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Hypertension. Robin Felker Bloomer Hill-NCSRHC September 16, 2009. Outline. Epidemiology of HTN Clinical Presentation Symptoms BP measurement and interpretation Interventions Behavior Modification Drugs Comorbitities and Complications HTN at Bloomer Hill. Epidemiology. Epidemiology.

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hypertension

Hypertension

Robin Felker

Bloomer Hill-NCSRHC

September 16, 2009

outline
Outline
  • Epidemiology of HTN
  • Clinical Presentation
    • Symptoms
    • BP measurement and interpretation
  • Interventions
    • Behavior Modification
    • Drugs
  • Comorbitities and Complications
  • HTN at Bloomer Hill
epidemiology1
Epidemiology
  • Hypertension is the most common primary diagnosis in US (PDx in 35 million office visits)
  • Framingham Heart Study suggests that individuals who are normotensive at age 55 have a 90 percent lifetime risk for developing hypertension
  • In Stage I HTN, achieving a sustained 12 mmHg reduction in SBP over 10 years will prevent 1 death for every 11 patients treated
    • If CVD or organ damage, only 9 patients would require such BP reduction to prevent a death
epidemiology2
Epidemiology
  • Age-adjusted prevalence of hypertension is significantly higher among blacks (39%) than among whites (29%)
  • Racial disparity in SBP control contributes to nearly 8,000 excess deaths annually from heart disease and stroke among blacks
  • Hypertension is the single largest contributor, of any medical condition, to racial disparity in adult mortality
clinical symptoms
Clinical Symptoms
  • Commonly ASYMPTOMATIC!
  • “Classic Sx”: Headache, epistaxis, dizziness
    • No more frequent in HT than non-HT patients
  • Flushing, sweating, blurred vision
  • Family history (first degree relatives)
  • Manifestations of organ damage
    • Will discuss later
natural history
Natural History
  • Essential Hypertension (95% of cases)
    • Age of onset: 20-50 years
    • Family history of hypertension (1st degree relatives)
    • Gradual onset, mild-to-moderate BP
    • Normal serum K+, urinalysis
  • Chronic Renal Disease (2-4%)
    • Increased creatinine, abnormal urinalysis
  • Primary aldosteronism (1-2%)
    • Decreased serum K+
proper bp measurement
Proper BP measurement
  • Persons should be seated quietly for at least 5 minutes in a chair (rather than on an exam table), with feet on the floor, and arm supported at heart level
  • Need an appropriate-sized cuff(cuff bladder encircling at least 80 percent of the arm)
  • Release air so needle falls 2-3 mmHg/sec
  • Be wary of stress, discomfort, and other evidence of “White Coat HTN”
  • Need elevated HTN on 2 separate occasions
things to think about
Things to think about
  • Ideal PE should include
    • BP confirmation, with verification in the contralateral arm
    • Examination of the optic fundi
    • Body mass index(BMI)/waist circumference
    • Auscultation for carotid, abdominal, and femoral bruits
    • Palpation of the thyroid gland
    • Thorough examination of the heart and lungs
    • Examination of the abdomen for enlarged kidneys, masses, and abnormal aortic pulsation
    • Palpation of the lower extremities for edema and pulses
    • Neurological assessment
things to think about1
Things to think about
  • Laboratory tests
    • Urinalysis and serum Cr/BUN (rule out renal disease)
    • Serum potassium (aldosteronism)
    • Blood glucose level (diabetes strongly linked to HTN and renal disease)
    • Serum Cholesterol (global vascular screen)
    • ECG (to monitor for LVH)
interventions
Interventions
  • Goal of treatment is to reduce cardiovascular and renal morbidity and mortality
  • A combination of lifestyle modifications and drug therapy are recommended
  • REMEMBER: The most effective therapy prescribed by the most careful clinician will control hypertension only if patients are motivated
behavior modifications
Behavior Modifications
  • Lifestyle modifications are recommended even for those with near normal BP: ≥ 120/80
  • Eight modifications are recommended by the AHA:
    • Eat a better diet, which may include reducing salt
    • Enjoy regular physical activity
    • Maintain a healthy weight
    • Manage stress
    • Avoid tobacco smoke
    • Understand hot tub safety
    • Comply with medication prescriptions
    • If you drink, limit alcohol
slide17

= Cardiac disease,

renal &

diabetes

drugs on the 4 list
Drugs (on the $4 list…)
  • Diuretics
    • Hydrochlorothiazide (HCTZ) and Chlorthalidone
    • Thiazide-like diuretics have been shown to be best first-line treatment
  • ACEI
    • Lisinopril, Enalapril, Captopril, Benazepril
  • ARB
  • BB
    • Atenolol, Bisoprolol, Carvedilol, Metoprolol, Naldolol, Pindolol, Propranolol, Sotalol
  • CCB
    • Diltiazem, verapamil
  • Most patients will need at least 2 drugs to achieve BP goals
    • Combos: Lisinopril-HCTZ, Enalopril-HCTZ, Atenolol-Chlorthalidone,
comorbidities obesity
Comorbidities: Obesity
  • BMI >30 is an increasingly prevalent risk factor for the development of hypertension and CVD
  • Intensive lifestyle modification should be pursued in these individuals
  • Consider drug treatment for components of metabolic syndrome
    • Obesity, glucose intolerance, high BP, high TGs, low HDL
comorbidities diabetes
Comorbidities : Diabetes
  • Target of <130/80 mmHg
  • Thiazide diuretics, BBs, ACEIs, ARBs, and CCBs are beneficial in reducing CVD and stroke incidence in diabetics
  • ACEI- or ARB-based treatments favorably affect the progression of diabetic nephropathy and reduce albuminuria
old age
Old Age
  • Hypertension occurs in more than two-thirds of individuals after age 65
    • However, this group has worst BP control
  • Lower initial drug doses may be indicated to avoid symptoms
  • But, standard recommendations should apply
tx in women
Tx in Women
  • Oral contraceptives may increase BP
    • Risk of hypertension increases with duration of use
  • Women taking oral contraceptives should have their BP checked regularly
    • Development of hypertension is a reason to consider other forms of contraception
tx in minorities
Tx in Minorities
  • Impact of hypertension are increased in African Americans
    • African-Americans develop high blood pressure at younger ages than other groups in the U.S.
    • Complications are more likely to develop with high blood pressure, including stroke, kidney disease, blindness, dementia, and heart disease
    • Reduced BP responses to monotherapy with BBs, ACEIs, or ARBs; want to include diuretic in treatment!
  • Differences in adherence by race may be due to affordability of medicines, personal beliefs, anticipated adverse effects, and health
  • BP control is lowest in Mexican American and Native American populations
target organ damage
Target organ damage
  • Heart
    • Left ventricular hypertrophy
    • Angina or prior myocardial infarction
    • Prior coronary revascularization
  • Heart failure
  • Brain
    • Stroke or transient ischemic attack
  • Chronic kidney disease
  • Peripheral arterial disease
  • Retinopathy
take home points
Take Home Points
  • Hypertension is a VERY common medical condition
    • Proper identification and treatment is essential to preventing CHF and target organ damage
  • Lifestyle modifications should start even in persons with near-normal BP (≥120/80)
  • Proper BP interventions include lifestyle modifications and drug interventions
    • Two-drug therapy may be necessary for control
    • First line control is usually thiazide-like diuretic
  • Tx of BP with comorbidities must take into account concurrent treatment of comorbid conditions
htn at bloomer hill
HTN at Bloomer Hill
  • It is essential to follow BP trends and address HTN in our patients
    • If someone has a high reading, ask about caffeine/smoking, have them sit for 5 minsand recheck BP in the exam room
    • Try for repeat visit in anyone with high BP, especially >140/90
    • Follow-up: every 6 months for well-controlled, monthly/bi-monthly if uncontrolled, monthly with med changes
    • Counseling on lifestyle modifications for almost every patient is warranted! Try for discrete goals that the patient is on-board with and document them for follow-up
references
References
  • Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7 Express).
  • Drugs for hypertension. Treatment Guidelines from the Medical Letter 2009; 7(77). http://medlet-best.securesites.com.libproxy.lib.unc.edu/restrictedtg/t77.html
  • Fiscella K, Holt K. Racial disparity in hypertension control: tallying the death toll. Ann Fam Med 2008;6:497-502.
  • Lilly. Pathophysiology of Heart Disease, ed 4.
  • http://www.webmd.com/hypertension-high-blood-pressure/hypertension-in-african-americans
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