Hypertension

1. Hypertension Diagnosis and Treatment October 2, 2014 Joshua M. Crasner,DO,FACC,FACOI

2. Incidence • 50 million people USA • SBP>115 incr risk CAD/CVA • Q 20mm incr=2X risk • JNC-8 has changed aggressive Tx • Pseudo-HTN Hypertension 2014

3. ESSENTIAL HYPERTENSION • Most common HBP( > 90 %)--multifactorial • increased peripheral resistance perpetuates the process of high blood pressure and all of its secondary effects • structural hypertrophy giving rise to smooth muscle hypercontractility • pressure varies throughout the day • major risk factor for coronary, renal, and cerebrovascular disease (50% of all USA deaths) • leading cause of doctor’s visit • carries prognostic value: 16X increased risk 40 y.o. smokes hypertension

4. BP MEASUREMENT • Patient seated/back supported/feet on floor • Should rest 5 minutes prior • Arm at heart level • No recent caffeine, tobacco, cocaine • Take medications as directed • Cuff size important • orthostatics hypertension

5. Hypertension Focus • Determine lifestyle/CV risk factors • ID and Tx secondary causes • ID target end organ damage • brain, heart, kidney, eyes, arteries Hypertension 2014

6. Lifestyle/CV risk factors • Cigarette smoking • Obesity • Inactivity • Dyslipidemia • Diabetes mellitus • Microalbuminuria • Male>55; Female>65 • FamHx: male<55; female<65 • Metabolic syndrome Hypertension 2014

7. Secondary Causes • Endocrine • Cardiac • Renal Hypertension 2014

8. Secondary CausesEndocrine • Pheochromocytoma • Primary Aldosteronism • Cushing’s disease Hypertension 2014

9. Pheochromocytoma • 5 P’s: pressure,pain,palps,perspiration,pallor • Adrenal tumor or sympth ganglia • 2-8 cases/million/year • 0.5% in hypertensive patients • Usually sustained HBP,sometimes paroxysmal • Associated with MEN-2 a/b • Plasma metanephrines most sensitive • CT after plasma, then surgery Hypertension 2014

10. Primary Aldosteronism • Adrenal oversecretion • Hypertension,hypokalemia,alkalosis,hyper-glycemia • 2-15% incidence • Screen w/aldo-renin ratio • Unusual hypokalemia,adrenal mass, early HTN, primary relative w/same • Tx w/spironolactone,eplerenone,surgery Hypertension 2014

11. Cushing disease • Hyperglycemia, hypokalemia,HTN • 24hr cortisol • Obese, moon facies, purple striae Hypertension 2014

12. Secondary CausesCardiac • Coarctation • Obstructive sleep apnea Hypertension 2014

13. Coarctation • Constriction beyond subclavian • Weak,delayed,absent FA pulse • Rib notching on CXR • Childhood • Tx surgical Hypertension 2014

14. Obstructive Sleep Apnea • Obese, retrognathia,large neck • Loud snoring • Daytime hypersomnolence, morning headache • Polysomnography test Hypertension 2014

15. Secondary CausesRenal • Renal parenchymal disease • Renovascular HTN • Renal artery stenosis • Fibromuscular dysplasia Hypertension 2014

16. Renal parenchymal disease • Common cause secondary HTN • Rapid loss renal fxn if HTN-ive • Creat,urineanalysis,protein • Decr elimination of salt and water,incrrenin, decrvasodilation all lead to incr volume/fluid retention • Dihydropyridine CCB help decrproteinuria Hypertension 2014

17. Renovascular HTNRAS FMD Hypertension 2014

18. RED FLAGS FOR SECONDARYHYPERTENSION • Abdominal bruit: renal artery stenosis • Palps,HA,pallor,perspiration: pheochromocytoma • Obesity,moonface,purplestriae: Cushing’s • Abd mass: polycystic kidney,hydroneph • Obesity,hypersomnolence: OSAS • Agitation, sweating: cocaine, ethanol,narc w/d • Hypokalemia: hyperaldosteronism • Hypercalcemia: hyperparathyroidism hypertension

19. Simple Guide to work up secondary causes of HTN hypertension

20. Pregnancy • Alpha methyldopa first DOC • Hydralazine,some BB ok, diuretics • Avoid ACEi/ARB/renin inhibitors Hypertension 2014

21. Drugs that raise BP • BCPs • EtOH • Decongestants,diet pills • NSAIDs • MOA • Cocaine • Marijuana • Licorice • cyclosporine Hypertension 2014

22. JNC-7 Definition of HTN JAMA 289; 2560-72: 2003 hypertension

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25. JNC-8 • 1. In the general population aged ≥60 years, initiate pharmacologic treatment to lower blood pressure (BP) at systolic blood pressure (SBP) ≥150 mm Hg or diastolic blood pressure (DBP) ≥90 mm Hg and treat to a goal SBP <150 mm Hg and goal DBP <90 mm Hg. (Strong Recommendation – Grade A) In the general population aged ≥60 years, if pharmacologic treatment for high BP results in lower achieved SBP (e.g., <140 mm Hg) and treatment is well tolerated and without adverse effects on health or quality of life, treatment does not need to be adjusted. (Expert Opinion – Grade E) 2. In the general population <60 years, initiate pharmacologic treatment to lower BP at DBP ≥90 mm Hg and treat to a goal DBP <90 mm Hg. (For ages 30-59 years, Strong Recommendation – Grade A; for ages 18-29 years, Expert Opinion – Grade E) 3. In the general population <60 years, initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg and treat to a goal SBP <140 mm Hg. (Expert Opinion – Grade E) 4. In the population aged ≥18 years with chronic kidney disease (CKD), initiate pharmacologic treatment to lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg and treat to goal SBP <140 mm Hg and goal DBP <90 mm Hg. (Expert Opinion – Grade E) 5. In the population aged ≥18 years with diabetes, initiate pharmacological treatment to lower BP at SBP ≥140 mm Hg or DBP ≥90 mm Hg and treat to a goal SBP <140 mm Hg and goal DBP <90 mm Hg. (Expert Opinion – Grade E) 6. In the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme inhibitor (ACEI), or angiotensin-receptor blocker (ARB). (Moderate Recommendation – Grade B) 7. In the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or CCB. (For general black population: Moderate Recommendation – Grade B; for black patients with diabetes: Weak Recommendation – Grade C) 8. In the population aged ≥18 years with CKD, initial (or add-on) antihypertensive treatment should include an ACEI or ARB to improve kidney outcomes. This applies to all CKD patients with hypertension regardless of race or diabetes status. (Moderate Recommendation – Grade B) 9. The main objective of hypertension treatment is to attain and maintain goal BP. If goal BP is not reached within a month of treatment, increase the dose of the initial drug or add a second drug from one of the classes in recommendation 6 (thiazide-type diuretic, CCB, ACEI, or ARB). The clinician should continue to assess BP and adjust the treatment regimen until goal BP is reached. If goal BP cannot be reached with two drugs, add and titrate a third drug from the list provided. Do not use an ACEI and an ARB together in the same patient. If goal BP cannot be reached using only the drugs in recommendation 6 because of a contraindication or the need to use more than three drugs to reach goal BP, antihypertensive drugs from other classes can be used. Referral to a hypertension specialist may be indicated for patients in whom goal BP cannot be attained using the above strategy or for the management of complicated patients for whom additional clinical consultation is needed. (Expert Opinion – Grade E) 10. Although this guideline provides evidence-based recommendations for the management of high BP and should meet the clinical needs of most patients, these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient. Future guidelines should cover the full range of cardiovascular care topics, to develop an integrated approach for prevention, detection, and evaluation, along with treatment goals. Individual recommendations from discrete guidelines—such as for hypertension, cholesterol, and obesity—may not reflect the integrated care needed for many patients seen in practice. There is also a need to harmonize the hypertension guideline with other cardiovascular risk guidelines and recommendations, thereby resulting in a more coherent overall cardiovascular prevention strategy. Author(s): • DebabrataMukherjee, M.D., F.A.C.C. (Disclosure hypertension

26. Summary JNC 8 James PA, et al.,JAMA,2013 Dec18 Hypertension 2014

27. JNC 8 recommendations • General non-African population • Thiazides, CCB,ACEi,or ARB initially • General African population • Thiazides or CCB initially • CKD • Include ACEi or ARB • Uptitrate/add RX after 1mo.if not at goal • Don’t use ACEi and ARB jointly • If >3 Rx needed refer to specialist Hypertension 2014 James PA, et al.,JAMA, 2013 Dec 18

28. 5 of 17 JNC 8 authors disagree!!! • ANSWER?? • FOLLOW THE AHA/ACC BP guidelines • Start lifestyle changes and then Rx at 140/90 up to age 80, then at 150/90 • Position paper of JACC July 2014 refutes, citing placement of mostly elderly African-American women at incr. risk for CVD mortality** **Krakoff, et al; JACC, July 29,2014;394-402 Hypertension 2014

29. Hypertension 2014

30. LAB TESTING • Urine analysis • Chemistry panel • Cholesterol • CBC • Endocrine • Drug screen hypertension

31. PHARMACOLOGIC TREATMENT • Heart failure: ACEi, ARB, diuretics, BB • Diabetes: ACEi, ARB • CAD/post-MI: BB, ACEi,(CCB for intol.) • Systolic HTN: ACEi/ARB with diuretic, BB, CCB • Pregnancy: labetalol, methyldopa, CCB • Prostate enlargement: alpha blocker • Renal disease: ACEi or ARB hypertension

32. Summary--BP Goals • <140/90 • Diabetics/CKD/High risk CAD <130/80 • Reduced EF; proteinuria <120/80 • Stay tuned for AHA/ACC update 2015 Hypertension 2014

33. REVIEW POINTS • Familiarity with target end-organ damage • What is ideal BP? • Causes of secondary hypertension • Ideal agents for condition(s) • Familiarity with treatment options hypertension