Good morning

1. Good morning 11 patients walk into your office You successfully prevent one from dying. What did you treat?

2. Hypertension Elizabeth Hutchinson MD August 7th 2013 Adapted from Residency Resource: Cheryl K. Seymour, MD Maine-Dartmouth Family Medicine Residency Augusta, ME

3. Objectives • New perspective • 6 Step Approach • Detect and Confirm • End Organ Damage • Secondary Causes • Cardiovascular Risks • Treatment • Adherence

4. Why is this important? Individuals with a normal BP at age 55 yo have a 90% lifetime risk of developing hypertension. VasanRS, Beiser A, Seshadri S, et al. Residual lifetime risk for developing hypertension in middle-aged women and men: The Framingham Heart Study. JAMA. 2002;287:1003-10.

5. Why is this important? HTN control is poor throughout all economic and ethnic groups. 43.7% of US population with hypertension were well-controlled in 2005-08. Prevalence of HTN and Controlled HTN — United States, 2005-2008 MMWR Supplements2011 / 60(01);94-97

6. Why is this important? The risk of CVD doubles with each increase of 20/10 mmHg (beginning at 115/75) JNC 7 Lewington S, Clarke R, Qizilbash N, et al. Age-specific relevance of usual blood pressure to vascular mortality: A meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360:1903-13.

7. Journal of Human Hypertension26, 641-643 (November 2012) | doi:10.1038/jhh.2012.3

8. Why is this important? For a patient with one risk factor and Stage 1 hypertension… NNT = 11 to prevent one death in 10 years NNT = 9 if patient has known CVD JNC 7 Ogden LG, He J, Lydick E, Whelton PK. Long-term absolute benefit of lowering blood pressure in hypertensive patients according to the JNC VI risk stratification. Hypertension. 2000;35:539-43.

9. Why is this important? “The most effective therapy prescribed by the most careful clinician will control hypertension only if patients are motivated… Empathybuilds trust and is a positive motivator.” JNC 7

10. 6 Step Approach • Detect and Confirm • End Organ Damage • Secondary Causes • Cardiovascular Risks • Treatment • Adherence

11. 6 Step Approach Find a partner and read about Penelope Spratt. Together answer the questions. Use your JNC 7 reference card

12. 6 Step Approach • Detect and Confirm • End Organ Damage • Secondary Causes • Cardiovascular Risks • Treatment • Adherence

13. Detect and confirm HTN • 2 readings on 2 different occasions • Give patients their BP and BP goal in writing

14. accurate reading Cuff bladder encircle >80% pts arm sphygmomanometer Deflate 2-3mm per second Siting comfortably Back supported Legs uncrossed Upper arm bared Arm at heart level SBPINACCURATELY HIGH IF: patient is supine, crossed legs, arm below the heart, arm unsupported, undersized cuff. AHA guidelines

15. 6 Step Approach • Detect and Confirm • End Organ Damage • Secondary Causes • Cardiovascular Risks • Treatment • Adherence

16. Physical Exam • Target organ damage Fundoscopic exam (retinopathy) Displaced PMI, rales, edema (LVH, CHF) • Secondary causes Bruits (renovascular) Thyroid (hyper/hypo) Pulses (coarctation) • Cardiovascular risk factors Peripheral pulses (PVD) Neuro exam (previous CVA)

17. End organ damage: > 180/120 + signs/symptoms H y p e r t e n s i v e e m e r g e n c y cerebrovascular: encephalopathy, hemorrhage ocular: retinal hemorrhages, papilledema cardiac: LV failure, MI, dissection renal: acute glomerulonephritis or nephropathy Other emergencies: eclampsia, cocaine use, rebound HTN after stopping antihypertensive agents, pheochromocytoma crisis

18. 6 Step Approach • Detect and Confirm • End Organ Damage • Secondary Causes • Cardiovascular Risks • Treatment • Adherence

19. Poor sleep NSAIDs Alcohol Smoking Anxiety Pain Ritalin OCPs OTC weight loss pill Palpitations Skin changes Edema Thyroid?? Pheochromocytoma?? OSA?? Secondary Causes - Penelope

20. Secondary causes Loud snoring Daytime somnolence obesity Obstructive sleep apnea Sleep study

21. Secondary causes • Age < 30 without family history of HTN and no obesity • Onset of hypertension before puberty • Actue rise in BP after starting ACE (0.5-1mg/dL) • mild hypokalemia, mild metabolic alkalosis CTA 64% sen / 92% spec MRA with gad 62% sen / 84% spec1 Renal artery duplex 56% sen / 93% spec2 Renal artery stenosis 1. Ann Intern Med 2004 Nov 2;141(9):674 2. Cardiovasc Ultrasound 2004 Jan 14; 2:1

22. Secondary causes Abnormal UA Primary renal disease Renal ultrasound

23. Secondary causes Arm to leg SBP difference > 20 mm Hg Delayed or absent femoral pulses Child/adolescent Murmur Turner’s syndrome Family history … MRI (adults) TTE (children) Coarctation of the aorta

24. Secondary causes Bradycardia/tachycardia Cold/heat intolerance Constipation/diarrhea Irregular, heavy, or absent menstrual cycle Thryoid disease TSH

25. Secondary causes Hypokalemia Aldosteronism aldosterone/renin ratio

26. Secondary causes Flushing Headaches Labile blood pressures Orthostatic hypotension Palpitations Sweating Syncope Pheochromocytoma 24-hour urine metanephrines Plasma free metanephrines

27. Secondary causes Buffalo hump Central obesity Moon facies Striae Cushing syndrome 24-hour urine cortisol Late-night salivary cortisol dexamethasone suppression

28. Secondary causes hypercalcemia Hyperparathyroidism PTH

29. 6 Step Approach • Detect and Confirm • End Organ Damage • Secondary Causes • Cardiovascular Risks • Treatment • Adherence

30. Diagnostic testing – Penelope • CMP • TSH • UA • EKG • FLP • Fasting glucose

31. 6 Step Approach • Detect and Confirm • End Organ Damage • Secondary Causes • Cardiovascular Risks • Treatment • Adherence

32. Therapeutic interventions • Life-style changes Smoking, Alcohol, Weight loss Salt reduction Stop OTC weight loss pill Meditation? • Medications HCTZ + consider second agent

33. Goals of Treatment Less than 140/90 UNLESS • Comorbidity (CVD, CKD, DM) Less than 130/80 • Proteinuria Less than 125/75

34. JNC 8: • Goals may be adjusted • Attention to Co-Morbidities • Age adjustments in approach: • Age >70 systolic goal 140 mmHg, begin therapy if resting > 160 mmHg

35. 6 Step Approach • Detect and Confirm • End Organ Damage • Secondary Causes • Cardiovascular Risks • Treatment • Adherence

36. Adherence • Continuity of care • Patient self management goals • Shared decision making • Patient education tools • BP tracking cards • Partner with community wellness groups • Multi-disciplinary teams

37. Patient self management goals • Blood pressure home monitoring indications: • Suspected white coat hypertension • Suspected episodic hypertension • Hypertension resistant to increasing medication doses • Hypotensive symptoms while taking antihypertensive medications • Autonomic dysfunction

38. Home blood pressure monitoring Validated upper arm cuffs Pharmacy cuffs inaccurate Check technique Avoid tobacco & caffeine Judicious timing/frequency

39. Systems – Institute for Health Care Improvement • Principles: • Emphasize patient activation or empowerment, collaborative goal setting • Sensitive to families & caregivers roles • Sensitive to different cultures • Use Assessments: knowledge, skills, confidence, supports, and barriers • Appropriate education materials • Use action plan, give copy to patient, follow up with patient

40. In summary… Hypertension is… Common condition As yet undertreated in this country Treatment prevents mortality 6 Step Approach

41. Case 1 A 62 yo female with schizophrenia and poor med compliance presents to the office after a 15 month absence. She has known HTN and is prescribed HCTZ 25 and Atenolol 25 daily. She was sent over from the BH Crisis Unit for evaluation because blood pressures there were 190 / 100. She has a headache and is anxious but denies any other complaints. How should you manage her blood pressure? Does she need to be admitted?

42. Bottom line: Assess for end-organ damage to determine disposition, then treat to lower BP.

43. Case 2 Is this white coat HTN? A 45 yo female with FH of HTN and generalized anxiety disorder presents to your office. She is very anxious about taking medicines but also anxious about having a stroke like her mother. She has been told she has “mild” HTN in the past. Her BP today is 187/89. At past visits she generally runs systolics in the 160-180s with a HR in the 90s. She tells you her BP when she checks at Walmart is always normal. Is this white coat HTN? What should you do?

44. Bottom line: White coat hypertension means BP are normal out of the office. People with white coat HTN are at increased risk for HTN and should be seen in follow-up regularly.

45. Case 3 You are on your surgery rotation and are seeing a patient for a quick H&P prior to their scheduled hemi-colectomy for a concerning colonic polyp that was non-resectable with colonoscopy. This 52 yo male has a PMH of HTN only and takes Atenolol and HCTZ daily. He believes his doctor told him not to take anything by mouth including medicines before the surgery. His pre-op blood pressure is 182/94. Did his doctor give him good advice? What should you do now?

46. Bottom line: Continue beta blockers prior to surgery.