Progress of the National High Blood Pressure Education Program

3. Progress of theNational High Blood Pressure Education Program Decreased morbidity and mortality from stroke and coronary heart disease (CHD) has been reached However, the incidences of renal failure and congestive heart failure are still increasing

6. Prevalence of Heart Failure,by Age, 1976-80 and 1988-91

7. Incidence of Reported End-Stage Renal Disease Therapy, 1982-1995

8. Public Health Challenges for the National High Blood Pressure Education Program Prevent blood pressure rise with age Decrease prevalence Increase awareness and detection Improve control Reduce cardiovascular risks

9. Public Health Challenges for the National High Blood Pressure Education Program (continued) Recognize importance of controlled isolated systolic hypertension Recognize importance of high-normal blood pressure Improve opportunities for treatment

10. Awareness, Treatment, and Control of High Blood Pressure in Adults*

11. Blood Pressure Measurement Patients should be seated with back supported and arm bared and supported. Patients should refrain from smoking or ingesting caffeine for 30 minutes prior to measurement. Measurement should begin after at least 5 minutes of rest. Appropriate cuff size and calibrated equipment should be used. Both SBP and DBP should be recorded. Two or more readings should be averaged.

12. Advantages of Self-Measurement Identifies “white-coat hypertension” Assesses response to medication Improves adherence to treatment Potentially reduces costs Usually provides lower readings than those recorded in clinic

13. Ambulatory Measurement Ambulatory monitoring can provide: readings throughout day during usual activities readings during sleep to assess nocturnal changes measures of SBP and DBP load Ambulatory readings are usually lower than in clinic Hypertension is now defined as SBP >135 mm Hg and DBP 85 mm Hg.

14. Classification of Blood Pressure for Adults

15. Evaluation Objectives To identify known causes To assess presence or absence of target organ damage and cardiovascular disease To identify other risk factors or disorders that may guide treatment

16. Evaluation Components Medical history Physical examination Routine laboratory tests Optional tests

17. Medical History Duration and classification of hypertension Patient history of cardiovascular disease Family history Symptoms suggesting causes of hypertension Lifestyle factors Current and previous medications

18. Physical Examination Blood pressure readings (2 or more) Verification in contralateral arm Height, weight, and waist circumference Fundus oculi examination Examination of the neck, heart, lungs, abdomen, and extremities Neurological assessment

19. Laboratory Tests and Other Diagnostic Procedures Routine biochemistry Special examination to determine presence of other risk factors and target organ damage See specific causes of hypertension

20. Laboratory Tests Recommended Before Initiating Therapy Urinalysis Complete blood count Blood chemistry (potassium, sodium, creatinine, and fasting glucose) Lipid profile 12-lead electrocardiogram

21. Optional Tests and Procedures Creatinine clearance Microalbuminuria 24-hour urinary protein Serum uric acid HbA1c Thyroid hormones Plasma renin activity and urinary Na+ excretion Echocardiography Vascular ultrasonography Measurement of (ABI)

22. Examples of IdentifiableCauses of Hypertension Renovascular disease Renal parenchymal disease Polycystic kidneys Aortic coarctation

23. Exogenous causesThat May Induce Hypertension Mineralocorticoids and derivatives Anabolic steroids Monoamine oxidase inhibitors Bromocriptine Cocaine

24. Components of Cardiovascular Risk in Patients With Hypertension Major Risk Factors: Smoking Dyslipidemia Diabetes mellitus Age older than 60 years Sex (men or postmenopausal women) Family history of cardiovascular disease

25. Clinical Risk Factors forStratification of Patients With Hypertension Heart disease Stroke or transient ischemic attack Nephropathy Peripheral arterial disease Retinopathy

27. Goal of HypertensionPrevention and Management To reduce morbidity and mortality by the least intrusive means possible. This may be accomplished by achieving and maintaining: SBP < 140 mm Hg DBP < 90 mm Hg controlling other cardiovascular risk factors

28. Treatment of arterial hypertension Decreases cardiovascular morbidity and mortality based on randomized controlled trials. Protects against stroke, coronary events, heart failure, progression of renal disease, progression to more severe hypertension, and all-cause mortality.

29. Lifestyle Modifications For Prevention and Management Lose weight if overweight. Limit alcohol intake. Increase aerobic physical activity. Reduce sodium intake. Maintain adequate intake of potassium. For Overall and Cardiovascular Health Maintain adequate intake of calcium and magnesium. Stop smoking. Reduce dietary saturated fat and cholesterol.

30. Drug Therapy A low dose of initial drug should be used, slowly titrating upward. Optimal formulation should provide 24-hour efficacy with once-daily dose with at least 50% of peak effect remaining at end of 24 hours. Combination therapies may provide additional efficacy with fewer adverse effects.

31. Classes ofAntihypertensive Drugs ACE inhibitors Adrenergic inhibitors Angiotensin II receptor blockers Calcium antagonists Direct vasodilators Diuretics

32. Combination Therapies ?-adrenergic blockers and diuretics ACE inhibitors and diuretics Angiotensin II receptor antagonists and diuretics Calcium antagonists and ACE inhibitors Other combinations (dihydropyridine calcium antagonists and betablockers)

33. Follow-up Follow up within 1-2 months after initiating therapy. Recognize that high-risk patients often require high dose or combination therapies and shorter intervals between changes in medications. Consider reasons for lack of responsiveness if blood pressure is uncontrolled after reaching full dose. Consider reducing dose and number of agents after 1 year at or below goal.

34. Algorithm for Treatment of Hypertension

35. Algorithm for Treatment of Hypertension

39. Specific Drug Indications Angina pectoris ?-blockers (effort) Calcium antagonists (rest angina) Atrial tachycardia and fibrillation ?-blockers Nondihydropyridine CCB Heart failure Betablockers ACEI/ATII receptors antagonists Frusemide Myocardial infarction Beta-blockers Diltiazem Verapamil

40. Specific Indications Dyslipidemia ACEI – CCB – alpha-blockers Benign prostatic hyperplasia alpha-blockers Renal failure (caution in renovascular hypertension with creatinine > 3 mg/dl) ACE inhibitors/ATII receptors antagonists Cyclosporine-induced hypertension Calcium antagonists

41. Specific Indications Essential tremor Non-cardioselective ?-? (propranolol) Hyperthyroidism ?-blockers Migraine Noncardioselective ?-? (propranolol) Nondihydropyridine CCB Perioperative hypertension ?-blockers (bisoprolol)

43. Algorithm for Treatment of Hypertension (continued)

44. Causes for InadequateResponse to Drug Therapy Nonadherence to therapy Volume overload Drug-related causes Associated conditions Identifiable causes of hypertension (secondary hypertension)

45. Hypertensive Emergencies and Urgencies Emergencies require immediate blood pressure reduction to prevent or limit target organ damage. Urgencies benefit from reducing blood pressure within a few hours. Elevated blood pressure alone rarely requires emergency therapy. Fast-acting drugs are available.

46. Drugs Available forHypertensive Emergencies Vasodilators Nitroprusside Nifedipine Nitroglycerin Enalaprilat Hydralazine Adrenergic Inhibitors Clonidine Labetalol Esmolol Phentolamine

47. Special Populations Racial and ethnic groups Children and adolescents Women Older persons

48. Children and Adolescents BP at 75th or higher percentile is considered elevated. Lifestyle modifications should be recommended. Drug therapy should be prescribed for higher levels of blood pressure. Attempts should be made to determine other causes of high BP and other cardiovascular RF.

49. 95th Percentile of Blood Pressure by Selected Ages and Height in Girls

50. 95th Percentile of Blood Pressure by Selected Ages and Height in Boys

51. Pregnant Women Chronic hypertension is high BP present before pregnancy or diagnosed before 20th week of gestation (4th-5th month). Preeclampsia is increased BP that occurs in pregnancy (generally after the 20th week) and is accompanied by edema, proteinuria, or both. ACE inhibitors and angiotensin II receptor blockers are contraindicated for pregnant women. Methyldopa is recommended for women diagnosed during pregnancy.

52. Older Persons Hypertension is common. SBP is better predictor of events than DBP. Pseudohypertension and “white-coat hypertension” may indicate need for readings outside office. Primary hypertension is most common cause, but common identifiable causes (e.g., renovascular hypertension) should be considered.

53. Older Persons (continued) Therapy should begin with lifestyle modifications. Starting doses for drug therapy should be lower than those used in younger adults. Goal of therapy is the same (< 140/90 mm Hg) although an interim goal of SBP < 160 mm Hg may be necessary. Diuretics and Dyidropiridine CCB well indicated

54. Special Situations Cardiovascular diseases Renal disease Diabetes mellitus Dyslipidemia

55. Cardiovascular Diseases Cerebrovascular disease Indication for treatment, except immediately after ischemic cerebral infarction Left ventricular hypertrophy Antihypertensive agents (except direct vasodilators) indicated (ACEI=ATII receptors antagonist > CCB > B-Blockers) Reduced weight and decreased sodium intake beneficial

56. Cardiovascular Diseases (continued) Peripheral arterial disease Limited or no data available (prefere ACEI – CCB – alpha-blockers)

57. Renal Disease Hypertension may result from renal disease that reduces functioning nephrons. Evidence shows a clear relationship between high BP and end-stage renal disease. BP should be controlled to < 130/85 mm Hg? or lower (< 125/75 mm Hg) in patients with proteinuria in excess of 1 gram per 24 hours. ACEI and ATII receptors blocker work well to control BP and slow progression of renal failure.

58. Diabetes Mellitus Drug therapy should begin along with lifestyle modifications to reduce BP to < 130/85 mm Hg. ACEI and ATII receptors antagonists, ?-blockers, calcium antagonists, and low dose-diuretics are preferred. Insulin resistance or high peripheral insulin levels may cause hypertension, which can be treated with lifestyle changes, insulin-sensitizing agents, antihypertensive drugs, and lipid-lowering agents.

59. Dyslipidemia Coexistence of hypertension and dyslipidemia requires aggressive management. Emphasis should be on weight loss; reduced intake of saturated fat, cholesterol, sodium, and alcohol; and increased physical activity. Lifestyle changes and hypolipidemic agents should be used to reach appropriate goals. Drugs not interfering with lipids: alphablockers – ACEI – ATII receptors antagonists - CCB

60. Sleep Apnea Obstructive sleep apnea is more common in patients with hypertension and is associated with several adverse clinical consequences. Improved hypertension control has been reported following treatment of sleep apnea.

61. Bronchial Asthma or Chronic Airway Disease Elevated blood pressure is common in acute asthma and it is possibly related to treatment with systemic corticosteroids or ?-agonists. ?-blockers and??-?-blockers may exacerbate asthma. ACEI frequently may induce cough and rarely bronchospasm. Diuretics, alpha-blockers and CCB may be used

62. Gout Diuretics can increase serum uric acid levels. Diuretics should be avoided in patients with gout. Diuretic-induced hyperuricemia does not require treatment in the absence of gout or urate stones.

63. Patients Undergoing Surgery When possible, surgery should be delayed until blood pressure is < 180/110 mm Hg. Those not on prior drug therapy may be best treated with cardioselective??-blockers before and after surgery. Those with controlled blood pressure should continue medication until surgery and begin as soon after surgery as possible.

64. Cocaine and Amphetamines Cocaine abuse must be considered in patients presenting to the emergency department with hypertension-related problems. Nitroglycerin is indicated to reverse cocaine-related coronary vasoconstriction. Acute amphetamine toxicity is similar to that of cocaine but longer in duration. Ongoing cocaine abuse does not appear to cause chronic hypertension.

65. Immunosuppressive Agents Immunosuppressive regimens produce widespread vasoconstriction in both transplant and nontransplant situations. Treatment is based on vasodilation including dihydropyridine calcium antagonists.