HypertensionHypertension

Howard L. Sacher, D.O.Long Island Cardiology and Internal Medicine

Learning ObjectivesLearning Objectives To know how to detect and diagnose hypertension

and its secondary causes.

To become familiar with updated recommendations for classifying hypertensive patients.

To understand the pharmacologic options for treating hypertension and their appropriate use.

To grasp the importance of counseling patients on lifestyle modification to help control hypertension

HypertensionHypertension

Hypertension is the most well established and important risk factor for– 1 Cardiovascular disease– 2 Cerebrovascular events– 3 Congestive Heart Failure (CHF)– 4 End stage renal disease (ESRD)

Hypertension (cont)Hypertension (cont)

There have been enormous advances in our understanding of the value of treating hypertension over the past three decades, yet the most recent surveys show that hypertension remains largely untreated and uncontrolled

Hypertension (cont)Hypertension (cont)

The relationship between systolic and diastolic blood pressure is strong, graded and continuous

A. The higher the BP, the higher the risk

B. Systolic BP is a better predictor of cardiovascular disease at all ages but particularly in the older age group

C. Diastolic BP does not rise with age after the fifth decade, a time when isolated systolic BP begins to increase sharply in prevalence

Patient EvaluationPatient Evaluation

Repeat BP’sTeach Patients to take BP’s

– Promotes participation by patient– May reduce costs by reducing visits

Ambulatory BP monitoring– BP – – Evaluate diurnal variations

Patient at a greater risk for end organ disease

Patient Evaluation (cont)Patient Evaluation (cont)

A. History – medication , lifestyle habits such as diet, exercise, smoking history, family history and review of symptoms that may reflect secondary hypertension, target organ disease or co-morbid conditions

Patient Evaluation (cont)Patient Evaluation (cont)

A. Physical Exam – 1. BP – standing and sitting in both arms and

legs1. Looking for patients with orthostatic hypotension

over 602. Coarctation of the aorta in younger patients3. Peripheral vascular disease

2. Fundoscopic exam – looking for evidence of hypertensive retinopathy

Patient Evaluation (cont)Patient Evaluation (cont)

3. Evaluation of the Heart1. S4 – decreased LV function compliance precedes

systolic dysfunction or S3 gallop

2. Evidence of CHF1. Rales (Crackles)

2. Hepatomegaly

3. Peripheral Edema

4. Neurological exam for evidence of Cerebrovascular disease

Patient Evaluation (cont)Patient Evaluation (cont)

5. Laboratory Evidence1. Complete blood count (CBC)

1. Renal failure and polycythemia

2. Chemistries – Na+, K+, creatinine, fasting glucose and lipid profile

1. K+ - low in hyperaldosteronism, high in renal failure

3. Urinalysis

4. 12 lead EKG1. LVH, Ischemia

PheochromocytomaPheochromocytoma

Pheochromocytoma– Catacholamine producing tumors can occur in the

adrenal gland or anywhere along the neuroectodermal crest; 10% of adults have multiple tumors

A. TriadA. Episodic HeadachesB. TachycardiaC. Diaphoresis with labile hypertension

B. Associated with multiple endocrine neoplastic (MEN) syndromes, neurofibromatosis, and Van Hipple Landau syndrome

PheochromocytomaPheochromocytoma

C. DiagnosisA. Postural hypertensionB. Resting tachycardiaC. Café au lait spotsD. Resting supine catacholamine levels > 2000 pg/ml (nep,

ep)E. Clonidine suppression test

A. Lowers catacholamine levels in essential HTN but not pheochromocytoma

F. Glucagon (2mg IV) increases plasma catecholamines at least three fold or >2000 1 to 3 minutes after administration in patients with pheochromocytoma

PheochromocytomaPheochromocytoma

D. Tumor Localization accomplished byA. CT scan

B. MRI

C. Radioisotope uptake studies

E. TreatmentA. Surgical removal of tumor

B. Alpha and beta adrenergic blockers are useful for chronic management or non-surgical cases (alpha blockers commonly used)

HyperaldosteronismHyperaldosteronism

A. Spontaneous hypokalemia while on diuretics and potassium supplements

B. Primary HyperaldosteronismA. Small unilateral adenoma (<1cm) is more common

in womenB. Bilateral adrenal hyperplasia is more common in men

A. DiagnosisA. Measure 24 hour urinary aldosterone measurements for two

days on high sodium diet (>!4g/ 24 hours)B. Increased aldosterone with low levels of plasma renin activityC. Adenomas detected by MRI

Hyperaldosteronism (cont)Hyperaldosteronism (cont)

B. TreatmentA. Surgery for small solitary adenomas

B. Medical treatment for adrenal hyperplasia

C. Diuretics and vasodilators

D. Aldosterone antagonists do not reduce BP adequately but may be needed to correct hypokalemia

Renal Artery StenosisRenal Artery Stenosis More commonly found stage 3 or resistant hypertension When bilateral can have reduced kidney function Clinical clues to renovascular disease

A. Onset before age 30 or recent onset of significant high BP after age 55

B. Abdominal bruit if diastolic and lateralized

C. Accelerated or resistant high blood pressure

D. Recurrent flash pulmonary edema

E. Renal failure with normal sediment

F. Co-exiting ASVD especially in long smokers

G. Acute renal failure – particularly after ACE I or Angiotensin receptors blockers

Renal Artery Stenosis (cont)Renal Artery Stenosis (cont)

D. DiagnosisA. Captopril enhances radionuclide renal scanB. Duplex doppler flow studiesC. MRI and MRAD. Definitive diagnosis – angiography

E. TreatmentA. Revascularization

A. Fibromuscular dysplasia – Percutaneous transluminal renal angioplasty (PTRA) is comparable to surgery

B. Atherosclerotic renal artery stenosis – ideal for PTCA with stenting if renal function normal

C. Surgery or PTCA with stenting to preserve renal function

LVH with left atrial enlargement

HTN 2nd to RAS

HTN 2nd to Fibromuscular Dysplasia

10-Minute Break10-Minute Break

JNC - VIJNC - VI

Joint National Committee (JNC) on the Detection, Evaluation and Control of High Blood Pressure

Emphasis: risk stratification for cardiovascular disease– Smoking– Dyslipidemia– Diabetes Mellitus– Old age– Male sex– Post-Menopausal– Family History of cardiovascular disease

At any given level of SBP the absolute risk of a At any given level of SBP the absolute risk of a coronary event increases dramatically as compared to coronary event increases dramatically as compared to

those with no risksthose with no risks

Classifying patients with HTN with consideration to target end Classifying patients with HTN with consideration to target end organ damage/clinical cardiovascular disease (TOD/CCD)organ damage/clinical cardiovascular disease (TOD/CCD)

Lifestyle ModificationsLifestyle Modifications Weight redistribution – lowers BP but also has effect on

lipids and glucose metabolism– There is a Metabolic Syndrome

Obesity High BP Hyperlipidemia Insulin resistance or Diabetes

Reduction of dietary sodium– Correlation between dietary sodium and blood pressure– most

patients benefit from reducing intake to below 2400mg/day, 6 g salt. Also enhances the efficacy of anti-hypertensive agents and may reduce potassium effect of diuretic agents and minimize hypokalemia. (i.e. processed foods)

Lifestyle Modifications (cont)Lifestyle Modifications (cont)

Alcohol – 1 ounce of ethanol– 24 ounces of beer– 10 ounces of wine– 2 ounce of 100 proof whisky

TobaccoAerobic Exercise

Diabetic Hypertensive patientsDiabetic Hypertensive patients

Blood glucose controlled Weight loss Aerobic exercise Angiotensin Converting Enzyme (ACE) Inhibitors

or Angiotensis Receptor Blockers (ARB) Treatment to lower BP using ACE-I and ARB

– Microvascular – retinopathy, nephropathy– Macrovascular – CAD, angina, AAA, CVA

BP goals < or = to 120 / 80

Congestive Heart FailureCongestive Heart Failure

Treatment– ACE I– ARB– Diuretics– B-Blockers– Digitalis

Monitor for– Orthostatic hypotension– Renal function– K+ levels

Post-Myocardial InfarctionPost-Myocardial Infarction

Treatment– ß-Blockers– ACE- I in patients with systolic dysfunction– Diltiazem or Verapamil in patients with non

Q-wave infarction may be used if B-blocker ineffective or contraindicated

Isolated Systolic Hypertension (ISH) Isolated Systolic Hypertension (ISH) and Hypertension in older patientsand Hypertension in older patients

Higher risk for cardiovascular diseaseLifestyle modificationsDecreased vascular compliance due to loss

of arterial elasticity associated with agingDrug of choice

– Low dose thiazide diuretics– Be concerned about postural hypotension or

cognitive dysfunction (central alpha 2 agonists)

Ischemic Heart DiseaseIschemic Heart Disease

Treatment– B-Blockers– Calcium channel blockers as a second choice if beta

blockers are contraindicated; or both drugs can be used together to achieve BP goals

– Treat risk factors High lipids Diabetes or Insulin resistance Weight loss ACE-Inhibitors

Renal DiseaseRenal Disease

Aggressive treatment to lower BP < or = 130/85 Goal will slow rate of disease progression ACE inhibitors are drugs of choice but must be

used with caution if creatinine >3 mg/dl and are not used when renovascular hypertension is suspected

Thiazide diuretics are not effective if serum creatinine is > 2.5 mg/dl and loop diuretics are required

African-Americans and HTNAfrican-Americans and HTNA. High prevalence

B. Occurs earlier, more severe and is associated with higher risks of cardiovascular disease

C. Stroke and heart disease mortality rates 80% and 50% higher respectively

D. End stage renal disease 320% higher

E. Lifestyle modifications

F. Diuretics are drugs of choice for uncomplicated hypertension

G. Ca channel blockers and alpha blockers are also effective

H. All other drugs can be used to achieve BP goals

Women and HTNWomen and HTN

Same therapy as menIf on OCP stop and monitor BPDuring pregnancy ACE-I and ARB should

be stoppedAlpha-Methyldopa during pregnancy

Patients Undergoing SurgeryPatients Undergoing Surgery

If BP is > 180/110, patient must be treated to reduce the risk of perioperative ischemic events

Cardio-selective beta-blockers, unless contraindicated, are drugs of choice

Hypertensive patients who are well controlled prior to surgery should be continued on their own regimen as soon as possible after surgery

Meta-analysis on the various first line drug treatmentsMeta-analysis on the various first line drug treatments

BPBP > > 95 95thth percentile is considered percentile is considered elevated in childrenelevated in children

Hypertensive EmergenciesHypertensive Emergencies

Reduce mean arterial pressure (MAP) no more than 25% (minutes to several hours) and then to 160/100 mmHg avoiding excessively rapid falls that may precipitate cerebral or coronary ischemia– Sublingual nifedipine is not recommended

because of the relatively high risk for these adverse events

Patient Education and Lifestyle Patient Education and Lifestyle modificationsmodifications

Lose excess weight. Cut the fat. Limit alcohol intake. Exercise regularly. Reduce sodium

intake. Stop smoking.

Follow-up:Follow-up:

Once stable, patients should be re-evaluated at least every 3 to 6 months

Review compliance, effectiveness and adverse reactions

Quality of life issues should be considered, including sexual function

At least annual evaluation of urinalysis, creatinine and potassium are appropriate, generally as part of a screening laboratory panel