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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


= 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 and complications
Comorbidities and Complications


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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