1. TANBIR SINDHAR, MD September 12, 2017
HYPERTENSION UPDATE
TANBIR SINDHAR, MD
September 12, 2017

2. Disclosures No actual or potential conflict of interest to disclose
No financial support or funding received for this presentation

3. Objectives Review the diagnosis and treatment of HTN
Discuss evidence based hypertension guidelines
Apply the guidelines to diagnose and treat BP

4. Prevalence 7.5 million people in Canada
Prevalence in adults is 22.6%, additional 20% have prehypertension
10% among yrs old, over 70% in age >80 yrs
1 in 5 adults have HTN, 1 in 3 are uncontrolled
1 in 5 people are unaware of their HTN
13 billion dollars in 2010, estimated to increase to 20 billion by 2020

6. Definition Pre-hypertension SBP 120-139, DBP 80-89
Stage 1 hypertension SBP , DBP 90-99
Stage 2 hypertension SBP >= 160, DBP >= 100

7. Causes of HTN Primary(essential) HTN Modifiable
Poor diet(low in fruits and vegetables)
High sodium intake
Obesity, sedentary lifestyle
Smoking
High alcohol intake

8. Secondary HTN Sleep apnea, CKD, Thyroid disorders, Adrenal, Pheo
Cushings
Coarctation of aorta
RAS, FMD
Drugs – decongestants, NSAIDs, OCPs, antidepressants, illegal drugs

9. Complications of HTN Heart failure(systolic and diastolic) MI
Ischemic stroke
ICH
CKD, ESRD
Death
CV mortality doubles up for every 20/10 mmHg increase in BP

10. Diagnosis of Hypertension
AOBP (Automated office blood pressure monitoring) IN OFFICE
A fib –limitation, less white coat effect, reduces errors
ABPM (Ambulatory blood pressure monitoring) AT HOME
Out of office BP measurement important to r/o white coat syndrome and masked hypertension
Mean 24 hour 130/80
Mean awake 135/85
HBPM (home BP monitoring) 135/85

11. Investigations
Medical history poor diet, poor sleep, stress, smoking, sedentary lifestyle
age, ethnicity, family history
Exam CVS, Abdomen, Fundoscopy
Labs CBC, electrolytes, renals, urine ACR, ECG(look for LVH)
Echo, Renal US, CTA
Referral to specialist resistant HTN, secondary HTN

12. Lifestyle changes- first line approach
Low sodium diet (<2300mg per day)
1500mg is adequate, 1/2 tsp= 1150 mg
80% of sodium intake is in processed foods, 10% is at the table, 10% hidden
Read labels- go for unsalted, low sodium options
% Daily value of sodium 5% or less
Reduction of sodium intake by 1800 mg/day (from 3500 mg to mg/day) will result in 1 MILLION fewer hypertensives in Canada*
*Cochrane review data

13. Diet Fresh fruits and vegetables High fiber Low fat dairy products
Non-animal protein
High in potassium

14. Exercise Smoking cessation Alcohol intake
30-60 minutes , 4 to 7 times a week
Moderate intensity (walking, cycling, swimming)
Weight reduction (BMI<25)
Smoking cessation
Alcohol intake

15. JNC8 Guidelines
Evidence drawn from RCTs to recommend treatment thresholds, goals and medications, published in JAMA in 2014
Recommendations-
Age 60 or older- BP goal < 150/90mmHg (only grade A recommendation)
Age < 60, BP goal SBP < 140/90mmHg
Age >18, with CKD and DM, treat to a goal SBP<140 and DBP<90 mmHg (Grade E-expert opinion)
Choice of initial antihypertensive- Thiazide,CCB,ACEI/ARB alone or in combo
Black patients with DM- Thiazide or CCB

16. Hypertension Canada (CHEP) 2017
Longer acting Diuretics preferred
Longer-acting, thiazide-like diuretics Chlorthalidone, Indapamide
(reduce coronary events and all-cause mortality, in addition to CV events and HF)
More effective BP lowering
Shorter-acting, Thiazides  HCTZ

17. Recommendations 1999-2016 Target BP < 140/90 mmHG
Life style modification
Antihypertensives
Thiazide
ACEI
ARB
CCB BB

18. Thiazide/thiazide-like
Recommendations 2017
Target BP < 135/85 mmHg
Life style modification
Antihypertensives
Thiazide/thiazide-like
ACEI
ARB
CCB BB
Single pill combo

19. SPC (Single pill combinations)
Better compliance
Better BP control
Lower risk of cardiovascular events
HOPE3
NEJM 2016 – ARB/diuretic vs placebo
ACCOMPLISH
NEJM 2008 – ACEI/CCB vs active control

20. ALLHAT trial
Antihypertensive and lipid-lowering treatment to prevent heart attack trial
JAMA, 2002
33,357 pts were randomized to chlorthalidone, lisinopril, amlodipine and doxazosin
Doxazosin was dropped due to higher rate of death and HF
No difference in other 3 in primary outcome

21. ALLHAT trial

22. HYVET HYpertension in the Very Elderly Trial
Age 80 or older with SBP >160 mmHg, NEJM in 2008
Randomised to Indapamide+/- perindopril or placebo to achieve target BP of 150/80 mmHg
Outcomes with indapamide+/- perindopril
30% reduction in stroke
64% reduction in HF
21% reduction in all-cause mortality
SAFE AND EFFECTIVE

23. ACCORD Action to Control CV Risk in Diabetes
T2DM with high CV risk randomised to SBP< 120 or SBP< 140
NEJM in 2010
Primary outcome- CV death, MI or stroke
No significant difference
Incidence of stroke was lower
Significant increase in adverse events with intensive treatment

24. SPRINT
NEJM 2015
9361 pts with SBP>130 or above (not diabetics), at high risk of CV events
Randomised to target BP <120 and <140
Lower rates of fatal and non-fatal CV events and death from any cause

25. Hypertension in diabetes
Common in both type1 and type2 DM
BP tends to rise at the onset of microalbuminria
Causes- nephropathy, salt retention and volume expansion, increase vascular stiffness
Treat BP to a goal of less than 130/80 (CDA and CHEP)
ADA- goal SBP 125—130 mmHg, if tolerated
ACEI or ARB as first line agent
Dihydropyridine CCB as add-on

26. Hypertension in CKD Acute and chronic kidney disease
Glomerular(fluid retention) and vascular(ischemia causing RAS activation)
PSGN, Nephrotic syndrome, acute vasculitis
Drug of choice- Loop diuretic, ACEI

27. Hypertension in CKD target BP < 130/80
First line- ACEI or ARB
ACEI/ ARB known to decrease albuminuria, delay worsening of gfr, delay need for dialysis
Second line- Loop diuretic if edema present(thiazide may be added on, but less effective if GFR<30)
Non-DHP CCB (Diltiazem or Verapamil) –maybe added on , as they lower proteinuria
CKD without proteinuriaACEI or ARB, add Dihydropyridine CCB or diuretic
Others- spironolactone or eplerenone in stubborn cases
One agent at bedtime (to treat “non-dippers”)

28. Hypertension in hospitalised patient
Definition ????
BP> 140/90 mmHg, prevalence is > 72 %
Hypertensive Urgency  BP > 180/110 without end organ damage
Hypertensive Emergency elevated BP with end organ damage-
ACS, ICH, Encephalopathy, dissecting aneurysm, etc

29. Causes of HTN in hospitalised patient
Pain
Anxiety
Undiagnosed or poorly controlled HTN
Withdrawal of antihypertensives
Withdrawal from alcohol, drugs
Post-op state
Bladder distension
IV fluids, steroids

30. WHEN TO TREAT Hypertensive emergency--- IMMEDIATE
Asymptomatic severe HTN (Hypertensive Urgency)--- No good quality evidence
do not need acute lowering of BP, must lower over hours to days
Initially aim to lower BP < 160/100
Do not lower MAP by over 25-30%
Treat with oral drugs- captopril or clonidine

31. Post-op HTN Pain, agitation,effects of anaesthesia
No Pain, no h/o HTN treat with oral captopril or clonidine, IV labetalol
Previous h/o HTN-resume anti-hypertensives, esp BB and clonidine

32. Secondary HTN Severe or refractory BP, despite 3 agents
Age at onset <20 or > 50 yrs
Unexplained hypokalemia
Negative family history
Malignant HTN
Sudden rise in BP in stable pt with controlled BP

33. Renovascular HTN Severe HTN, BP >180/120 in the following
After age 55
Acute rise rise in creatinine (>50%) after initiating ACEI/ ARB
Concomitant vascular disease (CAD, PVD)
Single atrophic kidney
Flash pulmonary edema or refractory chf
CTA, MRA, Captopril scan, angiography

34. Treatment
Atherosclerotic RAS  Medical management preferred antiplatelets, statin, maximize antihypertensives*
Angioplasty/ stenting – resistant cases, worsening renal failure, refractory CHF
FMD renal angioplasty(not stenting) / surgical revascularisation
*Cooper CJ, Murphy TP, Cutlip DE, et al. Stenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J Med 2014;370:13-22.

35. Hyperaldosteronism Upright morning aldosterone and renin measurement
Off ACEI/ARB, Diuretics, Dihydropyridine CCB, betablockers
Switch to verapamil, hydralazine, prazosin, doxazosin
Confirmatory tests Saline loading, Captopril suppression
CT/ MRI of adrenals- Adenoma vs Hyperplasia
Adrenal venous sampling- to ensure adenoma is hypersecretory and plan surgery
Bilateral adrenal hyperplasia- treat with spironolactone

36. Pheochromocytoma sudden rise in BP, headache, sweating, palpitations
Screening – 24 hour urine catecholamines and metanephrines
Plasma free metanephrines and non-metanephrines
If results borderline repeat testing
CT/MRI for confirmation
Definitive treatment- surgery
Alpha-blockers to control BP

37. Questions ?