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Hypertension

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  • This slide summarizes the classification of BP and the suggested treatment approaches from JNC 7 published in 2003.
    Two important differences from JNC6
    redefinition of BP goals such that we now talk about prehypertensive readings(those patients with BP 130-139/80-89 are at twice the risk to develop hypertension as those with lower values
    stage 2 and 3 were combined
  • Weight reduction + DASH is equivalent to 1-2 antihypertensives

Transcript

  • 1. Dr. Fuad Farooq Consultant Cardiologist
  • 2. Key Concepts • Hypertension is common disorder • Hypertension increases cardiovascular risk • Effective treatment confers benefit • Compelling indications for certain antihypertensive agents and blood pressure targets
  • 3. Definition of Hypertension
  • 4. Causes of Hypertension • Primary – 90-95% of cases – also termed “essential” of “idiopathic” • Secondary – about 5% of cases – Renal or renovascular disease – Endocrine disease • • • • Pheochomocytoma Cushing’s syndrome Conn’s syndrome Acromegaly and hypothyroidism – Coarctation of the aorta – Iatrogenic • Hormonal / oral contraceptive • NSAIDs
  • 5. Prevalence • • • • • Children - 4%  mostly secondary Middle age - 11-21% 50-59 years - 44% 60-69 years old - 54 % >70 years old - ≥ 64 %
  • 6. Risk Factors • Age is the major risk factor – Blood pressure increases with age in both men and women – The lifetime risk for hypertension is nearly 90% – The risks for high blood pressure increases in men over age 45 and women over age 55 • Family History – People with parents or other close relatives who have high blood pressure have an increased risk of developing it themselves
  • 7. Risk Factors • Obesity – About a third of patients with high blood pressure are overweight – BMI ≥ 35kg/m2 double the risk of hypertension than people with normal weights • Obstructive Sleep Apnea • Lifestyle Factors – – – – – Smoking High Salt (Na) and low Potassium intake Chronic Alcohol intake Physical Inactivity Stress
  • 8. Mortality Due to CHD per Quartile of Usual SBP USA Japan van den Hoogen et al. N Engl J Med 2000;342:1.
  • 9. Relationship Between Hypertension and IHD Mortality Lewington S, et al. Lancet 2002; 360:1903–13
  • 10. Key Message Above 115/75 mmHg, CVD risk doubles with each BP increase of 20/10 mmHg Role of blood pressure in cardiovascular morbidity and mortality. Prog Cardiovasc Dis. 1974;17:5-2.
  • 11. Blood Pressure Classification and Management BP Indications Classification Normal SBP DBP Lifestyle mm Hg mm Hg Changes <120 and <80 Initial Drug Therapy Compelling Without With Encourage Pre HTN 120-139 or 80-89 Yes No Yes* Stage 1 HTN 140-159 or 90-99 Yes Yes Yes Yes Yes Yes Stage 2 HTN >160 or >100 * Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mm Hg JNC VII. JAMA 2003;289:2560.
  • 12. Factors Contributing to Poor Blood Pressure Control 18% Took no action Increased dose Changed drug Prescribed add-on therapy Taylor Nelson Healthcare, Epson, Surrey England - Cardiomonitor 1992
  • 13. Goals of the Hypertensive Evaluation • Does the patient have primary or secondary (reversible) hypertension? • Is target organ damage present? • Are other cardiovascular (CV) risk factors present?
  • 14. Routine Work-up  Routine Tests • Electrocardiogram • Urinalysis • Blood glucose, and hematocrit • Serum potassium, creatinine, or the corresponding estimated GFR, and calcium • Lipid profile, after 9- to 12-hour fast, that includes high-density and low-density lipoprotein cholesterol, and triglycerides  Optional tests • Measurement of urinary albumin excretion or albumin/creatinine ratio  More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved
  • 15. "The Goal is to Get to Goal!” Hypertension < 140/90 mmHg -PLUSDiabetes or Renal Disease < 130/80 mmHg
  • 16. Lifestyle Modification Modification Weight reduction Approximate SBP Reduction (range) 5-20 mmHg/ 10 kg weight loss Adopt DASH eating plan 8-14 mmHg Dietary sodium reduction 2-8 mmHg Physical activity 4-9 mmHg Moderation of alcohol consumption 2-4 mmHg JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314
  • 17. Impact of a 5 mmHg Reduction Overall Reduction Stroke 14% Coronary Heart Disease 9% All Cause Mortality 7% Hypertension 2003;289:2560-2572.
  • 18. Dietary Approaches to Stop Hypertension • Lowers systolic BP – In normotensive patients by an average of 3.5 mm Hg – In hypertensive patients by 11.4 mm Hg http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/
  • 19. DASH Eating Plan • Low in saturated fat, cholesterol, and total fat • Emphasizes fruits, vegetables, and low fat diary products • Reduced red meat, sweets, and sugar containing beverages • Rich in magnesium, potassium, calcium, protein, and fiber • 1.5-3 gm sodium per day • Can reduce BP in 2 weeks Sacks FM. NEJM. 2001; 344:3-10.
  • 20. Classes of Antihypertensive
  • 21. Classes 1. 2. 3. 4. 5. 6. 7. 8. Diuretics β-blockers ACE Inhibitors Blockers of AT1 receptors (ARB) Calcium channel blockers α1-antagonists α2-Agonists Direct vasodilators
  • 22. Diuretics
  • 23. Carboanhydrase Inhibitors Carboanhydrase inhibitors (acetazolamide) – not used in the treatment of hypertension
  • 24. Loop Diuretics Loop diuretics bumetanide) (furosemide, etacrynic acid, – Strong short-lasting effect – Ability to excrete to 25 % of Na+ from filtrate – Block active reabsorption of Na+, Cl-, K+ from ascending limb of Henle´s loop – Rarely used as antihypertensive – only furosemide in low dosage – if simultaneously is very much reduced Glomerular filtration – They aren´t suitable for long-lasting application
  • 25. Thiazide Diuretics Thiazide diuretics chlorthalidone, clopamide) (hydrochlorothiazide, – Block reabsorption of Na+ and Cl- from distal tubulus – Effect is weaker then loop diuretics – they excrete about 5 % from Na+ filtrate – Most suitable diuretics for long–lasting treatment of hypertension – The most is used hydrochlorothiazide – daily dose 12.5 – 25 mg
  • 26. K+ Sparing Diuretics K-sparing diuretics - Spironolactone (aldosterone antagonist), Amiloride, Triamterene – Only in resistant hypertension and to assistant drugs in combinations to correct hypokalemia
  • 27. Side Effects of Diuretics DVERSE EFFECT DIURETICS SYMPTOMS 1. Hypovolemia Loop diuretic Thiazides Lassitude Thirst Muscle cramps Hypotension 2. Hypokalemia Acetazolamides Loop diuretics Thiazides Muscle weakness Paralysis Arrhythmia 3. Hyperkalemia Amilorides Triamterenes Spironolactone Arrhythmia Muscle cramps Paralysis
  • 28. Side Effects of Diuretics 4. Hyponatremia Thiazides Furosemides CNS symptoms Coma 5. Metabolic alkalosis Loop diuretics Thiazides Arrhythmia CNS symptoms Acetazolamides Amilorides Triamterene Kussmaul respirations Muscle weakness Neurological symptoms Lethargy Coma Seizure Stupor 6. Metabolic acidosis
  • 29. Side Effects of Diuretics 7. Hypercalcemia Thiazides Gout Tissue calcification Fatigue Depression Confusion Anorexia Nausea Vomiting Constipation Pancreatitis Increased urination 8. Hyperuricemia Thiazides Loop diuretics Gout
  • 30. β-blockers • • • Preferenced are selective before nonselective agents Don´t differ very much in antihypertensive effect, selection according to adverse effect profile Suitable for: – – – – • Younger patients with ↑ sympathicoadrenal activity Hyperkinetic circulation Patients under psychological stress Patients with existent ischaemic heart disease and mainly after myocardial infarction Agents: • • • • • Atenolol Metoprolol Bisoprolol Carvedilol Nebivolol
  • 31. β-blockers – Mechanism of Action
  • 32. β-blockers – Side Effects 1. Tendency to bronchoconstriction – Use with caution in patients with asthma and reactive airway disease 1. Negative chronotropic effects – Slowing of the resting heart rate and the development of sinus bradycardia - relatively contraindicated in patients with symptomatic bradycardia 1. Heart Block – By blocking AV node resulting in serious bradyarrhythmia complete or partial AV conduction defect (i.e., second or third degree AV block)
  • 33. β-blockers – Side Effects 4. Metabolic Effects – Worsening of lipid profile – Mask symptoms of hypoglycemia and can impair glucose tollerance – more at non-selective agents – Sleep disturbances, bad dreams → Depression – At very high doses can worsen heart failure; if indicated at chronic heart failure, dose should be increased step by step
  • 34. β-blockers !Selectivity of action is only relative! • At higher doses selectivity is dissapearing even among β1-selective agents appear β2lytic effects • Should not be combined with verapamil or a diltiazem • Treatment can´t be stopped abruptly – rebound effect!
  • 35. Calcium Channel Blockers (CCB)
  • 36. CCB – Mechanism of Action • Block influx of calcium to cell through slow L-type channels, lower its intracellular concentration what causes relaxation of smooth muscle in vessel wall, decrease of contractility, decrease of electrical irritability and conductivity
  • 37. CCB in Hypertension • Most commonly used Calcium channel blockers in treatment of hypertension are: – Dihydropyridines – especially Amlodipine (Norvasc) – Non dihydropyridines – Verapamil and Diltiazem only in presence of tachycardia – Prototype short-acting DHP nifedipine is contraindicated! • It reduces BP too rapidly, so induces reflex activation of sympathatic stimulation with subsequent increase of BP and such a repeated BP fluctuation causes worse vessel damage as untreated hypertension → instead of mortality decrease its increase!
  • 38. CCB in Hypertension • Ca++ blockers are suitable for – Patients with DM – Metabolic syndrome – Peripheral vascular disease • It has of particularly advantageous in treatment of isolated systolic hypertension • Nimodipine (1st generation) affinity to brain vasculature → effectively relieves spasms of cerebral arteries → used in subarachnoid bleeding
  • 39. CCB – Side Effects • Side effects of CCB are: – – – – – – – – Dizziness Headache Redness in the face Fluid buildup in the legs and ankle – dependent edema Rapid heart rate Slow heart rate Constipation Gingival overgrowth
  • 40. Renin Angiotensin Aldosterone system
  • 41. ACE Inhibitors • It block the conversion of angiotensin I to angiotensin II and at the same time block inactivation of bradykinin – Vasodilation in both resistant and capacitance vessels • Indication: – Hypertensive patients with heart failure – In acute myocardial infarction – In diabetes and diabetic nephropathy with or without microalbuminuria
  • 42. Main Benefits
  • 43. ACE Inhibitors • Hydrophilic ACEI: – Captopril – Ramipril – Enalapril – Lisinopril • Lipophilic ACEI: – Perindopril – Trandolapril – Quinapril
  • 44. ACE Inhibitors – Side Effects • • • • • • • • • • Hypotension Cough Hyperkalemia Angioedema Renal impairment Headache Dizziness Fatigue Nausea Rash and taste disturbances- with captopril
  • 45. ACE Inhibitors – Side Effects • A persistent dry cough is a relatively common adverse effect believed to be associated with the increases in bradykinin levels produced by ACE inhibitors • Patients who experience this cough are often switched to angiotensin II receptor antagonists
  • 46. ACE Inhibitors - Contraindications • • • • • • Previous angioedema associated with ACE inhibitor therapy Renal artery stenosis (bilateral or unilateral with a solitary functioning kidney) Hypersensitivity to ACE inhibitors Hyperkalemia (>5.5mmole/L) Creatinine >2.5mg/dl ACE inhibitors should be used with caution in patients with: – Impaired renal function – Aortic valve stenosis or cardiac outflow obstruction – Hypovolemia or dehydration
  • 47. ACE Inhibitors - Contraindications • In pregnancy - category D – Should be avoided in women who are likely to become pregnant – Taken during the first trimester have been reported to cause major congenital malformations, stillbirths, and neonatal deaths – Commonly reported fetal abnormalities include hypotension, renal dysplasia, anuria/oliguria, oligohydramnios, intrauterine growth retardation, pulmonary hypoplasia, patent ductus arteriosus, and incomplete ossification of the skull – Overall, about half of newborns exposed to ACE inhibitors are adversely affected
  • 48. Angiotensin Receptor Blockers • Most often replacement of ACEI in case of cough – Losartan – Valsartan – Candesartan – Irbesartan • Sometimes prescribed as 1st choice, even before ACEI  clinical studies indicate that they have among patients with HT and DM 2 slightly better protective effects than ACEI • Side effect profile (except cough) and contraindications are same as that of ACEI
  • 49. α1- Blockers • Along with BP reduction they reduce the size of prostate → Indicated mainly in older man with simultaneous benign prostate hyperplasia (BPH) • Other indications: – In combination for severe resistant hypertension – strong 1st dose phenomenon! → postural hypotension, syncopes
  • 50. α1- Blockers • Prazosin • Doxazosin • Terazosin Side effects – Hypotension – Orthostatic hypotension (postural hypotension) – thus alpha blockers should be taken at bedtime – First dose phenomenon may be reduced by starting at a low dose and titrating upwards as needed
  • 51. α2 - Agonists • Centraly acting – stimulation of central α2 receptors • Through negative feedback inhibit release of norepinephrine on periphery → reflex BP reduction – α-metyldopa – Clonidine • S/E: – Central depression – sleepiness, bad dreams – Clonidine has significant rebound phenomenon
  • 52. Direct vasodilators • Hydralazines – Specific mechanism of action is unknown • S/E: tachycardia, palpitations, lupus erythematodes
  • 53. What Medicine to Choose First?
  • 54. Relative Efficacy of Each group These observations are secondary to the plasma Renin activity, older and blacks have less activity than younger and white population N Engl J Med. 1993;328(13):914-21.
  • 55. Meta Analysis 14 12 10 SBP Reduction 8 (mmHg) 6 4 2 0 1/2 Standard Standard 2x Standard Thiazides BB ACEI ARB CCB • All five drug categories produced similar BP reductions • Blood pressure reduction achieved with half standard dose was only 20% lower than standard dose Law MR et al. BMJ. 2009;338:b1665.
  • 56. • The ASCOT trial found a lower rate of cardiovascular disease and death with a calcium channel blocker (Amlodipine) compared to a beta blocker (Atenolol) – Patients in the Amlodipine arm had a significantly lower mean blood pressure at the end of the study (3/2 mmHg) Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): Lancet. 2005;366(9489):895-906.
  • 57. Ramipril1 and Perindopril2 produced better outcomes than placebo in the HOPE and EUROPA trials of patients at increased cardiovascular risk, but the blood pressure was significantly lower in the treated patients: 3.3/1.4 mmHg (with a greater difference overnight) in HOPE and 5/2 mmHg in EUROPA 1. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med. 2000;342(3):145-53. 2. EURopean trial On reduction of cardiac events with Perindopril in stable coronary Artery disease Investigators. Lancet. 2003;362(9386):782-8.
  • 58. When differences in outcomes have been noted in trials comparing different antihypertensive drugs, the drug producing better outcomes had better blood pressure control
  • 59. AHA statement on the treatment of blood pressure in ischemic heart disease, and European Society of Hypertension/ESC guidelines on the management of hypertension all concluded that the amount of blood pressure reduction is the major determinant of reduction in cardiovascular risk in both younger and older patients with hypertension, NOT the choice of antihypertensive drug
  • 60. Is it appropriate to start multiple antihypertensive? Administering two drugs as initial therapy should be considered when the blood pressure is more than 20/10 mmHg above goal Fixed dose combinations can be used as it increased patient compliance The JNC 7 report. JAMA. 2003;289(19):2560-72.
  • 61. Is it appropriate to start 2 agents? • In ALLHAT, 60% of patients achieved SBP control • The mean number of drugs to achieve BP control was 1.6 • Inadequate titration of drug regimens is a primary reason patients do not reach BP goal • Patients and providers should be educated that more than one antihypertensive is the norm not the exception
  • 62. Low Dose Combinations • Meta-analysis of 354 • n=56,000 patients randomized trials of • Placebo adjusted antihypertensives: BB, reductions in SBP and ACEI, ARB, & CCB DBP • Dose of each agent • Prevalence in adverse expressed as a multiple effects based on dose of a standard dose Law MR et al. BMJ. 2009;338:b1665.
  • 63. Low Dose Combinations 19.9 20 SBP Reduction 10 (mmHg) 0 13.3 6.7 1 Drug 2 Drug 3 Drugs BP lowering effects from different drug categories were additive Law MR et al. BMJ. 2009;338:b1665.
  • 64. Low Dose Combinations • Adverse effects in all drug categories, except ACEI, were dose related • Prevalence of adverse effects in combination was less than additive Conclusion: Utilization of low dose combination therapy can effectively reduce blood pressure while limiting the incidence of side effects Law MR et al. BMJ. 2009;338:b1665.
  • 65. Compelling Indications for Individual Drug Classes Compelling Indication Initial Therapy Options Clinical Trial Basis Heart failure THIAZ, BB, ACEI, ARB, ARA ACC/AHA Heart Failure Guideline, MERIT-HF, COPERNICUS, CIBIS, SOLVD, AIRE, TRACE, ValHEFT, RALES Postmyocardial infarction BB, ACEI ACC/AHA Post-MI Guideline, BHAT, SAVE, Capricorn, EPHESUS High CAD risk THIAZ, BB, ACEI, CCB ALLHAT, HOPE, ANBP2, LIFE, CONVINCE
  • 66. Compelling Indications for Individual Drug Classes Compelling Indication Initial Therapy Options Clinical Trial Basis Diabetes ACEI, ARB, CCB, THIAZ, BB, NKF-ADA Guideline, UKPDS, ALLHAT Chronic kidney disease ACEI, ARB NKF Guideline, Captopril Trial, RENAAL, IDNT, REIN, AASK Recurrent stroke prevention THIAZ, ACEI PROGRESS
  • 67. "The Goal is to Get to Goal!” Hypertension -PLUSDiabetes or Renal Disease < 140/90 mmHg  Patients should return for < 130/80 mmHg follow-up and adjustment of medications every 1-2 months until the BP goal is reached
  • 68. When a Patient is Still Not at Goal? Optimize dosages or add additional drugs until goal blood pressure is achieved
  • 69. When a Patient is Still Not at Goal? What do you do when you are using several effective medications? Consider causes of resistant hypertension
  • 70. Causes of Resistant Hypertension  Improper BP measurement  Dietary and medicine non compliance  Inadequate diuretic therapy  Medication • Inadequate doses •Drug actions and interactions: Nonsteroidal anti-inflammatory drugs (NSAIDs), illicit drugs, sympathomimetics, oral contraceptives • Over-the-counter (OTC) drugs and herbal supplements  Excess alcohol intake  Identifiable causes of HTN JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314
  • 71. Identifiable Causes of Hypertension  Sleep apnea  Drug-induced or related causes  Chronic kidney disease  Primary aldosteronism  Renovascular disease  Chronic steroid therapy and Cushing’s syndrome  Pheochromocytoma  Coarctation of the aorta  Thyroid or parathyroid disease JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314
  • 72. Other Medications (1) Aspirin: • Use 75mg daily if patient is aged ≥50 years with blood pressure controlled to <150/90 mm Hg and either; target organ damage, diabetes mellitus, or 10 year risk of cardiovascular disease of ≥20% (2) Statin: • Use when 10 year risk of cardiovascular disease of ≥20% and with total cholesterol concentration ≥200mg/dl (3) Vitamins—no benefit shown, do not prescribe
  • 73. Rational Combination Therapy: Chinese Menu Approach
  • 74. Pharmacologic Sites of Action Veins Thiazides Loops Aldosterone Ant. Nitrates ACEI ARB Heart Beta Blockers Diltiazem Verapamil Via Central Mechanism: Clonidine Arteries Dihydropyridine CCBs Hydralazine Minoxidil Alpha1 Blockers ACEI ARB
  • 75. Chinese Menu Approach Veins Heart Thiazides Loops Aldosterone Ant. Nitrates Beta Blockers Diltiazem Verapamil ACEI ARB Via Central Mechanism: Clonidine Arteries Dihydropyridines Hydralazine Minoxidil Alpha1 Blockers ACEI ARB Choose one agent from each category
  • 76. Algorithm for Treatment of Hypertension Lifestyle Modifications Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices Without Compelling Indications Stage 1 HTN (SBP 140–159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. With Compelling Indications Stage 2 HTN (SBP >160 or DBP >100 mmHg) 2-drug combination for most (usually thiazide-type diuretic and ACEI, or ARB, or BB, or CCB) Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist. JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314
  • 77. Follow-up and Monitoring  Patients should return for follow-up and adjustment of medications every 1-2 months until the BP goal is reached  After BP at goal and stable, follow-up visits at 3to 6-month intervals  More frequent visits for stage 2 HTN or with complicating comorbid conditions  Continue to encourage self BP monitoring  Serum potassium and creatinine monitored 1–2 times per year JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314
  • 78. Malignant Hypertension (HTN Emergency) • Hypertensive emergencies encompass a spectrum of clinical presentations in which uncontrolled blood pressures lead to progressive or impending endorgan dysfunction • BP should be lowered aggressively over minutes to hours
  • 79. Malignant Hypertension (HTN Emergency) • Neurologic manifestations: – – – – • Cardiovascular manifestations: – – – – • Hypertensive encephalopathy Cerebral vascular accident/cerebral infarction Subarachnoid hemorrhage Intracranial hemorrhage Myocardial ischemia/infarction Acute left ventricular dysfunction Acute pulmonary edema Aortic dissection Other organ systems: – – – – Acute renal failure/insufficiency Retinopathy Eclampsia Microangiopathic hemolytic anemia
  • 80. Malignant Hypertension (HTN Emergency) • The history and the physical examination determine the nature, severity, and management of the hypertensive event • The history should focus on the presence of endorgan dysfunction, the circumstances surrounding the hypertension, and any identifiable etiology • The duration and severity of the patient’s preexisting hypertension
  • 81. Malignant Hypertension (HTN Emergency) • Patients may complain of specific symptoms that suggest end-organ dysfunction – Chest pain may indicate myocardial ischemia or infarction – Back pain may denote aortic dissection – Dyspnea may suggest pulmonary edema or congestive heart failure – Presence of neurologic symptoms may include seizures, visual disturbances, and altered level of consciousness and may be indicative of hypertensive encephalopathy
  • 82. Malignant Hypertension (HTN Emergency) • • • • Physical examination should assess whether end-organ dysfunction is present BP should be measured in both the supine and standing position as well as in both arms The presence of new retinal hemorrhages, exudates, or papilledema suggests a hypertensive emergency Evaluate for the presence of heart failure – Indicated jugular venous distention – Crackles on auscultation – Peripheral edema • • CNS findings may include changes in the patient's level of consciousness and visual fields, and/or the presence of focal neurologic signs Abdominal masses or bruits may be noted
  • 83. Malignant Hypertension (HTN Emergency) • • • • Immediate admission Close monitoring Parentral antihypertensive Selection of antihypertensive agent depends upon target organ at risk • Goal is to rapidly lower BP in minutes to hours
  • 84. Hypertensive Urgency • Severe hypertension (as defined by a Systolic BP >200mmHg &/or diastolic blood pressure above 120 mmHg) in asymptomatic patients without any evidence of target organ damage • Don't require immediate reduction in BP • Don't require admission in monitored setup • Treat with oral medications • BP should be lower in hour to days
  • 85. Take Home Message  For persons over age 50, SBP is a more important than DBP as CVD risk factor  Starting at 115/75 mmHg, CVD risk doubles with each increment of 20/10 mmHg throughout the BP range  Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN  Those with SBP 120–139 mmHg or DBP 80–89 mmHg should be considered prehypertensive who require health-promoting lifestyle modifications to prevent CVD
  • 86. Take Home Message • Start with one of CCB/ACEI/ARB/HCTZ – All have equal efficacy in lowering BP – Unless compelling indication • Use two or more drugs or in combination if needed – have additive effect • And the goal is TO GET THE GOAL