Ht Nlecture2009

HTN new Updates

Dr Ihab Suliman Dr Ihab Suliman MBBS,ECFMG(USA),DCBNC(UMBBS,ECFMG(USA),DCBNC(U

SA),SA),

MRCP(UK)MRCP(UK)

Associate Consultant CardiologyAssociate Consultant Cardiology

Member of the European Member of the European Working Group on Nuclear Working Group on Nuclear Cardiology & Cardiac CTCardiology & Cardiac CT

Case Case

40 years old male , came anxious to 40 years old male , came anxious to the clinic , previous history of drug the clinic , previous history of drug abuse , before coming to the clinic , abuse , before coming to the clinic , had one large CAPPUCINO with had one large CAPPUCINO with extra shot, BP 160/95, a diagnosis of extra shot, BP 160/95, a diagnosis of HTN is established if ??????? HTN is established if ???????

1- further 2 readings are 160/95.1- further 2 readings are 160/95.

2-there is history of DM.2-there is history of DM.

3- Cannot officially be made at this 3- Cannot officially be made at this time.time.

3- Cannot officially be made at this 3- Cannot officially be made at this time.time.

HTNHTNDefinedDefined

Average of 3 or more properly measured Average of 3 or more properly measured Blood Pressure readings over a period Blood Pressure readings over a period of weeks to Months.of weeks to Months.

Normal BP is below 120/80.Normal BP is below 120/80. Pre-HTN SBP 120-139/80-89Pre-HTN SBP 120-139/80-89 Stage 1 140-159/90-99Stage 1 140-159/90-99 Stage 2 equal or more 160/100Stage 2 equal or more 160/100

JAMA 2003 JAMA 2003

Properly MeasuredProperly Measured

Cuff SizeCuff Size

Bilateral Bilateral

Confirm with Manual Confirm with Manual

No recent caffeine or SmokingNo recent caffeine or Smoking

Hypertension Risk Hypertension Risk FactorsFactors

Sodium IntakeSodium Intake

Excess alcohol, Energy drinks.Excess alcohol, Energy drinks.

Genetic or Racial factorsGenetic or Racial factors

ObesityObesity Others DM, Lack of excerciseOthers DM, Lack of excercise

Benefits of HTN RxBenefits of HTN Rx

Reduced incidence of Stroke (35%-Reduced incidence of Stroke (35%-40%).40%).

Reduced Incidence of MI (20%-25%).Reduced Incidence of MI (20%-25%).

Reduced Incidence of Heart Reduced Incidence of Heart Failure( 50%)Failure( 50%)

NNTNNT

NNT to prevent one death if SBP is NNT to prevent one death if SBP is reduced by 12mmHg for 10 years is reduced by 12mmHg for 10 years is 11 .11 .

Case Case

55 years old obese Diabetic with 55 years old obese Diabetic with Type 2 DM, SBP is consistently Type 2 DM, SBP is consistently above 150 mmHg, the best initial above 150 mmHg, the best initial treatment will be ???treatment will be ???

1-HCTZ 12.5 MG PO DAILY.1-HCTZ 12.5 MG PO DAILY. 2-TENORMIN 50 MG PODAILY2-TENORMIN 50 MG PODAILY 3-LISINOPRIL 20 MG PO DAILY3-LISINOPRIL 20 MG PO DAILY 4-LISINOPRIL 10 MG PODAILY4-LISINOPRIL 10 MG PODAILY

4-LISINOPRIL 10 MG PODAILY4-LISINOPRIL 10 MG PODAILY You FU the patient by You FU the patient by A-POTASSIUMA-POTASSIUM B-RENINB-RENIN C-CREATININEC-CREATININE D-ECGD-ECG E— A&CE— A&C F-A,B,C,DF-A,B,C,D

E— A&CE— A&C The patient after starting Lisinopril The patient after starting Lisinopril

will be seen after with Basic Screenwill be seen after with Basic Screen A- one week then 3 monthyA- one week then 3 monthy B- every 3 monthsB- every 3 months C- within 3 days then 3monthsC- within 3 days then 3months

A- one week then 3 monthyA- one week then 3 monthy

45 years old male with DM , Prior 45 years old male with DM , Prior history of IHD, Last echo report EF history of IHD, Last echo report EF 45%, SBP 155, Creatinine 140, 45%, SBP 155, Creatinine 140, potassium 4, started on lisinopril 10 potassium 4, started on lisinopril 10 mg po daily, after 3 month on a mg po daily, after 3 month on a routine visit SBP 115, creatinine routine visit SBP 115, creatinine 155, potassium is 4.5 , No chest 155, potassium is 4.5 , No chest Pain or SOB, the next step will Pain or SOB, the next step will be ????be ????

A- DIC Lisinopril & Start Amlor .A- DIC Lisinopril & Start Amlor . B- refer to cardiology.B- refer to cardiology. C-No change & BC-No change & B D- DIC lisinopril & start ARBsD- DIC lisinopril & start ARBs E- Start Aliskiren E- Start Aliskiren

Hypertensive Urgency & Hypertensive Urgency & EmergencyEmergency

What is the difference ???What is the difference ??? 1- Symptoms.1- Symptoms.

2- Degree of Systolic BP.2- Degree of Systolic BP.

3- Degree of Diastolic BP3- Degree of Diastolic BP

1- Symptoms.1- Symptoms.

What are they??????What are they??????

Hypertensive Emergency Hypertensive Emergency SxSx

Headache Headache

Neurolological SXNeurolological SX

Chest Pain Chest Pain

AnuriaAnuria

Difference between Hypertensive Difference between Hypertensive Urgency & EmergencyUrgency & Emergency

Hypertensive Emergency Is any Hypertensive Emergency Is any Significantly SBP with sx.Significantly SBP with sx.

Hypertensive Urgency is BP above Hypertensive Urgency is BP above 230/120 without sx230/120 without sx

Difference between Hypertensive Difference between Hypertensive Urgency & EmergencyUrgency & Emergency

Hypertensive Emergency Is any Hypertensive Emergency Is any Significantly SBP with sx Treatment Significantly SBP with sx Treatment start immediately, avoid sublingual start immediately, avoid sublingual Nifedipine. Refer to ERNifedipine. Refer to ER

Hypertensive Urgency is BP above Hypertensive Urgency is BP above 230/120 without sx, BP should come 230/120 without sx, BP should come down to target within 24-48 Hoursdown to target within 24-48 Hours

Algorithm for Treatment of Hypertension Algorithm for Treatment of Hypertension (JNC 7) (JNC 7) JAMA, May 2003JAMA, May 2003

Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Drug(s) for the compelling indications

With Compelling Indications

Lifestyle Modifications

Stage 2 Hypertension 2-drug combination

for most

Stage 1 Hypertension Thiazide-type diuretics

for most.

May consider ACEI, ARB, BB, CCB, or

combination

Without Compelling Indications

Case Case

60 years old university teacher is 60 years old university teacher is working in university of london , he is working in university of london , he is married with children , not diabetic , married with children , not diabetic , not asthmatic , migrated from Nigeria, not asthmatic , migrated from Nigeria, labeled as first stage of HTN, SBP labeled as first stage of HTN, SBP 150, according to UK guidelines for 150, according to UK guidelines for HTN , the first line will be ?HTN , the first line will be ?

1-BB1-BB 2-CCB2-CCB 3-Hydralazine3-Hydralazine

2-CCB2-CCB His Colleague who is a an englishman His Colleague who is a an englishman

is 50 years old , visits the same doctor is 50 years old , visits the same doctor for the same clinical problem, he has for the same clinical problem, he has history of asthma, he is likely to get ??history of asthma, he is likely to get ??

1-candesartan1-candesartan 2-BB2-BB 3-lisinopril3-lisinopril

1-candesartan1-candesartan

Choosing drugs for patients newly diagnosed Choosing drugs for patients newly diagnosed with hypertensionwith hypertension

BHS Guidelines (June 2006)BHS Guidelines (June 2006)

Younger than 55 years55 years or olderOr black patients of any age

A C or D

A+C or A+D

A+C+D

Add •further diuretic therapy•Or alpha blocker•Or Beta Blocker•Consider seeking specialist advice

Abbreviations:

A: ACE-I (or ARB if ACE intolerant)

C: CCB

D: thiazide type diuretic

Step 1

Step 2

Step 3

Step 4

Hypertension and DiabetesRecommendations of the American Diabetic

Association

• Treat to BP <130/80 mmHg

• All patients with diabetes and hypertension should be treated with a regimen that includes either an ACEi or an ARB.

• If needed to achieve blood pressure targets, a thiazide diuretic should be added.

American Diabetes Association. Diabetes Care. 2005; 28 (Suppl 1): S10 – S17.

Conditions favoring the use of ARBs

Type 2 diabetic nephropathyType 2 diabetic nephropathy Diabetic microalbuminuriaDiabetic microalbuminuria ProteinuriaProteinuria Left ventricular hypertrpphyLeft ventricular hypertrpphy ACE-I induced coughACE-I induced cough

Case 1Case 1

45 years old Female discharged 45 years old Female discharged from Cardiac Unit last months after from Cardiac Unit last months after establishing diagnosis of CHF with establishing diagnosis of CHF with normal coronaries , EF 15%, on ASA, normal coronaries , EF 15%, on ASA, BB, Lasix 40mg BID , Zestril 20 mg, BB, Lasix 40mg BID , Zestril 20 mg, Statin. Statin.

SBP before admission to cardiology SBP before admission to cardiology was 200 mmHgwas 200 mmHg

What is the cause of her What is the cause of her cardiomyopathy?cardiomyopathy?

1-Viral 1-Viral

2-idiopathic2-idiopathic

3-Postpartum3-Postpartum

4-HTN4-HTN

HTNHTN

70 years old female with no prior active 70 years old female with no prior active cardiac problems, Informed in a private cardiac problems, Informed in a private clinic about being Hypertensive, 3 separate clinic about being Hypertensive, 3 separate visits, SBP 160-170 ,what is the next step??visits, SBP 160-170 ,what is the next step??

A-life style modfication.A-life style modfication. B-single agent anti hypertensive B-single agent anti hypertensive C- combination of two anti hypertensive C- combination of two anti hypertensive

agents.agents. D- a diagnosis of HTN cannot be made at D- a diagnosis of HTN cannot be made at

this time.this time.

C- combination of two anti C- combination of two anti hypertensive agents.hypertensive agents.

The following are The following are Positive trials?Positive trials?

1- I-Preseve1- I-Preseve

2- GISSI-AF2- GISSI-AF

3- HYPVET3- HYPVET

The following are The following are Positive trials?Positive trials?

3-HYPVET3-HYPVET

Prevalence of HTNPrevalence of HTN

Prevalence of HTN above the age of Prevalence of HTN above the age of 55 years in general population is 55 years in general population is

1- 90 % or more1- 90 % or more

2- 60% or more2- 60% or more

3- 30% or more3- 30% or more

1- 90 % or more1- 90 % or more

Case Case

22 years old lady with para 5, H/O 22 years old lady with para 5, H/O Pregnancy induced HTN, seen one week Pregnancy induced HTN, seen one week after the delivery of twins by C/S, she is after the delivery of twins by C/S, she is SOB , anxious & little bit sweaty , SOB , anxious & little bit sweaty , PaO2sat 92%, the best step in PaO2sat 92%, the best step in mangement will be????mangement will be????

A- give propranolol 10 mg po stat.A- give propranolol 10 mg po stat. B-IV line ,check D-Dimer, High flow B-IV line ,check D-Dimer, High flow

oxygen & call ER.oxygen & call ER. C-Midazolam 2 mg , ECG stat.C-Midazolam 2 mg , ECG stat.

B-IV line ,check D-Dimer, High flow B-IV line ,check D-Dimer, High flow oxygen & call ER.oxygen & call ER.

Scientific evidenceScientific evidence

Regarding studies of population The Regarding studies of population The strongest Scientific evidence comes strongest Scientific evidence comes fromfrom ?? ??

1- Metanalysis of methodologically 1- Metanalysis of methodologically sound RCTs that have consistent results.sound RCTs that have consistent results.

2-Single RCTs.2-Single RCTs. 3-Observational studies analysed by 3-Observational studies analysed by

Experts. Experts.

1- Metanalysis of methodologically 1- Metanalysis of methodologically sound RCTs that have consistent sound RCTs that have consistent results.results.

ALLHAT studyALLHAT study

The following is true about ALLHAT ??The following is true about ALLHAT ??

The largest trial in Hypertensive The largest trial in Hypertensive patients with mild to moderate renal patients with mild to moderate renal Impairement.Impairement.

Thiazide Diuertics become first lineRx Thiazide Diuertics become first lineRx in Simple uncomplicated HTN.in Simple uncomplicated HTN.

ACEIs cardiovascular mortality was ACEIs cardiovascular mortality was better than Diuretics. better than Diuretics.

Thiazide Diuertics become first Thiazide Diuertics become first lineRx in Simple uncomplicated lineRx in Simple uncomplicated HTN.HTN.

HERsHERsThe Heart & estrogen The Heart & estrogen

Replacement therapy studyReplacement therapy study The following is wrong about HERs??The following is wrong about HERs?? 1-It is example of an observational 1-It is example of an observational

trial .trial . 2- Reversed decades of thoughts on 2- Reversed decades of thoughts on

cardiovascular effects of hormone cardiovascular effects of hormone therapy.therapy.

3-Published in 19983-Published in 1998 4- It is an example of RCT.4- It is an example of RCT.

ARBs e.g Candesartan , can be used ARBs e.g Candesartan , can be used as first line antihypertensive Line , as first line antihypertensive Line , they are characterized by all the they are characterized by all the following except??following except??

1- Renal protection1- Renal protection 2-better tolerated than ACEI2-better tolerated than ACEI 3-Increased incidence of DM3-Increased incidence of DM

Development of new Development of new diabetes – CHARM studydiabetes – CHARM study

01020304050607080

No. of cases

developing new

Diabetes

Controlcandesartan

40%p=0.005

Lancet, 2003

© 2008, American Heart Association. All rights reserved.

• Blood pressure remaining above goal in spite of concurrent use of 3 antihypertensive agents of different classes.

• Ideally, 1 of the 3 agents should be a diuretic & all agents should be prescribed at optimal dose amounts.

Resistant Hypertension

ThankThank you you