Cure Pathologic Fear of Hypertension

Create Rational Approach to Drug Choice

Complement Rational Choice with Pearls

Consolidate new information with cases

• Those who do not have high blood pressure at age 55 face a 90 percent chance of developing it during their lifetimes.

• So high blood pressure is a condition that most people have at some point in their lives.

• 90% of Americans over 65 have hypertension or Prehypertension

You can at least cause Dys-Ease

Your Blood pressure is 128/84While drug treatment is recommended if your BP is at or above 140/90,

new medical guidelines state that a normal BP for most adults is less than 120/80. Ask your doctor what is right for you.

The risk of cardiovascular disease begins at 115/75In individuals aged 40 to 70 years, each 20/10 mm Hg increase in blood pressure doubles the risk of cardiovascular disease, including heart attack, stroke or kidney disease

This program includes: A free 30 day trial of Diovan, Diovan HCT and Lotrel, 3 medications proven to help lower blood pressure.

115/75

180/100

Low Risk High Risk

115/75

We’re Doomed, We’re Doomed

The Silent Killer

69% of people who have a heart attack, 77% of people who have a first stroke,

and 74% of people with chronic CHF

have high blood pressure.

95% of people who have a heart attack, 95% of people who have a first stroke,

and 95% of people with chronic CHF

Have eaten pickles in the previous 10 years

http://cybersmokeblog.blogspot.com/2013/03/do-you-agree-to-tell-whole-truth-and.html

Disease Low Dose Diuretic

Ace Inhibitors BetaBlockers

Death 28% 27% 27%

Stroke 37% 35% 11%

Coronary Heart Disease

28% 19% NS

45 Year Old Female Cholesterol 200 Non-Smoker Systolic of 190 10 Year Risk?

2% Risk of Heart Attack 1.4% if treated

65 Year Old Male Cholesterol 200 Non-Smoker Systolic of 155 10 Year Risk?

10% Risk of Heart Attack 7.2% if treated

90% Chance of Going 10 years with NO heart attack

92.8% If they Are Treated

65 Year Old Male Cholesterol 200 Smoker Systolic of 180 10 Year Risk?

25% Risk of Heart Attack 18% if treated

75% Chance of Going 10 years with NO heart attack

82% If they Are Treated

Accord Trial NEJM 2010;362:17

Diabetes PLUS◦ Heart Disease◦ OR◦ Albuminuria◦ OR◦ Hypertrophy◦ OR ◦ Two Risk Factors

Accord Trial NEJM 2010;362:17

Systolic of <120 vs Systolic of <140

Achieved 119 vs 133

Accord Trial NEJM 2010;362:17

Outcome: nonfatal myocardial infarction, nonfatal

stroke, or death from cardiovascular causes

Followed Almost 5 years

Accord Trial NEJM 2010;362:17

Composite Outcome:

1.87 vs 2.09 p=0.2

Death

1.28 vs 1.19

Accord Trial NEJM 2010;362:17

Stroke:

0.32 vs 0.53 p=0.01

Seven trials (22,089 subjects) -4/-3 better

…at present there is no evidence to support aiming for a blood pressure target lower than 140/90 mmHg in any hypertensive patient.

Fear of

Hypertension

Fear Of

Hypertension

Rational Approach to Treat HTN

High ReninLow Renin

IntuitiveRenin AngiotensinAldosterone

Sympathetic Nervous SystemAngiotensin VasoconstrictionAldosterone Sodium and Water

Characteristics Systolic and Diastolic Equally Elevated

Higher Hemoglobin Younger High Stress? White?

Not IntuitiveWhy is Renin Low?Flaws in Sodium Excretion VolumeParadoxical Aldosterone

Stiff Arteries & Volume Excess

Characteristics Isolated Systolic Hypertension Older Women African American Diabetes

So What?

Stimulate RAA Inhibit RAA

Diuretics

CCB’s

ACE’s / ARB’s

Beta Blockers?

Salt retaining Steroids◦ Corticosteroids◦ Anabolic Steroids◦ Oral contraceptives◦ Estrogens

NSAIDS

Weight 276 pounds BP 170/90 Blood sugars run 200-250

◦ Glucophage 500mg BID◦ Micronase 5mg qd◦ Zestril 20mg qd

Complaining of palpitations.

HCTZChlorthalidone

OrIndapamide

Transition

https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcSZnyeB7hSiohvoaUK2XPf8I3RkGhJcnxmgTzAxVstB5KyIxXmC

https://encrypted-tbn3.gstatic.com/images?q=tbn:ANd9GcRJ9hLG9bZqehwMhM3Au6sq1xi4x8gb1LY-PnnvCiqbwv7HJeJW

0 12.5 25 50 1000 12.5 25 50 100

Lasix for Hypertension

Only if:◦ Serious Edema◦ CrCl < 30◦ Torsemide probably better

Women: Only the ones with Prostate Glands

Men: only the ones with BIG Prostate Glands

When in Doubt, Cut It Out.

All the outcomes data are on the next slide

https://www.toledoblade.com/image/2013/01/09/670x_b1_a4-3_cCM_z_cT/Cedar-

Point-GateKeeper.jpg

Causes

Drugs Street Drugs Sleep Apnea Renal Artery Stenosis

The Situation

All 4 Classes added Still No Joy Add Spironolactone Especially if the potassium is on the low

side

The number one cause of Resistant Hypertension

https://encrypted-tbn3.gstatic.com/images?q=tbn:ANd9GcR7w6eOwm6ymMSLZxuF_7PpZ-oCCQo8xh_oJKrxhdtC4PfFtYWr

A Couple Stories

67 years old Norvasc 5 Lisinopril 40 Carvedilol 25 BID Chlorthalidone 25mg Blood Pressure is 192/105

Assess Compliance Assess Compliance Assess Compliance Consider Sleep Apnea Consider Spironolactone

52 year old female Non-smoker Blood Pressure 152/94 Which drug should be started?

Leave the Poor Woman Alone !!

Take away her home blood pressure machine

Exercise, Salt and Healthy Food

Cured Pathologic Fear of Hypertension

Created a Rational Approach to Drug Choice

Complemented Rational Choice with Pearls

Consolidated new information with cases