The Pharmacists’ Role in Treating Hypertension

Thomas Owens, MDSaint Francis University

CERMUSA

Objectives

1. Enhance your understanding of hypertension to include cardiovascular risks, management, and goals for individual patients

2. Review and discuss the current pharmacotherapy standards of care for hypertension

3. Describe the pharmacist’s role in counseling patients on hypertensive medications

Hypertension >140/90 mm Hg

• United States:

65 million adults

• Risk factors include:– Stroke, myocardial infarction,

heart failure, peripheral vascular disease, aortic dissection, chronic renal failure

• Hypertension price tag: $59.7 billion

Wexler & Feldman, 2005

Hypertension

• Typical onset– second decade of life

• Primary Hypertension– identifiable behaviors

• Secondary Hypertension– more discrete

Cecil, 2004

Ethnic Groups

• African Americans– 43% female & 39% male– Ratio 1:3 – Increase in sodium

sensitivity?

• Caucasians– 28% female – 29% male

• Mexican Americans– Ratio 1:4 or 1:5 DASH Diet

Cecil, 2004

Dietary Sodium Intake

Salt Hypothesis?

- Strong genetic underpinning

ADA, 2005

Metabolic Syndrome

• Risk of Hypertension increases with BMI

• Obesity accounts for 50% to 60% of new cases of hypertension

Cecil, 2004

Potential Causes of Hypertension

• Expanded plasma volume plus sympathetic over activity– Peripheral

vasoconstriction– Renal salt retention– Renal water retention

Sleep Apnea

www.sleepconsultants.com, 2007

Cecil, 2004

Blood Pressure Equation

Blood Pressure = Cardiac Output x Peripheral Vascular Resistance

Most pharmacologic agents lower

Some pharmacologic agents lower

Some pharmacologic agents lower both

Cecil, 2004

Genetics of High BP

• Sympathetic up-regulation leads to a cascade of events– Peripheral vascular

resistance

• Genetic factors– 30% of cases– 2x as likely if parents

have hypertensionDiscoveryedge.mayo.com, 2007; ADA, 2003

Systolic & Diastolic ??

• What is more important?– Depends on age

• Live long enough almost all develop systolic hypertension

120

80

systolic

diastolic

Cecil, 2004

Age Dependant Rise in BP

(Whelton & Rocella, 1995)

Framingham Study (age: 50-79)

(Khan, Wong, Larson, & Levy, 1999)

Systolic Hypertension

• Decreased distensibility of large arteries

• Majority of uncontrolled hypertension– Due to focus on

diastolic BPCecil, 2004

Risk of cardiovascular mortality by systolic BP

(National High Blood Pressure Education Program Working

Group, 1993)

Hypertension Study Results

• Hypertension is excess of 140/90 mm Hg

• Studies found– Increase risk when above 115 mm Hg systolic or

75 mm Hg diastolic– High normal BP had twice increased risk for

cardio disease– More studies are needed to fully understand

Cecil, 2004

The Silent Killer

• 1/3 of adults do not know they have hypertension

• Hypertension: 60% are treated– 45% of treated remain uncontrolled

Despite over 75 different antihypertensive agents in 9 different classes!

Cecil, 2004

Reclassification of BP Stages

Blood Pressure (mm Hg)

Classification

<120/80 Normal

120-139/80-89 Pre-hypertension

≥140/90 Hypertension

140-159/90-99 Stage 1

160-179/100-109 Stage 2

• Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC)

• New category “pre-hypertension”– Pharmacotherapy not recommended

– Lifestyle modification recommended!

Cecil, 2004; JNC, 2007

JNC Drug Therapy Recommendations

Blood Pressure (mm Hg)

Classification

<120/80 Normal

120-139/80-89 Pre-hypertension

≥140/90 Hypertension

140-159/90-99 Stage 1

160-179/100-109 Stage 2

recommendation (healthy)

≥130/80

(w/ heart and kidney disease or diabetes mellitus)

JNC, 2007

Modest reduction in BP = big benefits !!

• Decrease 5 mm Hg decreases risks– Small changes can have a big

difference

• Results of studies– Systolic surge 34 mm Hg = 3x

increase of stroke– Systolic ≥135 mm Hg = 74%

increase of cardio event

Blood Pressure (mm Hg)

Cardiovascular Risk

Exceeds 115/75 Increases

Each increase of 20/10 mm Hg

Doubles

Cecil, 2004; JNC, 2007

Clinical Presentation

• No specific signs or symptoms

• Possible symptoms– Occipital headache, dizziness, tinnitus, dimmed

vision, palpitations, fatigue

• Physical Exam– May reveal evidence

Cecil, 2004

Hypertensive Retinopathy

Grades of hypertensive retinopathy shown

(Forbes, Jackson, 2003)

Electrocardiogram (ECG or EKG)

GOOD

(Normal)

BAD

(Antero-Septal MI)

physiol.umin.jp/cardiovasc, 2007

Counseling Patients:Proper BP Readings

• At least 30 minutes before NO– Caffeine, decongestants, oral contraceptives, alcohol,

tobacco

• Sit down for at least 5 minutes

Arm above heart level

=Falsely low blood pressure reading

Arm below heart level

Falsely elevated blood pressure reading

Loose cuff or bladder Falsely elevated blood pressure reading

Cecil, 2004; ADA, 2005

Counseling Patients: Proper Fit of BP Cuff

Length of bladder of the cuff at least 80% circumference of arm

Bladder of cuff at least 40% circumference of arm

Place the center of the bladder over the brachial artery

Pump until radial pulse disappears, then continue for additional 30 mm Hg

Help Patients Understand: White Coat Hypertension

• Anxiety of going to doctor office raises BP– Recommend self-monitoring

• Daytime: >135/85 mm Hg

• Nighttime: >120/70 mm Hg

• 24 hr: >130/80 mm Hg

• Follow patients every 6 months for possible progression to persistent hypertension

Cecil, 2004

Closely Monitor Medications with High-Risk Patients

Cecil, 2004

Counseling Patients:Causes of Organ Damage

Major Risk Factors Target Organ Damage

Cigarette smoking Heart

Obesity (BMI >30 kg/m2) * Left ventricular hypertrophy

Physical inactivity Angina pectoris

Dyslipidemia * Myocardial infarction

Diabetes mellitus * Coronary revascularization

Age

Men: Older than 55

Women: Older than 65

Heart Failure

Brain

Stroke

Family History of pre-mature CVD

Men: Older than 55

Women: Older than 65

Transient ischemic attack

Hypertensive nephrosclerosis

GFR <60 mL/min

Any chronic disease

GFR <60 mL/min

Urine protein >150 mg/24hr

Urine protein >150 mg/24hr

Retinopathy

Peripheral atherosclerosis

•Components of metabolic syndrome (The JNC 7 Report. JAMA 2003)

Counseling Patients:Treatment

Risk Group Treatment

Mild RiskFree of CVD

Lifestyle modification

Low RiskPre-hypertension or Stage 1 or 2

Pre & Stage 1: Lifestyle modification

Stage 2: Lifestyle modification and medications

Moderate Risk1 or more cardio risk factors

Lifestyle modification and medications

High RiskEvident organ damage, diabetes, renal insufficiency

Lifestyle modification and medications

JNC, 2005

SUSPECTED DIAGNOSIS

CLINICAL FEATURES DIAGNOSTIC TESTING

Renal parenchymal hypertension

Elevated serum creatinine or abnormal urinalysis

24-Hour urine creatinine and protein, renal ultrasound

Renovascular disease

New elevation in serum creatinine, marked elevation in serum creatinine with initiation of ACEI or ARB, refractory hypertension, flash pulmonary edema, abdominal bruit

Captopril renogram, duplex Doppler sonography, magnetic resonance or CT angiogram, invasive angiogram

Coarctation of the aorta

Arm pulses > leg pulses, arm BP > leg BP, chest bruits, rib notching on chest radiograph

MRI, aortogram

Primary aldosteronism

Hypokalemia, refractory hypertension

Plasma renin and aldosterone, 24-hour urine potassium, 24-hour urine aldosterone and potassium after salt loading, adrenal CT scan

Cushing's syndromeTruncal obesity, purple striae, muscle

weaknessPlasma cortisol, urine cortisol after

dexamethasone, adrenal CT scan

PheochromocytomaSpells of tachycardia, headache,

diaphoresis, pallor, and anxiety

Plasma metanephrine and normetanephrine, 24-hour urine catechols, adrenal CT scan

Obstructive sleep apnea

Loud snoring, daytime somnolence, obesity

Sleep study

    ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; BP = blood pressure; CT = computed tomography. (Williams & Wilkins, 2002)

Counseling Patients: Lifelong Treatment

• Objective: reduce BP and metabolic abnormalities

• Pharmacotherapy & lifestyle modification– Reduce sodium intake– Weight loss– Exercise– Moderating alcohol– Reduce systolic BP by 21 to 55 mm Hg

Cecil, 2004

Counseling Patients: Dietary Changes

• Losing only 10 to 12 lbs lowers BP by 10/5 mm Hg

• Reduce daily salt– 10 to 6 grams

• Teach patients to read food labels

• DASH Diet– www.nhlbi.nih.gov/health/public/heart/dash

Cecil, 2004

Counseling Patients: Health Behaviors

Lifestyle modification

Recommendation Range of systolic blood pressure reduction

(mm Hg)

Weight loss Maintain a normal body weight based on BMI

5–20

DietaryApproaches

Diet high in fruits and vegetables, and reduced fat

8–14

Low sodium diet

Less than 6 grams 2–8

Exercise 30 min of aerobic activity at least 4 d/wk

4–9

ModerateAlcoholconsumption

2 drinks or less per day for men, and 1 drink or less per day for women

2–4

JNC, 2005

Counseling Patients:Helpful Resources

Barriers to Successful Health Behavior Modifications

• Lack of education• Lack of access to safe places to exercise• Added salt in prepared foods and restaurant

meals• Higher cost of foods low in salt

Patient self-management is realistic and feasible!

Cecil, 2004

Pharmacologic Therapy

• Scientific proof lowering BP reduces organ damage

• Certain classes of antihypertensive agents exert organoprotective effects– Not all medications equal

Cecil, 2004; JNC, 2005

Major Challenges for Science

1. Identify the key gene-environment interactions

2. Eliminate the patient and medical provider barriers

ADA, 2003

Counseling Patients:Target Blood Pressure

• Most patients below 140/90 mm Hg

• Patients w/ diabetes or chronic disease 130/80 mm Hg

• Help patients self-monitor BP– 1/3 do not know they are hypertensive

• Research studies on targeting BP

Cecil, 2004

Improve Hypertension Control Rates

1. Titrating blood pressure medications to achieve target goals

2. Most patients require 2 or 3 antihypertensive medications

3. Patient compliance with multi-drug regimens

ADA, 2005

Patient Compliance and Quality of Life

• Hypertension requires lifelong treatment

• Medications can produce side effects– Men often concerned with

sexual dysfunction

• Patients with controlled BP, rate a significantly higher quality of life

Cecil, 2004

Patient Compliance Principles

1. Titrating medical therapy based on home readings

2. Long-acting preparations w/ once daily dosing

3. Low dose combinations of medications from different drug classes

4. Fixed-dose combinations to reduce overall number of pills

JNC, 2005

Drug Therapy

• Old method: high-dose monotherapy• Recent studies (ex. ALLHAT)

– At least 2 medications of different classes to treat mild hypertension

– 3 or 4 different medications to treat more difficult cases

• Thiazide-type antihypertensive medications cost-effective

• Initial treatment:– Beta blockers, Angiotensin-converting enzyme (ACE)

inhibitors, Angiotensin receptor blockers, Calcium antagonists Cecil, 2004

Stage 2 Drug Therapy

• JNC recommends:– 2 drug combination– Additional medications needed for each 10 mm Hg

of systolic BP above goal– Great majority should include low-dose diuretic

• High-risk conditions (heart failure/diabetes)

– Angiotensin-converting enzyme inhibitors (ACE-Is)

– Angiotensin receptor blockers (ARBs)Cecil, 2004

Cardio Events in Hypertensive Patients

Verdecchia, Carin, Circo,2001

Left Ventricular Hypertrophy

www.medem.com, 2007

Counseling Patients: Contradictions & Side Effects

Considerations For Individualizing

Antihypertensive Drug Therapy

Hypertensive Sub-Populations

• Hypertensive patients with nephrosclerosis

• Diabetic hypertensive patients

• Hypertensive patients with coronary artery disease

• Isolated systolic hypertension in older persons

• Hypertensive disorders of women– Oral contraceptives– Pregnancy

Cecil, 2004

Hypertension Case Study

How would we modify his treatment since he did not change his health behaviors (and he is diabetic)?

Thank you for attending