Audience Response. Hypertension. Case: Mr. J. Measuring BP. Non-pharmacologic intervention. Case: Mr. J. Session ID: HTN411

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Audience Response http://rwpoll.com OR App downloads: Hypertension Chris Knight, MD cknight@uw.edu http://tiny.cc/rwiphone http://tiny.cc/rwdroid Session ID: HTN411 Case: Mr.

All of these make sense EXCEPT? A. 24-hour ambulatory monitoring B. Dietary counseling C. Exercise recommendations D. Fasting lipids, glucose E.

1 Audience Response OR App downloads: Hypertension Chris Knight, MD Session ID: HTN411 Case: Mr. J 52 y/o male patient comes in for evaluation of elevated BP. BP noted to be 148/88 in grocery store, now 138/86 p 84; otherwise healthy, asymptomatic. BMI 28, no regular exercise program. All of these make sense EXCEPT? A. 24-hour ambulatory monitoring B. Dietary counseling C. Exercise recommendations D. Fasting lipids, glucose E. Start hydrochlorothiazide Measuring BP Home BP monitoring 1/2 of patients have home measurements 10 mmhg or more lower than office Better correlated with end organ damage Multiple readings (home or office) more reliable Non-pharmacologic intervention Weight loss: 5-20 mmhg/10 kg DASH diet: 8-14 mmhg Salt restriction: 2-8 mmhg Exercise: 4-9 mmhg Alcohol moderation: 2-4 mmhg Case: Mr. J Mr. J comes back 4 months later. He now goes to the gym twice a week and pays more attention to salt but still eats at restaurants frequently. His LDL is 141, HDL 42. Home BP has been /85-95 for the most part; today his BP is 146/92, p 80. All of these make sense EXCEPT? A. Urinalysis C. Basic metabolic panel D. Albumin/creatinine ratio E. Do them all

2 Prevalence and impact Initial Evaluation Fasting lipids, glucose (Risk factor mod.) 90% lifetime risk at age 55 Risk of CVD doubles for each 20/10 > 115/75 BMP (K+, egfr) UA (for glomerulonephritis) Albumin/creatinine ratio (proteinuria) Consider EKG (for LVH) Case: Mr. J Mr. J reluctantly got his labs (he hates needles): K + 4.1, TC 190, HDL 60, Glucose 89, egfr > 60; Alb/cre ratio 8. The two of you decide to try a medication. Which do you prescribe? A. Amlodipine 5 mg daily B. Chlorthalidone 12.5 mg daily C. Atenolol 25 mg daily D. Hydrochlorothiazide 25 mg daily E. Lisinopril 10 mg daily Treatment Thiazide diuretics are particularly effective Chlorthalidone is twice as potent and has longer 1/2 life than HCTZ, but more hypokalemia ACEI, CCB also well studied as monotherapy CCB requires less monitoring Treatment Amlodipine + ACEI may have additional cardiovascular benefit ß-blockers (esp. atenolol) somewhat less effective at reducing stroke Most effective drug is the one the patient will take: fewer pills, fewer doses are good! Case: Mrs. S A 59 y/o woman with type 2 diabetes comes to your clinic as a new patient. She takes insulin, atorvastatin, and hydrochlorothiazide 25 mg daily for hypertension. Her BP is 133/84, HR 84. Labs show a hemoglobin A1C of 7.1% and urinary albumin/ creatinine ratio of 45. The best next step for her is: A. Home BP monitoring B. Discuss therapeutic lifestyle changes C. Add lisinopril 5 mg daily D. Add atenolol 25 mg daily E. 24-hour urine for protein excretion

3 Targets JNC 7, general: <140/90--but lower (<130)is better if you can get there JNC 7, DM/CKD: <130/80; more important in pts with protenuria Other diseases with lower targets: CHF, Aortic dissection, ASCVD Increased mortality when DBP < 60 with CAD? Specific indications for certain drugs CKD with proteinuria: ACE/ARB CHF: ACE/ARB, ß-blocker, aldosterone antagonists (low dose), diuretics Diabetes: Diuretics, ACE/ARB, ß-blocker, CCB Post-MI: ß-blocker, ACE (ARB?), aldosterone antagonist Case: Mrs. L A 85 y/o woman comes to your office as a new patient to discuss her blood pressure. She has been watching it at home, and it s typically / BMI is 22. She walks for 30 minutes 3 times weekly, eats a low sodium diet, and takes no medications. Your BP target for her would be: A /80-90 B /70-80 C. No evidence to support treatment Hypertension in the Elderly Isolated systolic hypertension more common Data limited in pts over 80; HyVET showed benefit with target 150/80 Beware orthostasis, polypharmacy Reasonable to target /80-90 and adjust target based on comorbidities Case: Mr. C A 75 y/o gentleman comes in for follow-up of hypertension. He is on hydrochlorothiazide 25 mg daily, lisinopril 40 mg daily, and amlodipine 10 mg daily. His blood pressure is sometimes well controlled, others not; today it is 180/100, pulse 64. Your next intervention should be: A. Add clonidine patch, 0.2 mg/day B. Add metoprolol SR 50 mg/day C. Ask him to bring in his pill bottles D. Measure renin/aldosterone ratio E. Check renal artery duplex Resistant hypertension Defined as hypertension that persists despite high doses of three drugs including a diuretic Causes: Drugs: not enough or too many Volume overload Secondary hypertension

4 Drugs: Non-adherence Complex medication regimens Cost concerns Discuss difficulties frequently 1-10 ranking of how likely they are to follow the plan Pill counts Drugs that cause hypertension NSAIDS! Calcineurin inhibitors: cyclosporine, tacrolimus Steroids (and OCPs) Erythropoietin Sympathomimetics: Cocaine, meth, decongestants Herbs: Licorice (real), bitter orange, ephedra Volume overload Excess salt intake Inadequate GFR: consider loop diuretic in CHF, chronic kidney disease Diuretic not given/taken Case: Mrs. P A 32 y/o woman who is 7 months pregnant comes in to see you to stay in touch. BP is 150/90 without proteinuria. The best therapeutic option for her is: A. Hydralazine 10 mg qid B. Methyldopa 250 mg bid C. Labetalol 100 mg bid D. Lisinopril 10 mg qd E. None of the above Hypertension in Pregnancy Mild: 140/90, Severe 160/110 Target: / (concern for placental hypoperfusion) Drugs of choice: Labetalol, Methyldopa, Hydralazine Contraindicated: ACE/ARB Case: Mr. M A 33 y/o gentleman comes in for evaluation of blood pressure. He had a BP of 150/94 noted at a health fair. He brings in an outside lab report that is notable for creatinine 0.9, K+ 3.3, UA normal. Which test is most appropriate?

5 Hyperaldosteronism Hyperaldosteronism Prevalence: 5-15% of hypertensives Symptoms: None Signs: Hypertension & hypokalemia Treatment resistant hypertension Diagnosis Renin/aldosterone ratio 24 hr urine aldosterone (high Na diet) Imaging (CT, Iodocholesterol) Adrenal vein sampling Hyperaldosteronism Management Aldosterone antagonists (less antiandrogenic effects with eplerenone, but $60/mo vs $10-20) Surgery if functional tumor is confirmed Case: Mr. J A 75 y/o man comes in for f/u of his second episode of flash pulmonary edema, now better. BP 154/100, creatinine 1.4 on hydrochlorothiazide and amlodipine. Which test is most appropriate? Renal artery stenosis Renal artery stenosis Prevalence: < 1% of mild hypertension, 10-45% of severe hypertension History: New elevation in BP or creatinine, flash pulmonary edema, atherosclerosis, lack of family history Signs: unilateral abdominal bruit, eye findings of severe hypertension Diagnosis Clinical prediction rule [Krijnen, Annals, 1998] Duplex ultrasonography Angio (MRA, CTA, catheter) MRA not helpful for fibromuscular dyplasia

6 Renal artery stenosis Management ACE/ARB highly effective but need to watch GFR closely in bilateral disease Medical management has equivalent long-term outcomes and better short-term outcomes than intervention Reserve angioplasty or surgery for those who don t respond to medical management Case: Ms. W A 47 y/o woman comes in complaining of hot flashes and dizziness, and occasional headaches. BP is 180/110, p 100 supine, and 140/60, p 128 standing. Which test is most appropriate? Pheochromocytoma Pheochromocytoma Prevalence: < 0.2% of hypertensives Symptoms: Headache, sweating, palpitations, visual blurring, pallor Signs: tachycardia, orthostatic hypotension, hyperglycemia Diagnosis Plasma free metanephrine (sensitive but 10-15% false positives, often due to medications) 24 hr urine metanephrines Imaging (MR, CT, nuclear medicine) Pheochromocytoma Management NO ß-BLOCKERS Surgery is preferred if possible Pre-op BP management with α-blockers, CCBs Manage crises with IV phentolamine or nitroprusside Case: Ms. F A 44 y/o woman comes in for evaluation of high blood pressure. She previously was normotensive, but over the last 2 years has gained 40 lb. and her blood pressure has gone up to 160/100s. She has to use her arms to get out of the chair. Which test is most appropriate?

7 Cushing s syndrome Cushing s syndrome Prevalence: < 0.5% of pts with hypertension History: Weight gain, new diabetes, hypertension Signs: Proximal muscle weakness (specific), cushingoid facies, striae, central obesity Diagnosis Dexamethasone suppression test 24-hr urinary cortisol Overnight cortisol/creatinine ratio Midnight salivary cortisol Cushing s syndrome Management Treatment is surgical if lesion is resectable Ketoconazole, mifepristone, paserotide all used in unresectable disease Case: Mr. K A 34 y/o man comes in for evaluation of fatigue. He reports trouble staying awake while at his desk, and has twice fallen asleep at the wheel. BP is 150/90. Which test is most appropriate? Sleep Apnea Consider sleep apnea in patients with refractory hypertension Raw association is strong (OR 3.8) but becomes more nebulous (OR 1.5, p=ns) when adjusted for comorbidities Small studies suggest treatment may help but limited data in resistant HTN Secondary HTN: Other Causes Coarctation: decreased femoral pulses Oral contraceptives Scleroderma renal crisis (use an ACE!) Hypothyroidism (rare) Hyperparathyroidism (rare)

8 Secondary HTN Principles Use your H&P! It s ok to manage some things medically Be sure to rule out medications (too few/too many) before starting the megaworkup Case: Mr. D A 58 y/o man comes in for evaluation of headache. He reports two days of worsening headache, and now feels foggy. BP is 240/140 and papilledema is present. Which is the best treatment plan? A. Sublingual nifedipine while waiting for medics to arrive B. ICU for IV fenoldopam, target 130/90 C. ICU for IV nitroprusside, target 180/105 D. Amlodipine 10 mg po, recheck 6h E. Furosemide 20 mg po and recheck tomorrow Hypertensive emergency Severe hypertension with acute retinal changes (hemorrhage, exudates, papilledema), acute renal insufficiency, or CNS findings Hypertensive encephalopathy typically nonfocal: headache, nausea, vomiting, altered MS, seizures Hypertensive emergency Treat with IV antihypertensives: nitroprusside, fenoldopam, hydralazine (esp. in eclampsia), labetalol, esmolol, phentolamine Target DBP within a few hours; maximum fall in BP should be 25% of initial measurements More rapid lowering increases risk of ischemia

RESISTENT HYPERTENSION. Dr. Helmy Bakr Professor and Head of Cardiology Dept. Mansoura University

RESISTENT HYPERTENSION. Dr. Helmy Bakr Professor and Head of Cardiology Dept. Mansoura University RESISTENT HYPERTENSION Dr. Helmy Bakr Professor and Head of Cardiology Dept. Mansoura University Resistant Hypertension Blood pressure remaining above goal in spite of concurrent use of 3 antihypertensive