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Treatment of Hypertension
A CLINICAL APPROACH
Dr.Sarma RVSN, M.D., M.Sc (Canada)
Consultant Physician and Chest Specialist, # 5, Jayanagar, Tiruvallur 602 001 93805 21221, (044) 27660593
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Treatment of Hypertension
A CLINICAL APPROACH
Management of Hypertension
Based on the latest recommendations of
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HYPERTENSION
The Problem is
Hypertension is asymptomatic in 85% of cases
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It is wrong To consider Hypertension as an isolated disease The Truth is Hypertension, DM, Dyslipidemia, Obesity often coexist They are the 4 pallbearers to the grave of CHD, CVD For all of them Primary and secondary prevention by TLC is the answer Afflicted with one, must be screened for all other thieves
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Treatment Goal
Goal BP Keep B.P. < 140/90 mm Hg in each patient This may be revised to 120/80 may be ? 110/70 MRFITs cut off values are 115/75 mm Hg
The Truth is It is essential to keep the B.P at or below the goal But, It also matters how the goal B.P. is achieved !
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Definitions
As per JNC VII and ISH (WHO) 2004 Normal SBP < 120 and DBP < 80 Pre HT SBP 120 to 139 mm Hg DBP 80 to 99 mm Hg
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Definitions
1. What is stage 1 HT ?
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Pre hypertension
Hypertension Stage 1 Stage 2
120-139
80-90
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Definitions
Are the values same for Diabetics , CKD? No, for DM, IHD and CKD the criteria are more stringent The cut off values are 10 mm lower Stage 1 Stage 2
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SBP 130 to 149 DBP 80 to 89 SBP 150 and more DBP 90 and more
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25
p=0.005 (DM)
DM non-DM
20
Events/1000 pt-years
15
10
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Target diastolic BP
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Rule of Halves
For every 800 adults in the community 400 are HT (either SBP or DBP or both) Of them only 200 are diagnosed HT Of them only 100 are started on treatment Of them only 50 are on correct drug Of them in only 25 the goal B.P. is attained Means 25 400 = 6% only have goal BP
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Under control (40%) Diagnosed HT 37% Under Un Rx. treatment HT (50%) (7.5% of the total hypertensives)
63%
Undiagnosed HT
England
6
France
24
Germany Scotland
22.5
> 65 years
India
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17.5
USA: JNC VI. Arch Intern Med 1997 Canada: Joffres et al. Am J Hypertens 2001
Dr.Sarma@works 1998
1998
1. What is ISH ?
2. What percentage of 65+ aged have ISH ? 3. Which is more harmful SBP or DBP ? 4. Why is ISH important ?
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40 + yrs
ISH
S&DHT
DHT Normal
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Persons who are normo-tensive at age 55 have a 90% lifetime risk for developing HTN.
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20
Normotensives
5 Year Risk (%)
15
Hypertensives
10
Stroke
5
Myocardial Infarction
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20 40 60 80
100
120
140
160
180
200
220
240
260
280
300
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1. What is ISH ?
SBP 140+ , DBP < 90
TODAYS PARADIGM
Why is it so?
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25)
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What are the so called CHD risk factors ? List discussed in previous slide What are known as CHD risk equivalents ? DM, PVD, CVA, Nephropathy, Retinopathy What is Framingham 10 CHD risk estimate ? 10 year CHD risk estimate based on age, sex, smoking, TC, HDL, SBP, Rx. for HT see the program
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Why is there TOD in HT ? What are the organs targeted for damage ? What is the basis of TOD ?
Stroke
Heart failure
Cerebral hemorrhage
Hypertension
All Vascular
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Endothelial NO Balance
NO
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Why is there TOD in HT ? It is a disease of blood vessels. What are the organs targeted for damage ? Heart, brain, kidney, eye, peripheral vessel What is the basis of TOD ? ED, Arterial stiffness and Atherosclerosis What tests we need to do to assess TOD ? List discussed
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10 mm
25 mm
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Progression of HT to LVH to HF
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0.99
0.98
Portion Surviving
0.97
0.96
0.95
0.94
Hypertensive-LVH
0.93
0 2 4 6 8 10 12 14 16 18
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40
30 20
Retinopathy
LVH
All-cause mortality
Diabetes + MAU
Peripheral/autonom ic neuropathy
Nephropathy
Because of variability in urinary albumin excretion, 2 of 3 specimens over 3-6 mon should be abnormal before considering diagnostic threshold positive False positive: exercise < 24 hours, fever, CHF, marked hyperglycemia, marked HTN, pyuria and hematuria.
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10.02
10
6.52
6
3.20 2.32
Microalbuminuria
Smoking
Hypertension
Cholesterol
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Target Organ Damage What is single most imp. predictor of CHD, HF, Death ? LVH LV mass index What is the time course of HT to LVH to LVF to death ? The chart is explained Can LVH be regressed at all ? Very much Yes. Diuretics and ACEi are the best Will drugs help to regress TOD ? Yes. All TOD regresses; LVF and CVA most How important is Micro-albuminuria ? The most important prognostic indicator of TOD
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Hypotension Pulsus alternans Trigeminy, Bigeminy Reduced volume of carotid LV apical Enlargement/displacement Sustained heave of apex Change in heart sounds
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Soft S1 Paradoxically split S2 S3 gallop S4 impaired LV compliance) Mitral regurgitation Pulmonary congestion rales
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Ankle-Brachial Index
Resting and post exercise SBP in ankle and arm. 1. Normal ABI > 1 (Ankle BP more than the arm BP) 2. ABI < 0.9 has 95% sensitivity for angiographic PVD
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What is this pattern in HT Dippers and Non-dippers ? What is its significance and clinical relevance ?
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150
140
Non - dippers
130
Dippers
120
110
6 8 10 12 14 16 18 20 22 24 2 4
90
Non - dippers
80
Dippers
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6 8 10 12 14 16 18 20 22 24 2 4
1. Less than 10% circadian variation in SBP and DBP 2. Essential hypertension patients are usually Dippers 3. Non dippers are Dx. by ABPM They are usually
1. Secondary HT cases 2. More end organ damage 3. More LVH 4. More responsive to salt restriction 5. Diabetics are non dippers 6. Diuretics convert a non dipper to dipper
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Systole
Diastole
PulseTrace PCA
Sphygmocor
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The correct Approach to HT Are all patients screened for hypertension? Step1 Are all hypertensives correctly identified? Are they evaluated for co-morbidities/TOD? Step 2 Are they assessed for CHD risk factors? Are the correct drug combinations prescribed? Step 3 What is the compliance for medicines & f/u? Is the goal B.P. achieved and maintained? Step 4 Are there any complications/ side effects?
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11. All HT must be screened for CHD risk factors & addressed
12. Target organ damage (TOD) must be investigated and Rx.
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Dr.Sarma@works
Lifestyle Modification
1. Life style modification is the sheet anchor in the management Hypertension. 2. This surely reduces the number of drugs used and their dosage in controlling HT.
3. Any drug treatment has value only when coupled with Life style modification.
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Lifestyle Modification
Modification
Approximate BP reduction (range) 520 mm/10 kg wt loss 814 mmHg 28 mmHg 49 mmHg
Weight reduction Adopt DASH eating plan Dietary sodium reduction Physical activity
24 mmHg
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Cost constraints
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On April 12, 1945, US President Franklin D. Roosevelt died of cerebral hemorrhage, a consequence of HT. It was a devastating illness for him. By current standards, President Roosevelts death was unnecessary. President Roosevelt was never treated with Anti-hypertensive drugs. Modern treatment would have controlled his BP and prolonged his life.
Arch Int Med, Sept, 23,1996
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Choice must be tailored to individual patient Should be rational and as per approved guidelines
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Physicians Bias in HT
Isolated SHT is often dubbed as aging factor To consider HT is only in the ARM and not in the body No concept of pulse pressure Not seeing the whole Worry about side effects Need to watch, not to worry
The A, B, C, D approach
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Ca++-blocker, Diuretic)
Renin
II
D+C+A
D + C II
Resistant HT / Intolerance
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IV: Add / substitute alpha blocker V: Re-consider 20 causes trial of spironolactone Dickerson et al. Lancet 353:2008-11;1999
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The A B C D classes
D Diuretics A ACEI, ARB
D A
B -Blockers
C Ca-Blockers
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Drug Combinations
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ACEI and ARB = A Beta Blockers = B Calcium Channel (CCB) = C Diuretics Drugs= D D and A combination is excellent D and B combination next D and C combination sixth A and B combination Third A and C combination fourth B and C combination fifth www.drsarma.in
Diuretics = D Rank 1 ACEI and ARB = A Rank 2 Beta Blockers = B Rank 3 CCB = C Rank 4 Ramace H, Losar H, Enace D Betaloc H, Atecard D, Tenoric Amlogaurd H, Stamlo D Losar A, Cardif Beta Amlopres L, Hipril A, Amlo LS Amlo AT, Amlobet, Beta Nicardia
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Beta blockers + Beta1 stimulants - Rebound HT, Paradoxical BP Beta blockers + Vepapamil Thiazide + Furesemide CCB + Thiazide Extreme bradycardia, HB, CHF Potential volume and K No RCTs to support the additive They nullify the effects of each other
Verapamil / Dilzem + Nefidepine Beta blocker + ACEI Sub clinical doses of two drugs Two drugs of same class -
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DIURETIC
Improve CHF, Systolic function, Ca saving Reduce LVH, Morbidity & Mortality My Bad aspects Potassium washout, in Uric acid, Ca Adverse on Lipids, Glucose control Dont use me in Gout, Hypokalaemia Dyslipedemia, Uncontrolled DM
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ACEI, ARB
My Good aspects Improve Diastolic function, Systolic function Control Proteinuria, Very favourable in DM Improve Coronary Ischemia, Good on Lipids Reduce LVH, Morbidity & Mortality My Bad aspects
Pregnancy, Creatinine is > 3 mg%, K 5.0 meq Bilateral Renal Artery Stenosis, Angio-edema
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Blocker
My Good aspects Heart rate, Forceof contraction, Conduction Myocardial O2 demand, Improve Ischemia Improve QUALY in CHD, Useful in CHF, Migraine My Bad aspects Constrict peripheral vessels, Bradycardia
Unfavourable on Lipids, Glucose Dont use me in Bradycardia, Conduction defects, Caution in CHF Prinzmetal Angina, MSD, PVD, BA, COPD, Dys lipid Pheochromocytoma, Chronic smokers
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Anti arrhythmic (Verapamil), Coronary BF (Diltz) Neutral on lipidemia, Vasospastic Angina My Bad aspects Fluid retention, Impair failing heart Adverse on Glucose control , Pedal edema ? Rx. Dont use me in Tachycardia, arrhythmias, CHF, Uncontrolled DM, Volume overload
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CV Mortality
Heart rate Use in DM Lipid effects Fluid & Na
Improves
No effect Negative Negative Enhances
Improves
No effect Excellent Excellent No effect No effect No effect
Improves
Bradycardia Negative Negative Vasoconstr. Bronchospa conduction
Increases
Tachycardia Negative Neutral Vasodilatory No effect No effect
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DIU
HCZ Chlortha Indapami Furosemi Torsemid Spirono Triamter
ACEi
Enalapril Ramipril Lisinopril Perindopr Quinapril Captopril Benazopr
ARB
Losartan Telmisart Valsartan Irbesartan Candesart
BB
Metoprol Carvedio Atenelol Labetolol Nebivol Bisiprol Pindolol Proprano
CCB
Amlodep Nefidepin Felodepin Nitrendep
Verapami Diltiazem
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Case 5
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CCB, ACEi
Not BB
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Case 5
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CCB, ACEi
Not BB
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Case 5
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CCB, ACEi
Not BB
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Case 5
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CCB, ACEi
Not BB
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Case 5
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CCB, ACEi
Not BB
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Case 2
Case 3 Case 4 Case 5
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Stage 1 HT
Stage 2 HT HT + Tachycardia HT + Bradycardia Heart Blocks BBB
Single Drug
Two Drugs Beta blockers CCB, ACEi
D or D + A
D + A, D + B Not CCB Not BB
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bloc, Tamsu bloc, HZ, ACEi /CCB MD, HYZ, CCB ACEi, CCB Indap, Amlo, Enalapril ACEi cough
bloc, Tamsu bloc, HZ, ACEi /CCB MD, HYZ, CCB ACEi, CCB Indap, Amlo, Enalapril ACEi cough
bloc, Tamsu bloc, HZ, ACEi /CCB MD, HYZ, CCB ACEi, CCB Indap, Amlo, Enalapril ACEi cough
bloc, Tamsu bloc, HZ, ACEi /CCB MD, HYZ, CCB ACEi, CCB Indap, Amlo, Enalapril ACEi cough
bloc, Tamsu bloc, HZ, ACEi /CCB MD, HYZ, CCB ACEi, CCB Indap, Amlo, Enalapril ACEi cough
bloc, Tamsu bloc, HZ, ACEi /CCB MD, HYZ, CCB ACEi, CCB Indap, Amlo, Enalapril ACEi cough
bloc, Tamsu bloc, HZ, ACEi /CCB MD, HYZ, CCB ACEi, CCB Indap, Amlo, Enalapril ACEi cough
Case 24
Hypertensives may present with cough watch out 1. Consider LVF as the cause of cough 2. Consider ACEI induced dry cough 3. Stop ACEI and give ARB or other agents 4. Check the composition of the cough remedy you give 5. Ephedrine, Pseudephedrine, should be avoided 6. Oral Beta agonists like Orciprenaline, Salbutamol, Terbutaline the less used, the better.
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Case 25
Secondary HT
Treatment
Usually Stage 2 - HT Secondary causes will be present May present in young individuals Look for secondary cause and treat Life style interventions must Vigorous efforts required to control HT Often two or even 3 drugs may be required Resistant HT may be encountered Anti HT drugs as per secondary cause ACEI or ARB in bilateral renal artery stenosis
Absolute contra
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Case 26
Pheochromocytoma Usually Stage 2 HT, Episodic or Labile Secondary adrenal medullay tumor May present in young individuals Treatment Surgical Ablation of the chromaffin tissue HT needs to be controlled before surgery Alpha blockers are the drugs of choice Phentolamine, Phenoxybenzamine, Prazocin Vigorous efforts required to control HT Often two or even 3 drugs may be required Resistant HT may be encountered Surgery First reduce HT, then surgery Do not use
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Beta blockers
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Case 27
Resistant Hypertension
Resistant HT
Reasons
Rationale
Usually Stage 2 HT May present in young individuals May have secondary causes Not taking medication (liers) Improper BP measurement Excessive Na intake, Inadequate diuretic Rx. Full doses of drugs not employed Drug interactions NSAIDs, SMA, OCP, OTC Herbal remedies, Excessive alcohol use Identify the above and correct Secondary causes to be searched for
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Case 29
Hypertensive emergencies
Treatment
Do not use
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Marked DBP elevation Acute TOD present Encephalopathy, MI, ACS, Pul Edema, Eclampsia, stroke, head trauma, lifethreatening arterial bleeding, or aortic dissection With TOD immediate admission to ICU IV Nitroprusside, Diazoxide, Labetolol Without TOD Combination of 2 or 3 drugs Close monitoring Life style modification not now no time No sublingual nefedipine,
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Case 30
Treatment
Marked DBP elevation May be SAH, ICH, Acute Brain Infarction In acute setting, no consensus on treatment of elevated BP HT at time of an acute stroke associated with increased risk of cerebral hemorrhage and edema, increased mortality After acute ischemic stroke, cerebral auto regulation affected Active treatment of BP in the first 7 days could worsen symptoms Recommendation not to start HT Rx. before 7 to 10 days after ischemic stroke
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1. Hypertension with BPH 2. In Pheochromoytoma before surgery 3. In the treatment of Ergot over dose 4. Raynauds syndrome and PVD, TAO 5. Vasospastic (prinzemetal Angina) 6. Diabetic neuropathy 7. Hypertensive smokers 8. Hypertension with Dyslipidemia
First dose syncope and Postural Hypotension How to avoid ?
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