hypertension with updated guidelines from aafp & jnc vii

HypertensionHypertension

With updated guidelines With updated guidelines from AAFP & JNC VIIfrom AAFP & JNC VII

Omar A. Khan, MD MHSOmar A. Khan, MD MHS

January 2006January 2006

ObjectivesObjectives

• Review the AAFP/JNC VII Review the AAFP/JNC VII diagnostic criteria for diagnostic criteria for hypertensionhypertension

• Review various treatment options, Review various treatment options, indications and side effects indications and side effects

Fast Facts about Fast Facts about Hypertension in the Hypertension in the

US:US:• Hypertensive population: Hypertensive population:

42,000,00042,000,000• Controlled hypertensives: Controlled hypertensives: 27%27%• Those unaware of Dx: Those unaware of Dx:

13,000,00013,000,000• Aware but untreated:Aware but untreated:

7,000,0007,000,000• Of those treated: Of those treated: 58% 58%

uncontrolleduncontrolled

JNC VIIJNC VII

JNC VIIJNC VII

Initial Drug TherapyInitial Drug TherapyBP BP ClassificatiClassificationon

SBP* SBP* (mm (mm Hg)Hg)

DBP* DBP* (mm (mm Hg)Hg)

Lifestyle Lifestyle ModificatModificat

ionion

Without Without Compelling Compelling IndicationsIndications

With With Compelling Compelling IndicationsIndications

NormalNormal <120<120 and and <80<80 EncourageEncourage

No No antihypertensive antihypertensive drug indicated.drug indicated.

Drug(s) for Drug(s) for compelling compelling indications.indications.

PrehypertenPrehypertensionsion

120–120–139139

or 80–or 80–8989 YesYes

Stage 1 Stage 1 hypertensiohypertensionn

140–140–159159

or 90–or 90–9999 YesYes

Thiazide-type Thiazide-type diuretic diuretic for most. May for most. May consider ACEI, consider ACEI, ARB, BB, CCB, ARB, BB, CCB, or combination.or combination.

Drug(s) for Drug(s) for compelling compelling indications.indications.

Other Other antihypertensive antihypertensive drugs (diuretic, drugs (diuretic, ACEI, ARB, BB, ACEI, ARB, BB, CCB) as needed.CCB) as needed.

Stage 2 Stage 2 hypertensiohypertensionn

160160 or or 100100 YesYes

Two-drug Two-drug combination combination for most (usuallyfor most (usuallythiazide-type thiazide-type diuretic diuretic and ACEI or ARB and ACEI or ARB or or BB or CCB).BB or CCB).

JNC 7: Classification and Management of Blood Pressure for Adults

JNC 7. May 2003. NIH publication 03-5233.

Diagnostic WorkupDiagnostic Workup

CVD Risk FactorsCVD Risk Factors

• HTNHTN• ObesityObesity• HyperlipidemiHyperlipidemi

aa• DiabetesDiabetes• Cigarette Cigarette

SmokingSmoking

• InactivityInactivity• Age:Age:

>55 in men>55 in men

>65 in women>65 in women

• Fam history of Fam history of premature premature CVDCVD

JNC 7: Treatment Algorithm for JNC 7: Treatment Algorithm for HypertensionHypertension

SBP=systolic blood pressure; DBP=diastolic blood pressure; ACEI=angiotensin- converting enzyme inhibitor; ARB=angiotensin receptor blocker; BB=-blocker; CCB=calcium channel blocker

JNC 7. May 2003. NIH publication 03-5233.

Optimize dosages or add additional drugs until goal blood pressure is achieved.Consider consultation with hypertension specialist.

Not at goal blood pressure

Without compelling indications

Stage 1 hypertension(SBP 140–159 or DBP 90–99 mm Hg)Thiazide-type diuretic for most.May consider ACEI, ARB, BB, CCB, or combination.

Stage 2 hypertension(SBP 160 or DBP 100 mm Hg)Two-drug combination for most (usually thiazide-type diuretic and ACEI or ARB or BB or CCB).

Lifestyle modifications

Not at goal blood pressure (<140/90 mm Hg)(<130/80 mm Hg for those with diabetes or chronic kidney disease)

Initial drug choices

With compelling indications

Drugs for compelling indicationsOther antihypertensive drugs (diuretic, ACEI, ARB, BB, CCB) as needed.

Compelling IndicationsCompelling Indications• Heart Failure:Heart Failure:

• Post- MI:Post- MI:• High CVD risk:High CVD risk:• DM:DM:

• CRFCRF– Cr > 1.5 in menCr > 1.5 in men– Cr > 1.3 in womenCr > 1.3 in women

• S/P CVAS/P CVA

Thiazide/loop, BB, ACEi, ARB, Thiazide/loop, BB, ACEi, ARB, Aldosterone antagonistAldosterone antagonist

BB, ACE, Aldosterone antagonistBB, ACE, Aldosterone antagonist Thiazide, BB, ACE, Ca channel Thiazide, BB, ACE, Ca channel

blockerblocker Thiazide, BB, ACE, ARB, CCBThiazide, BB, ACE, ARB, CCB

ACE, ARB. For creatinine 2-3 try ACE, ARB. For creatinine 2-3 try loop diureticloop diuretic

Thiazide, ACE inhibitorThiazide, ACE inhibitor

Lifestyle Modifications to Manage Lifestyle Modifications to Manage HTNHTN

ModificationModification RecommendationsRecommendations Approximate Systolic Approximate Systolic

Blood Pressure Blood Pressure ReductionReduction

Weight ReductionWeight Reduction Maintain normal body Maintain normal body weight (BMI 18.5-24.9)weight (BMI 18.5-24.9)

5-20 mm Hg for each 5-20 mm Hg for each 10 kg weight loss10 kg weight loss

Adapt Adapt DASHDASH eating plan eating plan Consume diets rich in Consume diets rich in fruits, vegetables, low fruits, vegetables, low fat dairy and low fat dairy and low saturated fatsaturated fat

8-14 mm Hg8-14 mm Hg

Dietary sodium reductionDietary sodium reduction Reduce sodium to no Reduce sodium to no more than 2.4 g/day more than 2.4 g/day sodium or sodium or 6 g/day NaCl6 g/day NaCl

2-8 mm Hg2-8 mm Hg

Increase physical activityIncrease physical activity Engage in regular Engage in regular aerobic activity such as aerobic activity such as walking walking (30 min/day on most (30 min/day on most days)days)

4-9 mm Hg4-9 mm Hg

Moderate alcohol Moderate alcohol consumptionconsumption

Limit alcohol to no more Limit alcohol to no more than 2 drinks/d for men than 2 drinks/d for men and 1 drinks/day for and 1 drinks/day for women.women.

2-4 mm Hg2-4 mm HgSource: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure JNCVII. JAMA. 2003;289:2560-2572.

Failures of Patient Failures of Patient EducationEducation

• 50% of patients discontinue their anti-50% of patients discontinue their anti-hypertensive within 1 year of hypertensive within 1 year of initiating treatment.initiating treatment.

• DASH diet for hypertension: DASH diet for hypertension: – limit sodiumlimit sodium– Increase fruits and vegetables (8-10/d)Increase fruits and vegetables (8-10/d)– Increase low fat dairy (3-4/d)Increase low fat dairy (3-4/d)

• Focus on diet history for hypertensive Focus on diet history for hypertensive patientspatients

Key Diet History Questions Key Diet History Questions for Patients with HTNfor Patients with HTN

• Do you use a salt shaker?Do you use a salt shaker?

• Do you taste your food before you add salt?Do you taste your food before you add salt?

• How often do you eat salty foods, such as chips, pretzels, How often do you eat salty foods, such as chips, pretzels, salted nuts, canned and smoked foods?salted nuts, canned and smoked foods?

• Do you read labels for sodium content?Do you read labels for sodium content?

• How many servings of fruits and vegetables do you eat How many servings of fruits and vegetables do you eat everyday?everyday?

• How often do you eat or drink dairy products? What kind?How often do you eat or drink dairy products? What kind?

• How often do you eat out? What kinds of restaurants?How often do you eat out? What kinds of restaurants?

• Do you like to drink alcohol? How much?Do you like to drink alcohol? How much?

• How often do you exercise, including walking?How often do you exercise, including walking?

TIPS on drugs for HTTIPS on drugs for HT

• CCB OK for isolated systolic CCB OK for isolated systolic hypertension (ISH)hypertension (ISH)

• For DM: ACEi or ARB with or without For DM: ACEi or ARB with or without diuretic, then add BB or CCBdiuretic, then add BB or CCB

• When ACEi causes cough, substitute When ACEi causes cough, substitute ARBARB

• Don’t use short acting CCB (increases Don’t use short acting CCB (increases deaths due to arrhythmias).deaths due to arrhythmias).

• Alpha blockers (e.g. clonidine) only as Alpha blockers (e.g. clonidine) only as second line (more side effects).second line (more side effects).

• Most patients should start with a Most patients should start with a diuretic as they enhance the diuretic as they enhance the effectiveness of other agents.effectiveness of other agents.

• Most patients will require more than Most patients will require more than one agent.one agent.

• Add a baby aspirin to improve Add a baby aspirin to improve cardiovascular outcomes.cardiovascular outcomes.

Special PopulationsSpecial Populations• Minorities:Minorities:

• Women:Women:

• Aged:Aged:

• Blacks have greater prevalence, Blacks have greater prevalence, severity, and impact and poorer severity, and impact and poorer response to monotherapy. ACE response to monotherapy. ACE induced angioedema is more induced angioedema is more commoncommon

• Estrogen containing oral Estrogen containing oral contraceptives elevate BP. Aldomet, contraceptives elevate BP. Aldomet, BB, and vasodilators OK in BB, and vasodilators OK in pregnancypregnancy

• Higher prevalence, ISH more Higher prevalence, ISH more common, more frequent common, more frequent complications from ACE, CCBcomplications from ACE, CCB

ThiazidesThiazides

• ChlorothiazideChlorothiazide (Diuril)(Diuril)• ChlorthalidoneChlorthalidone• HydrochlorthiazideHydrochlorthiazide(Microzide, (Microzide,

Hydrodiuril)Hydrodiuril)• PolythiazidePolythiazide (Renese)(Renese)• IndapamideIndapamide (Lozol)(Lozol)• MetolazoneMetolazone (Mykrox, (Mykrox,

Zaroxolyn)Zaroxolyn)

*All trade / brand / generic names are *All trade / brand / generic names are specific to the USAspecific to the USA

Benefits of Thiazide Benefits of Thiazide DiureticsDiuretics

• Evidence-based support for end Evidence-based support for end points that matter (prevention of CV points that matter (prevention of CV and all-cause mortality).and all-cause mortality).

• Reduced calcium excretion is a Reduced calcium excretion is a potential benefit for osteoporosis potential benefit for osteoporosis prevention.prevention.

Loop DiureticsLoop Diuretics

• BumetanideBumetanide (Bumex)(Bumex)• FurosemideFurosemide (Lasix)(Lasix)• TorsemideTorsemide (Demadex)(Demadex)

Potassium-sparing Diuretics•Amiloride (Midamor)•Triamterene (Dyrenium)*All trade / brand / generic names are *All trade / brand / generic names are specific to the USAspecific to the USA

Aldosterone Receptor Aldosterone Receptor BlockersBlockers

• Eplerone (Inspra)Eplerone (Inspra)• Spironolactone (Aldactone)Spironolactone (Aldactone)

Combined alpha- and beta- blockers•Carvedilol (Coreg)•Labetalol (Normodyne, Trandate)

*All trade / brand / generic names are *All trade / brand / generic names are specific to the USAspecific to the USA

Beta-blockersBeta-blockers

• AtenololAtenolol (Tenormin)(Tenormin)• BetaxololBetaxolol (Kerlone)(Kerlone)• BisoprololBisoprolol (Zebeta)(Zebeta)• MetoprololMetoprolol (Lopressor, (Lopressor,

Toprol XL)Toprol XL)• NadololNadolol (Corgard)(Corgard)• PropranololPropranolol (Inderal/XL)(Inderal/XL)• TimololTimolol (Blocadren)(Blocadren)

*All trade / brand / generic names are *All trade / brand / generic names are specific to the USAspecific to the USA

ACE inhibitorsACE inhibitors

• BenzaprilBenzapril (Lotensin)(Lotensin)• CaptoprilCaptopril (Capoten)(Capoten)• EnalprilEnalpril (Vasotec)(Vasotec)• FosinoprilFosinopril (Monopril)(Monopril)• LisinoprilLisinopril (Prinivil, Zestril)(Prinivil, Zestril)• MoexiprilMoexipril (Univasc)(Univasc)• PerindoprilPerindopril (Aceon)(Aceon)• QuinaprilQuinapril (Accupril)(Accupril)• Ramipril Ramipril (Altace)(Altace)• TrandolaprilTrandolapril (Mavik)(Mavik)

*All trade / brand / generic names are *All trade / brand / generic names are specific to the USAspecific to the USA

Angiotensin II Receptor Angiotensin II Receptor BlockersBlockers

• Candesartan Candesartan (Atacand)(Atacand)• Eprosartan Eprosartan (Tevetan)(Tevetan)• Irbesartan Irbesartan (Avapro)(Avapro)• Losartan Losartan (Cozaar)(Cozaar)• Olmesartan Olmesartan (Benicar)(Benicar)• Telmisartan Telmisartan (Micardis)(Micardis)• Valsartan Valsartan (Diovan)(Diovan)

*All trade / brand / generic names are *All trade / brand / generic names are specific to the USAspecific to the USA

Calcium channel Calcium channel blockersblockers

• DihydropyridinesDihydropyridines– Amlodipine (Norvasc)Amlodipine (Norvasc)– FelodipineFelodipine (Plendil) (Plendil)– IsradipineIsradipine

(Dynacirc CR)(Dynacirc CR)– Nicardipine (Cardene Nicardipine (Cardene

SR) SR)– Nifedipine (Adalat Nifedipine (Adalat

CC, Procardia CC, Procardia XL)XL)

– Nisoldipine (Sular)Nisoldipine (Sular)

• DHPs can have negative inotropic effects, unlike non-DHPs, DHPs can have negative inotropic effects, unlike non-DHPs, so use with caution in pts with impaired cardiac functionso use with caution in pts with impaired cardiac function

Calcium channel Calcium channel blockersblockers

• non-Dihydropyridines:non-Dihydropyridines:– Diltiazem Diltiazem

(Cardizem CD, (Cardizem CD, Dilacor XR, Tiazac, Dilacor XR, Tiazac, Cardizem LA)Cardizem LA)

– Verapamil (Calan Verapamil (Calan SR, Isoptin SR)SR, Isoptin SR)

• DHPs can have negative inotropic effects, unlike non-DHPs, DHPs can have negative inotropic effects, unlike non-DHPs, so use with caution in pts with impaired cardiac functionso use with caution in pts with impaired cardiac function

*All trade / brand / generic names are *All trade / brand / generic names are specific to the USAspecific to the USA

AlphaAlpha11 blockers blockers

• Doxazosin Doxazosin (Cardura)(Cardura)• PrazosinPrazosin (Minipress)(Minipress)• TerazosinTerazosin (Hytrin)(Hytrin)

*All trade / brand / generic names are *All trade / brand / generic names are specific to the USAspecific to the USA

Direct Vasodilators

• Hydralazine (Apresoline)• Minoxidil (Loniten)

*All trade / brand / generic names are *All trade / brand / generic names are specific to the USAspecific to the USA

Centrally acting drugsCentrally acting drugs

• ClonidineClonidine (Catapres)(Catapres)• MethyldopaMethyldopa (Aldomet)(Aldomet)• ReserpineReserpine (generic)(generic)• GuanfacineGuanfacine (generic)(generic)

*All trade / brand / generic names are *All trade / brand / generic names are specific to the USAspecific to the USA

Again: Treatment Again: Treatment AlgorithmAlgorithm

Lifestyle Modification

Not at goal BP

Initial Drug Choices

W/O Compelling Indications

Stage 1 Stage 2

With Compelling Indications

Drug for Indication

Thiaz, ACE, ARB, BB, CCB 2 Drug Combo Not at Goal BP

Adjust Dose or add additional agents

ReferencesReferences

• JNC 7 report: available via NIH JNC 7 report: available via NIH ((Publication 03-5233)

• JAMA 289 (19), May 21 2003 (online)

• AAFP monograph: #305AAFP monograph: #305

HTN True or FalseHTN True or False

• ACE Inhibitors should be initial drug therapy ACE Inhibitors should be initial drug therapy for most, either alone or combined with for most, either alone or combined with other drug classes.other drug classes.

• ACE InhibitorsACE Inhibitors ThiazidesThiazides should be initial should be initial drug therapy for most, either alone or drug therapy for most, either alone or combined with other drug classes.combined with other drug classes.

FalseFalse

• For persons over age 50, DBP is more important than SBP as CVD risk factor.

True or FalseTrue or False

• For persons over age 50, SBP is a more important than DBP as CVD risk factor.

FalseFalse

• Normal blood pressure is defined as SBP < 135 and DBP < 90.

True or FalseTrue or False

• Normal blood pressure is defined as SBP < 120 and DBP < 80. People with SBP 120 – 139 OR DBP 80 – 89 should be considered prehypertensive.

FalseFalse

• Those people whose BP is classified as prehypertensive should be initially treated with lifestyle modification from the time they are identified.

True or FalseTrue or False

• Those people whose BP is classified as prehypertensive should be initially treated with lifestyle modification from the time they are identified.

TrueTrue

• Key lifestyle modification measures that, if initiated in all prehypertensive and hypertensive individuals, are likely to lower BP, include all except…..• a) Weight reduction

• b) DASH Eating Plan

• c) Smoking cessation

• d) Dietary sodium reduction

• e) Physical activity

• f) Moderation of alcohol intake

• Key lifestyle modification measures that should be initiated in all prehypertensive and hypertensive individuals in order to lower BP include all except…..• a) Weight reduction

• b) DASH Eating Plan

• c) Smoking cessation

• d) Dietary sodium reduction

• e) Physical activity

• f) Moderation of alcohol intake

• If BP is >20/10 mmHg above goal, initiate therapy with a single agent and lifestyle modification.

True or FalseTrue or False

• False. If BP is >20/10 mmHg above goal, initiate therapy with two agents, one usually should be a thiazide-type diuretic.

FalseFalse

• Self measurement can help assess “white-coat” HTN.

True or FalseTrue or False

• Self measurement can help improve adherence with therapy, provide helpful information on response to therapy and assist in assessing “white-coat” HTN.

TrueTrue

• Most patients will only require one antihypertensive drug to achieve goal BP.

True or FalseTrue or False

• Most patients will require 2 or more antihypertensive drugs to achieve goal BP

FalseFalse