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Update on the Management of Hypertention. Timothy A. Denton, M.D. Divisions of Cardiology and Cardiothoracic Surgery Cedars-Sinai Medical Center Los Angeles. Outline. Role of BP Etiology of HTN Evaluation JNC VI. Why do we need blood pressure?. Why do we need blood pressure?.

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Update on the Management of Hypertention

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Update on the management of hypertention

Update on the Management of

Hypertention

Timothy A. Denton, M.D.

Divisions of Cardiology and Cardiothoracic Surgery

Cedars-Sinai Medical Center

Los Angeles


Update on the management of hypertention

Outline

  • Role of BP

  • Etiology of HTN

  • Evaluation

  • JNC VI


Update on the management of hypertention

Why do we need blood pressure?


Update on the management of hypertention

Why do we need blood pressure?

  • Get blood to the scalp

  • Distribute flow quickly


Update on the management of hypertention

Classification of HTN

  • Primary

  • Secondary


Update on the management of hypertention

Physiology of HTN

  • Primary Hypertension

  • ? Central / peripheral adrenergic

  • ? renal

  • ? hormonal

  • ? vascular


Update on the management of hypertention

Physiology of HTN

  • Secondary

  • Wide Pulse PressureAortic complianceStroke volume

  • Normal Pulse PressureRenalEndocrineNeurogenicMisc


Update on the management of hypertention

Etiology of HTN

Normal Pulse Pressure

  • RenalChronic pyelonephritisGlomerulonephritisPolycystic kidneyRenovascularOther renal

  • EndocrineOral contraceptivesAdrenocortical (Cushing, hyperaldo,17 hydroxylase, 11-hydroxylase)PheochromocytomaMyxedemaAcromegaly

  • NeurogenicPsychogenicFamilial dysautonomiaPolyneuritisIncreased intracranial pressureSpinal cord section

  • MiscCoarctationIntravascular volumePolyarteritis nodosaHypercalcemiaAcute intermittent porphyriaPre-eclampsia


Update on the management of hypertention

Etiology of HTN

Wide Pulse Pressure

  • Decreased aortic compliance

  • Increased stroke volumeAIThyrotoxicosisHyperkinetic heart syndromeFeverAV fistula / PDA


Update on the management of hypertention

Epidemiology of HTN

Harrison’s Principles of Internal Medicine, 12th Edition


Update on the management of hypertention

JNC VI

Joint National Committee on

Prevention, Detection, Evaluation,

and Treatment of

High Blood Pressure

JNC VI -- Arch Int Med 1997;157:2413


Update on the management of hypertention

Classification of HTN

JNC VI -- Arch Int Med 157:2413, 1997


Update on the management of hypertention

Risk Classification

JNC VI -- Arch Int Med 157:2413, 1997


Update on the management of hypertention

Undertreatment


Update on the management of hypertention

Undertreatment of Hypertension

Berlowitz, NEJM 1998;339:1957


Update on the management of hypertention

Undertreatment of Hypertension

Berlowitz, NEJM 1998;339:1957


Update on the management of hypertention

Undertreatment of Hypertension

Berlowitz, NEJM 1998;339:1957


Update on the management of hypertention

Classes of Anti-Hypertensives

(1999 PDR)

Adrenergic blockers

Alpha/Beta adrenergic blockers

ACE inhibitors

ACE + Ca blockers

ACE + diuretics

ARB’s

ARB’s with diuretics

Beta blockers

Beta blockers with diuretics

Calcium blockers

Diuretics

Rauwolfia derivatives

Vasodilators


Update on the management of hypertention

Preparations of Anti-Hypertensives by Class

(1999 PDR)

Adrenergic blockers

Alpha/Beta adrenergic blockers

ACE inhibitors

ACE + Ca blockers

ACE + diuretics

ARB’s

ARB’s with diuretics

Beta blockers

Beta blockers with diuretics

Calcium blockers

Diuretics

Rauwolfia derivatives

Vasodilators

6

5

11

4

5

4

2

15

6

25

24

2

18

Total = 127


Update on the management of hypertention

Special Considerations

In African-Americans: -- low probability of success with Beta blockers or ACEor ARB’s -- higher probability of success with diuretics or Ca blockers


Update on the management of hypertention

If you have not achieved goal,

you must change your therapy


Update on the management of hypertention

You push a medication’s dose

to EFFECT

or SIDE EFFECT

or maximal recommended dose


Update on the management of hypertention

“The committee recognizes that

the responsible clinician’s

judgment of the individual

patient’s needs remains paramount.”

JNC VI -- Arch Int Med 1997;157:2413


Update on the management of hypertention

Compelling Indications

JNC VI -- Arch Int Med 157:2413, 1997


Update on the management of hypertention

Pressure/Volume Relation

Pressure = 150 mmHg

Pressure = 120 mmHg

Fluid

Flux

Fluid

Flux

Vasculature


Update on the management of hypertention

Combination Drugs:

A Different Animal

  • Beta blocker + diuretic

  • ACE + diuretic

  • ACE + calcium blocker

  • ARB + diuretic

  • Diuretic + diuretic

  • “other” + diuretic


Update on the management of hypertention

HOPE Trial

Heart Outcomes Prevention Evaluation Study

NEJM 2000;342:145-153


Update on the management of hypertention

Backgroud

  • Activation of renin-angiotensin-aldosterone system may be amortality risk factor

  • ACE therapy can reduce MI’s Circ 1994;90:2056, Lancet 1992;340:1173,JNC VI NEJM 1992;327:669

HOPE Trial, NEJM 2000;342:145-153


Update on the management of hypertention

Design

  • Prospective, randomized

  • Two-by-two factorialramipril + vitamin E

  • 9,541 patients

HOPE Trial, NEJM 2000;342:145-153


Update on the management of hypertention

Inclusion Criteria

  • > 55 years old

  • CAD or CVA or PVD orDM + (HTN orhigh LDL orlow HDL orcigarettes ormicroalbuminuria)

HOPE Trial, NEJM 2000;342:145-153


Update on the management of hypertention

Run-In

  • 10,576 patients

  • ramipril 2.5 mg qd 7-10 daysthen placebo 10-14 days

  • 1,035 excluded(noncompliance, side effects, creat, K, withdrawal)

HOPE Trial, NEJM 2000;342:145-153


Update on the management of hypertention

Follow-up

  • First follow-up 1 month

  • Subsequent follow-ups q 6 months

  • Scheduled for 5 years

HOPE Trial, NEJM 2000;342:145-153


Update on the management of hypertention

Outcome Measures

  • Primary endpoint:CV death or MI or CVA

  • Secondary endpoints:All cause mortalityRevascularizationHospitalization for UA or CHFDM complicationsWorsening anginaCardiac Arrestany CHFUA with ECG changesDM development

HOPE Trial, NEJM 2000;342:145-153


Update on the management of hypertention

Results

HOPE Trial, NEJM 2000;342:145-153


Update on the management of hypertention

Angiotensinogen

Inactive

products

Renin

Inhibitor

Renin

increase nitric oxide,

prostacyclin

(improved endothelial function ?

anti-atherosclerotic?)

non-ACE

alternative

pathways

(chymase,

cathepsin G,

chymostatin

ATII generation)

Angiotensin I

ACE

Inhibitor

ACE

ACE

hypotension

Angiotensin II

Bradykinin

? angioedema

AT1 receptor

Inhibitor

cough

Vaso-

constriction

Vaso-

dilatation

Vasopressin

Endothelin-1

Adapted, Bonn, D. Lancet 1998;352:378


Update on the management of hypertention

Results

HOPE Trial, NEJM 2000;342:145-153


Update on the management of hypertention

Results

HOPE Trial, NEJM 2000;342:145-153


Update on the management of hypertention

Results

HOPE Trial, NEJM 2000;342:145-153


Update on the management of hypertention

Results

HOPE Trial, NEJM 2000;342:145-153


Update on the management of hypertention

Results

HOPE Trial, NEJM 2000;342:145-153


Update on the management of hypertention

Results

HOPE Trial, NEJM 2000;342:145-153


Update on the management of hypertention

Results

HOPE Trial, NEJM 2000;342:145-153


Update on the management of hypertention

Summary

  • Ramipril decreasedCV mortalityMI and CVAall-cause mortalityRevascularization ratesDM complicationsCHFWorsening anginaNew onset DM

  • Effects were see in all groups except those withoutcardiovascular disease

HOPE Trial, NEJM 2000;342:145-153


Update on the management of hypertention

Implications

  • We have a new standard of care

  • All patients with vascular disease should beconsidered for ACE inhibition (e.g., ramipril)


Update on the management of hypertention

How to Initiate Therapy

  • Initial Evaluation

  • Good history and physical exam (note comorbidities)

  • Take BP in both arms

  • Take BP at least 2 min apart and average them

  • Take BP at least on two separate office visits

  • Look for end-organ damage

  • Stratify patient

  • Initiate drug therapy based on comorbidity and risk


Update on the management of hypertention

Evidence of End-organ Damage

Eyes

spasm

AV nicking

exudates

edema

Lungs

rales

Neck

bruits

JVD

thyroid

Abd

bruits

masses

Heart

S4

S3

Murmur

Labs

Chem I

CBC

Lipids

ECG

Ext

pulses

edema


Update on the management of hypertention

Long-term Therapy

The patient must become expert on their own blood pressure


Update on the management of hypertention

Take BP at home


Update on the management of hypertention

Write each BP down in a log

  • 1x / day

  • 2x / day

  • 3x / day

  • 3x / week

  • etc…..


Update on the management of hypertention

Summary

  • Please, find more hypertensive patients

  • Please, treat more hypertensive patients

  • Consider risk / comorbidities

  • Please, achieve goal in more hypertensive patients


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