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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

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?

  • Get blood to the scalp

  • Distribute flow quickly


Classification of HTN

  • Primary

  • Secondary


Physiology of HTN

  • Primary Hypertension

  • ? Central / peripheral adrenergic

  • ? renal

  • ? hormonal

  • ? vascular


Physiology of HTN

  • Secondary

  • Wide Pulse Pressure Aortic compliance Stroke volume

  • Normal Pulse Pressure Renal Endocrine Neurogenic Misc


Etiology of HTN

Normal Pulse Pressure

  • Renal Chronic pyelonephritis Glomerulonephritis Polycystic kidney Renovascular Other renal

  • Endocrine Oral contraceptives Adrenocortical (Cushing, hyperaldo, 17 hydroxylase, 11-hydroxylase) Pheochromocytoma Myxedema Acromegaly

  • Neurogenic Psychogenic Familial dysautonomia Polyneuritis Increased intracranial pressure Spinal cord section

  • Misc Coarctation Intravascular volume Polyarteritis nodosa Hypercalcemia Acute intermittent porphyria Pre-eclampsia


Etiology of HTN

Wide Pulse Pressure

  • Decreased aortic compliance

  • Increased stroke volume AI Thyrotoxicosis Hyperkinetic heart syndrome Fever AV fistula / PDA


Epidemiology of HTN

Harrison’s Principles of Internal Medicine, 12th Edition


JNC VI

Joint National Committee on

Prevention, Detection, Evaluation,

and Treatment of

High Blood Pressure

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


Classification of HTN

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


Risk Classification

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



Undertreatment of Hypertension

Berlowitz, NEJM 1998;339:1957


Undertreatment of Hypertension

Berlowitz, NEJM 1998;339:1957


Undertreatment of Hypertension

Berlowitz, NEJM 1998;339:1957


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


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


Special Considerations

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


If you have not achieved goal,

you must change your therapy


You push a medication’s dose

to EFFECT

or SIDE EFFECT

or maximal recommended dose


“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


Compelling Indications

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


Pressure/Volume Relation

Pressure = 150 mmHg

Pressure = 120 mmHg

Fluid

Flux

Fluid

Flux

Vasculature


Combination Drugs:

A Different Animal

  • Beta blocker + diuretic

  • ACE + diuretic

  • ACE + calcium blocker

  • ARB + diuretic

  • Diuretic + diuretic

  • “other” + diuretic


HOPE Trial

Heart Outcomes Prevention Evaluation Study

NEJM 2000;342:145-153


Backgroud

  • Activation of renin-angiotensin- aldosterone system may be a mortality 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


Design

  • Prospective, randomized

  • Two-by-two factorial ramipril + vitamin E

  • 9,541 patients

HOPE Trial, NEJM 2000;342:145-153


Inclusion Criteria

  • > 55 years old

  • CAD or CVA or PVD or DM + (HTN or high LDL or low HDL or cigarettes or microalbuminuria)

HOPE Trial, NEJM 2000;342:145-153


Run-In

  • 10,576 patients

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

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

HOPE Trial, NEJM 2000;342:145-153


Follow-up

  • First follow-up 1 month

  • Subsequent follow-ups q 6 months

  • Scheduled for 5 years

HOPE Trial, NEJM 2000;342:145-153


Outcome Measures

  • Primary endpoint: CV death or MI or CVA

  • Secondary endpoints: All cause mortality Revascularization Hospitalization for UA or CHF DM complications Worsening angina Cardiac Arrest any CHF UA with ECG changes DM development

HOPE Trial, NEJM 2000;342:145-153


Results

HOPE Trial, NEJM 2000;342:145-153


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


Results

HOPE Trial, NEJM 2000;342:145-153


Results

HOPE Trial, NEJM 2000;342:145-153


Results

HOPE Trial, NEJM 2000;342:145-153


Results

HOPE Trial, NEJM 2000;342:145-153


Results

HOPE Trial, NEJM 2000;342:145-153


Results

HOPE Trial, NEJM 2000;342:145-153


Results

HOPE Trial, NEJM 2000;342:145-153


Summary

  • Ramipril decreased CV mortality MI and CVA all-cause mortality Revascularization rates DM complications CHF Worsening angina New onset DM

  • Effects were see in all groups except those without cardiovascular disease

HOPE Trial, NEJM 2000;342:145-153


Implications

  • We have a new standard of care

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


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


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


Long-term Therapy

The patient must become expert on their own blood pressure



Write each BP down in a log

  • 1x / day

  • 2x / day

  • 3x / day

  • 3x / week

  • etc…..


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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