NHLBL JNC IV References Sheet. National Guideline Clearing House - Brief Summary NEW: Archives of Internal Medicine 1997 Nov 24 BAD LINK - NEW URL -waiting for 1997 back issues to be placed on-line ? JNC V1: timing is everything Commentary - The Lancet 15 Nov 97. JNC - 6 Guidelines Editorial - American Journal of Kidney Diseases May 1998 JNC Redux Editorial - American Journal of Kidney Diseases May 1998 Treatment of hypertension; insights from the JNC V1 report. Am Fam Physician 1998 Oct 15; 58 (6; PubMed abstract)