Introduction III Benefits of Treating to Target Older than 60 with isolated systolic hypertension...

2000 Canadian Recommendations for the Management of Hypertension

2000 Canadian Recommendations

for the Management of Hypertension

Jan 18, 2001

2000 Canadian Recommendations for the Management of Hypertension

IntroductionHypertension as a Risk Factor

• Hypertension is a significant risk factor for:

– cerebrovascular disease– coronary artery disease– congestive heart failure– renal failure– peripheral vascular disease

2000 Canadian Recommendations for the Management of Hypertension

Introduction IIBenefits of Treating Hypertension

Younger than 60– reduces the risk of stroke by 42%– reduces the risk of coronary event by 14%

Older than 60– reduces overall mortality by 20% – reduces cardiovascular mortality by 33%– reduces incidence of stroke by 40%– reduces coronary artery disease by 15%

Introduction IIIBenefits of Treating to Target

• Older than 60 with isolated systolic hypertension (SBP 160 mm Hg and DBP < 90 mm Hg)

– 36% reduction in the risk of stroke– 25% reduction in the risk of coronary events

2000 Canadian Recommendations for the Management of Hypertension

23%16%

42%19%

Hypertensive patients who are treated but uncontrolled

Hypertensive patientswho are treated and controlled

Hypertensive patients who are unaware

Patients who are awarebut remain untreated

and uncontrolled

22% of Canadian adults 18 to 70 years of age have hypertension

Introduction IV The Challenge

Source : Joffres et al. (1997) Am. J. Hypertension 10: 1097-1102

2000 Canadian Recommendations for the Management of Hypertension

JNC VI Classification of Blood Pressure for Adults

Optimal <120 and <80

Normal <130 and <85

High–Normal 130–139 or 85–89

Hypertension

Stage 1 140–159 or 90–99

Stage 2 160–179 or 100–109

Stage 3 180 or 110

JNC 6 - Arch Int Med / Jan 1998

Category SBP DBP

Hypertension

1. Primary - 90% of all cases

- cause unknown

- “essential” or “idiopathic”

Benign gradual onset with prolonged course

Malignant abrupt with short course

can be fatal

severely damages

Hypertension

2. Secondary cause identifiable

- C.V., renal, pregnancy,

drugs, corticosteroids

- retain Na & H2O

Hypertension

Isolated hypertension:

If the patient has increased systolic BP with normal diastolic BP

Complications

• Heart - CAD - atherosclerotic changes

Angina, M.I., ( C.A. blood flow)

CHF - afterload, O2 need

Arrhythmias

• Brain - stroke microaneurysms

hemorrhage

Complications

• Kidneys renal failure

• Eyes visual disturbances

blindness

• Peripheral Vessels intermittent claudication

dissecting aortic aneurysm

Mechanisms of 1° Hypertension

1. Overactive SNS stimulation

- excite with nonepinephrine

- contractions

- vasoconstriction with workload &

B/P

Mechanisms of 1° Hypertension

2. Na & H2O retention by kidneys

- excessive secretion of renin

- H2O & Na retained

- volume & perfusion = B/P

- Most likely cause

Hypertension• Causes are however numerous &

interrelated

- environment

- psychological

- physiologic

Hypertension

• No obvious changes at first

• Changes widespread with time

• Large vessels sclerosed (narrowed)

• Small vessel damage

Vasoconstriction heart contractions (afterload) to maintain C.O.

chronic overwork

L.V. hypertrophy

coronary insufficiency M.I.

Con’t

LVF eventually

renal perfusion

Na & H2O retention

blood flow to kidneys, heart, eyes, brain

Progressive Impairment

Secondary Hypertension

Causes are numerous

• diabetes

• glomerulonephritis

• corticosteroid Rx

• Drugs - BCP - Amphetamines

- Estrogens - Thyroid hormones

Secondary Hypertension

Causes are numerous

• ICP

• anemia

• aortic regurgitation

Secondary Hypertension

Mechanisms1. secretion catecholamines

2. release renin

3. Na & blood volume

Dx: B/P high over several readings

averages >140

> 90

Assessment

1. Extent of organ involvement

2. Presence of C.V. risk factors

3. ID type

2000 Canadian Recommendations for the Management of Hypertension

Risk Assessment

Risk strata (typical 10 year risk of stroke or myocardial infarction): Low risk = less than 15%; medium risk = about 15-20% risk; high risk = about 20-30%; very high risk = 30% or more

1. TOD – Target Organ Damage2. ACC – Associated Clinical Conditions, including clinical cardiovascular disease or renal disease

Stratification of Risk to Quantify Prognosis

Reference: Chalmers J et al. WHO-ISH Hypertension Guidelines Committee. 1999 World Health Organization - International Society of Hypertension Guidelines for the Management of Hypertension. J Hypertens, 1999, 17:151-185.

Other Risk Factors & Disease History

Grade 1 Grade 2 Grade 3

BLOOD PRESSURE (mm Hg)

(mild hypertension)SBP 140-159 or

DBP 90-99

(moderate hypertension)SBP 160-179 or

DBP 100-109

(severe hypertension)SBP ? 180 or

DBP ? 110

MED RISKLOW RISK HIGH RISK

V HIGH RISK

V HIGH RISK

V HIGH RISKMED RISK MED RISK

HIGH RISKHIGH RISK

V HIGH RISKV HIGH RISK

I. no other risk factorsII. 1-2 risk factorsIII. 3 or more risk factors or TODor diabetes

IV. ACC

History

• Family Hx

• Diabetes

• Previous B/P

• results of hypertensives

• angina, dyspnea hx

• use of BCP, alcohol, steroids, diet pills

History con’t

• Weight gain

• Na intake

• stress, cultural food practices

• Risk factors chol.

Obesity

history of exercise

Physical Exam

• Retina edema, hemorrhage

• Neck distended veins, bruit

• Heart HR, murmurs

• Extremities p.p., edema

2000 Canadian Recommendations for the Management of Hypertension

Risk Stratification and Treatment

Lifestylemodifications(up to 12 months)

Lifestylemodifications(up to 6 mos)

Adapted from JNC VI; TOD = Target organ damage CCD = Clinical cardiovascular disease

Blood PressureStages (mm Hg) No Risk Factors

No TOD/CCD

One Risk Factorother than DMNo TOD/CCD

TOD/CCDand/or DM

High-Normal(130-139/ 85-89)

Lifestylemodifications

Lifestylemodifications

Drug therapy

Drug therapy

Drug therapyDrug therapyDrug therapyStages 2 and 3(160/ 100)

Stage 1(140-159/ 90-99)

Risk Group A Risk Group B Risk Group C

Interventions

• Nonpharmacological - weight reduction

- exercise

- Na

- relaxation

- monthly BP checks

- Ethol, coffee

- smoking cessation

Hypertensivepatient

Dietary Potassium

Dietary Sodium

Non Pharmacologic Recommendations for HypertensionLifestyle: Dietary

Magnesium supplementation

Calcium supplementation

For age over 44,

Restricted to a target range of 90-130 mmol/day. (Limitation of salt additives and foods with excessive added salt)

Daily dietary intake ≥ 60 mmol

Fresh fruits,

Vegetables,

Low fat dairy products,

Low fat diet,

in accordance with

Canada's Guide

to Healthy Eating

No conclusive studies for hypertension

No conclusive studies for hypertension

Jan 18, 2001

Pharmacological Diastolic > 95

1. Diuretics

a) thiazides - promote excretion Na & H2O

- Diuril, hydrodiuril

- hypokalemia possible

b) loop diuretics - loop of Henle

- minimize H2O & Na reabsorption

- Lasix

Pharmacological Diastolic > 95

1. Diuretics

c) Potassium sparing - promote H2O & Na excretion

- hyperkalemia

- aldactone

2. Sympatholytic Agents

- interrupt activity SNS with renin activity

- catapres & aldomet

Pharmacological Diastolic >95

3. Vasodilators

- dilate peripheral blood vessels

- Apresoline, minipres

4. Angiotension converting enzyme inhibitor

- inhibit Angio 1 to Angio 2

- afterload i.e. captopril

Pharmacological Diastolic >95

5. Ca channel blockers

- C.O. & rate

- nipedine

Hypertensive CrisisReduction in BP needed stat

• Malignant hypertension

• hypertensive encephalopathy - LOC

• heart failure

• toxemia

• dissecting aneurysm

• intracranial hemorrhage

Interventions for Crisis

ICU

IV Drugs

Monitoring

Continuous EKG

Management Long-term• Assess Knowledge - disease process

- consequences- administration drugs- diet- exercise- home monitoring

• Compliance

• Ineffective coping

Drugs• Never dose

• Never miss dose

• Take on time

• Side effects

• Never discontinue

Hypotensive Alert• Lie down with legs elevated

• No hot baths

• No excessive alcohol

Reasons for Noncompliance

• Asymptomatic

• Difficult lifestyle changes

• Annoying side effects

• Costs