Hypertension ABC s and D s. Stephen Workman MD MSC Division of GIM Halifax NS Canada

Transcription

1 Hypertension ABC s and D s Stephen Workman MD MSC Division of GIM Halifax NS Canada

2 Disclosures No industry affiliations in the last ten years No competing interests

3 Objectives Present CV risk management as a good news story Present several cases of a rare but treatable cause of HTN UPDATE on HTN management and diagnosis in Canada 2018 (Hypertension 2020) Putting the Guidelines into Practice Referral wish list Show some favourite water features in Eastern Canada

4 A quiz! Prevalence of HTN 15% 25% 40% (statscan) Lifetime risk of hypertension for a normotensive Canadian aged % 60% 90% (statscan) Treatment of SBP to < 150 has been shown to benefit patients older than (HYVET NEJM) Excellent control of BP, cholesterol NIDDM, obesity and smoking would reduce CV death by 30% 50% 75%

5 CV death is a GOOD NEWS STORY!!

6 CV morbidity and mortality: We are winning

7 Continued improvement yet

8 Cancer-- not decreasing

9 Population at risk for CHF as defined by BNP

10 BP and CHF

11 Why has CV death gone down so much? Control of risk factors BP control!! not if but when Statins for everyone? Smoking--way down Exercise--not so much. Diabetes. No.

12 Meander River Valley Near Windsor NS

13 Fun hypertension cases! It s NEVER lupus. (House) All the lupus patients are diagnosed BEFORE they become a diagnostic dilemma.

14 Quick--consult GIM stat!! 6_ year old woman Day 1 Post emergency colectomy. HR 150. SBP % on 3lpm. Clear CXR. CALL GIM!! It must be CHF!! Two prior admissions for MI. N coronaries X2. On Statin ASA PLAVIX Takotsubo CM on previous ECHO. Colonoscopy with polypectomy. Post procedure bleed. Emergency colectomy. Three year history of extreme and overwhelming fatigue. DX?

15 Google says Takotsubo is found in 3% of patients with PHEO Many case reports and reviews

16 A pregnant young woman with IUGR SBP 220 IUGR 30 at 38 Weeks Three year history of rage attacks (Very hard to accurately determine SBP due to extreme vasoconstriction) 24 hr Urinary catecholamines 10X ULN

17 Stat post op consult 72 year old man post prostate surgery Labile BP and shocky at times HGB 177 prior to surgery.

18 Yikes

19 Wow!

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21 Pheochromocytoma Rare but bad Atypical symptoms the norm 24 hour urine for catecholamines can rule it out Measured levels FAR higher than normal

22 Emmett and Meander River

23 Contrast previous cases with panic for Patient in ED 220/ yoa. Male. BMI 40. Long History of poorly controlled HTN. NIDDM. (BS 13) Stopped meds/ran out two months ago. Visited Walk In clinic and sent in to the ED No symptoms. Exam N. ECG possible LVH. Cr 122. U/A normal. What Next?

24 Hypertensive Urgency does not exist High BP (180 Systolic or 110 Diastolic) in a well patient. No end organ damage. Trip to ED increases admission and reduces BP control at six months and has no effect on the already very low rates of MACE 1: Patel KK, Young L, Howell EH, Hu B, Rutecki G, Thomas G, Rothberg MB. Characteristics and Outcomes of Patients Presenting With Hypertensive Urgency in the Office Setting. JAMA Intern Med Jul 1;176(7)

25 Assessment: High BP An emergency or not? Yikes! HTN >180/110 and NO target organ damage is an indication for immediate treatment NOT an indication for ED trip/admission Brain/eyes Heart Aorta Kidneys all can be damaged Hypertension with evidence of injury: CHF Angina Dissection ARF Papilledema Increase ICP CVA(?) All above require EMERGENT treatment

26 HTN Canada: What is new in Use chlorthalidone or indapamide NOT HCTZ (Longer half life better control reduced death) 2. Use combination medications as initial treatment (27% improvement(1)) Either ACE / ARB AND Diuretic or ACE / ARB AND CCB 3. Consider target SBP less than 120 based upon SPRINT evidence* 4. ABP or HBP no OABP (1) Fixed dose combinations for HTN Lancet Sept 2018

27 #4 ABP! OBP should NOT Be used!

28 #3 Sprint and shared decisions 1: SPRINT Research Group, Randomized Trial of Intensive versus Standard Blood- Pressure Control. N Engl J Med. 2015

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30 A is for Assessment and attitude The disease is hypertension and the treatment is drugs I don t want to have a stroke or heart attack! The disease is drugs and the treatment is hypertension I don t like to take pills you know! Many people in the world do not have access to even the most basic medications 15% of people worldwide have HTN controlled

31 Lifestyle--I had no idea Whelton PK, Carey RM, Aronow WS, et al 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. J Am Coll Cardiol

32 I will lose weight exercise AND eat less salt!! GREAT--we can get you off the pills later

33 Meander River Falls

34 B--the basics Diagnosis BP true--q 4-5 min for five or six readings --runs the risk of missing masked hypertension ABP--The gold standard and always worthwhile when there is any doubt about the diagnosis or patient acceptance (GIM can arrange ABP s) Do a framingham risk score online FRS for all patients!

35 Ambulatory BP mmhg Derived from Pickering TG, et al. Hypertension 2002:40: White Coat and Masked Hypertension 200 Derived from Pickering TG, et al. Hypertension 2002:40: MASKED HYPERTENSION TRUE HYPERTENSION NORMOTENSION WHITE COAT HYPERTENSION Manual Office BP mmhg

36 CV events per 1000 patient-year Okhubo T, et al. J Am Coll Cardiol 2005;46; The Prognosis of White Coat and Masked Hypertension CV Events Normal White coat Uncontrolled Masked

37 Exogenous Causes! Nonsteroidal anti-inflammatory drugs (NSAIDs), including cyclo-oxygenase-2 inhibitors (coxibs) Corticosteroids and anabolic steroids Oral contraceptive and sex hormones Vasoconstricting/sympathomimetic decongestants Calcineurin inhibitors (cyclosporin, tacrolimus) Erythropoietin and analogues Antidepressants: Monoamine oxidase inhibitors (MAOIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), selective serotonin reuptake inhibitors (SSRIs)

38 Etcetera! Licorice root Stimulants including cocaine Salt Excessive alcohol intake

39 Pennant River Near Sambro NS

40 Odds and ends Screen for sleep apnea with home sleep study via questionnaire or more thoroughly with a home sleep study Renal artery stenosis in older patients due to atherosclerosis is NOT an indication for angioplasty

41 Specific considerations for medications CHF/diastolic dysfunction/high LV filling pressures/peripheral edema/increased BNP: Chlorthalidone or indapamide reduce risk of overt CHF esp in elderly Angina Beta blocker or Diltiazem Increased creatinine: ACE or ARB increase dialysis free survival despite risk of decrease in GFR

42 Millrace, Kingston Ontario

43 I m on three drugs ARB CCB DIURETIC what next? Consider referral to Internal Medicine Spironolactone in low dose 12.5mg increase to 25mg if needed Follow lab, volume status Advise stopping meds if nausea and vomiting and risk of acute kidney injury

44 Hyperaldosteronism (CMAJ June ) Uncontrolled HTN (3 agents) Low Potassium at diagnosis with with diuretics Known Adrenal Mass and HTN Associated with significantly worse CV endpoints MACE 4-12X higher and death 2X age and BP matched controls Work up with Renin Aldo Ratio (Aldo suppresses renin) Test Renin Aldo Ratio with Potassium >4 and no Aldosterone blockade Workup patients for whom adrenalectomy would be considered Refer!

45 Referral wish list ABP for diagnosis or to convince a patient of diagnosis Resistant HTN--three drugs and not at target Low Potassium either at presentation or with addition of Diuretic and patient would consider adrenal surgery Compliance poor or suspect (40% of patients non compliant at some point!) High Framingham Risk score and resistant patient Concern about secondary HTN

46 Summary ABP or HBP Treat risk not just BP FRS for patients Hike Dual agents as initial treatment and DO NOT use HCTZ as diuretic choice Consider Adrenal surgery as option in select patients I tell my patients that my goal is to reduce their CV risk as much as possible and that 90% of CV risk can be avoided

47 The Keyhole Fundy National Park