PHOTO OFDr. Thomas

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Summary of Guidelines Summary of Guidelines

• JNC VI guidelines focus on: - Absolute risks and benefits used in compiling recommendations - Strong emphasis on risk stratification of patients including awareness of the importance of isolated systolic blood pressure - Re-emphasis on importance of lifestyle modification in prevention and treatment - First line drugs for uncomplicated patient are diuretics and beta-blockers

• JNC VI guidelines focus on: - Absolute risks and benefits used in compiling recommendations - Strong emphasis on risk stratification of patients including awareness of the importance of isolated systolic blood pressure - Re-emphasis on importance of lifestyle modification in prevention and treatment - First line drugs for uncomplicated patient are diuretics and beta-blockers

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Blood Pressure Classification Blood Pressure Classification

Class Systolic Diastolic

Optimal <120 <80

Normal <130 <85

High Normal 130-139 85-89

Class I HTN 140-159 90-99

Class II HTN 160-179 100-109

Class III HTN <=180 >=110Note: For patients not on anti-hypertensive therapy and with no acute illnesses. If SBB and DBP disagree, then use the higher class

Class Systolic Diastolic

Optimal <120 <80

Normal <130 <85

High Normal 130-139 85-89

Class I HTN 140-159 90-99

Class II HTN 160-179 100-109

Class III HTN <=180 >=110Note: For patients not on anti-hypertensive therapy and with no acute illnesses. If SBB and DBP disagree, then use the higher class

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Blood Pressure Follow-Up Blood Pressure Follow-Up

Systolic Diastolic Recommended Follow-up

<130 <85 Recheck in 2 years

130-139 85-89 Recheck in 1 year

140-159 90-90 Recheck in 2 months

160-179 100-109 Recheck in 1 month

>=180 >=110 Recheck in 1 week or admit

Systolic Diastolic Recommended Follow-up

<130 <85 Recheck in 2 years

130-139 85-89 Recheck in 1 year

140-159 90-90 Recheck in 2 months

160-179 100-109 Recheck in 1 month

>=180 >=110 Recheck in 1 week or admit

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Ambulatory BP Monitoring Ambulatory BP Monitoring

• Correlates more closely with target organ damage

• Helpful in certain populations: - Suspected “white coat hypertension” - Suspected drug resistance - Hypotensive symptoms on therapy - Episodic HTN - Autonomic dysfunction - NOT for use in basic diagnosis or screening for HTN

• Correlates more closely with target organ damage

• Helpful in certain populations: - Suspected “white coat hypertension” - Suspected drug resistance - Hypotensive symptoms on therapy - Episodic HTN - Autonomic dysfunction - NOT for use in basic diagnosis or screening for HTN

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Risk-based Treatment Groups Risk-based Treatment Groups

• Risk Group A: - No risk factors, no target organ disease, no known cardiovascular disease

• Risk Group B: - At least one risk factor but NOT diabetes, no target organ disease or cardiovascular disease

• Risk group C: - Target organ disease and / or cardiovascular disease and / or diabetes, with or without other risk factors

• Risk Group A: - No risk factors, no target organ disease, no known cardiovascular disease

• Risk Group B: - At least one risk factor but NOT diabetes, no target organ disease or cardiovascular disease

• Risk group C: - Target organ disease and / or cardiovascular disease and / or diabetes, with or without other risk factors

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Initial Evaluation Initial Evaluation

• Assess for target organ damage at baseline

• Identify any other cardiovascular risk factors

• Identify any potential secondary causes

• Assess for target organ damage at baseline

• Identify any other cardiovascular risk factors

• Identify any potential secondary causes

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Lab Evaluation Lab Evaluation

• Recommended tests to screen for target organ damage - Urinalysis - Renal function - CBC - Electrolytes - HDL - 12 lead EKG

• Optional tests to screen for target organ damage (not all-inclusive): - Creatinine clearance - Hemoglobin A1C - Urine microalbumin - TSH - 24 hour urine for protein - Fasting, full lipid panel

• Recommended tests to screen for target organ damage - Urinalysis - Renal function - CBC - Electrolytes - HDL - 12 lead EKG

• Optional tests to screen for target organ damage (not all-inclusive): - Creatinine clearance - Hemoglobin A1C - Urine microalbumin - TSH - 24 hour urine for protein - Fasting, full lipid panel

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Cardiovascular Risk Factors Cardiovascular Risk Factors

• Major Risk Factors:

- Smoking

- Dyslipidemia

- Diabetes

- Age >60 years

- All males and postmenopausal females

- Family history of CAD in women < 65 or men < 55 years old

• Major Risk Factors:

- Smoking

- Dyslipidemia

- Diabetes

- Age >60 years

- All males and postmenopausal females

- Family history of CAD in women < 65 or men < 55 years old

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Target Organ / Cardiovascular Disease Target Organ / Cardiovascular Disease

• Heart Disease - Left ventricular hypertrophy (LVH) - Angina or prior myocardial infarction - Prior coronary revascularization - Heart failure

• Stroke or transient ischemic attack• Nephropathy• Peripheral Vascular Disease• Hypertensive retinopathy

• Heart Disease - Left ventricular hypertrophy (LVH) - Angina or prior myocardial infarction - Prior coronary revascularization - Heart failure

• Stroke or transient ischemic attack• Nephropathy• Peripheral Vascular Disease• Hypertensive retinopathy

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Risk-Based Treatment Options Risk-Based Treatment Options

HTN Class Risk Gp A Risk Gp B Risk Gp C

High Normal Lifestyle Lifestyle Treatment Mgmt Mgmt

Class I Lifestyle Lifestyle Treatment Mgmt for Mgmt for 12 months 6 months

Class II-III Treatment Treatment Treatment

HTN Class Risk Gp A Risk Gp B Risk Gp C

High Normal Lifestyle Lifestyle Treatment Mgmt Mgmt

Class I Lifestyle Lifestyle Treatment Mgmt for Mgmt for 12 months 6 months

Class II-III Treatment Treatment Treatment

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Clues for Secondary Causes Clues for Secondary Causes

• Age, history, severity of HTN do not correlate with clinical picture

• Poor response to therapy

• Previously well-controlled

• Class III hypertension

• Sudden onset of hypertension

• Age, history, severity of HTN do not correlate with clinical picture

• Poor response to therapy

• Previously well-controlled

• Class III hypertension

• Sudden onset of hypertension

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Lifestyle Modification Lifestyle Modification

Should be seen as part of bothprevention and treatment

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Diet modification - DASH diet

• Weight reduction

• Increased physical activity

Should be seen as part of bothprevention and treatment

•

Diet modification - DASH diet

• Weight reduction

• Increased physical activity

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Lifestyle Modification Lifestyle Modification

• Moderation of sodium intake• Maintain appropriate intake of: - Potassium - Calcium - Magnesium

• Improve modifiable CV risk factors• Questionable benefit - caffeine reduction, relaxation / biofeedback

• Moderation of sodium intake• Maintain appropriate intake of: - Potassium - Calcium - Magnesium

• Improve modifiable CV risk factors• Questionable benefit - caffeine reduction, relaxation / biofeedback

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Treatment Steps Treatment Steps

• Step 1: If no other added indication, start with either diuretic or beta-blocker

• Step 2: If no response, increase dose

• Step 3a: If tolerated at higher dose, add a second drug

• Step 3b: If not tolerated at higher, substitute a new drug in its place

• Step 1: If no other added indication, start with either diuretic or beta-blocker

• Step 2: If no response, increase dose

• Step 3a: If tolerated at higher dose, add a second drug

• Step 3b: If not tolerated at higher, substitute a new drug in its place

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Treatment Steps Treatment Steps • Step 4: If still not controlled then: - Continue adding agents from other classes - Consider referral to a hypertensive specialist

• Resistant HTN: - Defined as BP > 140 / 90 or isolated systolic > 160 on three drugs (including a diuretic) at max dose

- Often still related to volume overload - Consider referral to hypertensive specialist

• Step 4: If still not controlled then: - Continue adding agents from other classes - Consider referral to a hypertensive specialist

• Resistant HTN: - Defined as BP > 140 / 90 or isolated systolic > 160 on three drugs (including a diuretic) at max dose

- Often still related to volume overload - Consider referral to hypertensive specialist

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Treatment Steps Treatment Steps • For Stage III hypertensive patient: - Start pharmacologic therapy sooner - Increase the dose or add a second agent sooner - Look for secondary causes sooner

• Step-down therapy: - Begin slowly weaning medications after adequate control for one year

- May be able to accelerate decrease in medications if also adherent to lifestyle modifications

• For Stage III hypertensive patient: - Start pharmacologic therapy sooner - Increase the dose or add a second agent sooner - Look for secondary causes sooner

• Step-down therapy: - Begin slowly weaning medications after adequate control for one year

- May be able to accelerate decrease in medications if also adherent to lifestyle modifications

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Special Populations Special Populations • African-Americans:

- More effective: diuretics, calcium antagonists

- Less effective: beta-blockers, ACE inhibitors as mono-therapies

- Okay to use less effective if have an additional indication

• African-Americans:

- More effective: diuretics, calcium antagonists

- Less effective: beta-blockers, ACE inhibitors as mono-therapies

- Okay to use less effective if have an additional indication

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Special Populations Special Populations • Children / Adolescents:

- Aggressively identify secondary causes - Lifestyle modification very important - Treat with smaller doses of medication - Avoid ACE and Angiotensin-II receptor blockers in sexually active / pregnant women - Check for use of anabolic steroids - No need to prohibit from exercise if asymptomatic

• Children / Adolescents:

- Aggressively identify secondary causes - Lifestyle modification very important - Treat with smaller doses of medication - Avoid ACE and Angiotensin-II receptor blockers in sexually active / pregnant women - Check for use of anabolic steroids - No need to prohibit from exercise if asymptomatic

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Special Populations Special Populations • Females: - Contraceptive use: If BP increase seems related to OCP use, discontinue OCP and BP should normalize

- Pregnancy: Defined as essential HTN if BP elevated before pregnant or before the 20th week of gestation - Avoid ACE, A-II receptor blockers - Use diuretics, alpha-methyl dopa, beta-blockers (after the 1st trimester)

• Females: - Contraceptive use: If BP increase seems related to OCP use, discontinue OCP and BP should normalize

- Pregnancy: Defined as essential HTN if BP elevated before pregnant or before the 20th week of gestation - Avoid ACE, A-II receptor blockers - Use diuretics, alpha-methyl dopa, beta-blockers (after the 1st trimester)

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Special Populations Special Populations • Elderly: - Isolated systolic HTN an important, more common problem

- Pulse pressure (SBP-DBP) a good predictor of risk in this population

- More effective: thiazide diuretic, thiazide + beta-blocker, and long acting dihydropyridine calcium antagonists

- Avoid postural hypotensive symptoms - Avoid cognitive symptoms

• Elderly: - Isolated systolic HTN an important, more common problem

- Pulse pressure (SBP-DBP) a good predictor of risk in this population

- More effective: thiazide diuretic, thiazide + beta-blocker, and long acting dihydropyridine calcium antagonists

- Avoid postural hypotensive symptoms - Avoid cognitive symptoms

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Additional Indications Additional Indications

• Coronary Artery Disease: - Avoid aggressive, quick lowering of BP

- Added benefit: beta-blocker, long-acting calcium antagonists

- Avoid: short-acting calcium antagonists

- ACE inhibitors may be useful after MI with LV function dysfunction

• Coronary Artery Disease: - Avoid aggressive, quick lowering of BP

- Added benefit: beta-blocker, long-acting calcium antagonists

- Avoid: short-acting calcium antagonists

- ACE inhibitors may be useful after MI with LV function dysfunction

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Additional Indications Additional Indications

• Heart Failure: - ACE inhibitors are standard therapy

- May substitute vasodilator and nitrate or A-II receptor blocker if not tolerated

- Carvedilol and other beta-blockers are showing more benefit in these patients

- Long-acting dihydropyridines are safe to use in these patients for the treatment of angina

• Heart Failure: - ACE inhibitors are standard therapy

- May substitute vasodilator and nitrate or A-II receptor blocker if not tolerated

- Carvedilol and other beta-blockers are showing more benefit in these patients

- Long-acting dihydropyridines are safe to use in these patients for the treatment of angina

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Additional Indications Additional Indications

• Diabetes:

- Blood pressure control an imperative for preventing target organ damage from DM

- ACE inhibitors help prevent / reduce proteinuria

- Avoid beta-blockers only if hypoglycemia is a significant risk or past history

• Diabetes:

- Blood pressure control an imperative for preventing target organ damage from DM

- ACE inhibitors help prevent / reduce proteinuria

- Avoid beta-blockers only if hypoglycemia is a significant risk or past history

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Additional Indications Additional Indications

• Dyslipidemia: - High dose thiazide and loop diuretics can induce increases in total cholesterol, LDL and triglycerides

- Low dose thiazides can be appropriate - Diet modification can reduce this effect - Beta-blockers may transiently increase triglycerides and lower HDL

- Alpha-blockers may slightly reduce total cholesterol and increase HDL

• Dyslipidemia: - High dose thiazide and loop diuretics can induce increases in total cholesterol, LDL and triglycerides

- Low dose thiazides can be appropriate - Diet modification can reduce this effect - Beta-blockers may transiently increase triglycerides and lower HDL

- Alpha-blockers may slightly reduce total cholesterol and increase HDL

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Additional Indications Additional Indications

• Reactive / Obstructive Airway Disease:

- Avoid beta-blockers and alpha-beta- blockers (carvedilol) unless only minimal lung disease and tolerated well by the patient

- Check for any OTC remedies for asthma since may exacerbate blood pressure

• Reactive / Obstructive Airway Disease:

- Avoid beta-blockers and alpha-beta- blockers (carvedilol) unless only minimal lung disease and tolerated well by the patient

- Check for any OTC remedies for asthma since may exacerbate blood pressure

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Summary Points Summary Points • Focus on risk-adjusting each patient to better meet that patient’s needs• Consider additional indications / added benefits or risks in your choice of therapy• Emphasize lifestyle modification focusing on cardiovascular healthy habits for both treatment and prevention• Remember the importance of isolated systolic hypertension especially in the elderly

• Focus on risk-adjusting each patient to better meet that patient’s needs• Consider additional indications / added benefits or risks in your choice of therapy• Emphasize lifestyle modification focusing on cardiovascular healthy habits for both treatment and prevention• Remember the importance of isolated systolic hypertension especially in the elderly

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PHOTO OFDr. Dennis

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Profile Profile

Ms. Barile

• 45 year old female• Presented 2 years ago with BP 150 / 100 at routine exam• Previous BP had been in high-normal range

Initial Diagnosis• Hypertension

• BP 150 / 90

Ms. Barile

• 45 year old female• Presented 2 years ago with BP 150 / 100 at routine exam• Previous BP had been in high-normal range

Initial Diagnosis• Hypertension

• BP 150 / 9026

Profile Profile

Ms. BarileDiagnostic Tests• Comprehensive history and physical• Urinalysis• EKG• Blood tests for glucose, BUN, creatinine, electrolytes and cholesterol profile

Diagnosis• Essential hypertension without diabetes or target organ abnormalities

Ms. BarileDiagnostic Tests• Comprehensive history and physical• Urinalysis• EKG• Blood tests for glucose, BUN, creatinine, electrolytes and cholesterol profile

Diagnosis• Essential hypertension without diabetes or target organ abnormalities 26 A

Profile Profile

Ms. BarileTreatment• Referred to nutritionist for dietary counseling

• Salt-restricted, low-fat diet with reduced calories

• Lose weight through increased regular exercise

• Lisinopril - 10mg daily

Ms. BarileTreatment• Referred to nutritionist for dietary counseling

• Salt-restricted, low-fat diet with reduced calories

• Lose weight through increased regular exercise

• Lisinopril - 10mg daily

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Classification of BP for AdultsAge 18 Years and Older

Classification of BP for AdultsAge 18 Years and Older

Systolic Diastolic Category (mmHg) (mmHg)

Optimal <120 <80 Normal <130 <85 High normal 130 - 139 85 - 89

Hypertension Stage I 140 - 159 90 - 99 Stage 2 160 - 179 100 - 109 Stage 3 > 180 > 110

Systolic Diastolic Category (mmHg) (mmHg)

Optimal <120 <80 Normal <130 <85 High normal 130 - 139 85 - 89

Hypertension Stage I 140 - 159 90 - 99 Stage 2 160 - 179 100 - 109 Stage 3 > 180 > 110

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Optimal Blood Pressure Optimal Blood Pressure

Optimal blood pressure is

that value below which further

reduction garners no additional

benefit to morbidity or mortality

Optimal blood pressure is

that value below which further

reduction garners no additional

benefit to morbidity or mortality

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Mean Systolic and Diastolic BP inU.S. Adult Population: NHANES IIIMean Systolic and Diastolic BP inU.S. Adult Population: NHANES III

Adult Population Mean Blood Pressure (mmHg) Systolic Diastolic

All 122 74

Normotensive 117 71

Hypertensive

- Treated 135 83 - Untreated 144 88

Adult Population Mean Blood Pressure (mmHg) Systolic Diastolic

All 122 74

Normotensive 117 71

Hypertensive

- Treated 135 83 - Untreated 144 88

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Office, Home and Ambulatory BloodPressure in 1438 Subjects

Age 25-64 Years: PAMELA Study

Office, Home and Ambulatory BloodPressure in 1438 Subjects

Age 25-64 Years: PAMELA Study

Blood Pressure (mmHg) Pulse SBP DBP Rate

Office 127 ± 17 82 ± 9.8 72 ± 8.6

Home 119 ± 17 75 ± 10 73 ± 10

24-hr mean 118 ± 11 74 ± 7 77 ± 8

Daytime 123 ± 11 79 ± 8 82 ± 9

Nighttime 108 ± 11 64 ± 8 67 ± 8

Blood Pressure (mmHg) Pulse SBP DBP Rate

Office 127 ± 17 82 ± 9.8 72 ± 8.6

Home 119 ± 17 75 ± 10 73 ± 10

24-hr mean 118 ± 11 74 ± 7 77 ± 8

Daytime 123 ± 11 79 ± 8 82 ± 9

Nighttime 108 ± 11 64 ± 8 67 ± 8

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Baseline Systolic and Diastolic BP andAdjusted Relative Risk of Coronary

Heart Disease Death: MRFIT Screens

Baseline Systolic and Diastolic BP andAdjusted Relative Risk of Coronary

Heart Disease Death: MRFIT Screens

SBP DBP (mm Hg)

(mmHg) <80 80-84 85-89 90-99 >100

< 120 1.00 1.35 1.36 0.98 3.23

120-129 1.19 1.30 1.49 1.49 1.84

130-139 1.67 1.61 1.67 1.91 2.64

140-159 2.52 2.22 2.67 2.56 2.99

> 160 4.19 3.20 3.41 3.41 4.57

SBP DBP (mm Hg)

(mmHg) <80 80-84 85-89 90-99 >100

< 120 1.00 1.35 1.36 0.98 3.23

120-129 1.19 1.30 1.49 1.49 1.84

130-139 1.67 1.61 1.67 1.91 2.64

140-159 2.52 2.22 2.67 2.56 2.99

> 160 4.19 3.20 3.41 3.41 4.5733

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TOMHS TOMHS

n

Acebutolol 132 Active

Amlodipine 131 Treatment Placebo

Chlorthalidone 136 Total (n=234)

Doxazosin 134 (n=668)

Enalapril 135

n

Acebutolol 132 Active

Amlodipine 131 Treatment Placebo

Chlorthalidone 136 Total (n=234)

Doxazosin 134 (n=668)

Enalapril 135

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Blood Pressure Changesin TOMHS

Blood Pressure Changesin TOMHS

Blood Pressure (mmHg)_____ Group Pre-Treatment Treatment (4 yrs)

Life style Modification + placebo 141 / 91 132 / 82

Life style Modification + drug treatment 140 / 91 124 / 79

Blood Pressure (mmHg)_____ Group Pre-Treatment Treatment (4 yrs)

Life style Modification + placebo 141 / 91 132 / 82

Life style Modification + drug treatment 140 / 91 124 / 79

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Summary Summary

Ms. BarileDiagnosis• Stage 1 essential hypertension without target organ involvement

Currently• Life-style adjustments: low-fat, low-sodium, low-calorie diet and increased exercise• BP is controlled to 134 / 82

Is this adequate?

Ms. BarileDiagnosis• Stage 1 essential hypertension without target organ involvement

Currently• Life-style adjustments: low-fat, low-sodium, low-calorie diet and increased exercise• BP is controlled to 134 / 82

Is this adequate? 39