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The Pharmacists Role in Treating Hypertension Thomas Owens, MD Saint Francis University CERMUSA.

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Presentation on theme: "The Pharmacists Role in Treating Hypertension Thomas Owens, MD Saint Francis University CERMUSA."— Presentation transcript:

1 The Pharmacists Role in Treating Hypertension Thomas Owens, MD Saint Francis University CERMUSA

2 Objectives 1.Enhance your understanding of hypertension to include cardiovascular risks, management, and goals for individual patients 2.Review and discuss the current pharmacotherapy standards of care for hypertension 3.Describe the pharmacists role in counseling patients on hypertensive medications

3 Hypertension >140/90 mm Hg United States: 65 million adults Risk factors include: –Stroke, myocardial infarction, heart failure, peripheral vascular disease, aortic dissection, chronic renal failure Hypertension price tag: $59.7 billion Wexler & Feldman, 2005

4 Hypertension Typical onset –second decade of life Primary Hypertension –identifiable behaviors Secondary Hypertension –more discrete Cecil, 2004

5 Ethnic Groups African Americans –43% female & 39% male –Ratio 1:3 –Increase in sodium sensitivity? Caucasians –28% female –29% male Mexican Americans –Ratio 1:4 or 1:5 DASH Diet Cecil, 2004

6 Dietary Sodium Intake Salt Hypothesis? - Strong genetic underpinning ADA, 2005

7 Metabolic Syndrome Risk of Hypertension increases with BMI Obesity accounts for 50% to 60% of new cases of hypertension Cecil, 2004

8 Potential Causes of Hypertension Expanded plasma volume plus sympathetic over activity –Peripheral vasoconstriction –Renal salt retention –Renal water retention Sleep Apnea, 2007 Cecil, 2004

9 Blood Pressure Equation Blood Pressure = Cardiac Output x Peripheral Vascular Resistance Most pharmacologic agents lower Some pharmacologic agents lower Some pharmacologic agents lower both Cecil, 2004

10 Genetics of High BP Sympathetic up- regulation leads to a cascade of events –Peripheral vascular resistance Genetic factors –30% of cases –2x as likely if parents have hypertension, 2007; ADA, 2003

11 Systolic & Diastolic ?? What is more important? –Depends on age Live long enough almost all develop systolic hypertension 120 80 systolic diastolic Cecil, 2004

12 Age Dependant Rise in BP (Whelton & Rocella, 1995)

13 Framingham Study (age: 50-79) (Khan, Wong, Larson, & Levy, 1999)

14 Systolic Hypertension Decreased distensibility of large arteries Majority of uncontrolled hypertension –Due to focus on diastolic BP Cecil, 2004

15 Risk of cardiovascular mortality by systolic BP (National High Blood Pressure Education Program Working Group, 1993)

16 Hypertension Study Results Hypertension is excess of 140/90 mm Hg Studies found –Increase risk when above 115 mm Hg systolic or 75 mm Hg diastolic –High normal BP had twice increased risk for cardio disease –More studies are needed to fully understand Cecil, 2004

17 The Silent Killer 1/3 of adults do not know they have hypertension Hypertension: 60% are treated –45% of treated remain uncontrolled Despite over 75 different antihypertensive agents in 9 different classes! Cecil, 2004

18 Reclassification of BP Stages Blood Pressure (mm Hg) Classification <120/80Normal 120-139/80-89Pre-hypertension 140/90Hypertension 140-159/90-99Stage 1 160-179/100-109Stage 2 Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) New category pre-hypertension –Pharmacotherapy not recommended –Lifestyle modification recommended! Cecil, 2004; JNC, 2007

19 JNC Drug Therapy Recommendations Blood Pressure (mm Hg) Classification <120/80Normal 120-139/80-89Pre-hypertension 140/90Hypertension 140-159/90-99Stage 1 160-179/100-109Stage 2 recommendation (healthy) 130/80 (w/ heart and kidney disease or diabetes mellitus) JNC, 2007

20 Modest reduction in BP = big benefits !! Decrease 5 mm Hg decreases risks –Small changes can have a big difference Results of studies –Systolic surge 34 mm Hg = 3x increase of stroke –Systolic 135 mm Hg = 74% increase of cardio event Blood Pressure (mm Hg) Cardiovascular Risk Exceeds 115/75Increases Each increase of 20/10 mm Hg Doubles Cecil, 2004; JNC, 2007

21 Clinical Presentation No specific signs or symptoms Possible symptoms –Occipital headache, dizziness, tinnitus, dimmed vision, palpitations, fatigue Physical Exam –May reveal evidence Cecil, 2004

22 Hypertensive Retinopathy Grades of hypertensive retinopathy shown (Forbes, Jackson, 2003)

23 Electrocardiogram (ECG or EKG) GOOD (Normal) BAD (Antero-Septal MI), 2007

24 Counseling Patients: Proper BP Readings At least 30 minutes before NO –Caffeine, decongestants, oral contraceptives, alcohol, tobacco Sit down for at least 5 minutes Arm above heart level = Falsely low blood pressure reading Arm below heart level Falsely elevated blood pressure reading Loose cuff or bladderFalsely elevated blood pressure reading Cecil, 2004; ADA, 2005

25 Counseling Patients: Proper Fit of BP Cuff Length of bladder of the cuff at least 80% circumference of arm Bladder of cuff at least 40% circumference of arm Place the center of the bladder over the brachial artery Pump until radial pulse disappears, then continue for additional 30 mm Hg

26 Help Patients Understand: White Coat Hypertension Anxiety of going to doctor office raises BP –Recommend self-monitoring Daytime: >135/85 mm Hg Nighttime: >120/70 mm Hg 24 hr: >130/80 mm Hg Follow patients every 6 months for possible progression to persistent hypertension Cecil, 2004

27 Closely Monitor Medications with High-Risk Patients Cecil, 2004

28 Counseling Patients: Causes of Organ Damage Major Risk FactorsTarget Organ Damage Cigarette smokingHeart Obesity (BMI >30 kg/m 2 ) *Left ventricular hypertrophy Physical inactivityAngina pectoris Dyslipidemia *Myocardial infarction Diabetes mellitus *Coronary revascularization Age Men: Older than 55 Women: Older than 65 Heart Failure Brain Stroke Family History of pre-mature CVD Men: Older than 55 Women: Older than 65 Transient ischemic attack Hypertensive nephrosclerosis GFR <60 mL/min Any chronic disease GFR <60 mL/min Urine protein >150 mg/24hr Retinopathy Peripheral atherosclerosis Components of metabolic syndrome (The JNC 7 Report. JAMA 2003)

29 Counseling Patients: Treatment Risk GroupTreatment Mild Risk Free of CVD Lifestyle modification Low Risk Pre-hypertension or Stage 1 or 2 Pre & Stage 1: Lifestyle modification Stage 2: Lifestyle modification and medications Moderate Risk 1 or more cardio risk factors Lifestyle modification and medications High Risk Evident organ damage, diabetes, renal insufficiency Lifestyle modification and medications JNC, 2005

30 SUSPECTED DIAGNOSIS CLINICAL FEATURESDIAGNOSTIC TESTING Renal parenchymal hypertension Elevated serum creatinine or abnormal urinalysis 24-Hour urine creatinine and protein, renal ultrasound Renovascular disease New elevation in serum creatinine, marked elevation in serum creatinine with initiation of ACEI or ARB, refractory hypertension, flash pulmonary edema, abdominal bruit Captopril renogram, duplex Doppler sonography, magnetic resonance or CT angiogram, invasive angiogram Coarctation of the aorta Arm pulses > leg pulses, arm BP > leg BP, chest bruits, rib notching on chest radiograph MRI, aortogram Primary aldosteronism Hypokalemia, refractory hypertension Plasma renin and aldosterone, 24-hour urine potassium, 24-hour urine aldosterone and potassium after salt loading, adrenal CT scan Cushing's syndrome Truncal obesity, purple striae, muscle weakness Plasma cortisol, urine cortisol after dexamethasone, adrenal CT scan Pheochromocytoma Spells of tachycardia, headache, diaphoresis, pallor, and anxiety Plasma metanephrine and normetanephrine, 24-hour urine catechols, adrenal CT scan Obstructive sleep apnea Loud snoring, daytime somnolence, obesity Sleep study ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; BP = blood pressure; CT = computed tomography. (Williams & Wilkins, 2002)

31 Counseling Patients: Lifelong Treatment Objective: reduce BP and metabolic abnormalities Pharmacotherapy & lifestyle modification –Reduce sodium intake –Weight loss –Exercise –Moderating alcohol –Reduce systolic BP by 21 to 55 mm Hg Cecil, 2004

32 Counseling Patients: Dietary Changes Losing only 10 to 12 lbs lowers BP by 10/5 mm Hg Reduce daily salt –10 to 6 grams Teach patients to read food labels DASH Diet – Cecil, 2004

33 Counseling Patients: Health Behaviors Lifestyle modification RecommendationRange of systolic blood pressure reduction (mm Hg) Weight lossMaintain a normal body weight based on BMI 5–20 Dietary Approaches Diet high in fruits and vegetables, and reduced fat 8–14 Low sodium diet Less than 6 grams2–8 Exercise30 min of aerobic activity at least 4 d/wk 4–9 Moderate Alcohol consumption 2 drinks or less per day for men, and 1 drink or less per day for women 2–4 JNC, 2005

34 Counseling Patients: Helpful Resources

35 Barriers to Successful Health Behavior Modifications Lack of education Lack of access to safe places to exercise Added salt in prepared foods and restaurant meals Higher cost of foods low in salt Patient self-management is realistic and feasible! Cecil, 2004

36 Pharmacologic Therapy Scientific proof lowering BP reduces organ damage Certain classes of antihypertensive agents exert organoprotective effects –Not all medications equal Cecil, 2004; JNC, 2005

37 Major Challenges for Science 1.Identify the key gene- environment interactions 2.Eliminate the patient and medical provider barriers ADA, 2003

38 Counseling Patients: Target Blood Pressure Most patients below 140/90 mm Hg Patients w/ diabetes or chronic disease 130/80 mm Hg Help patients self-monitor BP –1/3 do not know they are hypertensive Research studies on targeting BP Cecil, 2004

39 Improve Hypertension Control Rates 1.Titrating blood pressure medications to achieve target goals 2.Most patients require 2 or 3 antihypertensive medications 3.Patient compliance with multi-drug regimens ADA, 2005

40 Patient Compliance and Quality of Life Hypertension requires lifelong treatment Medications can produce side effects –Men often concerned with sexual dysfunction Patients with controlled BP, rate a significantly higher quality of life Cecil, 2004

41 Patient Compliance Principles 1.Titrating medical therapy based on home readings 2.Long-acting preparations w/ once daily dosing 3.Low dose combinations of medications from different drug classes 4.Fixed-dose combinations to reduce overall number of pills JNC, 2005

42 Drug Therapy Old method: high-dose monotherapy Recent studies (ex. ALLHAT) –At least 2 medications of different classes to treat mild hypertension –3 or 4 different medications to treat more difficult cases Thiazide-type antihypertensive medications cost- effective Initial treatment: –Beta blockers, Angiotensin-converting enzyme (ACE) inhibitors, Angiotensin receptor blockers, Calcium antagonists Cecil, 2004

43 Stage 2 Drug Therapy JNC recommends: –2 drug combination –Additional medications needed for each 10 mm Hg of systolic BP above goal –Great majority should include low-dose diuretic High-risk conditions (heart failure/diabetes) –Angiotensin-converting enzyme inhibitors (ACE-Is) –Angiotensin receptor blockers (ARBs) Cecil, 2004

44 Cardio Events in Hypertensive Patients Verdecchia, Carin, Circo,2001

45 Left Ventricular Hypertrophy, 2007

46 Counseling Patients: Contradictions & Side Effects Considerations For Individualizing Antihypertensive Drug Therapy

47 Hypertensive Sub-Populations Hypertensive patients with nephrosclerosis Diabetic hypertensive patients Hypertensive patients with coronary artery disease Isolated systolic hypertension in older persons Hypertensive disorders of women –Oral contraceptives –Pregnancy Cecil, 2004

48 Hypertension Case Study How would we modify his treatment since he did not change his health behaviors (and he is diabetic)?

49 Thank you for attending

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