Hypertension (HTN) Lecture Note
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1 Hypertension (HTN) Lecture Note October, 2009 Chuang-Ye Hong, MD, PhD, FACP Wan-Fang Hospital Taipei Medical University
2 Outline Definition Epidemiology Measurement of BP Secondary cause Target organ damage Co-morbidity History taking PE Lab Treatment goal Life style modification Compelling indication / special consideration Drugs Resistant HTN HTN emergency
3 Definition of HTN JNC VII (2003) Normal < 120 / 80 Pre-HTN / Stage 1 HTN / Stage 2 HTN > or = 160 / 100 No acute illness, no anti-htn drug Systolic or diastolic HTN? Labile HTN, White coat HTN
4 Epidemiology / Etiology Prevalence : around 30% in adults 60% are treated, half of them are adequately controlled (USA 2000) Each 20 mmhg SBP or 10 mmhg DBP elevation : 2 X CV complications > 90% Essential HTN, no identifiable cause ; BP = CO X PR Secondary HTN (<20 or > 50 y) : sudden, severe, refractory, recurrent
5 Measurement of BP (1) Sit quietly for > 5 min No smoking or caffeine for 30 min Cuff : > 80% of arm (small cuff - falsely high readings) Korotkoff sounds : first and last sounds Electronic machine Which arm : higher reading side
6 Measurement of BP (2) 2 measurements each visit, separated by > 2 min 2 separate clinical visits before diagnosis of HTN Standing BP to R/O orthostatic hypotension (>20 fall of SBP, >10 DBP) Ambulatory BP monitoring (ABPM) : BP decrease by 10-20% during the night (HTN>120/75) Self measurement at home (HTN>135/85)
7 Secondary HTN (1): Kidney Renal parenchymal disease Renovascular disease Fibromuscular dysplasia (young) or Atherosclerosis (elderly) Abdominal bruit MRA (MRI), RA angiography Stent or surgery or drug ARB / ACEI : Contraindicated
8 Secondary HTN (2): Endocrine Hyperthyroidism : systolic HTN Aldosteronism : hypokalemia, aldo/renin>20; CT/MRI; Spironolactone (Aldacotone) Cushing s disease : cortisol/acth Pheochromocytoma : paroxysmal; metanephrine; alpha and then betablocker Hypercalcemia Myxedema
9 Secondary HTN (3) Coarctation of aorta : children, low BP in lower extremity Drugs : NSAID, Decongestant, Steroid, OCP, Licorice, Epo, Cyclosporine, MAO inhibitor, Amphetamine, Cocaine Sleep apnea : morning HTN Polycythemia
10 Target Organ Damage (1) Heart : LVH (PMI, ECG, echo) LV dysfunction (CHF, echo, systolic, diastolic) CAD (angina, MI) Brain : CVA / TIA, ruptured aneurysm Carotid bruit Hypertensive encephalopathy (Brain edema)
11 Target Organ Damage (2) Kidney : Renal failure (Creatinine) Proteinuria Vascular : Intermittant claudication (PAOD) Aortic aneurysm Aortic dissection Retinopathy Eclampsia
12 CV Risk Factors (Co-Morbidity) Hypertension DM Hyperlipidemia Smoking Obesity Age (Man > 45, Woman > 55) Family history of premature CV disease (Man < 55, Woman < 65)
13 Initial Evaluation : PE (1) Co-morbidity (2) Secondary cause (3) Target organ damage BP, both arm Eye fundi (3) Body mass index / Waist circumference (1) Carotid bruit (3) Thyroid gland (2), Heart (3), Lung (3) Abdomen for kidney (2), aortic pulsation (3) and bruit (2) Leg edema (3), pulse (2,3) Neurological assessment (3)
14 Initial Evaluation : Lab (1) Co-morbidity (2) Secondary cause (3) Target organ damage Serum creatinine (2,3), K (2), glucose (1) Lipid profile (cholesterol: total, HDL and LDL; triglyceride) (1) ECG (3) Urinalysis Optional : serum calcium, thyroid stimulating hormone, uric acid
15 Management of BP (* Compelling indication : CHF, MI, High CAD Risk, DM, CKD, Stroke) Pre-HTN ( /80-89) : No * : Life style modification * : Drug for compelling indication Stage 1 HTN ( /90-99) : No * : thiazide diuretic for most (may consider ACEI, ARB, BB, CCB) Stage 2 HTN (> or = 160/100) : No * : Two-drug combination for most (usually including thiazide)
16 Treatment Goal and Life Style modification Goal : < 140 / 90 For Kidney disease and DM : <130/80 Life Style Modification : Weight loss (BMI < 25) Exercise (walking > 30 min/day) Diet rich in fruit and vegetable, low total and saturated fat NaCl < 6 g/day (Na 100 mmol or 2.4 g/day) Alcohol <30 ml/day for man, 15 ml for woman
17 Compelling indications Angina : BB MI : BB, ACEI CHF : ACEI/ARB, loop diuretics, (aldosterone antagonist, BB) CKD : ACEI/ARB, loop diuretics DM : ACEI/ARB (DM nephropathy) CVA : ACEI/Thiazide (acute stage : goal 160/100?)
18 Special Consideration Pregnant women : Methyldopa, BB, Vasodilator (ACEI and ARB contraindicated) Aldosteronism : Aldosterone antagonist Pheochromocytoma : Alpha blocker first, then BB Aortic aneurysm : BB, ACEI Aortic dissection : BB first, then vasodilator
19 Anti-HTN Drugs Diuretics Beta-Blockers (BB) Calcium Channel Blockers (CCB) Angiotensin Converting Enzyme Inhibitor (ACEI) Angiotensin Receptor Blocker (ARB) Alpha-Blockers Centrally Acting Agents (Direct-acting) Vasodilators
20 Diuretics Thiazide diuretic Hydrochlorothiazide (Dichlotride, D50) 50 mg/#, 1#, qd, po Loop diuretic Furosemide (Lasix) 40 mg/#, 1#, qd. po 20 mg/vial, 1 vial, IV/IM Potassium sparing diuretic Spironolactone (Aldactone), 25 mg/# Amiloride 5 mg + D50 (Moduretic), 1#, qd, po
21 Thiazide Diuretic in Hypertension Cheap and effective EBM: reduce stroke, MI and save life Add thiazide, if response to other antihypertensive drug is inadequate Elderly or Black patients respond well For CHF or renal insufficiency, use Loop diuretic such as Lasix (IV, if needed)
22 ADR of Diuretics Metabolic: Increase glucose, uric acid (! ) Increase triglyceride and cholesterol (Thiazide) Decrease Na, K, Mg (K-sparing ones increase K) Others: Pancreatitis (Thiazide) Gynecomastia (Aldactone) Ototoxicity (Lasix) Muscle cramp (Decreased K) Impotence (?) Nephrotoxicity of diuretics (mercurial & herbal diuretics) Azotemia
23 Beta-Blocker Beta-adrenergic blocking agent (antagonist) One of the greatest medical achievements in 20 th century Sir James Black, Nobel Laureate ICI (now Astra-Zeneca) Also developed H2 antagonist for peptic ulcer at SKB (now GSK)
24 Types of Beta-blocker Propranolol Atenolol (Inderal), tid (Tenormin), qd Lipid solubility High Low Membrane (CNS) effect Beta-1 (cardiac) Selectivity Elimination (+) (-) (-) (+) Liver metabolism Kidney excretion Both drugs have no Intrinsic Sympathomimetic (partial agonist) activity
25 Application of Beta-blocker Hypertension Coronary artery disease (angina, MI) Arrhythmia Migraine Essential tremor Hyperthyroidism
26 ADR of Beta-blockers Reduce heart rate, induce bronchospasm, impair myocardial contractility May also induce Raynaud s phenomenon, impotence and metabolic side effect (increase triglyceride and decrease HDL) Cardiac selectivity and ISA are relative, not absolute. Beware of sensitive patients. Abrupt withdrawal is dangerous! Receptor up-regulation
27 Calcium Channel Blockers Calcium channel blocker (antagonist) Three types: Share calcium channel blocking activity Differ in effect and side effect Nifedipine (Adalat): similar to direct vasodilator Verapamil (Isoptin): similar to beta-blocker Diltiazem (Herbesser): milder effect All have short acting and long acting preparations
28 Effects of Ca-blockers Nifedipine Verapamil Diltiazem BP Heart Rate Myocardial Contractility (Reflex) Angina
29 Nifedipine-like Ca-blockers Dihydropyridines Nifedipine (Adalat) 5 mg/capsule, 1 capsule tid po Sublingual for rapid onset (avoid) 30 mg/extended release tablet, 1 tablet qd Felodipine (Plendil) 5 mg/#, 1# qd bid Amlodipine (Norvasc) 5 mg/#, 1# qd
30 ACEI and ARB Angiotensin converting enzyme inhibitor (Inhibit the production of Angiotensin II) Angiotensin Receptor Blocker Cough in ACEI, not in ARB Hyperkalemia Also used for CHF & Diabetic nephropathy Contra-indication: Renal artery stenosis Pregnancy (Fetal mortality)
31 ACEI and ARB ACEI Captopril (Capoten), 25 mg/#, 1# tid Enalapril (Renitec), 5 mg/#, 1# qd Lisinopril (Zestril), 10 mg/#, 1# qd ARB Losartan (Cozaar), 50 mg/#, 1# qd Losartan + Thiazide = Hyzaar, 1# qd Telmisartan (Micardis), Valsartan (Diovan), Candesartan (Blopress)
32 Alpha-blockers Selective alpha 1 adrenergic receptor blocker Arterial Vasodilation, reflex tachycardia Doxazosin (Doxaben), 2 mg/#, 1# qn Terazosin (Hytrin), Prazosin (Minipress) First dose effect: orthostatic hypotension Also used in BPH Non-selective alpha-blocker: phenoxybenzamin (Phentolamin): PIPE
33 Alpha/Beta-Blocker Vasodilation with little reflex tachycardia Carvedilol (Dilatrend): Also for CHF!
34 Centrally Acting Drugs Drowsiness, slow heart rate, impotence Clonidine (Catapres), mg/#, 1# qn - bid Stimulate pre-synaptic alpha 2 receptor Relieve of menopausal syndrome Acute withdrawal syndrome Methyldopa (Aldomet) Reserpin
35 Direct Vasodilators Arterial smooth muscle relaxation Reflex tachycardia and water retention Combine with beta-blocker and/or diuretic Minoxidil, Hair growing Apresoline No Viagra please!!
36 Resistant HTN Three drug therapy including a diuretic Compliance? Excessive sodium intake / water retention Drug induced? Associated conditions : obesity, insomnia/anxiety, excessive alcohol Secondary hypertension? Surgery?
37 Hypertensive Crisis HTN Urgency (>180/120, no acute TOD) : Control BP in hours using oral drug HTN Emergency (with TOD) : Intravenous drug in ICU Lower mean arterial pressure by 25% within 2 hours, (then to 160/100 over next 2 to 24 hours?)
38 Parenteral Agents for Hypertensive Emergency Sodium nitroprusside (Nipride) Arterial and venous vasodilation Pre-load and after-load reduction Also for CHF Rapid onset, titratable, short lived ICU, intra-arterial BP monitoring Thiocyanate toxicity Nitroglycerin : also for angina, CHF Labetalol (Trandate) : alpha/beta blocker
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