Hypertension Dr. J. Antony Gagnon, Pharm.D., CDE, CAE Part I

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Presentation transcript:

Hypertension Dr. J. Antony Gagnon, Pharm.D., CDE, CAE Part I Pharmacy Program Coordinator Hamilton Family Health Team

Hypertension is a Major Risk Factor Untreated individuals with high blood pressure have an increased risk of: Stroke (four times greater risk of hemorrhagic stroke) Atherosclerotic cardiovascular events Congestive heart failure Renal failure Peripheral vascular disease Dementia Effective treatment has been shown to reduce the risk of recurrent stroke and to reduce cognitive decline in patients with dementia Woo D, Haverbusch M, Sekar P, Kissela B, Khoury J, Schneider A, Kleindorfer D, Szaflarski J, Pancioli A, Jauch E, Moomaw C, Sauerbeck L, Gebel J, Broderick J. Effect of untreated hypertension on hemorrhagic stroke. Stroke 2004;35:1703-8.

2006 Canadian Hypertension Education Program Recommendations Scope of the problem More than 90% of Canadians are estimated to develop hypertension during adulthood Approximately one half of adult Canadians are hypertensive by age 60. Even normotensive 55 or 65 year olds have a 90% chance of developing hypertension over the next 20 years 2006 Canadian Hypertension Education Program Recommendations

Awareness, Treatment and Control ~ 2.4 million Ontarians have BP >140/90mmHg (22%) HTN treated but uncontrolled Aware but untreated & BP uncontrolled 21% 22% 13% 43% Chart from CHEP 2004 Recommendations p.16 in slide package. It comes from Joffres MR et al. Distribution of blood pressure and hypertension in Canada and the United States. Am J Hyper 2001;14:1099-1105. This pie chart shows the results of the Canadian Heart Health Survey regarding hypertension awareness, treatment and control. While one study can highlight concerns for discussion and further study, there is a need for further evidence (in particular Canadian) to validate this pattern and understand if lack of awareness is truly an issue. The Canadian Heart Health Survey is due to be repeated in 2006. “2.4 million figure comes from Towards an Integrated Stroke Strategy, Report of the Joint Working Group, June 2000. Speakers please note: Of the 13% of patients who are treated and BP controlled, 9% are diabetic patients who are treated and BP controlled. Hypertensive and unaware HTN Treated & BP controlled Source: Joffres et al. Am J Hyper 2001;14:1099-1105.

Impact of High-Normal BP on Risk of Cardiovascular Disease Cumulative incidence of CV events in women without hypertension according to baseline blood pressure SBP 130-139 DBP 85-89 SBP 120-129 SBP <120 mmHg Data from the Framingham Heart Study’s long-term follow-up indicate that the lifetime risk of developing hypertension is about 90%. The data are from a community-based prospective cohort study of 1,298 participants from the Framingham Heart Study who were between 55 and 65 years old and free of hypertension at baseline (1976-1998). The residual life-time risk for developing hypertension was estimated for participants who reached the age of 65 free of hypertension. A study investigating association between BP category and CVD risk in the Framingham Heart Study concluded that those with BP <120 had fewer vascular events than those with blood pressure in the range of 120-130. High normal BP (SBP 130-139 DBP 85-89) was associated with an increased risk of CVD. Vasan, RS et al. Impact of high-normal blood pressure on the risk of cardiovascular disease. NEJM 2001;345:1291-1297. The JNC 7 Report identified a new category—pre-hypertension—to address the future risk of cardiovascular disease associated with blood pressures previous classified as high normal. The JNC 7 Report stresses the importance of recommending lifestyle modification for individuals with systolic BP 120-139 mmHg or diastolic 80-89 mmHg and classifies this as pre-hypertension The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, JAMA 2003;289:2560-2572. Source: Vasan, RS et al. NEJM 2001;345:1291-1297.

Cardiovascular Risk Factors Assessment of the overall cardiovascular risk Cardiovascular Risk Factors Presence of Risk Factors Increasing age (Men > 55, Women > 65) Male gender Smoking Family history of premature cardiovascular disease (age< 55 in men and < 65 in women) Dyslipidemia (TC > 6.5 or LDL > 4 HDL Men < 1.0 and Women < 1.3) Sedentary lifestyle Abdominal obesity Presence of Diabetes Presence of Target Organ Damage Microalbuminuria or proteinuria Left ventricular hypertrophy Chronic kidney disease (glomerular filtration rate < 60 ml/min/1.73 m2) Presence of atherosclerotic vascular disease Previous stroke or TIA CHD Peripheral arterial disease CV Risk Factors that may alter thresholds and targets in the treatment of HTN 2006 Canadian Hypertension Education Program Recommendations

Assessment of the overall cardiovascular risk Search for exogenous potentially modifiable factors that can induce/aggravate hypertension Presription Drugs: NSAIDs, including Coxibs Corticosteroids and anabolic steroids Oral contraceptive and sex hormones Vasoconstricting/sympathomimetic decongestants Calcineurin inhibitors (cyclosporin, tacrolimus) Erythropoietin and analogues Monoamine oxidase inhibitors (MAOIs) Midodrine Other: Licorice root Stimulants including cocaine Salt Excessive alcohol use Sleep apnea 2006 Canadian Hypertension Education Program Recommendations

Assessment of the overall cardiovascular risk Assessing global risk: the interaction between blood pressure and risk factors Blood pressure (mmHg) Other risk factors and disease history Normal SBP 120-129 or DBP 80-84 High normal SBP 130-139 or DBP 85-89 Grade 1 SBP 140-159 or DBP 90-99 Grade 2 SBP 160-179 or DBP 100-109 Grade 3 SBP ≥180 or DBP ≥110 I. No other risk factors Average risk Low added risk Moderate added risk High added risk II. 1-2 risk factors Very high added risk III. ≥3 risk factors or target organ damage or diabetes IV. Associated clinical conditions Adapted from WHO/ISH Recommendations on Hypertension. Journal of Hypertension 2003, Vol 21 No 6 2006 Canadian Hypertension Education Program Recommendations

2006 Canadian Hypertension Education Program Recommendations Criteria for the diagnosis of hypertension and recommendations for follow-up 2006 Canadian Hypertension Education Program Recommendations

Blood pressure target values for treatment of hypertension Goals of Therapy Blood pressure target values for treatment of hypertension Condition Target SBP / DBP mmHg Isolated systolic hypertension <140 Systolic/Diastolic Hypertension • Systolic BP • Diastolic BP <90 Diabetes and Chronic Kidney disease • Systolic • Diastolic <130 <80 Proteinuria <125 <75 2006 Canadian Hypertension Education Program Recommendations

2006 Canadian Hypertension Education Program Recommendations Clinic, Home/Self, Ambulatory (ABP) Blood Pressure Measurement equivalence numbers A clinic blood pressure of 140/90 mmHg has the equivalent risk of a: Description Blood Pressure mmHg Home/Self pressure average 135 / 85 Daytime average ABP 24-hour average ABP 130 / 80 2006 Canadian Hypertension Education Program Recommendations

2006 Canadian Hypertension Education Program Recommendations Goals of Therapy To optimally reduce cardiovascular risk reduce the blood pressure to specified targets. This usually requires two or more drugs and lifestyle changes. The systolic target is more difficult to achieve however controlling systolic blood pressure is as important if not more important than controlling diastolic blood pressure. 2006 Canadian Hypertension Education Program Recommendations

Treatment of hypertension Reducing hypertension-related complications in the “general” population of patients with hypertension depends more on the extent of blood pressure lowering achieved than on the choice of any specific “first-line” drug class Treat to target The treatment of hypertension is all about global atherosclerotic risk reduction Monotherapy is not (usually) enough Lifestyle modifications are the cornerstone of both antihypertensive and anti-atherosclerotic therapy 2006 Canadian Hypertension Education Program Recommendations

Lifestyle Therapies in Hypertensive Adults Intervention Target Exercise 30-60 minutes at least 4x/week Sodium reduction 65-100 mMol/day Diet DASH diet Weight loss Waist circumference BMI <25 kg/m2 Men 102 cm (40 in) & women  88 cm (35 in) Alcohol reduction <2 drinks/day Smoking Smoke free environment . Source: Adapted from CHEP 2005 Recommendations 2006 Canadian Hypertension Education Program Recommendations

Lifestyle Recommendations for Hypertension Dietary Dietary Sodium Restrict to target range of 65-100 mmol/day (Most of the salt in food is hidden and comes from processed food) Dietary Potassium If required, daily dietary intake >80 mmol Calcium supplementation No conclusive studies for hypertension Magnesium supplementation • Fresh Fruits • Vegetables • Low Fat dairy products • Low saturated fat diet in accordance with the DASH diet http://www.hc-sc.gc.ca/hpfb-dgpsa/onpp-bppn/food_guide_rainbow_e.html 2006 Canadian Hypertension Education Program Recommendations

Impact of Lifestyle Therapies on BP in Hypertensive Adults Intervention Targeted Change SBP/DBP Sodium reduction 100 mMol or 1 tsp/day 5.8/-2.5 Weight loss  4.5 kg  7.2/-5.9 Alcohol reduction  2.7 drinks/day  4.6/-2.3 Exercise* 3 times/week  -7.4/-5.8 Dietary Patterns DASH diet  11.4/-5.5 Note: the extent of blood pressure change from each intervention should not be compared because the participants, the type and duration of the intervention, and the basic design of the trials differed substantially. Miller ER et al. Results of aggregate and meta analysis of short term trials. J Clin Hyper 1999;3:191-8. Pescatello, LS, Franklin, B A, Fagard, R, Farquhar, W B. Kelley, G A., Ray, CA. Exercise and hypertension. Medicine and Science in Sports & Exercise 2004;36(3). Source: Miller ER et al. Results of aggregate and meta analysis of short term trials. J Clin Hyper 1999;3:191-8. * Exercise and Hypertension, Medicine and Science in Sports & Exercise 2004;36(3). 2006 Canadian Hypertension Education Program Recommendations

Indications for Pharmacotherapy Usual blood pressure threshold values for initiation of pharmacological treatment of hypertension Condition Initiation SBP / DBP mmHg • Systolic/Diastolic hypertension 140/90 • Diabetes • Chronic Kidney Disease 130/80 2006 Canadian Hypertension Education Program Recommendations

Indications for Pharmacotherapy In low risk patients with stage 1 hypertension (140-159/90-99 mmHg) lifestyle modification can be the sole therapy. Over 90% of Canadians with hypertension have other risk factors and pharmacotherapy should be considered in these patients if blood pressure remains equal to or above 140/90 mmHg with lifestyle modification. Patients with target organ damage (e.g. proteinuria) are recommended to be treated with pharmacotherapy if blood pressure is equal to or above 140/90 Patients with known atherosclerotic disease (e.g. past stroke) are recommended to be treated with pharmacotherapy even if the blood pressure is normal (see compelling indications) Patients with diabetes or chronic kidney disease should be considered for pharmacotherapy if the blood pressure is equal or over 130/80 mmHg 2006 Canadian Hypertension Education Program Recommendations

Choice of Pharmacological Treatment: Uncomplicated Associated risk factors? or Target organ damage/complications? Concomitant diseases/conditions? Treatment in the absence of specific indication NO Individualized Treatment (and compelling indications) YES 2006 Canadian Hypertension Education Program Recommendations

Lifestyle modification Triple or Quadruple Therapy Treatment of Diastolic-Systolic Hypertension without Other Compelling Indications For Specific Agents TARGET <140/90 mmHg Lifestyle modification therapy Thiazide diuretic ACE-I ARB Long-acting CCB Beta- blocker* * Not indicated as first line therapy over 60 CONSIDER Nonadherence? Secondary HTN? Interfering drugs or lifestyle? White coat effect? Dual Combination Triple or Quadruple Therapy 2006 Canadian Hypertension Education Program Recommendations

Considerations Regarding the Choice of First-Line Therapy Beta adrenergic blockers are not recommended for patients age 60+ without another compelling indication Diuretic-induced hypokalemia should be avoided through the use of potassium sparing agent ACE-I are not recommended (as monotherapy) for black patients without another compelling indication 2006 Canadian Hypertension Education Program Recommendations

Going Beyond First- Line Therapy 2006 Canadian Hypertension Education Program Recommendations

Useful Dual Combinations For additive hypotensive effect in add-on therapy Combine an agent from Column 1 with any in Column 2 Column 1 Column 2 • Thiazide diuretic • Long-acting calcium channel blocker * • Beta adrenergic blocker • ACE Inhibitor • ARB Dual combination of agents within column 1 and within column 2 have less than additive hypotensive effect but may be indicated in specific settings (e.g. column 2 drugs in patients following myocardial infarction) * Caution should be exercised when using a non DHP-CCB and a beta-blocker 2006 Canadian Hypertension Education Program Recommendations

Lifestyle modification Treatment of Isolated Systolic Hypertension without Other Compelling Indications For Specific Agents TARGET <140 mmHg Lifestyle modification therapy Thiazide diuretic ARB Long-acting DHP CCB CONSIDER Nonadherence? Secondary HTN? Interfering drugs or lifestyle? White coat effect? Dual therapy *If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as ACE inhibitors, alpha blockers, centrally acting agents, or nondihydropyridine calcium channel blocker). Triple therapy 2006 Canadian Hypertension Education Program Recommendations

Choice of Pharmacological Treatment for Hypertension Individualized treatment Compelling indications: Ischemic Heart Disease Recent ST Segment Elevation-MI or non-ST Segment Elevation-MI Left Ventricular Systolic Dysfunction Cerebrovascular Disease Left Ventricular Hypertrophy Non Diabetic Chronic Kidney Disease Renovascular Disease Smoking Diabetes Mellitus With Diabetic Nephropathy Without Diabetic Nephropathy Global Vascular Protection for Hypertensive Patients Statins if 3 or more additional cardiovascular risks Aspirin once blood pressure is controlled 2006 Canadian Hypertension Education Program Recommendations

2006 Canadian Hypertension Education Program Recommendations Pharmacological Treatment of Hypertension with Compelling Indications For Specific Agents 2006 Canadian Hypertension Education Program Recommendations

2006 Canadian Hypertension Education Program Recommendations Pharmacological Treatment of Hypertension with Compelling Indications For Specific Agents 2006 Canadian Hypertension Education Program Recommendations

Global Vascular Protection for Hypertensive Patients: Statins Statins are recommended in high-risk hypertensive patients with established atherosclerotic disease or with at least 3 of the following criteria: • Male • age 55 or older • Smoking • Type 2 Diabetes • Total-C/HDL-C ratio of 6 mMol/L or higher • Family History of Premature CV disease • Previous Stroke or TIA • LVH • ECG abnormalities • Microalbuminuria or Proteinuria • Peripheral Vascular Disease ASCOT-LLA Lancet 2003;361:1149-58 2006 Canadian Hypertension Education Program Recommendations

Global Vascular Protection for Hypertensive Patients: ASA Consider low dose ASA Caution should be exercised if BP is not controlled. 2006 Canadian Hypertension Education Program Recommendations

Global Vascular Protection for Hypertensive Patients: ACE inhibitors ACE-inhibitors are recommended for all patients with established atherosclerotic disease (e.g., stroke, TIA, coronary artery disease or PAD) even if another antihypertensive agent already controls BP 2006 Canadian Hypertension Education Program Recommendations

2006 Canadian Hypertension Education Program Recommendations Summary I INDIVIDUALIZING THERAPY consider concomitant risk factors and/or concurrent diseases, other patient characteristics and preferences (e.g. age, diabetes, CVD) and other considerations e.g. costs LIFESTYLE MODIFICATION alone if effective to reach the goal value or in combination with pharmacological treatment 2006 Canadian Hypertension Education Program Recommendations

2006 Canadian Hypertension Education Program Recommendations Summary II PROMOTING ADHERENCE a multi-faceted approach should be used to improve adherence with both non pharmacological and pharmacological strategies TREATING TO TARGET BP treat aggressively using combinations of drugs and lifestyle modification to achieve individualized targets 2006 Canadian Hypertension Education Program Recommendations

Key CHEP messages for the management of hypertension Assess global cardiovascular risk in all hypertensive patients Lifestyle modifications are the cornerstone of both antihypertensive and antiatherosclerotic therapy Treat to target (<140/90 mmHg; <130/80 mmHg in patients with diabetes or chronic kidney disease) Combinations of drugs are usually required to achieve blood pressure targets Focus on patient adherence to lifestyle modifications and antihypertensive therapy 2006 Canadian Hypertension Education Program Recommendations

2006 Canadian Hypertension Education Program Recommendations