Improving outcomes in the treatment of hypertension disorders
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Improving Outcomes in the Treatment of Hypertension Disorders. Mohamed Siddique, M.D. FACP Program Director/Chief of Medicine Sinai-Grace Hospitals Detroit Medical Center/Wayne State University. Objectives. Review epidemiology of hypertension in the United States

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Improving outcomes in the treatment of hypertension disorders

Improving Outcomes in the Treatment of Hypertension Disorders

Mohamed Siddique, M.D. FACP

Program Director/Chief of Medicine

Sinai-Grace Hospitals

Detroit Medical Center/Wayne State University


Objectives

Objectives

  • Review epidemiology of hypertension in the United States

  • Discuss new classification of Blood pressure

  • Evaluation of hypertensive patients

  • Discuss latest guidelines and clinical trials in hypertension

  • Special population and ethnic considerations

  • Identify barriers to success


References

References

  • National High Blood Pressure Education Program Coordinating Committee (NHBPEP CC)

    • Represents 46 professional, voluntary, and Federal organizations.

  • Joint National Committee (JNC 7 Vs 6) – Reasons:

    • Many new hypertension observational studies and clinical trials

    • New, useful, clear, and concise guideline for clinicians

    • Simplify classification of hypertension

    • Lack of awareness of JNC reports and its use by clinicians


National high blood pressure education program coordinating committee

National High Blood Pressure Education Program Coordinating Committee

American Academy of Family Physicians

American Academy of Neurology

American Academy of Ophthalmology

American Academy of Physician Assistants

American Association of Occupational Health Nurses

American College of Cardiology

American College of Chest Physicians

American College of Occupational and Environmental Medicine

American College of Physician

American Society of Internal Medicine

American College of Preventive Medicine

American Dental Association

American Diabetes Association

American Dietetic Association

American Heart Association

American Hospital Association

American Medical Association

American Nurses Association

American Optometric Association

American Osteopathic Association

American Pharmaceutical Association

American Podiatric Medical Association

American Public Health Association

American Red Cross

American Society of Health-System Pharmacists

American Society of Hypertension

American Society of Nephrology

Association of Black Cardiologists

Citizens for Public Action on High Blood Pressure and Cholesterol, Inc.

Hypertension Education Foundation, Inc.

International Society on Hypertension in Blacks

National Black Nurses Association, Inc.

National Hypertension Association, Inc.

National Kidney Foundation, Inc.

National Medical Association

National Optometric Association

National Stroke Association

NHLBI Ad Hoc Committee on Minority Populations

Society for Nutrition Education

The Society of Geriatric Cardiology

Federal Agencies:

Agency for Healthcare Research and Quality

Centers for Medicare & Medicaid Services

Department of Veterans Affairs

Health Resources and Services Administration

National Center for Health Statistics

National Heart, Lung, and Blood Institute

National Institute of Diabetes and Digestive and Kidney Diseases


References jnc 7

References - JNC 7

M Meta-analysis (Results from clinical trials)

RARandomized controlled trials (Experimental)

RERetrospective analyses (Case controlled)

FProspective studies (Cohort studies, including historical or prospective follow up)

XCross-sectional survey (Prevalence)

PRPrevious review or position statements

CClinical interventions (Nonrandomized)


Epidemiology

EPIDEMIOLOGY


Epidemiology1

EPIDEMIOLOGY

  • 70 million Americans have elevated blood pressure (Increase from 50m, 1988-94)

  • Due to obesity and aging population

  • 35m women, 30m men

  • 48m Non-Hispanics, 9m Non-Hispanic black, 3m Mexicans, 5m others

  • 1 Billion worldwide

  • 7.1 million deaths per year attributable to hypertension


Epidemiology cont

Epidemiology-cont.

  • Normal BP at age 55 – 90% chance of developing HTN in one’s lifetime

  • Systolic hypertension increases with age

  • Diastolic hypertension predominates before age 50

  • SBP greater than 140 mmHg is more important CVD risk factor than DBP, in patients over age 50 (Isolated systolic hypertension)

  • Risk of CVD begins at 115/75 mmHg. It doubles with each increment of 20/10 mmHg


Epidemiology cont1

Epidemiology-cont.

  • NIDDM (DM Type 2) occurs twice as frequently in hypertensive patients compared with matched normotensive patients

  • It is more prevalent and devastating in lower socioeconomic group

  • Young black males are most adversely affected by HTN

    • One-third higher prevalence

    • Higher incidence of stroke

    • higher incidence of renal failure(4-17 times)

    • Higher incidence of heart diseases


Epidemiology cont2

Epidemiology-cont.

  • Hypertension is more clearly associated with Android than Gynecoid obesity

  • Risk of Atherosclerosis increased by 8-fold in smokers, and by 25-fold in smokers with hypertension

  • Excess weight is associated with increase in BP

  • Weight reduction is associated with decrease in BP independent of salt intake


Epidemiology cont3

Epidemiology - cont.

‘76-’80‘88-’91‘91-94‘99-2000

Aware: % of. Pt. told by physician 51 73 68 70

Treated: % of Pt. taking medication 31 55 54 60

Controlled: % of Pt. with BP control 10 29 27 34

(SBP <140 mmHg and DBP < 90 mmHg)


Epidemiology cont4

Epidemiology - cont.

% Decline in Mortality1970198019902000

Coronary Heart Disease 0 30 40 50

Stroke 0 30 50 60

Non-cardiovascular 0 10 10 8

(RF, CVA, PVD)


Classification of blood pressure in adults age 18 years

Classification of Blood Pressure in Adults Age 18 years

CategorySystolicDiast.

Normal<120and<80

Pre-Hypertension120-139 or 80-89

Stage 1 Hypertension 140-159 or 90-99

Stage 2 Hypertension>160 or >100


Detection and confirmation

Detection and Confirmation

  • Measure blood pressure at each patient visit

  • Initial elevated readings should be confirmed on at least two subsequent visits one to several weeks apart

  • Patient should be seated with their arm bared, supported at heart level

  • Patient should not have smoked or ingested caffeine within 30 minutes before measurement

  • Measure BP after 5 minutes of rest


Detection and confirmation cont

Detection and Confirmation-cont.

  • Two or more readings separated by 2 minutes should be averaged

  • Use appropriate size cuff

  • Disappearance of sound phase 5 should be used for the diastolic reading

  • DBP of >120 mm Hg or SBP of >210 mm Hg are associated with evidence of Target Organ Damage(TOD)

  • Damage to target organs (Heart, Brain, and Large Arteries) correlates better with out-of-office measurements than with office measurements


False elevation of blood pressure

False Elevation of Blood Pressure

  • Inappropriately small cuff

  • Arm below level of heart

  • Muscular effort to hold up arm

  • Recent exertion

  • Environmental stimuli


False low blood pressure

False Low Blood Pressure

  • Arm above level of heart

  • Tight clothing around arm

  • Cuff deflation too rapid

  • Cuff too large

  • Extreme stethoscope pressure over brachial artery


Primary hypertension

Primary Hypertension

  • Heredity

  • Sodium

  • Other salts - Calcium, Chloride, Magnesium

  • Hyper-insulinemia (Metabolic Syndrome)

    • Volume retention

    • Vascular hypertrophy

    • Sympathetic over activity


Secondary hypertension

Secondary Hypertension

  • Sleep apnea

  • Drug-induced or related causes

  • Chronic kidney disease

  • Primary aldosteronism

  • Reno vascular disease

  • Chronic steroid therapy and Cushing’s syndrome

  • Pheochromocytoma

  • Coarctation of the aorta

  • Thyroid or parathyroid disease


Secondary hypertension cont

Secondary Hypertension-cont.

When to suspect secondary hypertension

  • Onset <30 (Diastolic) or >50 years of age (Systolic)

  • Sudden worsening of previously controlled hypertension

  • Failure to respond to therapy

  • Hypokalemia (with no diuretics) - primary aldosteronism

  • Labile hypertension, hypertension with anesthesia – pheochromocytom

  • MEN II,neurofibromatosis – pheochromocytoma

  • H/A, palpitation, diaphoresis – pheochromocytoma

  • Sudden deterioration in renal function - Reno vascular

  • Renal failure after ACE inhibitor - Reno vascular


Evaluation

Evaluation


Patient evaluation

Patient Evaluation

  • Evaluation of patients with documented HTN has three objectives:

  • Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guides treatment.

  • Reveal identifiable causes of high BP.

  • Assess the presence or absence of target organ damage and CVD.


History

History

  • Family history of hypertension - seen in essential hypertension

  • Age of onset of hypertension - < 30, >50

  • Medications - oral contraceptives, decongestants, amphetamines

  • Alcohol use - >2 drinks/day can raise blood pressure

  • DM - cardiovascular risk factor

  • Headache/palpitations/diaphoresis - seen with pheochromocytoma

  • Stroke/TIA/Angina - target organ involvement


Physical exam

Physical Exam

  • Blood pressure both arms - with discrepancy, use higher value

  • Orthostatic blood pressure - volume depletion with Pheo.

  • Pulses, BP in legs - screen for Coarctation

  • Fundoscopic - target organ damage

  • Cardiac - target organ damage

  • Abdominal mass/bruit - Endovascular hypertension

    • Renal Bruit in renal artery can also contribute to HTN

  • Central obesity, striae - Cushings


Laboratory tests

Laboratory Tests

  • Routine Tests

    • Electrocardiogram

    • Urinalysis

    • Blood glucose, and hematocrit

    • Serum potassium, creatinine, or the corresponding estimated GFR, and calcium

    • Lipid profile, after 9- to 12-hour fast, that includes high-density and low-density lipoprotein cholesterol, and triglycerides

  • Optional tests

    • Measurement of urinary albumin excretion or albumin/creatinine ratio

  • More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved


Prognostic factors

Prognostic Factors

  • Race - African American

  • Youth onset

  • Male sex

  • Diastolic BP> 100

  • Diabetes Mellitus

  • Hypercholesterolemia

  • Android obesity


Prognostic factors cont

Prognostic Factors-cont.

Evidence of end organ damage

A.Cardiac

Cardiomegaly

EKG changes of left ventricular hypertrophy

Myocardial Infarction

Congestive Heart Failure

B.Eyes

Exudate or hemorrhage

Papilledema

C.Renal

Impairment

Proteinuria

D.CNS

Cerebrovalcular accident


Cvd risk factors

CVD Risk Factors

  • Hypertension*

  • Cigarette smoking

  • Obesity* (BMI>30 kg/m2)

  • Physical inactivity

  • Dyslipidemia*

  • Diabetes mellitus*

  • Microalbuminuria or estimated GFR <60 ml/min

  • Age (older than 55 for men, 65 for women)

  • Family history of premature CVD

    (men under age 55 or women under age 65)

*Components of the metabolic syndrome.


Management of hypertension

MANAGEMENT OF HYPERTENSION


Goals of therapy

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 of age.


Non pharmacological therapy

Non Pharmacological Therapy

ModificationRecommendationAvg. SBP Reduction

  • Weight reductionBMI 18.5-24.9 5-20 mm Hg/10 kg

  • Diet (DASH)*Fruits, vegetables,8-14 mm Hg

    low fat

  • Sodium reduction2.4 g Na or 6 g Nacl2-8 mm Hg

  • Aerobic physicalRegular, 30 min/day4-9 mm Hg

    activity

  • Alcohol Men: < 2 drinks/day2-4 mm Hg

    consumption Women: < 1 drink/day

    *(DASH) Dietary Approaches to Stop Hypertension Eating Plan


Pharmacologic therapy

Pharmacologic Therapy

1.Diuretics

2.Adrenergic inhibitors

-Beta adrenergic blockers

-Central-acting adrenergic inhibitors

-Peripheral-acting adrenergic antagonists

-Alpha 1 adrenergic blockers

-combined Alpha and Beta adrenergic blockers

3.Vasodilators

4.Angiotensins - converting enzyme inhibitor

5.Calcium channel blocking agents


Clinical factors influencing drug selection

Clinical Factors Influencing Drug Selection

  • Age

  • Race

  • Sex

  • Weight

  • Level of pretreatment blood pressure

  • Efficacy and safety

  • Adverse-effects profile(clinical and laboratory)

  • Cost

  • Compliance

  • concomitant disease(CAD, obesity, COPD, DM, renal disease etc.)

  • Convenience of dosing

  • concomitant medications(prescription and over-the -counter drugs)


Antihypertensive prescription

Antihypertensive prescription

198719901995

Diuretics$410*18% $380 13% 330 10%

Beta-blockers68030 600 22 600 17

ACE inhibitors40018 800 29 1,100 32

Calcium Channel 26011 500 29 1,000 29

Other agents51023 500 18 400 12

Total$2,260100% 2,780 100% 2,780 100%

*Millions


Newer guidelines

Newer Guidelines

  • Lifestyle modifications

  • Initial drug choice

    Without compelling indications

    • Stage 1 Hypertension (SBP 140-159 or DBP 90-99 mm Hg)

      Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination

    • Stage 2 Hypertension (SBP >160 or DBP >100 mm Hg)

      2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB).

      With compelling indications

      See slide

  • Advanced drug choice

    • Optimize dosages or add additional drugs until goal BP is achieved


  • Coexisting morbidity on the choice of antihypertensive drugs compelling

    Coexisting Morbidity on the Choice of Antihypertensive Drugs – Compelling

    ConditionPreferred Drugs

    Ischemic heart diseasebeta blocker, Calcium channel blocker

    CHFDiuretics, ACE inhibitors

    Peripheral vascular diseaseDiuretics, CCB, ACE inhi., alpha-1 bl

    Supraventricular arrhythmiasBeta blockers, CCB

    Orthostatic hypotensionBeta blockers, ACE inhibitors

    Bronchospastic diseaseDiuretics, ACE inhi. CCB

    Diabetes mellitusACE inhi., B-1 blockers, CCB

    Chronic renal failureLoop diuretics, B-blockers, Vasodil

    HyperlipidemiaAlpha-1 blockers, ACE, CCB

    GoutACE, CCB

    Sexual dysfunctionACE inhib., CCB


    Special groups

    Special Groups


    Minority populations

    Minority Populations

    • In general, treatment similar for all demographic groups.

    • Socioeconomic factors and lifestyle important barriers to BP control.

    • Prevalence, severity of HTN increased in African Americans.

    • African Americans demonstrate somewhat reduced BP responses to monotherapy with BBs, ACEIs, or ARBs compared to diuretics or CCBs.

    • These differences usually eliminated by adding adequate doses of a diuretic.


    White coat hypertension

    White Coat Hypertension


    Left ventricular hypertrophy

    Left Ventricular Hypertrophy

    • LVH is an independent risk factor that increases the risk of CVD.

    • Regression of LVH occurs with aggressive BP management: weight loss, sodium restriction, and treatment with all classes of drugs except the direct vasodilators hydralazine and minoxidil.


    Hypertension in older persons

    Hypertension in OlderPersons

    • More than two-thirds of people over 65 have HTN.

    • This population has the lowest rates of BP control.

    • Treatment, including those who with isolated systolic HTN, should follow same principles outlined for general care of HTN.

    • Lower initial drug doses may be indicated to avoid symptoms; standard doses and multiple drugs will be needed to reach BP targets.


    Isolated systolic hypertension

    Isolated Systolic Hypertension

    Definition:Systolic blood pressure of 140-159 mm Hg.

    Facts:3/4 of Primary care physicians don’t treat with SBP of 140 to 159

    Most Primary care physicians don’t control SBP to <140 mm Hg.

    Incidence:5% of the total population.

    25% in people older than age 75.

    Rapid rise in heart rate and BP occurs in the early hours of the morning(circadian rhythm leading to stroke, myocardial infarction and sudden death


    Dementia

    Dementia

    • Dementia and cognitive impairment occur more commonly in people with HTN.

    • Reduced progression of cognitive impairment occurs with effective antihypertensive therapy.


    Peripheral arterial disease pad

    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.


    Hypertension in women

    Hypertension 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, preferred for the safety of the fetus. ACEI and ARBs contraindicated in pregnancy.


    Barriers to success

    Barriers To Success

    • Lack of awareness, both by health care personnel and the patients

    • Asymptomatic

    • No immediate consequence of stopping therapy

    • Lack of educating patients

    • Co-morbid conditions

    • Inappropriate and inadequate treatment

    • Complicated regimens

    • Medication cost

    • Side effects of medicines

    • Managed care

    • Lack of follow up


    Improving compliance

    Improving Compliance

    • Involve the patient in decision making

    • Use medicines to reduce BP to near normotensive level with minimal side effects

    • Educate patients

    • Follow up regularly

    • Start one drug at a time (step wise approach)

    • Prescribe simple regimen

    • Start slow and increase the dose gradually, particularly in older patients (5-10 mmHg reduction at each step)

    • Anticipate side effects


    Benefits of lowering blood pressure

    BENEFITS OF LOWERING BLOOD PRESSURE

    Reduction In:

    • Stroke - 35% to 40%

    • MI - 20% to 25%

    • CHF - >50%


    Recommendations

    Recommendations


    Recommendations for treatment of hypertensive patients

    Recommendations For Treatment Of Hypertensive Patients

    • Aggressive approach against all modifiable cardiovascular risk factors(obesity, smoking, diet, exercise, etc.)

    • Non-pharmacologic therapy and continued observation for pre-hypertension

    • If diastolic BP remains above 90 mmHg despite non-pharmacologic therapy, antihypertensive drug therapy should be started


    Recommendations cont

    Recommendations-cont.

    • Isolated systolic hypertension should receive drug therapy

    • Systolic pressure should be at or below 140 mm Hg or to the lowest systolic pressure consistent with safety and tolerance

    • Diastolic pressure should be reduced at or below 90 mmHg or to the lowest diastolic pressure consistent with safety and tolerance

    • In patients with DM and CKD the goal should be <130/80


    Recommendations cont1

    Recommendations-cont.

    • A gradual reduction of blood pressure is desirable

    • Therapy should be gentle in the elderly who have sluggish baro-receptor and sympathetic nervous system response and impaired cerebral auto regulation

    • Simplest regimen and fewest number of pills should be prescribed to achieve the highest compliance rate

    • Drugs with the least side effects should be prescribed


    Conclusions

    CONCLUSIONS

    Hypertension is a silent killer

    Hypertension is a systemic disease affecting multiple organs

    Early detection and treatment will reduce the mortality and

    morbidity

    Treatment should be individualized to each patient

    Simple regimen should be tried first

    Education of the patient is one of the most important factor in

    improving the compliance with medicines


    Thank you

    THANK YOU


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