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Update on the Management of Hypertention

Update on the Management of Hypertention. Timothy A. Denton, M.D. Divisions of Cardiology and Cardiothoracic Surgery Cedars-Sinai Medical Center Los Angeles. Outline. Role of BP Etiology of HTN Evaluation JNC VI. Why do we need blood pressure?. Why do we need blood pressure?.

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Update on the Management of Hypertention

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  1. Update on the Management of Hypertention Timothy A. Denton, M.D. Divisions of Cardiology and Cardiothoracic Surgery Cedars-Sinai Medical Center Los Angeles

  2. Outline • Role of BP • Etiology of HTN • Evaluation • JNC VI

  3. Why do we need blood pressure?

  4. Why do we need blood pressure? • Get blood to the scalp • Distribute flow quickly

  5. Classification of HTN • Primary • Secondary

  6. Physiology of HTN • Primary Hypertension • ? Central / peripheral adrenergic • ? renal • ? hormonal • ? vascular

  7. Physiology of HTN • Secondary • Wide Pulse Pressure Aortic compliance Stroke volume • Normal Pulse Pressure Renal Endocrine Neurogenic Misc

  8. Etiology of HTN Normal Pulse Pressure • Renal Chronic pyelonephritis Glomerulonephritis Polycystic kidney Renovascular Other renal • Endocrine Oral contraceptives Adrenocortical (Cushing, hyperaldo, 17 hydroxylase, 11-hydroxylase) Pheochromocytoma Myxedema Acromegaly • Neurogenic Psychogenic Familial dysautonomia Polyneuritis Increased intracranial pressure Spinal cord section • Misc Coarctation Intravascular volume Polyarteritis nodosa Hypercalcemia Acute intermittent porphyria Pre-eclampsia

  9. Etiology of HTN Wide Pulse Pressure • Decreased aortic compliance • Increased stroke volume AI Thyrotoxicosis Hyperkinetic heart syndrome Fever AV fistula / PDA

  10. Epidemiology of HTN Harrison’s Principles of Internal Medicine, 12th Edition

  11. JNC VI Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure JNC VI -- Arch Int Med 1997;157:2413

  12. Classification of HTN JNC VI -- Arch Int Med 157:2413, 1997

  13. Risk Classification JNC VI -- Arch Int Med 157:2413, 1997

  14. Undertreatment

  15. Undertreatment of Hypertension Berlowitz, NEJM 1998;339:1957

  16. Undertreatment of Hypertension Berlowitz, NEJM 1998;339:1957

  17. Undertreatment of Hypertension Berlowitz, NEJM 1998;339:1957

  18. Classes of Anti-Hypertensives (1999 PDR) Adrenergic blockers Alpha/Beta adrenergic blockers ACE inhibitors ACE + Ca blockers ACE + diuretics ARB’s ARB’s with diuretics Beta blockers Beta blockers with diuretics Calcium blockers Diuretics Rauwolfia derivatives Vasodilators

  19. Preparations of Anti-Hypertensives by Class (1999 PDR) Adrenergic blockers Alpha/Beta adrenergic blockers ACE inhibitors ACE + Ca blockers ACE + diuretics ARB’s ARB’s with diuretics Beta blockers Beta blockers with diuretics Calcium blockers Diuretics Rauwolfia derivatives Vasodilators 6 5 11 4 5 4 2 15 6 25 24 2 18 Total = 127

  20. Special Considerations In African-Americans: -- low probability of success with Beta blockers or ACE or ARB’s -- higher probability of success with diuretics or Ca blockers

  21. If you have not achieved goal, you must change your therapy

  22. You push a medication’s dose to EFFECT or SIDE EFFECT or maximal recommended dose

  23. “The committee recognizes that the responsible clinician’s judgment of the individual patient’s needs remains paramount.” JNC VI -- Arch Int Med 1997;157:2413

  24. Compelling Indications JNC VI -- Arch Int Med 157:2413, 1997

  25. Pressure/Volume Relation Pressure = 150 mmHg Pressure = 120 mmHg Fluid Flux Fluid Flux Vasculature

  26. Combination Drugs: A Different Animal • Beta blocker + diuretic • ACE + diuretic • ACE + calcium blocker • ARB + diuretic • Diuretic + diuretic • “other” + diuretic

  27. HOPE Trial Heart Outcomes Prevention Evaluation Study NEJM 2000;342:145-153

  28. Backgroud • Activation of renin-angiotensin- aldosterone system may be a mortality risk factor • ACE therapy can reduce MI’s Circ 1994;90:2056, Lancet 1992;340:1173,JNC VI NEJM 1992;327:669 HOPE Trial, NEJM 2000;342:145-153

  29. Design • Prospective, randomized • Two-by-two factorial ramipril + vitamin E • 9,541 patients HOPE Trial, NEJM 2000;342:145-153

  30. Inclusion Criteria • > 55 years old • CAD or CVA or PVD or DM + (HTN or high LDL or low HDL or cigarettes or microalbuminuria) HOPE Trial, NEJM 2000;342:145-153

  31. Run-In • 10,576 patients • ramipril 2.5 mg qd 7-10 days then placebo 10-14 days • 1,035 excluded (noncompliance, side effects, creat, K, withdrawal) HOPE Trial, NEJM 2000;342:145-153

  32. Follow-up • First follow-up 1 month • Subsequent follow-ups q 6 months • Scheduled for 5 years HOPE Trial, NEJM 2000;342:145-153

  33. Outcome Measures • Primary endpoint: CV death or MI or CVA • Secondary endpoints: All cause mortality Revascularization Hospitalization for UA or CHF DM complications Worsening angina Cardiac Arrest any CHF UA with ECG changes DM development HOPE Trial, NEJM 2000;342:145-153

  34. Results HOPE Trial, NEJM 2000;342:145-153

  35. Angiotensinogen Inactive products Renin Inhibitor Renin increase nitric oxide, prostacyclin (improved endothelial function ? anti-atherosclerotic?) non-ACE alternative pathways (chymase, cathepsin G, chymostatin ATII generation) Angiotensin I ACE Inhibitor ACE ACE hypotension Angiotensin II Bradykinin ? angioedema AT1 receptor Inhibitor cough Vaso- constriction Vaso- dilatation Vasopressin Endothelin-1 Adapted, Bonn, D. Lancet 1998;352:378

  36. Results HOPE Trial, NEJM 2000;342:145-153

  37. Results HOPE Trial, NEJM 2000;342:145-153

  38. Results HOPE Trial, NEJM 2000;342:145-153

  39. Results HOPE Trial, NEJM 2000;342:145-153

  40. Results HOPE Trial, NEJM 2000;342:145-153

  41. Results HOPE Trial, NEJM 2000;342:145-153

  42. Results HOPE Trial, NEJM 2000;342:145-153

  43. Summary • Ramipril decreased CV mortality MI and CVA all-cause mortality Revascularization rates DM complications CHF Worsening angina New onset DM • Effects were see in all groups except those without cardiovascular disease HOPE Trial, NEJM 2000;342:145-153

  44. Implications • We have a new standard of care • All patients with vascular disease should be considered for ACE inhibition (e.g., ramipril)

  45. How to Initiate Therapy • Initial Evaluation • Good history and physical exam (note comorbidities) • Take BP in both arms • Take BP at least 2 min apart and average them • Take BP at least on two separate office visits • Look for end-organ damage • Stratify patient • Initiate drug therapy based on comorbidity and risk

  46. Evidence of End-organ Damage Eyes spasm AV nicking exudates edema Lungs rales Neck bruits JVD thyroid Abd bruits masses Heart S4 S3 Murmur Labs Chem I CBC Lipids ECG Ext pulses edema

  47. Long-term Therapy The patient must become expert on their own blood pressure

  48. Take BP at home

  49. Write each BP down in a log • 1x / day • 2x / day • 3x / day • 3x / week • etc…..

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