Joshua M. Crasner,DO,FACC,FACOI

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1 Joshua M. Crasner,DO,FACC,FACOI

2 50 million people USA SBP>115 incr risk CAD/CVA Q 20mm incr=2x risk JNC-8 almost changed aggressive Tx Pseudo-HTN Hypertension

3 Most common HBP( > 90 %)--multifactorial increased peripheral resistance perpetuates the process of high blood pressure and all of its secondary effects structural hypertrophy giving rise to smooth muscle hypercontractility pressure varies throughout the day major risk factor for coronary, renal, and cerebrovascular disease (50% of all USA deaths) leading cause of doctor s visit carries prognostic value: 16X increased risk 40 y.o. smokes Hypertension

4 Patient seated/back supported/feet on floor Should rest 5 minutes prior Arm at heart level No recent caffeine, tobacco, cocaine Take medications as directed Cuff size important orthostatics Hypertension

5 Determine lifestyle/cv risk factors ID and Tx secondary causes ID target end organ damage brain, heart, kidney, eyes, arteries Hypertension

6 CNS: headache,confusion,visual,weakness,di sorientation, seizures Renal: nocturia,hematuria,oliguria,edema Opthal: blurred,diplopia,papilledema CV:chest pain, palp s,dyspnea,murmur,bruits,rhythm Hypertension

7 Cigarette smoking Obesity Inactivity Dyslipidemia Diabetes mellitus Microalbuminuria Male>55; Female>65 Fam Hx: male<55; female<65 Metabolic syndrome Hypertension

8 Endocrine Cardiac Renal Hypertension

9 Pheochromocytoma Primary Aldosteronism Cushing s disease Hypertension

10 5 P s: pressure,pain,palps,perspiration,pallor Adrenal tumor or sympth ganglia 2-8 cases/million/year 0.5% in hypertensive patients Usually sustained HBP,sometimes paroxysmal Associated with MEN-2 a/b Plasma metanephrines most sensitive CT after plasma, then surgery Hypertension

11 Adrenal oversecretion Hypertension,hypokalemia,alkalosis,hyperglycemia 2-15% incidence Screen w/aldo-renin ratio Unusual hypokalemia,adrenal mass, early HTN, primary relative w/same Tx w/spironolactone,eplerenone,surgery Hypertension

12 Hyperglycemia, hypokalemia,htn 24hr cortisol Obese, moon facies, purple striae Hypertension

13 Coarctation Obstructive sleep apnea Pregnancy Post-op Aging Increased cardiac output Hypertension

14 Constriction beyond subclavian Weak,delayed,absent FA pulse Rib notching on CXR Childhood Tx surgical Hypertension

15 Obese, retrognathia,large neck Loud snoring Daytime hypersomnolence, morning headache Polysomnography test Hypertension

16 Renal parenchymal disease Renovascular HTN Renal artery stenosis Fibromuscular dysplasia Hypertension

17 Common cause secondary HTN Rapid loss renal fxn if HTN-ive Creat,urine analysis,protein Decr elimination of salt and water,incr renin, decr vasodilation all lead to incr volume/fluid retention Dihydropyridine CCB help decr proteinuria Hypertension

18 Atherosclerotic, e.g.cad Smokers>50, new HTN Systolic/diastolic high pitched abd bruit Suspect B/L if decr renal fxn w/ use of ACEi/ARB PTA but higher restenosis Rx White female<30 No family Hx HTN PTA treatment of choice Hypertension

19 Abdominal bruit: renal artery stenosis Palps,HA,pallor,perspiration: pheochromocytoma Obesity,moon face,purple striae: Cushing s Abd mass: polycystic kidney,hydroneph Obesity,hypersomnolence: OSAS Agitation, sweating: cocaine, ethanol,narc w/d Hypokalemia: hyperaldosteronism Hypercalcemia: hyperparathyroidism Hypertension

20 Simple Guide to work up secondary causes of HTN Hypertension

21 Alpha methyldopa first DOC Hydralazine,some BB ok, diuretics Avoid ACEi/ARB/renin inhibitors Hypertension

22 BCPs EtOH Decongestants,diet pills NSAIDs MAO Cocaine Marijuana Licorice cyclosporine Hypertension

23 CATEGORY SYSTOLIC BP DIASTOLIC BP normal < 120 and < 80 Pre-HTN or Hypertension Stage or Stage 2 ** 160 or 100 JAMA 289; : 2003 **Add 2 nd Rx Hypertension

24 Hypertension

25 Hypertension

26 1. In the general population aged 60 years, initiate pharmacologic treatment to lower blood pressure (BP) at systolic blood pressure (SBP) 150 mm Hg or diastolic blood pressure (DBP) 90 mm Hg and treat to a goal SBP <150 mm Hg and goal DBP <90 mm Hg. (Strong Recommendation Grade A) In the general population aged 60 years, if pharmacologic treatment for high BP results in lower achieved SBP (e.g., <140 mm Hg) and treatment is well tolerated and without adverse effects on health or quality of life, treatment does not need to be adjusted. (Expert Opinion Grade E) 2. In the general population <60 years, initiate pharmacologic treatment to lower BP at DBP 90 mm Hg and treat to a goal DBP <90 mm Hg. (For ages years, Strong Recommendation Grade A; for ages years, Expert Opinion Grade E) 3. In the general population <60 years, initiate pharmacologic treatment to lower BP at SBP 140 mm Hg and treat to a goal SBP <140 mm Hg. (Expert Opinion Grade E) 4. In the population aged 18 years with chronic kidney disease (CKD), initiate pharmacologic treatment to lower BP at SBP 140 mm Hg or DBP 90 mm Hg and treat to goal SBP <140 mm Hg and goal DBP <90 mm Hg. (Expert Opinion Grade E) 5. In the population aged 18 years with diabetes, initiate pharmacological treatment to lower BP at SBP 140 mm Hg or DBP 90 mm Hg and treat to a goal SBP <140 mm Hg and goal DBP <90 mm Hg. (Expert Opinion Grade E) 6. In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin-receptor blocker (ARB). (Moderate Recommendation Grade B) 7. In the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or CCB. (For general black population: Moderate Recommendation Grade B; for black patients with diabetes: Weak Recommendation Grade C) 8. In the population aged 18 years with CKD, initial (or add-on) antihypertensive treatment should include an ACEI or ARB to improve kidney outcomes. This applies to all CKD patients with hypertension regardless of race or diabetes status. (Moderate Recommendation Grade B) 9. The main objective of hypertension treatment is to attain and maintain goal BP. If goal BP is not reached within a month of treatment, increase the dose of the initial drug or add a second drug from one of the classes in recommendation 6 (thiazide-type diuretic, CCB, ACEI, or ARB). The clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached. If goal BP cannot be reached with two drugs, add and titrate a third drug from the list provided. Do not use an ACEI and an ARB together in the same patient. If goal BP cannot be reached using only the drugs in recommendation 6 because of a contraindication or the need to use more than three drugs to reach goal BP, antihypertensive drugs from other classes can be used. Referral to a hypertension specialist may be indicated for patients in whom goal BP cannot be attained using the above strategy or for the management of complicated patients for whom additional clinical consultation is needed. (Expert Opinion Grade E) 10. Although this guideline provides evidence-based recommendations for the management of high BP and should meet the clinical needs of most patients, these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient. Future guidelines should cover the full range of cardiovascular care topics, to develop an integrated approach for prevention, detection, and evaluation, along with treatment goals. Individual recommendations from discrete guidelines such as for hypertension, cholesterol, and obesity may not reflect the integrated care needed for many patients seen in practice. There is also a need to harmonize the hypertension guideline with other cardiovascular risk guidelines and recommendations, thereby resulting in a more coherent overall cardiovascular prevention strategy. Author(s): Debabrata Mukherjee, M.D., F.A.C.C. (Disclosure Hypertension

27 Patient Subgroup Target SBP Target DBP > 60 years <150 <90 <60 years <140 <90 >18 years w CKD <140 <90 >18 years w DM <140 <90 James PA, et al.,jama,2013 Dec18 Hypertension

28 General non-african population Thiazides, CCB,ACEi,or ARB initially General African population CKD Thiazides or CCB initially Include ACEi or ARB Uptitrate/add RX after 1mo.if not at goal Don t use ACEi and ARB jointly If >3 Rx needed refer to specialist James PA, et al.,jama, 2013 Dec 18 Hypertension

29 ANSWER?? FOLLOW THE AHA/ACC BP guidelines Start lifestyle changes and then Rx at 140/90 up to age 80, then at 150/90 Position paper of JACC July 2014 refutes, citing placement of mostly elderly African-American women at incr. risk for CVD mortality** Stage 2(>160/100 or >20 goal, add 2 nd Rx **Krakoff, et al; JACC, July 29,2014; Hypertension

30 JACC 65, No.18, May 12, 2015, Treatment of HTN in Patients with CAD Renal denervation equivocal JNC-7 supported Target BP in HF pts <140/90, consider <130/90 Hypertension

31 Ischemic systolic HF avoid CCB s s/a diltiazem/verap..dihydropyridine CCB s ok (amlodipine/felodipine)..praise and V- HEFT trials Avoid clonidine Avoid doxazosin (ALLHAT trial) Hypertension

32 Hypertension

33 Urine analysis Chemistry panel Cholesterol CBC Endocrine Drug screen Hypertension

34 Heart failure: ACEi, ARB, diuretics, BB Diabetes: ACEi, ARB CAD/post-MI: BB, ACEi,(CCB for intol.) Systolic HTN: ACEi/ARB with diuretic, BB, CCB Pregnancy: labetalol, methyldopa, CCB Prostate enlargement: alpha blocker Renal disease: ACEi or ARB Hypertension

35 Lima, et al., JACC 2015; 65: CARDIA study Conclusion: longterm exposure over 25 yrs leads to systolic/diastolic dysfxn middle age. Aggressive diastolic BP control rec d Hypertension

36 <140/90 Diabetics/CKD/High risk CAD <130/80 Reduced EF; proteinuria <120/80 Hypertension

37 Familiarity with target end-organ damage What is ideal BP? Causes of secondary hypertension Ideal agents for condition(s) Familiarity with treatment options Hypertension

JNC Evidence-Based Guidelines for the Management of High Blood Pressure in Adults

JNC Evidence-Based Guidelines for the Management of High Blood Pressure in Adults JNC 8 2014 Evidence-Based Guidelines for the Management of High Blood Pressure in Adults Table of Contents Why Do We Treat Hypertension? Blood Pressure Treatment Goals Initial Therapy Strength of Recommendation