hypertension howard l. sacher, d.o. long island cardiology and internal medicine
TRANSCRIPT
HypertensionHypertension
Howard L. Sacher, D.O.Long Island Cardiology and Internal Medicine
Learning ObjectivesLearning Objectives To know how to detect and diagnose hypertension
and its secondary causes.
To become familiar with updated recommendations for classifying hypertensive patients.
To understand the pharmacologic options for treating hypertension and their appropriate use.
To grasp the importance of counseling patients on lifestyle modification to help control hypertension
HypertensionHypertension
Hypertension is the most well established and important risk factor for– 1 Cardiovascular disease– 2 Cerebrovascular events– 3 Congestive Heart Failure (CHF)– 4 End stage renal disease (ESRD)
Hypertension (cont)Hypertension (cont)
There have been enormous advances in our understanding of the value of treating hypertension over the past three decades, yet the most recent surveys show that hypertension remains largely untreated and uncontrolled
Hypertension (cont)Hypertension (cont)
The relationship between systolic and diastolic blood pressure is strong, graded and continuous
A. The higher the BP, the higher the risk
B. Systolic BP is a better predictor of cardiovascular disease at all ages but particularly in the older age group
C. Diastolic BP does not rise with age after the fifth decade, a time when isolated systolic BP begins to increase sharply in prevalence
Patient EvaluationPatient Evaluation
Repeat BP’sTeach Patients to take BP’s
– Promotes participation by patient– May reduce costs by reducing visits
Ambulatory BP monitoring– BP – – Evaluate diurnal variations
Patient at a greater risk for end organ disease
Patient Evaluation (cont)Patient Evaluation (cont)
A. History – medication , lifestyle habits such as diet, exercise, smoking history, family history and review of symptoms that may reflect secondary hypertension, target organ disease or co-morbid conditions
Patient Evaluation (cont)Patient Evaluation (cont)
A. Physical Exam – 1. BP – standing and sitting in both arms and
legs1. Looking for patients with orthostatic hypotension
over 602. Coarctation of the aorta in younger patients3. Peripheral vascular disease
2. Fundoscopic exam – looking for evidence of hypertensive retinopathy
Patient Evaluation (cont)Patient Evaluation (cont)
3. Evaluation of the Heart1. S4 – decreased LV function compliance precedes
systolic dysfunction or S3 gallop
2. Evidence of CHF1. Rales (Crackles)
2. Hepatomegaly
3. Peripheral Edema
4. Neurological exam for evidence of Cerebrovascular disease
Patient Evaluation (cont)Patient Evaluation (cont)
5. Laboratory Evidence1. Complete blood count (CBC)
1. Renal failure and polycythemia
2. Chemistries – Na+, K+, creatinine, fasting glucose and lipid profile
1. K+ - low in hyperaldosteronism, high in renal failure
3. Urinalysis
4. 12 lead EKG1. LVH, Ischemia
PheochromocytomaPheochromocytoma
Pheochromocytoma– Catacholamine producing tumors can occur in the
adrenal gland or anywhere along the neuroectodermal crest; 10% of adults have multiple tumors
A. TriadA. Episodic HeadachesB. TachycardiaC. Diaphoresis with labile hypertension
B. Associated with multiple endocrine neoplastic (MEN) syndromes, neurofibromatosis, and Van Hipple Landau syndrome
PheochromocytomaPheochromocytoma
C. DiagnosisA. Postural hypertensionB. Resting tachycardiaC. Café au lait spotsD. Resting supine catacholamine levels > 2000 pg/ml (nep,
ep)E. Clonidine suppression test
A. Lowers catacholamine levels in essential HTN but not pheochromocytoma
F. Glucagon (2mg IV) increases plasma catecholamines at least three fold or >2000 1 to 3 minutes after administration in patients with pheochromocytoma
PheochromocytomaPheochromocytoma
D. Tumor Localization accomplished byA. CT scan
B. MRI
C. Radioisotope uptake studies
E. TreatmentA. Surgical removal of tumor
B. Alpha and beta adrenergic blockers are useful for chronic management or non-surgical cases (alpha blockers commonly used)
HyperaldosteronismHyperaldosteronism
A. Spontaneous hypokalemia while on diuretics and potassium supplements
B. Primary HyperaldosteronismA. Small unilateral adenoma (<1cm) is more common
in womenB. Bilateral adrenal hyperplasia is more common in men
A. DiagnosisA. Measure 24 hour urinary aldosterone measurements for two
days on high sodium diet (>!4g/ 24 hours)B. Increased aldosterone with low levels of plasma renin activityC. Adenomas detected by MRI
Hyperaldosteronism (cont)Hyperaldosteronism (cont)
B. TreatmentA. Surgery for small solitary adenomas
B. Medical treatment for adrenal hyperplasia
C. Diuretics and vasodilators
D. Aldosterone antagonists do not reduce BP adequately but may be needed to correct hypokalemia
Renal Artery StenosisRenal Artery Stenosis More commonly found stage 3 or resistant hypertension When bilateral can have reduced kidney function Clinical clues to renovascular disease
A. Onset before age 30 or recent onset of significant high BP after age 55
B. Abdominal bruit if diastolic and lateralized
C. Accelerated or resistant high blood pressure
D. Recurrent flash pulmonary edema
E. Renal failure with normal sediment
F. Co-exiting ASVD especially in long smokers
G. Acute renal failure – particularly after ACE I or Angiotensin receptors blockers
Renal Artery Stenosis (cont)Renal Artery Stenosis (cont)
D. DiagnosisA. Captopril enhances radionuclide renal scanB. Duplex doppler flow studiesC. MRI and MRAD. Definitive diagnosis – angiography
E. TreatmentA. Revascularization
A. Fibromuscular dysplasia – Percutaneous transluminal renal angioplasty (PTRA) is comparable to surgery
B. Atherosclerotic renal artery stenosis – ideal for PTCA with stenting if renal function normal
C. Surgery or PTCA with stenting to preserve renal function
LVH with left atrial enlargement
HTN 2nd to RAS
HTN 2nd to Fibromuscular Dysplasia
10-Minute Break10-Minute Break
JNC - VIJNC - VI
Joint National Committee (JNC) on the Detection, Evaluation and Control of High Blood Pressure
Emphasis: risk stratification for cardiovascular disease– Smoking– Dyslipidemia– Diabetes Mellitus– Old age– Male sex– Post-Menopausal– Family History of cardiovascular disease
At any given level of SBP the absolute risk of a At any given level of SBP the absolute risk of a coronary event increases dramatically as compared to coronary event increases dramatically as compared to
those with no risksthose with no risks
Classifying patients with HTN with consideration to target end Classifying patients with HTN with consideration to target end organ damage/clinical cardiovascular disease (TOD/CCD)organ damage/clinical cardiovascular disease (TOD/CCD)
Lifestyle ModificationsLifestyle Modifications Weight redistribution – lowers BP but also has effect on
lipids and glucose metabolism– There is a Metabolic Syndrome
Obesity High BP Hyperlipidemia Insulin resistance or Diabetes
Reduction of dietary sodium– Correlation between dietary sodium and blood pressure– most
patients benefit from reducing intake to below 2400mg/day, 6 g salt. Also enhances the efficacy of anti-hypertensive agents and may reduce potassium effect of diuretic agents and minimize hypokalemia. (i.e. processed foods)
Lifestyle Modifications (cont)Lifestyle Modifications (cont)
Alcohol – 1 ounce of ethanol– 24 ounces of beer– 10 ounces of wine– 2 ounce of 100 proof whisky
TobaccoAerobic Exercise
Diabetic Hypertensive patientsDiabetic Hypertensive patients
Blood glucose controlled Weight loss Aerobic exercise Angiotensin Converting Enzyme (ACE) Inhibitors
or Angiotensis Receptor Blockers (ARB) Treatment to lower BP using ACE-I and ARB
– Microvascular – retinopathy, nephropathy– Macrovascular – CAD, angina, AAA, CVA
BP goals < or = to 120 / 80
Congestive Heart FailureCongestive Heart Failure
Treatment– ACE I– ARB– Diuretics– B-Blockers– Digitalis
Monitor for– Orthostatic hypotension– Renal function– K+ levels
Post-Myocardial InfarctionPost-Myocardial Infarction
Treatment– ß-Blockers– ACE- I in patients with systolic dysfunction– Diltiazem or Verapamil in patients with non
Q-wave infarction may be used if B-blocker ineffective or contraindicated
Isolated Systolic Hypertension (ISH) Isolated Systolic Hypertension (ISH) and Hypertension in older patientsand Hypertension in older patients
Higher risk for cardiovascular diseaseLifestyle modificationsDecreased vascular compliance due to loss
of arterial elasticity associated with agingDrug of choice
– Low dose thiazide diuretics– Be concerned about postural hypotension or
cognitive dysfunction (central alpha 2 agonists)
Ischemic Heart DiseaseIschemic Heart Disease
Treatment– B-Blockers– Calcium channel blockers as a second choice if beta
blockers are contraindicated; or both drugs can be used together to achieve BP goals
– Treat risk factors High lipids Diabetes or Insulin resistance Weight loss ACE-Inhibitors
Renal DiseaseRenal Disease
Aggressive treatment to lower BP < or = 130/85 Goal will slow rate of disease progression ACE inhibitors are drugs of choice but must be
used with caution if creatinine >3 mg/dl and are not used when renovascular hypertension is suspected
Thiazide diuretics are not effective if serum creatinine is > 2.5 mg/dl and loop diuretics are required
African-Americans and HTNAfrican-Americans and HTNA. High prevalence
B. Occurs earlier, more severe and is associated with higher risks of cardiovascular disease
C. Stroke and heart disease mortality rates 80% and 50% higher respectively
D. End stage renal disease 320% higher
E. Lifestyle modifications
F. Diuretics are drugs of choice for uncomplicated hypertension
G. Ca channel blockers and alpha blockers are also effective
H. All other drugs can be used to achieve BP goals
Women and HTNWomen and HTN
Same therapy as menIf on OCP stop and monitor BPDuring pregnancy ACE-I and ARB should
be stoppedAlpha-Methyldopa during pregnancy
Patients Undergoing SurgeryPatients Undergoing Surgery
If BP is > 180/110, patient must be treated to reduce the risk of perioperative ischemic events
Cardio-selective beta-blockers, unless contraindicated, are drugs of choice
Hypertensive patients who are well controlled prior to surgery should be continued on their own regimen as soon as possible after surgery
Meta-analysis on the various first line drug treatmentsMeta-analysis on the various first line drug treatments
BPBP > > 95 95thth percentile is considered percentile is considered elevated in childrenelevated in children
Hypertensive EmergenciesHypertensive Emergencies
Reduce mean arterial pressure (MAP) no more than 25% (minutes to several hours) and then to 160/100 mmHg avoiding excessively rapid falls that may precipitate cerebral or coronary ischemia– Sublingual nifedipine is not recommended
because of the relatively high risk for these adverse events
Patient Education and Lifestyle Patient Education and Lifestyle modificationsmodifications
Lose excess weight. Cut the fat. Limit alcohol intake. Exercise regularly. Reduce sodium
intake. Stop smoking.
Follow-up:Follow-up:
Once stable, patients should be re-evaluated at least every 3 to 6 months
Review compliance, effectiveness and adverse reactions
Quality of life issues should be considered, including sexual function
At least annual evaluation of urinalysis, creatinine and potassium are appropriate, generally as part of a screening laboratory panel