Hypertension Update Beverly J. Mathis, D.O. OOA May 2015 Objectives Learn new recommendations for BP treatment goals Approach to hypertension in the office Use of hypertensive drugs, and how to tailor their use to your patient. Hypertension most common office visit in US, (nonpregnant) Up to 30% of adults have hypertension 1
Historical perspective First Joint National Commission report was in 1974 giving education and guidelines on hypertension. 10 years later, the incidence of stroke went down 50% and cardiovascular disease went down 25%. JNC 8 Released in JAMA 2014 Evidence based approach based on randomized control trials Strict so 75% of literature from 1966-2009 was not included 2
Graded A: Strong substantial benefit B: Moderate recommendation C: Weak D: Against recommendation E: Expert opinion Recommendations 1-3 1) Age over 60 with a BP >150/90 Grade A If BP lower than 150/90 and tolerated by do not need additional adjustment. Grade E 2) Age 35-59 BP goal of 90 Diastolic Grade A BP goal of 140 systolic Grade E 3) Age 18-29 BP goal of <140/90 Grade E Recommendation 4 4) CKD >18 to keep BP 140/90 Grade E (CKD defined as GFR <60, Albuminuria >30mg) Exception: Pts with >3g of proteinuria BP of 130/80 (kidney outcome only) No recommendation for age >70. No data. 3
Recommendation 5 5) Diabetes for age >19 BP of 140/90 Grade E ADA recommended this first. Recommendation 6 6) Non black population including diabetics. Grade B Initial therapy with thiazide type diuretic, then calcium channel blocker, and then ACEi or ARB Recommendation 7 7) Black populations Initial treatment with thiazide diuretic or CCB. Grade B Black patients with Diabetes ACE or ARB Grade C 4
Recommendation 8 8) Patient >18 with CKD Initial or additional treatment should be with an ACEi or ARB Grade B Includes diabetics and non-diabetics Direct renin inhibitors not include. NO beneficial studies for kidney or CV outcome. Recommendation 9 9) If BP goal not reached in 1 month: Increase dose of initial drug or add second drug. Grade E Uncontrolled on 2 or more drugs and a referral may be indicated. Grade E 5
Evaluation of patient with hypertension Good history and physical CMP Urinalysis, presence of protein is very important Lipid profile EKG or echo can be helpful Risk factors for hypertension Age Obesity Family history Race CKD, DM, hyperlipidemia High sodium intake, alcohol intake Physical activity 6
Contributing causes of hypertension Glucocorticosteroids, oral contraceptive drugs, especially higher estrogen NSAIDS!!!!!! And decongestants Antidepressants with Norepinephrine, ie, effexor Weight loss meds Stimulants,ie, ritalin Contributing causes of hypertension II Cocaine and meth Primary aldosteronism Renovascular hypertension Obstructive sleep apnea Pheochromocytoma, Cushing, Hypo and hyperthyroidism Primary hyperparathyroidism 7
Does it matter what drug you use? There is no uniform agreement as to which antihypertensive drugs should be given as initial treatment. The American Heart Assoc and the 2013 European society of Hypertension and Cardiology all concluded that the amount of BP reduction is the major determinant of the reduction of cardiovascular risk, not the drug. (Unless they have another reason to take a certain drug) Thiazides 1)Chlorthalidone (12.5-25mg/day) More effective at lowering BP, longer lasting and more 1.5x more potent. More Potassium losses. Hydrocholorothiazide On more formularies and in combinations. Both decrease urinary calcium excretion and are advantageous in osteoporosis. Disadvantages to Thiazides Hypokalemia, hypomagnesemia and hyperuricemia Dehydration Orthostasis Aggravation of gout. 8
Calcium Channel Blockers Dihydropyridines (Amlodipine, Nifedipine) Vasodilating. Helpful in heart failure and patients with orthostasis from autonomic neuropathy. Non dihydrophyridines (Diltiazem, Verapamil) Lowers heart rate. Useful in patients with reactive airway disease and co-existing tachyarrhythmias Disadvantages of a CCB Dihydropyridines- due to vasodilator effects can cause edema. Non dihydropyridines- Can cause bradycardia and constipation. ACE Inhibitors Good for about everyone except Pregnant women Women of child bearing age who might become pregnant Patients who tend to be hyperkalemic Less effective in blacks but use in DM and CHF Low side effect profile: cough, angioedema 9
Uses of ACE inihibitors Hypertension Heart failure Reducing proteinuria in CKD Reducing hyperfiltration in DM Angiotensin Receptor Blockers Much the same effect but not as many studies Angioedema but not cough can cross over Losartan increases uric acid excretion so useful in pts with gout. Beta Blockers Not recommended for first line therapy Indicated in tachycardias, angina, post MI and CHF Useful in migraine Carvedilol and metoprolol most studied in heart disease, atenolol in hypertension 10
Disadvantages of beta blockers Bradycardia Depression Glucose intolerance Bronchoconstriction Should not be used in patients on cocaine Alpha blockers i.e.doxasosin Not indicated as initial therapy unless patient has urinary outlet or prostate problems. Should not be given with Viagra, etc. Slight increase in CV risk if given alone Central alpha agonists Only useful in the acute setting and prn Side effects of dry mouth and sedation limit is use chronically i.e. pt would benefit from sedation. Alpha methyl dopa still most studied drug in pregnancy 11
Vasodilators Hydralazine should always be given with beta blocker to prevent tachycardia Shown to improve mortality in Class II CHFand more efficacious in blacks when mixed with nitrates. Has to be given tid or qid in hypertension Minoxidil, strongest BP med, causes hirsuitism and fluid retention. Should reserve for patients on high doses of at least 3 drugs 12