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CONTROL OF HYPERTENTION IN SPECIAL GROUPS

CONTROL OF HYPERTENTION IN SPECIAL GROUPS. HYPERTENTION IN PREGNANCY. Complicates 10-20% of pregnancies Elevation of BP ≥140 mmHg systolic and/or ≥90 mmHg diastolic, on two occasions at least 6 hours apart. Etiology & Definition. Chronic Hypertension Gestational Hypertension Preeclampsia

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CONTROL OF HYPERTENTION IN SPECIAL GROUPS

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  1. CONTROL OF HYPERTENTION IN SPECIAL GROUPS

  2. HYPERTENTION IN PREGNANCY

  3. Complicates 10-20% of pregnancies Elevation of BP ≥140 mmHg systolic and/or ≥90 mmHg diastolic, on two occasions at least 6 hours apart. Etiology & Definition

  4. Chronic Hypertension Gestational Hypertension Preeclampsia Preeclampsia superimposed on Chronic Hypertension Categories

  5. “Preexisting Hypertension” Definition Systolic pressure ≥ 140 mmHg, diastolic pressure ≥90 mmHg, or both. Presents before 20th week of pregnancy or persists longer then 12 weeks postpartum. Causes Primary = “Essential Hypertension” Secondary = Result of other medical condition (ie: renal disease) Chronic Hypertension

  6. Prenatal Care for Chronic Hypertensives • Electrocardiogram should be obtained in women with long-standing hypertension. • Baseline laboratory tests • Urinalysis, urine culture, and serum creatinine, glucose, and electrolytes • Tests will rule out renal disease, and identify comorbidities such as diabetes mellitus. • Women with proteinuria on a urine dipstick should have a quantitative test for urine protein.

  7. Treatment for Chronic Hypertension • Avoid treatment in women with uncomplicated mild essential HTN as blood pressure may decrease as pregnancy progresses. • May taper or discontinue meds for women with blood pressures less than 120/80 in 1st trimester. • Reinstitute or initiate therapy for persistent diastolic pressures >95 mmHg, systolic pressures >150 mmHg, or signs of hypertensive end-organ damage. • Medication choices = Oral methyldopa and labetalol.

  8. Definition = New onset of hypertension and proteinuria after 20 weeks gestation. Systolic blood pressure ≥140 mmHg OR diastolic blood pressure ≥90 mmHg Proteinuria of 0.3 g or greater in a 24-hour urine specimen Preeclampsia before 20 weeks, think MOLAR PREGNANCY! Categories Mild Preeclampsia Severe Preeclampsia Eclampsia Occurrence of generalized convulsion and/or coma in the setting of preeclampsia, with no other neurological condition. Preeclampsia

  9. Severe Preeclampsia must have one of the following: Symptoms of central nervous system dysfunction = Blurred vision, scotomata, altered mental status, severe headache Symptoms of liver capsule distention = Right upper quadrant or epigastric pain Nausea, vomiting Hepatocellular injury = Serum transaminase concentration at least twice normal Systolic blood pressure ≥160 mm Hg or diastolic ≥110 mm Hg on two occasions at least six hours apart Thrombocytopenia = <100,000 platelets per cubic milimeter Proteinuria = 5 or more grams in 24 hours Oliguria = <500 mL in 24 hours Severe fetal growth restriction Pulmonary edema or cyanosis Cerebrovascular accident Preeclampsia

  10. Affects 10-25% of patients with chronic HTN Preexisting Hypertension with the following additional signs/symptoms: New onset proteinuria Hypertension and proteinuria beginning prior to 20 weeks of gestation. A sudden increase in blood pressure. Thrombocytopenia. Elevated aminotransferases. Preeclampsia superimposed on Chronic Hypertension

  11. Treatment of Preeclampsia • Definitive Treatment = Delivery • Major indication for antihypertensive therapy is prevention of stroke. • Diastolic pressure ≥105-110 mmHg or systolic pressure ≥160 mmHg • Choice of drug therapy: • Acute – IV labetalol, IV hydralazine, SR Nifedipine • Long-term – Oral methyldopa or labetalol

  12. Mild hypertension without proteinuria or other signs of preeclampsia. Develops in late pregnancy, after 20 weeks gestation. Resolves by 12 weeks postpartum. Can progress onto preeclampsia. Often when hypertension develops <30 weeks gestation. Indications for and choice of antihypertensive therapy are the same as for women with preeclampsia. Gestational Hypertension

  13. Nulliparity Preeclampsia in a previous pregnancy Age >40 years or <18 years Family history of pregnancy-induced hypertension Chronic hypertension Chronic renal disease Antiphospholipid antibody syndrome or inherited thrombophilia Vascular or connective tissue disease Diabetes mellitus (pregestational and gestational) Multifetal gestation High body mass index Male partner whose previous partner had preeclampsia Hydrops fetalis Unexplained fetal growth restriction Risk Factors for Hypertension in Pregnancy

  14. Evaluation of Hypertension in Pregnancy • History • ID and Complaint • HPI (S/S of Preeclampsia) • Past Medical Hx, Past Family Hx • Past Obstetrical Hx, Past Gyne Hx • Social Hx • Medications, Allergies • Prenatal serology, blood work • Assess for Hypertension in Pregnancy risk factors • Physical • Vitals • HEENT = Vision • Cardiovascular • Respiratory • Abdominal = Epigastric pain, RUQ pain • Neuromuscular and Extremities = Reflex, Clonus, Edema • Fetus = Leopold’s, FM, NST

  15. Laboratory Tests CBC (Hgb, Plts) Renal Function (Cr, UA, Albumin) Liver Function (AST, ALT, ALP, LD) Coagulation (PT, PTT, INR, Fibrinogen) Urine Protein (Dipstick, 24 hour) Evaluation of Hypertension in Pregnancy

  16. Depends on severity of hypertension and gestational age!!!! Observational Management Restricted activity Close Maternal and Fetal Monitoring BP Monitoring S/S of preeclampsia Fetal growth and well being (NST, and U/S) Routine weekly or biweekly blood work Management of Hypertension in Pregnancy

  17. Medical Management Acute Therapy = IV Labetalol, IV Hydralazine, SR Nifedipine Expectant Therapy = Oral Labetalol, Methyldopa, Nifedipine Eclampsia prevention = MgSO4 Contraindicated antihypertensive drugs ACE inhibitors Angiotensin receptor antagonists Management of Hypertension in Pregnancy

  18. Proceed with Delivery Vaginal Delivery VS Cesarean Section Depends on severity of hypertension! May need to administer antenatal corticosteroids depending on gestation! Only cure is DELIVERY!!! Management of Hypertension in Pregnancy

  19. Definitions and classification of office BP levels (mmHg)* Hypertension: SBP >140 mmHg ± DBP >90 mmHg * The blood pressure (BP) category is defined by the highest level of BP, whether systolic or diastolic. Isolated systolic hypertension should be graded 1, 2, or 3 according to systolic BP values in the ranges indicated.

  20. JNC 8: Graded Recommendations • A – Strong evidence • B – Moderate evidence • C – Weak evidence • D – Against • E – Expert Opinion • N – No recommendation

  21. JNC 8: Drug TreatmentThresholds and Goals • Age > 60 yo • Systolic: • Threshold > 150 mmHg • Goal < 150 mmHg • LOE: Grade A • Diastolic: • Threshold > 90 mmHg • Goal < 90 mmHg • LOE: Grade A

  22. JNC 8: Drug TreatmentThresholds and Goals • Age < 60 yo • Systolic: • Threshold > 140 mmHg • Goal < 140 mmHg • LOE: Grade E • Diastolic: • Threshold > 90 mmHg • Goal < 90 mmHg • LOE: Grade A for ages 40-59; Grade E for ages 18-39

  23. JNC 8: Drug TreatmentThresholds and Goals • Age > 18 yo with CKD or DM • JNC 7: < 130/80 (MDRD NEJM 1994) • Systolic: • Threshold > 140 mmHg • Goal < 140 mmHg • LOE: Grade E • Diastolic: • Threshold > 90 mmHg • Goal < 90 mmHg • LOE: Grade E

  24. JNC 8: Initial Drug Choice • Nonblack, including DM • Thiazide diuretic, CCB, ACEI, ARB • LOE: Grade B • Black, including DM • Thiazide diuretic, CCB • LOE: Grade B (Grade C for diabetics)

  25. JNC 8: Initial Drug Choice • Age > 18 yo with CKD and HTN (regardless of race or diabetes) • Initial (or add-on) therapy should include an ACEI or ARB to improve kidney outcomes • LOE: Grade B • Blacks w/ or w/o proteinuria • ACEI or ARB as initial therapy (LOE: Grade E) • No evidence for RAS-blockers > 75 yo • Diuretic is an option for initial therapy

  26. JNC 8: Subsequent Management • Reassess treatment monthly • Avoid ACEI/ARB combination • Consider 2-drug initial therapy for Stage 2 HTN (> 160/100) • Goal BP not reached with 3 drugs, use drugs from other classes • Consider referral to HTN specialist • LOE: Grade E

  27. Blood pressure goals in hypertensive patients SBP, systolic blood pressure; CV, cardiovascular; TIA, transient ischaemic attack; CHD, coronary heart disease; CKD, chronic kidney disease;DBP, diastolic blood pressure.

  28. Hypertension treatment for people with diabetes SBP, systolic blood pressure; DBP, diastolic blood pressure; RAS, renin–angiotensin system.

  29. Hypertension treatment for people with nephropathy SBP, systolic blood pressure; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; RAS, renin–angiotensin system.

  30. Comparison of RecentGuideline Statements

  31. Comparison of RecentGuideline Statements

  32. Goal BP **KDIGO: <140/90 w/o albuminuria <130/80 if >30 mg/24hr *ADA: < 140/80 or lower

  33. Lifestyle changes for hypertensive patients * Unless contraindicated. BMI, body mass index.

  34. Hypertension in the Elderly • Fastest growing segment of the population • Prevalence of hypertension is very high • Several issues make managing HTN unique: • Often present with isolated systolic HTN • More likely to present with comorbidities • Many clinical trials in HTN have excluded these patients (particularly for those 80 years and older) • Elderly are more susceptible to certain adverse effects (orthostatic hypotension)

  35. Hypertension in the Elderly • HYVET demonstrated that treatment of HTN to goal BP less than 150/80 mm Hg in patients >80 years old was safe and effective • But…what about a lower BP goal? • And…what about the patients age 60-80?

  36. Hypertension in the Elderly • Two “treat-to-target” trials in this age group • Japanese Trial to Assess Optimal SBP (JATOS) • 4416 patients aged 65-85 (average age of 74) • Randomized to SBP<140 vs. SBP 140-160 • Achieved BP of 136/75 vs. 146/78 • No difference in CV events or renal failure (p=0.99) • VALISH trial • 3079 patients aged 70-84 (average age of 76) • Randomized to SBP<140 or SBP 140-149 • No significant reductions in stroke, CV events, or renal failure • Overall event rates were lower than anticipated in both of these studies JATOS Study Group. Hypertens Res 2008;31:2115-27. Ogihara T et al. Hypertension 2010;56:196-202.

  37. Hypertension in the Elderly • The opposing arguments: • The Japanese trials had low event rates and may not represent the risks in other populations • Data from other studies suggests a goal SBP closer to 140mm Hg may be more appropriate for ages 60-80 • Methodology may have prevented JNC-8 panel from considering the results in their analysis • The “Speed Limit” effect Wright JT Jr et al. Ann Intern Med 2014;160:499-504.

  38. Hypertension in Diabetics • Action to Control CV Risk in Diabetes (ACCORD) • Randomized, double-blind trial • Included patients with T2DM and high CV risk • Randomized to SBP<120 or SBP<140 • Primary outcome of CV death, MI, or stroke • Results • Mean SBP of 119 mm Hg vs. 133 mm Hg • No significant difference in primary outcome (HR=0.88, p=0.2) • Incidence of stroke was lower with intensive treatment (HR 0.59, p=0.01) • Significant increase in serious adverse events The ACCORD Study Group. N Engl J Med 2010;362:1575-85.

  39. Comparisons to Other Guidelines Adapted from Salvo M et al. Ann Pharmacother 2014;48:1242-8.

  40. Comparisons to Other Guidelines Adapted from Salvo M et al. Ann Pharmacother 2014;48:1242-8.

  41. Hypertension and The KidneyUpdate: Clinical Trials Paul J. Scheel, Jr., M.D. Director, Division of Nephrology The Johns Hopkins University School of Medicine

  42. Primary Diagnosis in Patients With Kidney Disease Patient Primary Diagnosis Other Glomerulonephritis Diabetes 45% Hypertension USRDS 2010Annual Data Report. The data reported here have been supplied by the USRDS. The interpretation and reporting of these data are the responsibility of the author(s) and in no way should be seen as an official policy or interpretation of the U.S. government. Available at: www.usrds.org. Accessed 3/28/05.

  43. Combination Therapy for BP Control: Rule Rather Than Exception Trial/Systolic Blood Pressure Achieved ALLHAT IDNT RENAAL UKPDS ABCD MDRD HOT AASK 138 mm Hg 138 mm Hg 141 mm Hg 144 mm Hg 132 mm Hg 132 mm Hg 138 mm Hg 128 mm Hg Number of BP Medications Adapted from Bakris et al. Am J Kidney Dis. 2000;36:646-661.

  44. 95 98 101 104 107 110 113 116 119 Lower BP Slows Decline in GFR MAP (mmHg) 0 -2 -4 -6 Untreated HTN -8 GFR (mL/min/year) -10 -12 130/85 140/90 -14 Bakris GL et al. Am J Kidney Dis.2000; 36(3):646-661.

  45. Hypertension and The KidneySignificant Publications 2013 • The Coral Trial • Symplicity HTN I, II, III Study • JNC VIII

  46. Atherosclerotic Narrowing of Proximal Renal Artery

  47. CORAL Trial • 947 Patients • Radomized • Medical Therapy • Medical Therapy plus Stent • Systolic HTN despite 2 or more drugs or CKD • Endpoints: Death,MI, Stroke, CHF, Progressive CKD or Need for Dialysis

  48. Kaplan–Meier Curves for the Primary Outcome. Cooper CJ et al. N Engl J Med 2014;370:13-22.

  49. Cooper et al.NEJM. 2014;370(1):13-22

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