Systemic Hypertension

Transcription

1 Systemic Hypertension Physiology & Molecular Biology Nicky R. Holdeman, O.D. M.D. FAAO Associate Dean for Clinical Education Chief of Medical Services University Eye Institute University of Houston

2 >38% of U.S. adults

3 Worldwide, systemic HTN affected 972 million adults in 2000 estimates from 2007 exceeded 1.56 billion Since HTN is usually asymptomatic, the diagnosis is often made at a late stage when target organ damage has already occurred Lancet 9 / 2007

4 Symptoms patients associated with elevations of blood pressure: - HA, dizziness, palpitations, sweats, tiredness, neck pain, nausea, chest pain, visual changes, and nervousness Patients were less likely to take HTN meds when symptoms were absent. BMJ 7 / 2012

5 SYMPTOMS OF SYSTEMIC HYPERTENSION THE MAJORITY OF PATIENTS ARE ASYMPTOMATIC UNTIL THERE IS AN END ORGAN DEFICIT MODERATE ELEVATIONS OF BP MAY INFREQUENTLY PRODUCE VAGUE, NON SPECIFIC SYMPTOMS, SUCH AS: - SUBOCCIPITAL HEADACHES - PALPITATIONS - FACIAL FLUSHING - LIGHTHEADEDNESS - FATIGUE HYPERTENSIVE CRISIS (>220 / 120 mm Hg) MAY HAVE OVERT EVIDENCE OF TARGET ORGAN DYSFUNCTION - TOD DICTATES EMERGENCY vs URGENCY TREATMENT

6

7

8 Frightening Fact The residual lifetime risk of developing HBP for a normotensive person age is at least 90% based on use of the 140/90 mm Hg cutpoint JAMA 2003

9

10 Pediatric HTN is increasing with pediatric obesity, yet HTN and pre-hypertension frequently undiagnosed Numerous normal and abnormal cutoffs exist which make it difficult for clinicians to remember The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents

11 FEATURES OF SYSTEMIC HTN HTN IS THE MOST COMMON CHRONIC DISORDER IN THE U.S. HTN IS A MAJOR RISK FACTOR FOR HEART ATTACKS, STROKE, HEART FAILURE, RENAL FAILURE, PERIPHERAL VASCULAR DISEASE, DEMENTIA, AND RETINOPATHY DETECTION AND TREATMENT HAVE BEEN NEGLECTED BY BOTH PATIENTS AND PHYSICIANS - 38% OF ADULTS IN THE US (75M) HAVE A BP 140/90 mm Hg; ANOTHER 59 M HAVE PRE-HTN - >15% ARE UNAWARE OF THEIR DISEASE AND THUS UNTREATED - 16 % OF HTN ADULTS KNOW THEIR BP IS ELEVATED BUT NOT RECEIVING TX - 48% OF PATIENTS BEING TREATED ARE NOT PROPERLY CONTROLLED ( BP is not < 140/90 mm Hg)

12 OK, SO SYSTEMIC HTN SEEMS TO BE A MAJOR HEALTH PROBLEM, BUT WHAT DOES THIS HAVE TO DO WITH OPTOMETRY? OR WHY DO I NEED TO KNOW THIS? As a primary care provider, we should be interested in the health of the entire patient, not just their eyes

13 CONCLUSION Hypertension, particularly if poorly controlled, appears related to an increased risk for OAG. J Glaucoma 2004

14 DPP of < 56 mmhg increases the risk of glaucoma progression This risk should be considered in patients who demonstrate glaucoma progression in the absence of other clinical findings to explain advancement of disease

15 Nocturnal BP reduction of >20% is associated with the development of disc hemorrhages and VF progression in patients w/ OAG

16 SO, HIGH OR LOW BP CAN AFFECT THE PROGNOSIS OF PATIENTS WITH GLAUCOMA. CAN HIGH BLOOD PRESSURE HAVE OTHER OCULAR AFFECTS?

17

18 The incidence of diabetic macular edema is high Controlling both BG and BP appears to reduce this risk ECP can help family physicians provide better overall diabetes care

19 For each 10 mm Hg higher DBP, a 1.5 X increased risk of RVO was noted. In patients with CKD, a 2.2 X increased risk of RVO was seen. ECP should be aware of screening for CV risk factors and CKD in pts with RVO Invest Ophth Vis Sci 7 / 2011

20 49,321 men followed for 6 years 262 cases of RRD Those w/ HTN (w/o myopia) had a 2.3 fold increased risk of RRD compared to normotensive patients

21 * *

22

23 RATIONALE FOR IN-OFFICE TESTING OF BP BY ALL HEALTH CARE PROVIDERS VERY COMMON DISEASE (75M + 59M) WITH DIRECT OPHTHALMIC IMPLICATIONS CLINICALLY SILENT (ASYMPTOMATIC) HIGH INCIDENCE OF MORBIDITY AND MORTALITY - HTN IS A MAJOR RISK FACTOR FOR THE 1 ST AND 3 RD LEADING CAUSES OF DEATH IN THE U. S. TREATABLE CONDITION - TX IS HIGHLY EFFECTIVE IN REDUCING WELL KNOWN COMPLICATIONS

24 SO WHERE DO WE BEGIN? (HINT IT S NOT WICKAPEDIA) Look for evidence based information from recent peer reviewed articles (Don t worry about the fine print the articles shown indicate that I follow my own rules!)

25 Recommendations based on observational studies and expert consensus

26 Guidelines relied primarily on evidence from randomized controlled trials. Targets based not on data, but on the absence of data JAMA 2014

27 114 page report, written by a large committee on behalf of the ACC / AHA - released on 11/15/2017 New definition of hypertension, with aggressive new treatment targets

28 GETTING TO THE HEART OF THE MATTER DEMOGRAPHICS AND DEFINITION OF HTN > 75 MILLION AMERICAN ADULTS HAVE A BLOOD PRESSURE 140/90 mm Hg - > 59 MILLION MORE ARE AT RISK TO DEVELOP HTN (PRE- HYPERTENSION) MORBIDITY AND MORTALITY INCREASES LINEARLY WITH INCREASED LEVELS OF EITHER SBP OR DBP MODEST ELEVATIONS IN BP MAY CAUSE INCREASED RISKS FOR TARGET ORGAN DAMAGE IN SOME PATIENTS - 1/3 OF CAD DEATHS OCCUR AT PRE-HTN LEVELS HYPERTENSION IS THE BP ASSOCIATED WITH AN INCREASE IN CV EVENTS CURRENTLY DEFINED (by most organizations) AS A BP 140 / 90 mmhg, BUT NOT ALL AGREE

29 (JNC 7) Pre-hypertensive Stage 1 HTN St 2

30 IT DOESN T HAVE TO BE HIGH TO BE BAD CV events can occur at levels below those that would normally trigger the use of antihypertensive therapy High normal BP is now called prehypertension or stage 1 and should be closely monitored

31 HTN HAS BEEN CLASSIFIED ACCORDING TO AGE, FROM NEWBORN TO ADULTS - 120/80 mmhg MAY BE ABNORMALLY HIGH FOR SOME INDIVIDUALS AND TOO LOW FOR OTHERS ISOLATED SYSTOLIC HTN (ISH) - SBP 140 mmhg WITH A DBP < 90 mmhg - INCIDENCE INCREASES AFTER AGE 60 - DUE TO REDUCED ELASTICITY AND FIBROSIS OF LARGE ARTERIES ( STIFF PIPES ) - ISH IS NOT AN INEVITABLE CONSEQUENCE OF AGING; HOWEVER, IT IS THE MOST COMMOM SUBTYPE OF HTN IN OLDER ADULTS

32

33 PULSE PRESSURE A GOOD PREDICTOR OF CV MORTALITY PP = SBP DPB Each 10mm Hg rise in PP increases the risk of death from CVD by 22% PP is a risk factor for stroke and heart disease but isn t superior to SBP. JAMA 2002

34 WHITE COAT HYPERTENSION UNTREATED BP > 140/90 mmhg IN THE OFFICE AND < 130/80 mmhg AT HOME OR w/ ABPM, WITH NO EVIDENCE OF TOD OCCURS IN 10% OF PATIENTS - 50% OF PATIENTS WILL HAVE A GRADUAL INCREASE IN BP OVER TIME, EVEN USING ABPM HOME READINGS AND ABPM HELP IN ESTABLISHING THE TRUE DIAGNOSIS

35 P & T 9 / 2016

36 MASKED HYPERTENSION (MH) BP is normal in the office and elevated outside the office setting Affects 5% of normal, healthy, untreated adults Unlike WCH, MH has a more serious prognosis and can only be undertreated JAMA 04

37 RESISTANT HTN RH is persistent elevation (>140/90 mm Hg) in office measured BP, despite the use of 3 or more antihypertensive agents According to ABPM, 62% of RH patients had true RH and 38% had normal values and were considered to have white coat effect Hypertension 5 / 2011

38 WHAT RISK FACTORS CONTRIBUTE TO HIGH BLOOD PRESSURE AND WHAT RISK FACTORS CONTRIBUTE TO CARDIOVASCULAR DISEASE?

39 RISK FACTORS FOR SYSTEMIC HYPERTENSION RACE [ BLACKS (38%) > WHITES (29%) ] AGE ( > 55 FOR MEN ; > 65 FOR WOMEN ) FAMILY HISTORY OF HTN OBESITY (BMI 30) USE OF TOBACCO PRODUCTS SEDENTARY LIFESTYLE EXCESSIVE INTAKE OF SODIUM, ETOH, SATURATED FAT, AND CAFFEINE CERTAIN MEDICATONS (INCLUDING OTC) LIFE STYLE CHANGES SLEEP APNEA AND SLEEP DISORDED BREATHING

40 CARDIOVASCULAR RISK FACTORS SYSTEMIC HYPERTENSION (+) CIGARETTE SMOKING OBESITY (BMI 30) (+) PHYSICAL INACTIVITY ( SENDENTARY LIFESTYLE) DYSLIPIDEMIA ( TG or HDL) (+) DIABETES MELLITUS (or pre- diabetes) (+) AGE (>55 FOR MEN, >65 FOR WOMEN) FAMILY HISTORY OF PREMATURE HEART DISEASE (men <55 years or women <65 years) (+) Components of the metabolic syndrome

41 Elevated BP is a physical sign, but people who have HTN generally have other problems. Just lowering the BP is tunnel vision, as a syndrome has evolved All CV risk factors need to be indentified and addressed

42 METABOLIC SYNDROME (DEADLY QUARTET / SYNDROME X) OBESITY INSULIN RESISTANCE INSULIN RESISTANCE HYPERGLYCEMIA (pre DM / DM) HYPERGLYCEMIA HYPERINSULINEMIA EXCESSIVE INSULIN DYSLIPIDEMIA (stimulates sympathetic activity, increases vascular tone, promotes vascular hypertrophy, and increases Na retention) ELEVATED VLDL HYPERTENSION (or pre-htn)

43 WHAT ARE THE CURRENT CLASSIFICATIONS OF HIGH BLOOD PRESSURE IN ADULTS?

44 CLASSIFICATION OF BLOOD PRESSURE FOR ADULTS AGED 18 YEARS OR OLDER BP SYSTOLIC DIASTOLIC CLASSIFICATION BP, mmhg BP, mmhg NORMAL <120 and <80 PRE-HYPERTENSION or STAGE or STAGE or 100 When the SBP and the DBP fall into different catagories, the higher category should be selected to classify the patients BP status (JNC 7 )

45 Blood Pressure (mm Hg) JNC ACC/AHA <120 and <80 Normal BP Normal BP and <80 Pre HTN Elevated BP or Pre HTN Stage 1 HTN or Stage 1 HTN Stage 2 HTN 160 or 100 Stage 2 HTN Stage 2 HTN

46 The Definitions, While Arbitrary Are: HIGH 140 / 90 mm Hg or > PRE HYPERTENSION (or STAGE 1 HTN) / mm Hg NORMAL 120 / 80 mm Hg or <

47 CLINICAL ASPECTS OF HTN MOST PATIENTS WITH HTN (90 95%) WILL HAVE ESSENTIAL OR PRIMARY HTN - NO DEFINABLE CAUSE FOR THE DISEASE - INSIDIOUS ONSET AND ASYMPTOMATIC FOR YEARS - IF UNDETECTED OR INADEQUATELY TREATED, MORBIDITY AND MORTALITY INCREASES ATHEROSCLEROSIS IS A CONFOUNDING MEDIATOR OF DISEASE, WHICH ACCELERATES VASCULAR INJURY AND END ORGAN DAMAGE - ALTERS THE VESSELL WALLS (plaque formation) - ALTERS PLATELET AGGREGATION (thrombus formation) HEART ATTACK AND STROKE ARE THE MAJOR CAUSES OF DEATH AND DISABILITY

48

49

50

51

52

53

54 Echocardiogram, EKG, and CXR helps to identify LVH

55

56

57

58 If the BP is elevated, this patient does not have WCH Concealment / banking Concealment / deviation Concealment / tapering

59 CRVO

60 Exudates CWS

61 CWS Optic nerve swelling Splinter / flame and dot hemorrhages HTN Emergency

62 ODEMS optic disc edema with a macular star Macular star If BP is elevated, this is a HTN Emergency

63 Cotton wool spots

64

65

66 Measuring Blood Pressure Three Common Questions IS THERE A RIGHT WAY AND WRONG WAY TO MEASURE A PATIENTS BLOOD PRESSURE AT AN OFFICE VISIT? I DON T WANT TO BE ACCUSED OF PRACTICING MEDICINE; IS IT OK TO CHECK BLOOD PRESSURE? ARE THERE OTHER WAYS TO DETERMINE A PATIENTS BLOOD PRESSURE INSTEAD OF MEASURING IT IN THE OFFICE?

67 - some patients are misdiagnosed as HTN and are treated, when drugs are not indicated (WCH) - some cases of HTN are overlooked (MH) - about 38% of treated patients are diagnosed with RH, when they actually have WCE

68

69 Monitoring Blood Pressure Patterns Variable ABPM CBPM HBPM True BP Yes? Yes (?) Diurnal BP rhythm Yes No No Dipping Yes No No Predict CV events Yes Yes Yes Detects WCH, MHT, RH Yes No Yes Duration of drugs Yes No Yes Reimbursement Partial Yes No

70 Neither clinic nor home measurements had sufficient sensitivity or specificity to be recommended as a single diagnostic test for HTN. USPSTF 2015 : ABPM should be the reference standard for confirming an office based diagnosis, to R/O WCH, and to avoid unnecessary treatment Most 3 rd party plans & Medicaid will not cover ABPM - in-office readings remain important BJM 2015

71 The single most important thing physicians do in their medical life is take an accurate BP measurement With a poor BP reading, patients are at risk for over treatment or under treatment of BP. JAMA 6 / 08

72 Medical Students Fall Short on Blood Pressure Challenge Only 1 / 159 medical students correctly performed all 11 elements in a BP check challenge; the avg was 4 steps performed correctly. JAMA Publish 9 / 2017

73 JAMA

74

75

76

77 Using a cuff that is too small (overestimates BP) or too large (underestimates BP) is the most common error in BP measurements

78

79

80

81

82

83

84

85 FACTORS AFFECTING THE ACCURACY OF IN-OFFICE BP FACTOR MAGNITUDE, SBP/DBP, mm Hg White coat reaction To physician 11 to 28 / 3 to 15 To nonphysician 1 to 12 / 2 to 7 Acute smoking 6/5 Acute caffeine ingestion 11/5 Acute ethanol ingestion 8/8 Distended urinary bladder 15/10 Talking; signing 7/8

86 FACTOR MAGNITUDE, SBP/DBP, mm Hg Cuff too narrow 10 / 2 to 8 Cuff not centered 4/3 Cuff over clothing 5 to 50 Elbow too low 6 Back unsupported 6 to 10 Arm unsupported 1 to 7 / 5 to 11 Too slow deflation 2 / 5 to 6 Multiple factors lead to increasingly inaccurate BP measurements

87 IF THE BLOOD PRESSURE IS TRULY ELEVATED, HOW SOON SHOULD THE PATIENT BE SEEN BY THEIR PCP?

88 FOLLOW-UP SCHEDULE BASED ON BLOOD PRESSURE MEASUREMENTS Systolic Diastolic Follow-up Recommended <120 and <80 Recheck in 1-2 years or Recheck in 6-12 months * or Confirm within 1-2 months or Evaluate or refer to source of care within 2 weeks 180 or 110 Evaluate or refer to source of care immediately or within 1 wk depending on clinical situation. * Patients in the 130/80 to 139/89 mmhg BP range are at 2x the risk to develop hypertension or have a MI as those with lower values.

89 WHAT WILL HAPPEN IF I REFER A PATIENT WITH ELEVATED BP TO THEIR PCP? FIRST OFF, YOUR PERSONAL AND PROFESSIONAL STOCK GOES WAY UP!

90 YOU CANT BUY THIS KIND OF PUBLICITY!

91 EVALUATION OF PATIENTS WITH NEWLY DIAGNOSED HTN OBJECTIVES - IDENTIFY 2 CAUSES OF HTN - ASSESS PRESENCE OR ABSENCE OF TOD - IDENTIFY ANY CONCOMITANT DISORDERS (MET-S) - ASSESS LIFESTYLE HABITS THAT AFFECT BP EVALUATION REQUIRES A CAREFUL MEDICAL HISTORY, ROS, PHYSICAL EXAMINATION (INCLUDING OPHTHALMOSCOPY), CALCULATION OF THE BMI, AND APPROPRIATE ANCILLARY TESTING

92 CLASSIC FEATURES OF ESSENTIAL OR PRIMARY HYPERTENSION ONSET IN THE 4 TH OR 5 TH DECADE FAMILY HISTORY OF HTN GRADUAL INCREASE IN BP w/ BP < 180 / < 110 mm Hg AT DIAGNOSIS ASYMPTOMATIC HISTORY, ROS, PHYSICAL EXAM, AND ROUTINE LAB STUDIES ARE NORMAL ( no TOD damage at time of diagnosis) BP CONTROLLED WITH LIFESTYLE CHANGES AND 1-2 DRUGS BP CONTROL IS MAINTAINED ONCE ACHIEVED IF THE PATIENT IS COMPLIANT WITH MEDS

93 CALCULATING BODY MASS INDEX ( BMI ) 1. MULTIPLY BODY WEIGHT IN POUNDS BY ( HEIGHT IN INCHES ) X ( HEIGHT IN INCHES ) 3. DIVIDE # 1 BY # 2 BMI 18.5 BMI BMI BMI BMI > 40 UNDERWEIGHT HEALTHY WEIGHT OVERWEIGHT (>30 = obese) VERY OVERWEIGHT EXTREMELY OVERWEIGHT

94 TESTING PATIENTS WITH NEWLY DIAGNOSED MILD TO MODERATE HTN CBC URINALYSIS (UA) SERUM CREATININE SERUM ELECTROLYTES (K+, Na) SERUM URIC ACID FASTING GLUCOSE (FPG) BLOOD CALCIUM TSH PLASMA LIPID PROFILE - TOTAL CHOLESTEROL, HDL, LDL, TRIGLYCERIDES ECG CXR

95 ,TSH

96 WHAT IF THE PATIENT DOESN T FIT THE TYPICAL PROFILE OF PRIMARY HTN And / Or THE BLOOD PRESSURE DOESN T RESPOND TO TREATMENT?

97 Age: 24 Nl ROS & PMH No FH of HTN BP: 280 / 160 mm Hg Retinopathy (TOD) Hypertensive Crisis HTN Urgency Dx: focal segmental glomerulosclerosis (FSGS)

98 Depending on the cause, the underlying condition may be resolved (See chapter for more extensive list of causes)

99 Normal renal arteriogram

100 Renal artery stenosis (RAS)

101 Polycystic kidney disease

102 Pheochromocytoma Secretes epinephrine and norepinephrine Detect VMA and metanephrine Mineralocorticoid Excess Secretes aldosterone Hypokalemia & hypocalcemia

103 BP in arms >> BP in legs

104 DOES TREATING HYPERTENSION REALLY MAKE A SIGNIFICANT DIFFERENCE IN THE PATIENTS PROGNOSIS? IF SO, SHOULD DIFFERENT PATIENTS HAVE DIFFERENT TREATMENT GOALS?

105 JAMA 2 / 2014

106

107 Groups Spar Over New HTN Guidelines From JNC-8

108 (Systolic Blood Pressure Intervention Trial) 5yr study of 2636 robust, ambulatory adults, 75 yrs, w/ HTN, but w/o diabetes. BP taken with AOBP digital device w/o a Dr or nurse in the room SBP 120 mmhg compared to SBP 140 mmhg resulted in significantly lower rates of fatal and non-fatal CV events and death from any cause. SPRINT stopped after 3.14 yrs JAMA 5 / 2016

109 BG control (<6% vs 7 7.9%) lowered the incidence of DR (7.3% vs 10.4%), but not vision loss Tight lipid control reduced the incidence of DR (6.5% vs 10.2%), but not vision loss Tight BP control (<120 vs <140) did not lower the incidence of DR (10.4% vs 8.8%) or vision loss Action to Control Cardiovascular Risk in Diabetes NEJM 7 / 2010

110 DON T GO TOO LOW IN THE ELDERLY 521 patients > 85 yrs or older were followed 9 yrs Patients with a SBP < 140 mmhg had an increased risk for death, compared to patients whose SBP was mmhg J Am Geriat Soc 6 / 06

111 MANAGEMENT OF HYPERTENSION THE PATIENT SHOULD BE REFERRED IN A TIMELY MANNER FOR CONTROL OF BOTH THE SYSTOLIC AND DIASTOLIC BP THE GOAL IS TO REDUCE MORBIDITY AND MORTALITY BY THE LEAST INTRUSIVE MEANS, WHILE AVOIDING ADVERSE SIDE EFFECTS MAINTAIN SBP < 140 mm Hg AND THE DBP < 90 mm Hg FOR MOST PEOPLE - JNC - 7 A LOWER BP (130/80 mm Hg) MAY BE NECESSARY IN SOME PATIENTS WITH MULTIPLE RISK FACTORS OR PRE- EXISTING TARGET ORGAN DAMAGE (TOD) - JNC - 8 A HIGHER BP (150/90 mm Hg) MAY BE APPROPRIATE FOR PATIENTS > 60 YRS OF AGE - SPRINT FOR ROBUST, NON-DM ADULTS, >75, A SBP < 120 HAS A LOWER FATALITY RATE THAN A SBP <140 mm Hg ACC/AHA TARGET OF 130/80 mm Hg REDUCES CV RISK

112 GENERAL SUGGESTIONS for BP CONTROL Healthy adults <50, to possibly 60 yrs of age, should ideally have a BP 120/80 mm Hg For robust pts 60 to 80, BP target is /90 mm Hg. A SBP of 120 mm Hg may be appropriate for some pts, if there are no adverse symptoms or organ dysfunction For pts >80, especially if frail, a target of 150/90 mm Hg is usually appropriate but more intensive tx may be of benefit if well tolerated For pts with hx of CVA, renal disease, or DM, a suggested target is 130/80 mm Hg

113 JNC 7 - IN ADDITION TO AN APPROPRIATE BP, MANAGEMENT MUST ALSO ADDRESS CONCURRENT MEDICAL CONDITIONS (METABOLIC SYNDROME ) ULTIMATELY, TREATMENT IS STRATIFIED BASED ON THE LEVEL OF BP, RISK FACTORS, AND EVIDENCE OF TOD (see Table 4) LIFESTYLE MODIFICATIONS ARE RECOMMENDED FOR ALL GROUPS AT ALL STAGES: - DECREASES BP - DECREASES CARDIOVASCULAR RISKS - ENHANCES EFFECTS OF ANTI-HYPERTENSIVE AGENTS - LITTLE COST AND MINIMAL RISK - MAY PREVENT THE DEVELOPMENT OF HTN IN PRE-HYPERTENSIVE PATIENTS

114 DON T SMOKE!!

115 QUESTION WHAT 6 NUMBERS (normal and abnormal) SHOULD EVERYONE KNOW? BP BMI TOTAL CHOLESTEROL TRIGLYCERIDES LDL HDL

116 IDEAL LIPID PROFILE TOTAL CHOLESTEROL < DESIRABLE BORDERLINE HIGH HIGH TRIGLYCERIDES < ACCEPTABLE BORDERLINE HIGH HIGH LDL ( BAD or LOUSY CHOLESTEROL ) < OPTIMAL NEAR OR ABOVE OPTIMAL BORDERLINE HIGH HIGH VERY HIGH HDL ( GOOD or HAPPY CHOLESTEROL ) < LOW ACCEPTABLE OPTIMAL

117 WHAT ABOUT THE DRUGS? Many patients will not implement or adhere to lifestyle modifications, or they are not enough to reach the goal BP.

118 Commonly Prescribed Oral Anti-Hypertensive Agents Classification Example Diuretics Hydrochlorothiazide Calcium Channel Blockers Amlodipine ACE-inhibitors Ramipril Beta Blockers * Propranolol Angiotensin Receptor Blockers Valsartan Direct Renin Inhibitor Aliskiren

119

120 But, things can change.. For patients < 60, β blockers had similar outcomes compared to other anti-htn drugs For older subjects, major CV events (especially strokes) occurred more often with β blockers than other drugs CMAJ 6 / 06 BMJ 5 / 07

121 Non-black pts: ACE-I, ARB, CCB, or thiazide diuretic Black pts: CCB, or thiazide diuretic Beta-blockers are no longer recommended for initial tx

122

123

124 Efficacy, tolerability, safety and cost are important factors for drug selection

125 Patients aged 80 or older and who had a SBP <130 mm Hg while being treated w / 2 or more BP medications, had an increased risk of mortality compared to those who were receiving no or 1 antihypertensive medication. JAMA Int Med 4 / 2015

126 On avg, about 50% of pts d/c meds by 1 yr

127 52,039 newly diagnosed HTN patients 50% of subjects were nonadherent at 1 yr 39.1% discontinued meds after a single dispensation American J of Hypertension 11 / 11

128

129 IN SUMMARY

130 DR NICKS TOP 7 PICKS FROM RECENT STUDIES FOR PATIENTS 50, AN ELEVATED SBP IS A STONGER CARDIOVASCULAR RISK FACTOR THAN AN ELEVATED DBP BEGINNING AT 115 / 75 mmhg, EACH INCREMENT OF 20 / 10 mmhg DOUBLES THE CARDIOVASCULAR RISK PRE-HYPERTENSION WARRANTS MANAGEMENT WITH LIFESTYLE MODIFICATIONS FOR MOST PATIENTS WITH HTN, THE BP GOAL IS AT LEAST <140 / <90 mm Hg, BUT THE TARGET MAY BE LOWERED TO <130 / 80 mm Hg or LOWER FOR PATIENTS WITH, CVD, DM OR RENAL DISEASE

131 THIAZIDE DIURETICS ARE RECOMMENDED AS INITIAL THERAPY FOR MOST PATIENTS WITH UNCOMPLICATED HTN. MOST HTN PATIENTS WILL REQUIRE 2 OR MORE MEDICATIONS TO ACHIEVE BP GOALS, ESPECIALLY WHEN THE INITIAL BP IS 20 /10 mmhg ABOVE GOAL THE DOCTOR PATIENT RELATIONSHIP AND PATIENT MOTIVATION ARE CRITICAL IN FOSTERING TREATMENT ADHERENCE