Management of Hypertension Ahmed El Hawary MD Suez Canal University
Minimal vs. Optimal Care Resources more than science affect type of care and level of management. what is possible (minimal care) and what is ideal (optimal care): Evaluation (relying more on detailed history and physical examination) Initiation and type of therapy (stressing dietary therapy, life style, use of less expensive drugs, and initiate therapy at higher thresholds of BP).
Minimal vs. Optimal Care Duration of BP monitoring before drug therapy Life style and diet therapy Threshold of BP in low risk Threshold of BP in intermediate risk Threshold of BP in high risk Drug of first choice Minimal Care Weeks to months +++ 160/100 150/90 140/85 Small dose thiazide Optimal Care Weeks to months ++ 160/100 140/90 135/85 Individualize
Key Messages - JNC VII For persons over age 50, SBP is a more important than DBP as CVD risk factor. Starting at 115/75 mmhg, CVD risk doubles with each increment of 20/10 mmhg throughout the BP range. Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN. Those with SBP 120 139 mmhg or DBP 80 89 mmhg should be considered prehypertensive who require lifestyle modifications to prevent CVD.
Key Messages - JNC VII Thiazide-type diuretics should be initial drug therapy for most, either alone or combined with other classes. Certain high-risk conditions are compelling indications for other drug classes. Most patients will require two or more drugs to achieve goal BP. If BP is >20/10 mmhg above goal, initiate therapy with two agents, one usually should be a thiazide type.
Goals of Therapy Reduce CVD and renal morbidity and mortality. Treat to BP <140/90 mmhg or BP <130/80 mmhg in patients with diabetes or chronic kidney disease. Achieve SBP goal especially in persons >50 years.
CVD Risk Factors 1. HTN 2. Cigarette smoking 3. Obesity* (BMI >30 kg/m 2 ) 4. Physical inactivity 5. Dyslipidemia 6. Diabetes mellitus 7. Microalbuminuria or estimated GFR <60 ml/min 8. Age (older than 55 for men, 65 for women) 9. Family history of premature CVD.
TOD or Associated CVD Heart: LVH. CHD; Angina, MI, CABG, PCI. HF. Brain: Stroke, TIA or dementia. Chronic kidney disease. Peripheral arterial disease. Aortic aneurysm. Retinopathy.
Group A (low risk): Risk Profile No other risk factors. No TOD or associated CVD. Group B (intermediate risk) One or more other risk factors (not diabetes). No TOD or associated CVD. Group C (high risk) Diabetes. TOD and / or associated CVD.
Lifestyle Modification Modification Weight reduction Adopt DASH eating plan Approximate SBP reduction (range) 5 20 mmhg/10 kg weight loss 8 14 mmhg Dietary sodium reduction Physical activity Moderation of alcohol consumption 2 8 mmhg 4 9 mmhg 2 4 mmhg
Algorithm for Treatment of HTN Lifestyle Modifications Not at Goal BP (<140/90 mmhg) (<130/80 mmhg for those with diabetes or chronic kidney disease) Initial Drug Choices No Compelling Indications Compelling Indications Stage 1 Thiazide for most. May consider ACEI, ARB, BB, CCB, or combination. Stage 2 Two-drug for most Thiazide-type and ACEI, or ARB, or BB, or CCB Not at Goal BP Drugs for the indications and antihypertensive drugs as needed. Optimize dosages or add additional drugs until goal. Consider consultation with specialist.
Classification and Management of BP for Adults Initial drug therapy BP SBP mmhg DBP mmhg Lifestyle modification Without compelling indication With compelling indications Normal <120 and <80 Encourage Pre HTN 120 139 or 80 89 Yes No antihypertensive drug indicated. Drug(s) for compelling indications. Stage 1 140 159 or 90 99 Yes Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Drug(s) for the compelling indications. Stage 2 >160 or >100 Yes Two-drug combination for most (usually thiazide-type diuretic and ACEI or ARB or BB or CCB). Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed.
Follow-up Based on Initial Measurements Initial Blood Pressure SBP DBP Followup Recommended < 130 < 85 Recheck in 2 years 130-139 85-89 Recheck in 1 year, give lifestyle advice 140-159 90-99 Confirm within 2 months, give lifestyle advice 160-179 100-109 Evaluate/refer to care within 1 month 180 110 Evaluate/refer to care within 7 days
Follow-up and Monitoring Patients should return for follow-up and adjustment of medications until the BP goal is reached. More frequent visits for stage 2 HTN or with co morbid conditions. Serum potassium and creatinine 1 2 times per year. After BP at goal and stable, follow-up at 3- to 6-month. Co morbidities, such as HF, diabetes, and CAD influence the frequency of visits.
Special Considerations Compelling Indications. Other Special Situations: Minority populations. LVH. PAD. HTN in older persons. Postural hypotension. HTN in women. HTN in children and adolescents. HTN urgencies and emergencies.
Compelling Indications for Individual Drug Classes Compelling Indication Initial Therapy Options Clinical Trial Basis Heart failure THIAZ, BB, ACEI, ARB, ALDO ANT ACC/AHA Heart Failure Guideline, MERIT-HF, COPERNICUS, CIBIS, SOLVD, AIRE, TRACE, ValHEFT, RALES Post myocardial infarction BB, ACEI, ALDO ANT ACC/AHA Post-MI Guideline, BHAT, SAVE, Capricorn, EPHESUS High CAD risk THIAZ, BB, ACE, CCB ALLHAT, HOPE, ANBP2, LIFE, CONVINCE
Compelling Indications for Individual Drug Classes Compelling Indication Diabetes Chronic kidney disease Recurrent stroke prevention Initial Therapy Options THIAZ, BB, ACE, ARB, CCB ACEI, ARB THIAZ, ACEI Clinical Trial Basis NKF-ADA Guideline, UKPDS, ALLHAT NKF Guideline, Captopril Trial, RENAAL, IDNT, REIN, AASK PROGRESS
Specific Drug Indications Some antihypertensive drugs may have favorable effects on co morbid conditions: Angina B-blockers CCB Myocardial infarction B-blockers ACE-I Atrial tachy and AF B-blockers NDH-CCB Heart failure Hyperthyroidism Carvedilol B-blockers Valsartan Migraine Nonelective B-blockers NDH-CCB Preoperative HTN B-blockers Osteoporosis Thiazides
Specific Drug Indications Cyclosporine-induced HTN CCB Essential tremor Nonselective B-blockers Dyslipidemia Alpha-blockers Prostatism Alpha-blockers DM (1and 2) with proteinuria ACE-I (preferred) CCB Renal insufficiency ACE-I DM (type 2) Low-dose diuretics
Combination Therapies Beta-blockers and diuretics. ACE-I and diuretics. ARBs and diuretics. CCB and diuretics. CCB and ACE-I. Other combinations.
LVH LVH is an independent risk for CVD. Regression of LVH occurs with aggressive BP management with; Weight loss. Sodium restriction. Treatment with all classes of drugs except the direct vasodilators hydralazine and minoxidil.
Peripheral Arterial Disease (PAD) PAD is equivalent in risk to ischemic heart disease. Any class of drugs can be used in most PAD patients. Other risk factors should be managed aggressively. Aspirin should be used.
HTN in Older Persons More than two-thirds of people over 65 have HTN. This population has the lowest rates of BP control. Isolated systolic HTN, should follow same principles for general care of HTN. Lower initial drug doses may be indicated to avoid symptoms; standard doses and multiple drugs are needed to reach BP targets.
Postural Hypotension Decrease in standing SBP >10 mmhg, associated with dizziness / fainting. More frequent in older patients with diabetes, taking diuretics, vasodilators, and some psychotropic drugs. BP in these individuals should be monitored in the upright position. Avoid volume depletion and excessively rapid dose titration of drugs.
HTN in Women Oral contraceptives may increase BP, and BP should be checked regularly. In contrast, HRT does not raise BP. Development of HTN - consider other forms of contraception. Pregnant women with HTN should be followed carefully. Methyldopa, BBs, and vasodilators are preferred for the safety of the fetus. ACEI and ARBs contraindicated in pregnant, or those likely to become pregnant.
Children and Adolescents HTN defined as BP 95 th percentile or greater, adjusted for age, height, and gender. Use lifestyle interventions first, then drug therapy for higher levels of BP or if insufficient response to lifestyle modifications. Drug choices similar in children and adults, but effective doses are often smaller. Uncomplicated HTN not a reason to restrict physical activity.
Hypertensive Urgencies and Emergencies Patients with marked BP elevations and acute TOD (e.g., encephalopathy, AMI, UA, pulmonary edema, eclampsia, stroke, head trauma, life-threatening arterial bleeding, or aortic dissection) require hospitalization and parenteral drug therapy. Patients with markedly elevated BP but without acute TOD usually do not require hospitalization, but should receive immediate combination oral therapy.
Drugs for Hypertensive Emergencies Vasodilators Nitroprusside Nicardipine Fenoldopam Nitroglycerin Adrenergic Inhibitors Labetalol Esmolol Phentolamine Enalaprilat Hydralazine
Considerations in Drug Choices Use thiazides cautiously in gout or hypo natremia. ACE-I should not be used in individuals with a history of angioedema. Aldosterone antagonists and potassium-sparing diuretics can cause hyperkalemia.
Improving Adherence to Therapy Be aware of signs of non-adherence. Establish goal of therapy. Encourage a positive attitude about achieving goals. Educate patients about the disease and therapy. Maintain contact with patients. Encourage lifestyle modifications. Keep care inexpensive and simple.
Improving Adherence to Therapy Clinician empathy increases patient trust, motivation, and adherence to therapy. Integrate therapy into daily routine. Prescribe long-acting drugs. Adjust therapy to minimize adverse affects. Continue to add drugs systematically to meet goal. Consider using nurse case management. Utilize other health professionals. Try a new approach if current regime is inadequate.
Causes of Resistant HTN Improper BP measurement. Excess sodium intake. Inadequate diuretic therapy. Medication: Inadequate doses. Drug actions and interactions (e.g., NSAIDs, sympathomimetics, oral contraceptives). Over-the-counter (OTC) drugs and herbal supplements. Excess alcohol intake. Identifiable causes of HTN.