HYPERTENSION

HypertensionHypertension is the most common public health

problem in developed countries

Called Silent Killer

No cure is available, but prevention and management decrease the incidence of hypertension and disease sequelae.

Definition: Persistently high arterial blood pressure, defined as systolic blood pressure above 140 mm Hg and/or diastolic blood pressure above 90 mm Hg

Hypertension: The Silent Killer

Facts & Figures

50 million Americans & 1 billion worldwide affected

Most common primary care diagnosis (35 million visits annually)

Normotensive at age 55 have 90% lifetime risk of Hypertension

Continuous & consistent relationship with CVDBetween ages 40-70, starting from 115/75CVD risk doubles with each increment of 20/10

Prevalence

Prevalence on hypertension by age

Age % Hypertension

18~29 4

30~39 11

40~49 21

50~59 44

60~69 54

70~79 64

80 + 65

Causes of Hypertension1- Primary hypertension (90 – 95%) - Essential hypertension

2- Secondary hypertension (5 – 10%) - Renal diseases - Endocrine disease

- Steroid excess- Growth hormone excess

- Catecholamine excess- Vascular causes

- Drugs

Hypertension - Guidelines

JNC- VII Classification of BP for adults (+18 yrs)

CATEGORYSBP mm Hg

DBP mm Hg

Normal <120 & <80

Prehypertension

120-139 or 80-89

Stage-I 140-159 or 90-99

Stage-II >160 or >100

VARIOUS TERMS & DEFINITIONS

Isolated systolic hypertension

SBP greater than 140mm, DBP less than 90mm

65-75 % of elderly hypertensive have ISHT

Resistant hypertension

It is the failure to reach goal BP in patients who are adhering to full doses of an appropriate three-drug regimen that includes a diuretic.

Uncontrolled hypertension

BP above recommended level (treated or untreated)

Complicated hypertension

Hypertension with co-morbidities

Chronic Complications

Organ Condition Symptoms, signs/events

Heart LVH, CAD Angina / MI

Artery Atherosclerosis

CAD/CVD/PAD

Aneurysm Stroke

Kidney Nephropathy Microalbuminuria

Eye (retina) Retinopathy Blurring of vision

Brain CVD TIA/Stroke

End / Target organ damage

Prevalence of Cardiovascular Disease

Estimated Number of Persons With Cardiovascular Disease in the US

10 20 30 40 50 60

High BP

CAD

CHF

Stroke

Other

50,000,000

12,200,000

4,600,000

4,400,000

2,800,000

Prevalence (millions)

BP=blood pressure, CAD=coronary artery disease, CHF=congestive heart failure

(24%)

American Heart Association® . 2000 Heart and Stroke Statistical Update. 1999

Hypertension Risk Factors

Modifiable Cigarette smoking Obesity Physical inactivity- sedentary life style Dyslipidemia Diabetes mellitus Microalbuminuria

Non - Modifiable Age Family history Sex

Hypertension : Symptoms

Most of the patients do not complain of any

symptoms

Symptomatic patients may have one or more of the

following symptoms

- Headache

- Confusion

- Severe shortness of breath

- Visual disturbances

- Nausea and vomiting

Hypertension - Management

Life style modification: Regular physical exercise Stop smoking Stop alcohol Dietary controls : weight control

Restrict salt intake 4-6 gm/day Restrict saturated fats

Hypertension - Management

Category Drugs

Diuretics Hydrochlorothiazide, Indapamide

ACE-Is Enalapril, Perindopril

ARBs Olmesartan, Valsartan, Losartan

Beta blockers Nebivolol, Atenolol

Alpha blockers Terazosin, Prazosin

CCB Amlodipine, Diltiazem

Pharmacological management

Hypertension - Management

Goals of Therapy

The goal of antihypertensive therapy is the reduction of cardiovascular and renal morbidity and mortality.

Most patients with hypertension, reach the DBP goal once SBP is at goal, the primary focus should be on achieving the SBP goal.

Goal BP <140/90 mmHg : Achieving target BP is associated with a decrease in CVD complications.

Goal BP is <130/80 mmHg (patients with HT and diabetes or renal disease)

Ideal Antihypertensive Drug

Good efficacy

Minimal or no serum glucose imbalance

Minimal or no electrolyte imbalance

Minimal or no lipid profile imbalance

Improve quality of life Physical activity, sleep, sexual functions.

Dosage compliance

The correct Approach to Hypertension

16

JNC 7 Algorithm

Anti Hypertensive drug classes

TheA, B, C, D approach

Anti Hypertensive Drug Classes

19

• ACEi – Angiotensin converting enzyme inhibitors - let us call them ‘A’

• ARB – Angiotensin Receptor Blockers – Let us call them also as ‘A’

• BB – Beta Receptor Blockers – let us call them ‘B’

• CCB – Calcium channel blockers – let us call them ‘C’

• Diuretics – let us call them ‘ D ’

AGE

Younger (< 55)

AB/CD Rule – HT Treatment

ACEi, Beta-blocker Ca++-blocker, Diuretic)(AB/CD =

Dickerson et al. Lancet 353:2008-11;1999

Resistant HT /Intolerance

Add / substitute alpha blockerRe-consider 20 causes trial of spironolactone

IV:V:

Older (> 55)

ACEi / ARB

BB

A + B A + B + D

DiureticCCB

D + C + A D + C

I

II

III III

II

I

Drugs for Compelling Indications

DIURETICS

Mode Of Action:

Eliminate excess fluid & NaCl

Decrease Na+ & water

reabsorption

Reduce Blood Volume

Reduce

BP

DIURETICS

Indications:

Hypertension

Management of CHF

Edema due to Renal Dysfunction

Side effects: Electrolyte imbalance - Arrhythmias

Dyslipidemia

Impotence

Loss of Libido

BETA BLOCKERS

Mode of actionBlock Beta AdrenoreceptorsDecrease in CODecrease in Renin Release from the Kidneys

Reduce

BP

BETA BLOCKERSIndications:

HypertensionAngina with Myocardial IschemiaPost MIArrhythmiasHeart failure

Side effects: Bradycardia Fatigue Bronchospasm Impotence Dyslipidemia

1 blocker

Inhibit 1 receptor

↓ Peripheral vascular resistance

↓ Blood pressure

ALPHA BLOCKER

Mechanism of action:

ALPHA BLOCKER

Indications:

Hypertension

Side effects: Dizziness Headache Nasal congestion

CALCIUM CHANNEL BLOCKERS

Mode of action:

Interference with Ca ++ uptake in smooth

muscles & cardiac muscleDilation of peripheral arterioles

Reduction in PVR

Reduction in Afterload

No effect on preload

Negative inotropic effect

CALCIUM CHANNEL BLOCKERS

Indications: Hypertension Angina

Side effects: Reflex tachycardia Flushing Edema Headache Constipation Hypotension

ACE - INHIBITORS

Mode of action:

Inhibit Angiotensin converting enzyme

Decrease formation of angiotensin II

Prevent degradation of bradykinin

ACE - INHIBITORSIndications:

HypertensionHeart failurePost MIDiabetic Nephropathy

Adverse effects: Hypotension Hyperkalemia Dry cough Angioedema Rash

ANGIOTENSIN-II RECEPTOR INHIBITOR

Blocks the AT1 receptors

Cause effective blockage of RAAS

Indications:Hypertension

Heart failure

Post MI

Follow-up and Monitoring Patients should return for follow-up and adjustment of

medications until the BP goal is reached.

More frequent visits for stage 2 HTN or with complicating co morbid conditions.

Serum potassium and creatinine monitored 1–2 times per year.

After BP at goal and stable, follow-up visits at 3- to 6-month intervals.

Co morbidities, such as heart failure, associated diseases, such as diabetes, and the need for laboratory tests influence the frequency of visits.

New Features and Key Messages

Thiazide-type diuretics should be initial drug therapy for most, either alone or combined with other drug classes.

Certain high-risk conditions are compelling indications for other drug classes.

Most patients will require two or more antihypertensive drugs to achieve goal BP.

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

New Features and Key Messages

The most effective therapy prescribed by the careful clinician will control HTN only if patients are motivated.

Motivation improves when patients have positive experiences with, and trust in, the clinician.

Empathy builds trust and is a potent motivator.

The responsible physician’s judgment remains paramount.

THANK YOU