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  1. 1. Management of the Elderly Patient With Hypertension November 4, 2007 Joe Anderson, PharmD, PhC, BCPS Office: 272-3664 Email: [email_address] College of Pharmacy University of New Mexico Health Sciences Center
  2. 2. Learning Objectives <ul><li>Classify a patient’s blood pressure according to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII). </li></ul><ul><li>Define isolated systolic hypertension. </li></ul><ul><li>For a patient with hypertension, provide appropriate recommendations for lifestyle modification and pharmacotherapy. </li></ul><ul><li>Identify patient barriers to adherence with antihypertensive medication therapy. </li></ul><ul><li>Describe and demonstrate the proper procedure for measuring blood pressure according to recommendations from the American Heart Association (AHA). </li></ul>
  3. 3. Blood Pressure Classification: JNC VII BP = blood pressure; SBP = systolic blood pressure; DBP = diastolic blood pressure > 100 or > 160 Stage 2 hypertension 90 – 99 or 140 – 159 Stage 1 hypertension 80 - 89 or 120 – 139 Prehypertension < 80 and < 120 Normal DBP (mmHg) SBP (mmHg) BP Classification
  4. 4. Hypertension: a major risk factor for CVD <ul><li>Prevalence: ~ 72 million people in the U.S. age > 20 yrs. </li></ul><ul><ul><li>1 in 3 adults have HTN </li></ul></ul><ul><ul><ul><li>2/3 of adults > 60 yrs have HTN </li></ul></ul></ul><ul><ul><li>~ 30% are unaware </li></ul></ul><ul><li>90 – 95% of cases are due to essential HTN </li></ul><ul><li>Starting at 115/75 mmHg, CVD risk doubles with each increment of 20/10 mmHg throughout the BP range </li></ul><ul><ul><li>The BP relationship to risk of CVD is continuous, consistent, and independent of other risk factors. </li></ul></ul>
  5. 5. Prevalence of Hypertension in the United States* † *Based on NHANES 1999  2000 data. Hypertension is defined as blood pressure  140/90 mmHg or antihypertensive treatment. † Low reliability due to large relative error. Fields et al. Hypertension . 2004:44;398-404 . Hypertension Prevalence Age
  6. 6. Hypertension Prevalence by Age and Race/Ethnicity in Men and Women Hypertension Prevalence Based on NHANES 1999-2000. Error bars indicate 95% confidence intervals. Data are weighted to the US population. Non-Hispanic White Non-Hispanic Black Mexican American Hajjar I, Kotchen TA. JAMA. 2003;290:199-206. Age, y Men Women Age, y
  7. 7. Lifetime Risk of Developing Hypertension Among Adults Aged 55 to 65 Years* *Residual lifetime risk of developing hypertension among adults aged 55 to 65 years with a blood pressure <140/90 mmHg. Risk of Hypertension (%) Years Men Women Vasan RS, et al. JAMA . 2002; 287:1003-1010.
  8. 8. Prospective Studies Collaboration. Lancet . 2002;360:1903-1913 Usual Diastolic BP (mm Hg) Usual Systolic BP (mm Hg) Ischemic Heart Disease Mortality 50-59 60-69 70-79 80-89 Age at Risk (Y) 40-49 50-59 60-69 70-79 80-89 Age at Risk (Y) 40-49 Blood Pressure: Lower is Better Ischemic Heart Disease Mortality Ischemic Heart Disease Mortality BP=Blood pressure 256 128 64 32 16 8 4 2 1 0 120 140 160 180 256 128 64 32 16 8 4 2 1 0 80 90 100 110 70
  9. 9. Isolated Systolic Hypertension <ul><li>SBP > 140 mm Hg with a DBP < 90 mmHg </li></ul><ul><li>The most prevalent form of HTN in the elderly </li></ul><ul><li>Results from arteriosclerosis and arterial calcification </li></ul>N Engl J Med 2007;357:789-96.
  10. 10. Isolated Systolic Hypertension and CVD Risk in Framingham Heart Study Age-adjusted annual CVD event rate per 1000 Wilking SV et al. JAMA. 1988;260:3451-3455. Men Women ISH BP  160/<95 mmHg BP <140/95 mmHg 82 43 33 2.4 18 2.5 CVD=cardiovascular disease ISH = isolated systolic hypertension P<0.001 for difference between both men and women with ISH and blood pressure (BP) < 140/95 mmHg
  11. 11. Benefits of Lowering BP Average Percent Reduction Stroke incidence 35–40% Myocardial infarction 20–25% Heart failure 50%
  12. 12. BP Control Rates Trends in awareness, treatment, and control of high blood pressure in adults ages 18–74 34 27 29 10 Control 59 54 55 31 Treatment 70 68 73 51 Awareness 1999–2000 II (Phase 2) 1991–94 II (Phase 1) 1988–91 II 1976–80 National Health and Nutrition Examination Survey, Percent Sources: Unpublished data for 1999–2000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6.
  13. 13. JNC 7 <ul><li>Express—Succinct evidence-based recommendations. Published in JAMA May 21, 2003, and as a Government Printing Office publication. </li></ul><ul><li>Full Report—comprehensive justification and rationale. </li></ul>
  14. 14. Hypertension: Goals of Therapy <ul><li>Reduce CVD and renal morbidity and mortality. </li></ul><ul><li>Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients with diabetes or chronic kidney disease. </li></ul><ul><li>Goals the same for ISH </li></ul><ul><ul><ul><li>To avoid hypoperfusion: </li></ul></ul></ul><ul><ul><ul><ul><li>If SBP < 160 mmHg, goal < 140 mmHg </li></ul></ul></ul></ul><ul><ul><ul><ul><li>If SBP 160 – 179 mmHg, interim goal a decrease of 20 mmHg </li></ul></ul></ul></ul><ul><ul><ul><ul><li>If SBP > 180 mmHg, interim goal (< 160 mmHg) </li></ul></ul></ul></ul>
  15. 15. Patient Evaluation <ul><li>Evaluation of patients with documented HTN has three objectives: </li></ul><ul><li>Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guides treatment. </li></ul><ul><li>Reveal identifiable causes of high BP. </li></ul><ul><li>Assess the presence or absence of target organ damage and CVD. </li></ul>
  16. 16. CVD Risk Factors <ul><li>Hypertension* </li></ul><ul><li>Cigarette smoking </li></ul><ul><li>Obesity* (BMI > 30 kg/m 2 ) </li></ul><ul><li>Physical inactivity </li></ul><ul><li>Dyslipidemia* </li></ul><ul><li>Diabetes mellitus* </li></ul><ul><li>Microalbuminuria or estimated GFR <60 ml/min </li></ul><ul><li>Age (older than 55 for men, 65 for women) </li></ul><ul><li>Family history of premature CVD </li></ul><ul><li>(men under age 55 or women under age 65) </li></ul>*Components of the metabolic syndrome.
  17. 17. Identifiable Causes of Hypertension <ul><li>Sleep apnea </li></ul><ul><li>Drug-induced or related causes </li></ul><ul><li>Chronic kidney disease </li></ul><ul><li>Primary aldosteronism </li></ul><ul><li>Renovascular disease </li></ul><ul><li>Chronic steroid therapy and Cushing’s syndrome </li></ul><ul><li>Pheochromocytoma </li></ul><ul><li>Coarctation of the aorta </li></ul><ul><li>Thyroid or parathyroid disease </li></ul>
  18. 18. Target Organ Damage <ul><li>Heart </li></ul><ul><ul><li>Left ventricular hypertrophy </li></ul></ul><ul><ul><li>Angina or prior myocardial infarction </li></ul></ul><ul><ul><li>Prior coronary revascularization </li></ul></ul><ul><ul><li>Heart failure </li></ul></ul><ul><li>Brain </li></ul><ul><ul><li>Stroke or transient ischemic attack </li></ul></ul><ul><li>Chronic kidney disease </li></ul><ul><li>Peripheral arterial disease </li></ul><ul><li>Retinopathy </li></ul>
  19. 19. Laboratory Tests <ul><li>Routine Tests </li></ul><ul><ul><li>Electrocardiogram </li></ul></ul><ul><ul><li>Urinalysis </li></ul></ul><ul><ul><li>Blood glucose, and hematocrit </li></ul></ul><ul><ul><li>Serum potassium, creatinine, or the corresponding estimated GFR, and calcium </li></ul></ul><ul><ul><li>Lipid profile, after 9- to 12-hour fast, that includes high-density and low-density lipoprotein cholesterol, and triglycerides </li></ul></ul><ul><li>Optional tests </li></ul><ul><ul><li>Measurement of urinary albumin excretion or albumin/creatinine ratio </li></ul></ul><ul><li>More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved </li></ul>
  20. 20. Algorithm for Treatment of Hypertension Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices Lifestyle Modifications Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. With Compelling Indications Stage 2 Hypertension (SBP > 160 or DBP > 100 m mHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) Stage 1 Hypertension (SBP 140 –159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Without Compelling Indications Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist.
  21. 21. Antihypertensive Treatment: Compelling Indications *ARBs may be used in patients unable to tolerate ACEIs Compelling Indications Long-acting dihydropyridine CCB BB or ARB or CCB BB or CCB BB or Thiazide or CCB Amlodipine or Felodipine or Thiazide Aldosterone antagonist or Amlodipine or Felodipine or Thiazide 2 nd Choice Thiazide ACEI* + thiazide ACEI or ARB ACEI or ARB BB + ACEI* ACEI* + BB 1 st Choice ISH Recurrent Stroke Chronic Kidney Disease Diabetes Coronary Artery Disease Heart Failure
  22. 22. Management of HTN: Lifestyle Modification Approximate SBP reduction (range) Modification 5–20 mmHg/10 kg weight loss Weight reduction 8–14 mmHg Adopt DASH eating plan 2–8 mmHg Dietary sodium reduction 4–9 mmHg Physical activity 2–4 mmHg Moderation of alcohol consumption
  23. 23. Management of HTN: Lifestyle Modification <ul><li>Institute of Medicine Dietary Sodium & Potassium Recommendations </li></ul><ul><li>Sodium </li></ul><ul><ul><li>Age < 50 yrs: 65 mmol/day (~ 3.8 gm/day) </li></ul></ul><ul><ul><li>Age 51 – 70 yrs: 55 mmol/day (~ 3.2 gm/day) </li></ul></ul><ul><ul><li>Age > 71 yrs: 50 mmol/day (~ 2.9 gm/day) </li></ul></ul><ul><li>Potassium </li></ul><ul><ul><li>All adults: At least 120 mmol/day (~ 4.7 gm/day) </li></ul></ul><ul><li>Increase dietary K + /Na + ratio from 0.2 to 2.0 </li></ul>N Engl J Med 2007;356:1966-78.
  24. 24. Treatment of Hypertension: Clinical Studies SHEP : Systolic Hypertension in the Elderly, n=4,736; 1 st drug: chlorthalidone Syst-Eur : Systolic Hypertension in Europe, n=4,695; 1 st drug: nitrendipine ns ns ns BP differences between randomized treatment groups were 12/4 in SHEP, 10/4 in Syst-Eur Randomized Controlled Trials in Isolated Systolic Hypertension (ISH) ns
  25. 25. Treatment of Hypertension: Clinical Studies <ul><li>Meta-analysis of 8 trials in elderly patients with ISH (SBP > 160 & DBP < 95 mmHg) </li></ul><ul><ul><li>Treatment for mean 3.8 years: </li></ul></ul><ul><ul><ul><li>Decreased mortality by 13% </li></ul></ul></ul><ul><ul><ul><li>Decreased CV mortality by 18% </li></ul></ul></ul><ul><ul><ul><li>Decreased stroke by 30% </li></ul></ul></ul><ul><ul><ul><li>Decreased CHD events by 23% </li></ul></ul></ul>Lancet 2000;355:865-72.
  26. 26. Treatment of Hypertension: Clinical Studies <ul><li>The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) </li></ul><ul><li>Randomized, double-blind, multi-center clinical trial </li></ul><ul><li>Determine whether occurrence of fatal CHD or nonfatal MI is lower for high-risk hypertensive patients treated with newer agents (CCB, ACEI, alpha-blocker) compared with a diuretic </li></ul><ul><li>42,418 high-risk hypertensive patients ≥ 55 years </li></ul> JAMA 2002;288:2981-2997.
  27. 27. Years to CHD Event 0 1 2 3 4 5 6 7 Number at Risk: Chlorthalidone 15,255 14,477 13,820 13,102 11,362 6,340 2,956 209 Amlodipine 9,048 8,576 8,218 7,843 6,824 3,870 1,878 215 Lisinopril 9,054 8,535 8,123 7,711 6,662 3,832 1,770 195 Cumulative Event Rates for the Primary Outcome (Fatal CHD or Nonfatal MI) by ALLHAT Treatment Group Chlorthalidone Amlodipine Lisinopril www.allhat.org JAMA 2002;288:2981-2997 Cumulative CHD Event Rate 0 .04 .08 .12 .16 .2 0.81 0.99 (0.91-1.08) L/C 0.65 0.98 (0.90-1.07) A/C p value RR (95% CI)
  28. 28. Cumulative Event Rates for Stroke by ALLHAT Treatment Group Number at risk: Chlor 15,255 14,515 13,934 13,309 11,570 6,385 3,217 567 Amlo 9,048 8,617 8,271 7,949 6,937 3,845 1,813 506 Lisin 9,054 8,543 8,172 7,784 6,765 3,891 1,828 949 Chlorthalidone Amlodipine Lisinopril www.allhat.org JAMA 2002;288:2981-2997 Cumulative Stroke Rate Years to Stroke 0 1 2 3 4 5 6 7 0 .02 .04 .06 .08 .1 0.02 1.15 (1.02-1.30) L/C 0.28 0.93 (0.81-1.06) A/C p value RR (95% CI)
  29. 29. Cumulative Event Rates for All-Cause Mortality by ALLHAT Treatment Group Cumulative Mortality Rate Years to Death 0 1 2 3 4 5 6 7 0 .05 .1 .15 .2 .25 .3 Number at risk: Chlor 15,255 14,933 14,564 14,077 12,480 7.185 3,523 428 Amlo 9,048 8,847 8,654 8,391 7,442 4,312 2,101 217 Lisin 9,054 8,853 8,612 8,318 7,382 4,304 2,121 144 Chlorthalidone Amlodipine Lisinopril www.allhat.org JAMA 2002;288:2981-2997 0.90 1.00 (0.94-1.08) L/C 0.20 0.96 (0.89-1.02) A/C p value RR (95% CI) 0.90 1.00 (0.94-1.08) L/C 0.20 0.96 (0.89-1.02) A/C p value RR (95% CI)
  30. 30. Cumulative Event Rates for Combined CVD by ALLHAT Treatment Group Cumulative Combined CVD Event Rate Years to Combined CVD Event 0 1 2 3 4 5 6 7 0 .1 .2 .3 .4 .5 Number at risk: Chlor 15,255 13,752 12,594 11,517 9,643 5,167 2,362 288 Amlo 9,048 8,118 7,451 6,837 5,724 3,049 1,411 153 Lisin 9,054 7,962 7,259 6,631 5,560 3,011 1,375 139 Chlorthalidone Amlodipine Lisinopril www.allhat.org JAMA 2002;288:2981-2997 <0.001 1.10 (1.05-1.16) L/C 0.12 1.04 (0.99-1.09) A/C p value RR (95% CI)
  31. 31. Cumulative Event Rates for Heart Failure by ALLHAT Treatment Group Cumulative CHF Rate Years to HF 0 1 2 3 4 5 6 7 0 .03 .06 .09 .12 .15 Chlorthalidone Amlodipine Lisinopril Number at risk: Chlor 15,255 14,528 13,898 13,224 11,511 6,369 3,016 384 Amlo 9,048 8,535 8,185 7,801 6,785 3,775 1,780 210 Lisin 9,054 8,496 8,096 7,689 6,698 3,789 1,837 313 www.allhat.org JAMA 2002;288:2981-2997 <.001 1.19 (1.07-1.31) L/C <.001 1.38 (1.25-1.52) A/C p value RR (95% CI)
  32. 32. Treatment of Hypertension <ul><li>Thiazide diuretics have repeatedly been demonstrated to prevent the cardiovascular complications of hypertension, and are 1st line drugs for uncomplicated hypertension </li></ul><ul><li>Thiazide diuretics enhance the efficacy of most other antihypertensive drugs and are therefore useful as add-on therapy </li></ul><ul><li>ACE inhibitors , angiotensin receptor antagonists , or beta-blockers should be used as 1st line treatments in patients with compelling indications </li></ul><ul><li>Most patients will require at least 2 drugs to achieve goal BP </li></ul>
  33. 33. Follow-up and Monitoring <ul><li>Follow-up should occur at least monthly until goal BP is reached </li></ul><ul><li>Serum potassium and creatinine should be monitored 1-2 times per year </li></ul><ul><li>Once BP is at goal and stable, follow-up can occur every 3-6 months; more frequently if the patient has other co-morbidities </li></ul>
  34. 34. Follow-up and Monitoring: Drugs <ul><li>Thiazides </li></ul><ul><ul><li>Adverse Effects </li></ul></ul><ul><ul><ul><li>loop/thiazide diuretics: hypokalemia, hypomagnesemia, hyperuricemia, hyperglycemia </li></ul></ul></ul><ul><ul><li>Monitoring </li></ul></ul><ul><ul><ul><li>blood pressure </li></ul></ul></ul><ul><ul><ul><li>serum creatinine and BUN </li></ul></ul></ul><ul><ul><ul><li>serum potassium, magnesium, glucose </li></ul></ul></ul>
  35. 35. Follow-up and Monitoring: Drugs <ul><li>Thiazides </li></ul><ul><ul><li>Adverse Effects </li></ul></ul><ul><ul><ul><li>loop/thiazide diuretics: hypokalemia, hypomagnesemia, hyperuricemia, hyperglycemia </li></ul></ul></ul><ul><ul><li>Monitoring </li></ul></ul><ul><ul><ul><li>blood pressure </li></ul></ul></ul><ul><ul><ul><li>serum creatinine and BUN </li></ul></ul></ul><ul><ul><ul><li>serum potassium, magnesium, glucose </li></ul></ul></ul>
  36. 36. Follow-up and Monitoring: Drugs <ul><li>ACE-inhibitors </li></ul><ul><ul><li>Adverse Effects </li></ul></ul><ul><ul><ul><li>dry, non-productive cough (1-10% incidence), taste disturbances (2-7% incidence), skin rash (1-7% incidence), hyperkalemia (1-4% incidence), angioedema (very rare, but very serious) </li></ul></ul></ul><ul><ul><ul><li>elevations in serum creatinine and BUN (common) </li></ul></ul></ul><ul><ul><ul><li>neutropenia (rare) </li></ul></ul></ul><ul><ul><li>Monitoring </li></ul></ul><ul><ul><ul><li>blood pressure </li></ul></ul></ul><ul><ul><ul><li>serum potassium, </li></ul></ul></ul><ul><ul><ul><li>serum creatinine and BUN </li></ul></ul></ul><ul><ul><ul><li>CBC </li></ul></ul></ul>
  37. 37. Follow-up and Monitoring: Drugs <ul><li>Angiotensin II receptor antagonists </li></ul><ul><ul><li>Adverse Effects </li></ul></ul><ul><ul><ul><li>angioedema (very rare, but very serious, potential for cross reactively b/w ACEIs) </li></ul></ul></ul><ul><ul><ul><li>elevations in serum creatinine and BUN (common) </li></ul></ul></ul><ul><ul><li>Monitoring </li></ul></ul><ul><ul><ul><li>blood pressure </li></ul></ul></ul><ul><ul><ul><li>serum potassium, </li></ul></ul></ul><ul><ul><ul><li>serum creatinine and BUN </li></ul></ul></ul>
  38. 38. Follow-up and Monitoring: Drugs <ul><li>Beta-blockers </li></ul><ul><ul><li>Adverse Effects </li></ul></ul><ul><ul><ul><li>smooth muscle constriction (bronchospasm and cold extremities) </li></ul></ul></ul><ul><ul><ul><li>exaggerated cardiac response (bradycardia, heart block, decreased contractility) </li></ul></ul></ul><ul><ul><ul><li>CNS penetration (insomnia, fatigue, dizziness, depression); may be more common with lipophilic agents </li></ul></ul></ul><ul><ul><li>Monitoring </li></ul></ul><ul><ul><ul><li>blood pressure </li></ul></ul></ul><ul><ul><ul><li>heart rate </li></ul></ul></ul><ul><ul><ul><li>query patient regarding CNS disturbances </li></ul></ul></ul><ul><ul><ul><li>symptoms of heart failure, breathing difficulties, etc. in patients predisposed to these problems </li></ul></ul></ul>
  39. 39. Follow-up and Monitoring: Drugs <ul><li>Calcium Channel Blockers </li></ul><ul><ul><li>Dihydropyridines </li></ul></ul><ul><ul><ul><li>Adverse Effects </li></ul></ul></ul><ul><ul><ul><ul><li>hypotension, dizziness </li></ul></ul></ul></ul><ul><ul><ul><ul><li>peripheral edema </li></ul></ul></ul></ul><ul><ul><li>Non-Dihydropyridines </li></ul></ul><ul><ul><ul><li>Adverse Effects </li></ul></ul></ul><ul><ul><ul><ul><li>hypotension, dizziness </li></ul></ul></ul></ul><ul><ul><ul><ul><li>constipation (esp. verapamil) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>bradycardia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>exacerbation of heart failure </li></ul></ul></ul></ul>
  40. 40. Management of HTN: JNC VII *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 <130/80 mmHg. Two-drug combination for most † (usually thiazide-type diuretic and ACEI or ARB or BB or CCB). Yes or > 100 > 160 Stage 2 Hypertension Drug(s) for the compelling indications. ‡ Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Yes or 90–99 140–159 Stage 1 Hypertension Drug(s) for compelling indications. ‡ No antihypertensive drug indicated. Yes or 80–89 120–139 Prehypertension Encourage and <80 <120 Normal With compelling indications Without compelling indication Initial drug therapy Lifestyle modification DBP* mmHg SBP* mmHg BP classification
  41. 41. T.J. is a 63-year-old African-American male who has been referred to the pharmacist-managed hypertension clinic. Following 3 separate determinations, T.J.’s BP averages 158/108 mm Hg. He also has diabetes and hyperlipidemia. All laboratory values are normal except for a serum creatinine of 1.7 mg/dL and 2+ proteinuria. His ECG meets the criteria for left ventricular hypertrophy. He weighs 72 kg.
  42. 42. How should T.J.’s hypertension be classified? <ul><li>A. Prehypertensive </li></ul><ul><li>B. Stage 1 </li></ul><ul><li>C. Stage 2 </li></ul><ul><li>D. Hypertensive urgency </li></ul>
  43. 43. What is an appropriate treatment strategy for T.J. at this point? <ul><li>Lifestyle modification alone </li></ul><ul><li>Lifestyle modification + single-drug therapy </li></ul><ul><li>Lifestyle modification + 2-drug therapy </li></ul><ul><li>Single-drug therapy alone </li></ul><ul><li>2-drug therapy alone </li></ul>
  44. 44. What is T.J.’s goal BP? <ul><li>< 120/75 mmHg </li></ul><ul><li>< 120/80 mmHg </li></ul><ul><li>< 130/80 mmHg </li></ul><ul><li>< 130/90 mmHg </li></ul><ul><li>< 140/90 mmHg </li></ul>
  45. 45. Which of the following lifestyle interventions should be recommended for T.J.? <ul><li>I. Low salt diet </li></ul><ul><li>II. Low potassium/high calcium diet </li></ul><ul><li>III. Abstinence from alcohol </li></ul><ul><li>I only </li></ul><ul><li>III only </li></ul><ul><li>I and III only </li></ul><ul><li>II and III only </li></ul><ul><li>All of the above should be recommended </li></ul>
  46. 46. Considering the management of risk factors and coexisting conditions, the preferred antihypertensive regimen for T.J. would be which one of the following? <ul><li>Atenolol + HCTZ </li></ul><ul><li>Nifedipine GITS + HCTZ </li></ul><ul><li>Doxazosin + lisinopril </li></ul><ul><li>Captopril + amlodipine </li></ul><ul><li>Furosemide + metoprolol </li></ul><ul><li>HCTZ + benazepril </li></ul>
  47. 47. Adherence to Medication <ul><li>Adherence to medications for chronic disease is estimated to be 50% </li></ul><ul><li>Recent study of patients treated for both HTN and Hyperlipidemia revealed adherence to both medications was only 44% at 3 months, 36% at 6 months and 36% at 12 months </li></ul>“ Drugs don’t work in patients who don’t take them.” — C. Everett Koop, M.D. N Engl J Med 2005;353:487-97. Arch Intern Med. 2005;165:1147-1152
  48. 48. Adherence to Medication <ul><li>Factors Contributing to Medication Adherence </li></ul><ul><ul><li>Misunderstanding of the condition or treatment </li></ul></ul><ul><ul><li>Denial of illness because of lack of symptoms </li></ul></ul><ul><ul><li>Perception of drugs as symbols of ill health </li></ul></ul><ul><ul><li>Lack of patient involvement in the care plan </li></ul></ul><ul><ul><li>Unexpected adverse effects of medications </li></ul></ul><ul><ul><li>Cost of medications </li></ul></ul>
  49. 49. Adherence to Medication <ul><li>Clinicians contribute to patients’ poor adherence </li></ul><ul><ul><li>Prescribing complex regimens </li></ul></ul><ul><ul><li>Failing to explain the benefits and side effects of a medication adequately </li></ul></ul><ul><ul><li>Not considering the patient’s lifestyle </li></ul></ul><ul><ul><li>Not considering the cost of the medications </li></ul></ul><ul><ul><li>Having poor therapeutic relationships with their patients </li></ul></ul>
  50. 50. Adherence to Medication <ul><li>Methods of Improving Medication Adherence </li></ul><ul><ul><li>A patient-centered strategy is crucial for treatment success </li></ul></ul><ul><ul><ul><li>encourage a positive attitude about achieving treatment goals </li></ul></ul></ul><ul><ul><ul><li>educate patients about medication side effects </li></ul></ul></ul><ul><ul><ul><li>educate patients about the disease and its complications </li></ul></ul></ul><ul><ul><ul><li>keep care inexpensive and simple </li></ul></ul></ul><ul><ul><ul><li>maintain contact with patients; consider telecommunication </li></ul></ul></ul><ul><ul><ul><li>encourage patients to monitor BP at home </li></ul></ul></ul>
  51. 51. Adherence: BP Self Monitoring <ul><li>Provides information on: </li></ul><ul><ul><li>Response to antihypertensive therapy </li></ul></ul><ul><ul><li>Improving adherence with therapy </li></ul></ul><ul><ul><li>Evaluating white-coat HTN </li></ul></ul><ul><ul><li>Home measurement devices should be checked regularly </li></ul></ul>BP tracker available at: http://www.americanheart.org/presenter.jhtml?identifier=3002529
  52. 52. Hypertension: Resources <ul><li>DASH Diet: http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/new_dash.pdf </li></ul><ul><li>JNC VII Guidelines: http://www.nhlbi.nih.gov/guidelines/hypertension/ </li></ul><ul><li>Personalized Medication Dosing Schedule: http://www.mypillbox.org/mypillbox.php </li></ul><ul><li>American Heart Association: http://www.americanheart.org/presenter.jhtml?identifier=2114 </li></ul><ul><ul><li>High BP risk calculator: http://www.americanheart.org/presenter.jhtml?identifier=3027275 </li></ul></ul>
  53. 53. Questions??? To encourage medication adherence, Dr. Gratner brought in a sketch artist to show them what they will look like in 6 months without medications.
  54. 54. D.J. is a 47-year-old high school biology teacher with hypertension that was diagnosed 9 months ago. He has been started on lifestyle modification and atenolol 25 mg once daily. He has no side effects or problems. The patient admits to poor adherence with his diet and his medication regimen stating that he “just doesn’t seem to be motivated to follow the regimens.” When you questioned him, he admits to missing 3 doses/week, which is confirmed by his refill records. His father died of an MI at age 61 and the patient understands the risks of his hypertension.
  55. 55. Which one of the following may improve D.J.’s adherence? A. Change his medication to long-acting verapamil B. Order 24-hour ABPM C. Initiate daily home BP monitoring D. Warn him that he is likely to die from his BP
  56. 56. What one additional approach may be used to improve D.J.’s adherence? A. Tell him that if he is worried about side effects that these fears are unfounded B. Ask him to express his goals for therapy and how you can assist him to achieve them C. Inform him that he must follow your directions or treatment is useless D. Give him more time to adjust to the regimen and new lifestyle
  57. 57. Assessing Blood Pressure <ul><li>Alteration in blood pressure (BP) monitoring technique can result in significantly different readings </li></ul><ul><ul><li>Incorrect cuff size is the most common error 1 </li></ul></ul><ul><ul><li>Body position, arm position, inter-arm differences, and cuff placement will also affect the reading 2 </li></ul></ul>1 Manning DM, et al. Circulation. 1983;68:763-66. 2 Pickering TG, et al. Circulation. 2005;111:697-716.
  58. 58. Assessing Blood Pressure <ul><li>AHA BP monitoring recommendations </li></ul><ul><ul><li>Remove clothing from upper arm </li></ul></ul><ul><ul><li>Sit quietly for 5 minutes </li></ul></ul><ul><ul><li>Legs uncrossed, back and arm supported </li></ul></ul><ul><ul><li>Mid-point of cuff even with mid-point of sternum </li></ul></ul><ul><ul><li>Cuff size determined by arm circumference </li></ul></ul><ul><ul><li>Lower end of cuff 2-3 cm above antecubital fossa </li></ul></ul><ul><ul><li>Cuff inflated to 30 mmHg above the point when the radial pulse disappears/ deflated at a rate of 2-3 mmHg/second </li></ul></ul><ul><ul><li>Bilateral measurement, the higher of the two arms should be used </li></ul></ul>Circulation 2005;111:697-716.
  59. 59. Assessing Blood Pressure <ul><li>AHA BP monitoring recommendations </li></ul><ul><ul><li>Patient should avoid tobacco or caffeinated beverages for 30 minutes prior </li></ul></ul><ul><ul><li>Arm should be supported at heart level </li></ul></ul><ul><ul><li>Cuff size </li></ul></ul><ul><ul><ul><li>Most accurate is to measure arm circumference </li></ul></ul></ul><ul><ul><ul><ul><li>Regular 27 – 34 cm; Large 35 – 44 cm; Thigh 45 – 51 cm; child 22 – 26 cm </li></ul></ul></ul></ul><ul><ul><ul><li>Width: 40% of upper arm circumference </li></ul></ul></ul><ul><ul><ul><li>Length: 80% of upper arm circumference </li></ul></ul></ul><ul><ul><li>Cuff position </li></ul></ul><ul><ul><ul><li>Center of bladder over the brachial artery </li></ul></ul></ul><ul><ul><ul><li>Lower border of cuff should be 2.5cm above the antecubital crease </li></ul></ul></ul>Circulation 2005;111:697-716.
  60. 60. Assessing Blood Pressure <ul><li>Palpatory method: </li></ul><ul><ul><li>Empty air from the cuff and apply the cuff firmly around the patient's arm. </li></ul></ul><ul><ul><li>Feel the radial pulse. </li></ul></ul><ul><ul><li>Inflate the cuff until the radial pulse disappears.  </li></ul></ul><ul><ul><li>Inflate 30-40 mmHg over and release slowly until the pulse returns. That denotes systolic pressure. </li></ul></ul><ul><ul><ul><li>Diastolic blood pressure cannot be obtained by this method. </li></ul></ul></ul><ul><ul><ul><li>Identification of systolic blood pressure by palpatory method helps one to avoid a lower systolic reading by auscultatory method if there is an auscultatory gap. </li></ul></ul></ul><ul><ul><ul><li>It also minimizes the discomfort of over inflating the bladder of the cuff. </li></ul></ul></ul>
  61. 61. Assessing Blood Pressure <ul><li>Auscultatory method : </li></ul><ul><ul><li>Keep the bell of stethoscope over the brachial artery and inflate blood pressure cuff to a level higher than the systolic pressure determined by the palpatory method. </li></ul></ul><ul><ul><ul><li>Deflate at rate of 2-3 mmHg per second </li></ul></ul></ul><ul><ul><li>Record systolic and diastolic pressures based on the Korotkoff sounds. </li></ul></ul><ul><ul><ul><li>First sound is SBP </li></ul></ul></ul><ul><ul><ul><li>Disappearance of sounds is DBP </li></ul></ul></ul><ul><ul><li>Record BP in each arm, repeat in higher arm. </li></ul></ul>
  62. 62. Assessing Blood Pressure <ul><li>Let’s Practice! </li></ul>