CONTROL OF HYPERTENTION IN SPECIAL GROUPS HYPERTENTION IN PREGNANCY Etiology & Definition Complicates 10-20% of pregnancies Elevation of BP 140 mmHg systolic and/or 90 mmHg diastolic, on two occasions at least 6 hours apart. Categories Chronic Hypertension Gestational Hypertension Preeclampsia Preeclampsia superimposed on Chronic Hypertension Chronic Hypertension Preexisting Hypertension Definition Systolic pressure 140 mmHg, diastolic pressure 90 mmHg, or both. Presents before 20 th week of pregnancy or persists longer then 12 weeks postpartum. Causes Primary = Essential Hypertension Secondary = Result of other medical condition (ie: renal disease) Prenatal Care for Chronic Hypertensives Electrocardiogram should be obtained in women with long-standing hypertension. Baseline laboratory tests Urinalysis, urine culture, and serum creatinine, glucose, and electrolytes Tests will rule out renal disease, and identify comorbidities such as diabetes mellitus. Women with proteinuria on a urine dipstick should have a quantitative test for urine protein. Treatment for Chronic Hypertension Avoid treatment in women with uncomplicated mild essential HTN as blood pressure may decrease as pregnancy progresses. May taper or discontinue meds for women with blood pressures less than 120/80 in 1 st trimester. Reinstitute or initiate therapy for persistent diastolic pressures >95 mmHg, systolic pressures >150 mmHg, or signs of hypertensive end-organ damage. Medication choices = Oral methyldopa and labetalol. Preeclampsia Definition = New onset of hypertension and proteinuria after 20 weeks gestation. Systolic blood pressure 140 mmHg OR diastolic blood pressure 90 mmHg Proteinuria of 0.3 g or greater in a 24-hour urine specimen Preeclampsia before 20 weeks, think MOLAR PREGNANCY! Categories Mild Preeclampsia Severe Preeclampsia Eclampsia Occurrence of generalized convulsion and/or coma in the setting of preeclampsia, with no other neurological condition. Preeclampsia Severe Preeclampsia must have one of the following: Symptoms of central nervous system dysfunction = Blurred vision, scotomata, altered mental status, severe headache Symptoms of liver capsule distention = Right upper quadrant or epigastric pain Nausea, vomiting Hepatocellular injury = Serum transaminase concentration at least twice normal Systolic blood pressure 160 mm Hg or diastolic 110 mm Hg on two occasions at least six hours apart Thrombocytopenia = 140 mmHg Goal < 140 mmHg LOE: Grade E Diastolic: Threshold > 90 mmHg Goal < 90 mmHg LOE: Grade A for ages 40-59; Grade E for ages 18-39 JNC 8: Drug Treatment Thresholds and Goals Age > 18 yo with CKD or DM JNC 7: < 130/80 (MDRD NEJM 1994) Systolic: Threshold > 140 mmHg Goal < 140 mmHg LOE: Grade E Diastolic: Threshold > 90 mmHg Goal < 90 mmHg LOE: Grade E JNC 8: Initial Drug Choice Nonblack, including DM Thiazide diuretic, CCB, ACEI, ARB LOE: Grade B Black, including DM Thiazide diuretic, CCB LOE: Grade B (Grade C for diabetics) JNC 8: Initial Drug Choice Age > 18 yo with CKD and HTN (regardless of race or diabetes) Initial (or add-on) therapy should include an ACEI or ARB to improve kidney outcomes LOE: Grade B Blacks w/ or w/o proteinuria ACEI or ARB as initial therapy (LOE: Grade E) No evidence for RAS-blockers > 75 yo Diuretic is an option for initial therapy JNC 8: Subsequent Management Reassess treatment monthly Avoid ACEI/ARB combination Consider 2-drug initial therapy for Stage 2 HTN (> 160/100) Goal BP not reached with 3 drugs, use drugs from other classes Consider referral to HTN specialist LOE: Grade E Medical Education & Information for all Media, all Disciplines, from all over the World Powered by 2013 ESH/ESC Guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) - J Hypertension 2013;31: Blood pressure goals in hypertensive patients SBP, systolic blood pressure; CV, cardiovascular; TIA, transient ischaemic attack; CHD, coronary heart disease; CKD, chronic kidney disease; DBP, diastolic blood pressure. Recommendations SBP goal for most Patients at lowmoderate CV risk Patients with diabetes Consider with previous stroke or TIA Consider with CHD Consider with diabetic or non-diabetic CKD 140/90 Threshold>140/90 < 60 yrEldery SBP >160>140/90 150/90 >60 yrConsider SBP>140/90>150/90 >80 yr if 160/100"Markedly>160/100 w/ 2 drugselevated BP" Goal BP GroupBP Goal (mm Hg) GeneralDM*CKD** JNC 8: