UNIBA Hypertension With Jnc7 and Mnt 28-6-12

7/28/2019 UNIBA Hypertension With Jnc7 and Mnt 28-6-12

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Hypertension: Medical Management

and Nutritional Approaches


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Circuits

Pulmonary circuitThe blood pathway

between the right side of the

heart, to the lungs, and back

to the left side of the heart.

Systemic circuit

The pathway between the

left and right sides of theheart.


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Distribution of Blood in the Body Organs

Figure 15-13: Distribution of blood in the body at rest


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Regulation of Blood Pressure

Figure 15-22: The baroreceptor reflex: the response to increased blood pressure


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Baroreceptor and ChemoreceptorReflexes


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Hypertension

Persistently high arterial blood

pressure

Systolic blood pressure above 140

mm Hg and/or diastolic blood

pressure above 90 mm Hg

Normotensive = 120/80 mm Hg

Prehypertensive = 120139/80-89

mm Hg

Stage 1 hypertension = 140159/90-

99 mm Hg

Stage 2 hypertension = >160/>100

mm Hg


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Prevalence and Incidence

29% of adult US population

Related to body mass index

High prevalence in African Americans

5% of pediatric population; prevalence increases

with age

Strong positive relationship between blood pressure

and risk of CVD events


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Pathophysiology

Blood pressure is a function of cardiac output

multiplied by peripheral resistance

Affected by diameter of blood vessel

Atherosclerosis decreases diameter, increases bloodpressure

Drug therapy increases diameter, lowers blood

pressure


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Circulatory Systems in the Body

1. Coronarysupplies blood to heartmuscle (can form collateralcirculation)

2. Cerebralsupplies blood to head3. Splanchnicsupplies blood to

abdomen (exercise removes blood

and food attracts blood to this area)4. Pulmonarysupplies blood to lungs

(O2 and CO2 exchange)


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Determinants of Blood Pressure

1. Blood volume

2. Vascular resistance to pressure

3. Heart stroke volume


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Vascular Resistance

Viscosity of blood

Width of vessels(constriction or

dilation)controlled by muscle tone invessel walls


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Regulation of Blood Pressure

1. Sympathetic nervous system (SNS)respondsimmediately; baroreceptors monitor BP

Vasomotor center in brain

SNS innervated tissues contract or dilate vascularbed

2. Renin-angiotensin systemretains Na and H2O to

increase blood volume; constricts blood vessels;increases aldosterone

3. Kidneysrespond to renin-angiotensin system;aldosterone and antidiuretic hormone (ADH) are sent

out as needed


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Homeostatic Control ofBlood Pressure

Short term

Sympathetic nervous system

VasoconstrictionVasodilation

Long term

Fluid volumeRenin-angiotensin system


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Hypertension

1. 90% HTN is essential HTN (cause unknown;

perhaps prenatal impacts?)

2. 10% HTN is secondary to other diseases

3. HTN is a risk factor for MI, CVA, renal failure


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Renin-Angiotensin Cascade

Redrawn from Guyton AC: Textbook of medical physiology, ed 8, Philadelphia, 1991, WB Saunders.


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Causes of Hypertension

Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.


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Identifiable causes of hypertension Chronic kidney disease\

Coarctation of the Aorta Cushings Syndrome

Drug induced

Obstructive uropathy

Pheochromocytoma Primary aldosteronism and other mineralocorticoid excess

states

Renovascular HTN stenosis and fibromuscular dysplasia

Sleep Apnea Thyroid (either HYPER or HYPO) or parathyroid disease


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Risk Factors for Developing

Hypertension

(Adapted from National High Blood Pressure Education Program Working Group report on primary prevention of hypertension.

Arch Intern Med 153:186, 1993. Copyright 1993, American Medical Association. Reprinted with permission.)


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Risk Stratification in Patients with

Hypertension

(From The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. sixth report

(JNC VI). Arch Intern Med 157:2413, 1997.)


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Uncontrolled Hypertension

Leads to increased

Workload on heart

Damage to arteries

Atherosclerosis

Coronary heart disease esp. CHF

Strokes

Transient ischemic attacks (TIAs)

Kidney damage

Microvascular hemorrhages in brain and eye


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The DASH Diet Trials

Randomized feeding trial comparing effects of 3 diet

patterns: control, high fruits/vegetables, and high

fruits/vegetables/whole grains/lowfat dairy (DASH diet)

DASH diet high in potassium, magnesium, calcium,fiber and low in fat, saturated fat, and cholesterol

DASH diet significantly lowered BP in all groups, but

especially in African-Americans


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Effects of Diet on BP (DASH Trial)


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For persons over age 50, SBP is a more important

than DBP as CVD risk factor.

Persons who are normotensive at age 55 have a 90%

lifetime risk for developing HTN.

Those with SBP 120139 mmHg or DBP 8089 mmHg

should be considered prehypertensive who require

health-promoting lifestyle modifications to prevent

CVD.

New Features and Key Messages


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New Features and Key Messages(Continued)

Thiazide-type diuretics should be initial drug therapy for

most, either alone or combined with other drug classes.

Certain high-risk conditions are compelling indications forother drug classes.

Most patients will require two or more antihypertensive

drugs to achieve goal BP.

If BP is >20/10 mmHg above goal, initiate therapy with two

agents, one usually should be a thiazide-type diuretic.


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Blood Pressure Classification

Normal 100

BP Classification SBP mmHg DBP mmHg


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CVD Risk

HTN prevalence ~ 50 million people in the United States.

The BP relationship to risk of CVD is continuous, consistent,

and independent of other risk factors.

Each increment of 20/10 mmHg doubles the risk of CVD

across the entire BP range starting from 115/75 mmHg.

Prehypertension signals the need for increased education to

reduce BP in order to prevent hypertension.


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Benefits of Lowering BP

Average Percent Reduction

Stroke incidence 3540%

Myocardial infarction 2025%

Heart failure 50%


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BP Control Rates

Trends in awareness, treatment, and control of highblood pressure in adults ages 1874

National Health and Nutrition Examination Survey, Percent

II

197680

II(Phase 1)

198891

II(Phase 2)

199194 19992000

Awareness 51 73 68 70

Treatment 31 55 54 59

Control 10 29 27 34

Sources: Unpublished data for 19992000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6.


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BP Measurement Techniques

Method Brief Description

In-office Two readings, 5 minutes apart, sitting in

chair. Confirm elevated reading in

contralateral arm.Ambulatory BP monitoring Indicated for evaluation of white-coat HTN.

Absence of 1020% BP decrease during

sleep may indicate increased CVD risk.

Self-measurement Provides information on response to therapy.May help improve adherence to therapy and

evaluate white-coat HTN.


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CVD Risk Factors

Microalbuminuria orestimated GFR 30 kg/m2)

Physical inactivity

Dyslipidemia*

Diabetes mellitus*

*Components of the metabolic syndrome.


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Target Organ Damage

Heart Left ventricular hypertrophy

Angina or prior myocardial infarction

Prior coronary revascularization

Heart failure

Brain

Stroke or transient ischemic attack

Chronic kidney disease

Peripheral arterial disease

Retinopathy


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Goals of Therapy

Reduce CVD and renal morbidity and mortality.

Treat to BP


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Lifestyle Modification

Modification Approximate SBP reduction

(range)

*Weight reduction 520 mmHg/10 kg weight loss

*Adopt DASH eating plan 814 mmHg

*Dietary sodium reduction 28 mmHg

Physical activity 49 mmHg

*Moderation of alcohol

consumption

24 mmHg

*medical nutrition therapy interventions


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Classification ofAntihypertensive Drugs

Diuretics

Thiazides

Loop diuretics

Potassium-sparing diuretics Beta blockers (BB)

Angiotensin II receptor blockers (ARBs)

Alpha-beta blockers

Alpha1 receptor blockers ACE inhibitors (angiotensin converting enzyme)

Calcium antagonists

Direct vasodilators


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Algorithm for Treatment of Hypertension

Not at Goal Blood Pressure (100 mmHg)

2-drug combination for most (usually

thiazide-type diuretic and

ACEI, or ARB, or BB, or CCB)

Stage 1 Hypertension(SBP 140159 or DBP 9099 mmHg)

Thiazide-type diuretics for most.

May consider ACEI, ARB, BB, CCB,

or combination.

Without CompellingIndications

Not at Goal

Blood Pressure

Optimize dosages or add additional drugs

until goal blood pressure is achieved.

Consider consultation with hypertension specialist.


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Compelling Indications

These are reasons for using a particular class ofmedications

For example, patients with diabetes, kidney damage,and high blood pressure should begin treatment with

ACE inhibitors.

Heart attack (in conjunction with hypertension) is acompelling indication for the prescription of beta-blockers and, in certain instances, ACE inhibitors

Heart failure should first be treated with ACE inhibitorsand diuretics.


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Classification and Managementof BP for adults

BP

classification

SBP*

mmHg

DBP*

mmHg

Lifestyle

modification

Initial drug therapy

Without compelling

indication

With compelling

indications

Normal 100 Yes Two-drug combination for

most (usually thiazide-type

diuretic and ACEI or ARB or

BB or CCB).

*Treatment determined by highest BP category.Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.

Treat patients with chronic kidney disease or diabetes to BP goal of


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Minority Populations

In general, treatment similar for all demographic groups.

Socioeconomic factors and lifestyle important barriers to BP control.

Prevalence, severity of HTN increased in African Americans.

African Americans demonstrate somewhat reduced BP responses to

monotherapy with BBs, ACEIs, or ARBs compared to diuretics or

CCBs.

These differences usually eliminated by adding adequate doses of a

diuretic.


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Children and Adolescents

HTN defined as BP95th percentile or greater, adjusted for age,

height, and gender.

Use lifestyle interventions first, then drug therapy for higher levels ofBP or if insufficient response to lifestyle modifications.

Drug choices similar in children and adults, but effective doses are

often smaller.

Uncomplicated HTN not a reason to restrict physical activity.


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Lifestyle Modifications

Sodium: not more than 2.4 grams sodium/day

Activity: activity like brisk walking 30 minutes/day most

days of the week

Alcohol: not more than 1 drink a day for women; 2drinks a day for men

DASH diet: low in sodium, high in potassium, calcium,

cholesterol, saturated fat

Weight: weight loss of as little as 10 lb can prevent or

treat high blood pressure


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Weight Management

Risk of developing high blood pressure is 2-6 times

higher in overweight than normal weight persons

20-30% of the hypertension in the US is attributable to

excess weight In Framingham, weight increase of 10% predicted rise

in blood pressure of 7 mm/hg

Weight gain during adult life is responsible for much of

the rise in blood pressure seen with aging


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Weight Management

Excess body weight may increase blood pressurethrough increased insulin resistance andhyperinsulinemia, activation of the sympathetic nervousand renin-angiotensin systems, and changes in the

kidney Weight loss lowers vascular resistance, total blood

volume, cardiac output, and sympathetic nervoussystem activity; improves insulin resistance

Weight loss in an overweight person is the single mosteffective lifestyle intervention to reduce blood pressure


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Weight Management

In the Trial of Antihypertensive Intervention and

Management, goal for energy intake to facilitate weight

loss was 25 kcals/kg minus 500 to 1000 kcal daily to

produce a .5 to 1 kg weight loss/week to achieve totalweight loss of 4.5 kg.

Wylie-Rosett et al, 1993


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Sodium and Hypertension

Relationship between sodium and hypertension is strongerin

Older people

Those with a family history of hypertension Those with higher blood pressures at baseline

30-50% of hypertensives and 15-25% of normotensivesare salt sensitive

Salt sensitivity more common in black race, obesity,advanced age, diabetes, renal dysfunction, use ofcyclosporine


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Sodium and Hypertension

Addition of a sodium restriction to a DASH diet lowers

SBP 3 mmHg and DBP 2 mmHg

This reduction is associated with a 17% reduction in

prevalence of hypertension, 6% reduction in CHD, 15%reduction in stroke and TIA


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Salt Restriction

Recommendation is for moderate salt restriction (6

grams salt, 100 mEq or 2400 mg Na daily)

Salt is the issue, because chloride ion with sodium

raises blood pressure May normalize blood pressure in Stage 1 hypertension


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Levels of Na Restriction

g Na mEq Na Description

4 174 No added salt

2-3 87-130 Mild to moderate

restriction1 43 Strict sodium restriction

0.5 22 Severe sodium restriction


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Alcohol and Hypertension

5-7% of hypertension is due to alcohol

consumption

3 drinks per day is the threshold for raisingblood pressure; associated with a 3 mmHg

increase


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Physical Activity and Hypertension

Less active persons are 30-50% more likely to develop

hypertension than active persons

Medium to high levels of activity protective against

stroke (Framingham) Walking reduces blood pressure in adults by an

average of 2%

In a meta-analysis of 54 randomized trials, walking

reduced blood pressure an average of 4 mmHg,

irrespective of weight change


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Potassium

In population studies, potassium intake and blood

pressure are inversely related

Sodium/potassium ratio is important

Sodium/potassium ratio of 1:1 a 3.4 mmHg decrease insystolic BP is predicted

High potassium intake inversely related to stroke


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Other Factors

Calcium, Magnesium, and Lipids: role still unclear

DASH diet high in lowfat dairy products


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Response to Dietary Rx

Salt sensitive respond well to sodium restriction

Most respond to increased potassium in diet.

1.1 to 3.3 g Na is safe

1.9 to 5.6 g K is recommended to achieve ratio Na:K of1, which is goal

If taking a potassium-wasting diuretic drug, increasedpotassium in diet is essential.

Most respond to increased calcium (at least the RDA)usethe DASH diet protocol


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DASH Diet

Works within 14 days

Lowers BP quite well

Includes more potassium, calcium,

other nutrients


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DASH Fact Sheet

www.nhlbi.nih.gov/heal

th/public/heart/hbp/dash/

new_dash.pdf


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DASH Diet contd

Pattern

7-8 whole grains

4-5 vegetables

4-5 fruits

2-3 low-fat or fat-free dairy products

6 oz or less meat/poultry/fish

4-5 servings nuts, beans, or legumes/week2-3 servings fat (total kcal = 27% fat)

DASH Diet Patterns for


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DASH Diet Patterns forDifferent Calorie Levels

Kcals Grain Veg Fruit Dairy Meat/

Pro

Nuts/

Legume

Fats/

oils

1600 6 4 4 2 1 .5 1

2000 8 5 5 3 2 1 2

2600 10 5 5 3 2 1 2

3100 13 6 6 4 2 1 3


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Sodium

Processed and restaurant foods provide 80% of sodiumintake

Read labels; sodium content of different brands varies

10% added in cooking at home and at table; 10% naturally

occurring Americans consume ~4,000 mg/day; 2005 Dietary Guidelines

for Americans recommend


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Food Label Terms

Sodium free, no sodium =


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Salt Substitutes

Composition: KCl, CaCl, Al-Cl KCl can provide extra potassium for those taking

diuretics

KCl can be harmful if patient has renal insufficiency

Lite salt contains sodium

Some spices and herbs are low in sodium

Others are high in sodium

Classification of


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Classification ofAntihypertensive Drugs

Diuretics

Thiazides

Loop diuretics

Potassium-sparing diuretics Beta blockers (BB)

Angiotensin II receptor blockers (ARBs)

Alpha-beta blockers

Alpha1 receptor blockers ACE inhibitors (angiotensin converting enzyme)

Calcium antagonists

Direct vasodilators


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Renin-Angiotensin Aldosterone System

Angiotensinogen

Non-ACE pathways(eg, chymase)

Vasoconstriction

Cell growth

Na/H2O retention

Sympathetic activation

Renin Angiotensin I

Angiotensin II

ACE

Cough,

angioedema

Benefits? Bradykinin

Inactive

fragments

Vasodilation

Antiproliferation

(kinins)

Aldosterone AT2

AT1

Lif t l M difi ti f P ti f


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Lifestyle Modifications for Prevention ofHypertension

Lose weight if overweight

Limit alcohol

Increase physical activity

Decrease sodium intake Keep potassium intake at adequate levels

Take in adequate amounts of calcium and magnesium

Decrease intake of saturated fat and cholesterol Stop smoking


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Summary

Lifestyle modifications for prevention of hypertension

quite effective!

Management of hypertensionvery important to reduce

risk of heart attack or stroke

Documents

UNIBA Hypertension With Jnc7 and Mnt 28-6-12