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HYPERTENSION

HYPERTENSION. Background for understanding the Hypertension literature. Jeffrey J. Kaufhold, MD Nephrology. HYPERTENSION SUMMARY. Background for understanding the literature of Hypertension Review of Joint National Commission Recommendations (VII) 2003

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HYPERTENSION

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  1. HYPERTENSION Background for understandingthe Hypertension literature. Jeffrey J. Kaufhold, MDNephrology

  2. HYPERTENSIONSUMMARY • Background for understanding the literature of Hypertension • Review of Joint National Commission Recommendations (VII) 2003 • Clinical Evaluation and Case histories.

  3. Nat’l Health & Nutrition Exam Survey NHANES JNC 7 Dec 2003

  4. HypertensionLiterature Summary • Malignant Hypertension - 1958 Kincaid-Smith and others DBP > 130 • VA Cooperative Studies - 1967 DBP 115-129 mm Hg - 1970 DBP 90 -114 mm Hg

  5. HYPERTENSIONLiterature Summary • US Public Health Service 1977 Prospective placebo controlled trial for DBP 90-115 mm Hg • HDFP 1979 Introduced concept of Stepped Care • Oslo Study 1980 Treatment of Mild Hypertension • Medical Research Clinics (MRC) 1985 Single blind and community based.

  6. HYPERTENSIONPARALLEL WORK • 1948 to 1972 Framingham Study 20 year follow-up on 5000 pts • 1982 MRFIT Randomized primary prevention trial Lower than expected rate of mortality in controls led to NS reduction. • 1984 LRC (Lipid Research Clinics) Treatment of hyperlipidemia reduced risk of heart disease, all-cause mortality not effected.

  7. HYPERTENSIONRecent Works • 1985 HDFP follow-up Study Long term surveillence for drug side effects: 9-25 % • 1992 Gurwitz Ann Int Med Antihypertensive therapy and the initiation of Tx for DM. Diabetes and HTN are linked, drugs and diabetes are NOT. • 1993 VA Cooperative Study, Materson, NEJM Compares 6 agents. Efficacy in 55 % range. Drug intolerance 6 to 14 %.

  8. Joint National Commission • JNC 1 1980 founded on HDFP • JNC 2 1984 Intro of ACE, alpha B. • JNC 3 1986 Special situations • JNC 4 1988 Many agents 1st line • JNC 5 1993 Back to stepped care. • JNC 6 1997 ACE for Diabetics • JNC 7 2003

  9. HYPERTENSIONJNC V • "Because diuretics and B-Blockers are the only classes of drugs that have been used in long-term controlled trials and shown to reduce morbidity and mortality, they are recommended as first- choice agents unless they are contraindicated or unacceptable, or unless there are special indications for other agents."

  10. HYPERTENSIONJNC VII Outline • Epidemiology of HTN • Evaluation of HTN • NON Pharmacologic treatments: Wt loss, diet, exercise, alcohol • Drug treatment • Special Issues in HTN

  11. Normal Prehypertension Stage 1 Stage 2 < 120 / 80 120 -139 / 80-89 140-159 / 90-99 > 160 / >100 Stages of Hypertension

  12. Treatment of Hypertension • Single agent – HCTZ for most pts. B-Blocker for females/ high heart rate. • Stage 2 I start with DHP CCB (procardia XL) • plus one or both of above. • Resistant HTN I look for CLASSES of agents

  13. Case Presentation • 56 y.o. A.A. male prior weight lifter presents for refractory HTN. • Normal labs and UA. Normal CXR and EKG. • Meds: Clonidine 0.2 BID • ACE inhibitor • Diltiazem 300 mg daily

  14. Case Presentation • Physical Exam: • BP 170 / 110 Pulse 85 • Edema 2 +

  15. Case Presentation • Special populations help define your approach. • African Americans: • CHF • Diabetics:

  16. Case Presentation • Special populations help define your approach. • African Americans: Volume Mediated, Low renin low Aldo. • CHF: ACE, Diuretics, B-blocker • Diabetics: ACE or ARB.

  17. Case Presentation • 56 y.o. A.A. male with edema, HTN • Normal labs and UA. Normal CXR and EKG. • Meds: Clonidine 0.2 BID • ACE inhibitor • Diltiazem 300 mg daily • Whats Missing???

  18. Case Presentation • 56 y.o. A.A. male with refractory HTN. • Meds: Clonidine 0.2 BID • ACE inhibitor - Stopped • Diltiazem 300 mg daily • I added HCTZ 50 mg daily.

  19. Case Presentation • 56 y.o. A.A. male with refractory HTN. • Meds: Clonidine 0.2 BID • Diltiazem 300 mg daily • HCTZ 50 mg daily. • Still swelling, BP a little better. 156 / 100.

  20. Case • 56 y.o. AA male with refractory HTN. • I changed diuretics to Lasix and Zaroxolyn. • I get a call 3 days later: Swellings gone, but I can’t get out of bed – too dizzy!

  21. Case Presentation • 56 y.o. A.A. male with refractory HTN. • Meds: Lasix 40 mg BID • Zaroxolyn 5 mg weekly • No swelling, BP 126 / 80. • Pt reports joint pain and swelling. What test do you order next?

  22. Case • Uric acid level is 12 • Creatinine 1.4 • K 3.8 • Glucose 244 (nonfasting)

  23. Case • Started Allopurinol for gout. • Pt started exercising and watching diet. • Sugars normalized without treatment.

  24. Classes of Antihypertensives • Diuretics • Rate control agents • ACE/ ARB’s • Vasodilators • Central agents: clonidine, aldomet. • Big Guns

  25. Classes of Antihypertensives • Diuretics • Thiazide: HCTZ/ Combination drugs, • Metolazone • K sparing: Spironolactone, Triamterine • Amiloride • Loop Diuretic: • Lasix, Bumex, Demedex • Edecrin (non sulfa)

  26. Classes of Antihypertensives • Diuretics • Rate control agents • BBlocker, • Verapamil, Diltiazem (CCB’s) • Amiodorone, Digoxin • target pulse rate less than 70 to achieve maximal effectiveness. (not much bang for the buck once pulse lower than 60, with increased risk.)

  27. Classes of Antihypertensives • Diuretics • Rate control agents • ACE/ ARB’s • Multitude of benefits for the • Kidneys and heart • May get extra benefit from addition of HCT.

  28. Classes of Antihypertensives • Diuretics, Rate control agents, ACE/ ARB’s • Vasodilators • Alpha blockers - Cardura, Hytrin • DHP CCB’s Nifedipine, Amlodipine, Felodipine • Nitric oxide synthase stimulators - hydralazine, Minoxidil, Isordil

  29. Classes of Antihypertensives • Diuretics, Rate control agents, ACE/ ARB’s • Vasodilators • Central agents: • clonidine, (remember to consider the patch) • aldomet - (used more commonly by Obstetrics)

  30. Classes of Antihypertensives • Diuretics, Rate control agents, ACE/ ARB’s • Vasodilators, Central agents • Big Guns: • Minoxidil - must have rate control and loop diuretic on board before starting this. • Phenoxybenzamine - peripheral alpha-1 blocker.

  31. Nephrology level htn • I tell the pt that will need to control the main route plus the main detours causing the HTN. • Rate control (pulse < 78) • Diuretic • Vasodilator DHP CCB, Hydralazine, Cardura, Minoxidil. • ACE / ARB (accept 30% increase in creat if BP responds)

  32. Refer to Nephrologist • If unable to control on 3 drug regimen which includes Rate control, diuretic. • If you are considering Minoxidil • If creatinine climbs more than 30 % or if creatinine is over 2.0.

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