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66 hypertension
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  • Partners in Healthcare Education, LLC 2009
  • Partners in Healthcare Education, LLC 2009 More than 60 million persons in the United States have some form of cardiovascular disease (CVD), such as congestive heart failure, stroke, hypertension, or hardening of the arteries or other disease of the circulatory system. Although CVD may have traditionally been considered “a man’s disease,” National Health and Nutrition Examination Survey (NHANES) III data (1988-1994) showed a nearly equal prevalence between males and females, with actually ~ 32 million females and ~ 30 million males affected. According to the NHANES III data, occurrence of CVD is highest among blacks. Of the total population of women with CVD, ~ 40% are black, ~ 24% are white, and ~ 27% are Mexican Americans. Of males with CVD, ~ 41% are black, ~ 30% are white, and ~29% are Mexican Americans. American Heart Association. Heart Disease and Stroke Statistics – 2003 Update. Dallas, Tex: American Heart Association; 2002.
  • Wright, 2009
  • Partners in Healthcare Education, LLC 2009 The traditional view of CVD is based on the Framingham Heart Study model of a stepwise increase in CVD risk with multiple independent risk factors. Recently, this model has evolved into a more dynamic one as new epidemiologic and clinical evidence has been published. The current model shows clustering of risk factors, such as hypertension, dyslipidemia, and diabetes along with smoking, gender, and increasing age, emphasizing the synergistic interaction of these risk factors. This dynamic, interactive effect of risk factors places individuals—even those with mild levels of  2 risk factors—at profound risk for CVD. Fuster V, Gotto AM Jr. Risk reduction. Circulation. 2000;102:IV94–IV102. Kannel WB. Framingham study insights into hypertensive risk of cardiovascular disease. Hypertens Res. 1995;18:181-196. Kannel WB. Risk stratification in hypertension: new insights from the Framingham study. Am J Hypertens . 2000;13:3S-10S. Poulter N. Coronary heart disease is a multifactorial disease. Am J Hypertens. 1999;12:92S-95S.
  • Partners in Healthcare Education, LLC 2009 Hypertension and hypercholesterolemia impair vascular endothelial function by reducing the bioavailability of nitric oxide, an important contributor to vascular smooth muscle relaxation and consequential vasodilation. Nitric oxide depletion also accelerates other atherogenic mechanisms. The endothelium is damaged by the release of reactive molecular groups (eg, oxidants) and elevation of angiotensin II via upregulation of the AT 1 receptor, which increases the deleterious effects of this vasoactive peptide. By downregulating AT 1 receptor expression and activation, statins reduce BP as well as LDL-C. Although hypertension and hypercholesterolemia exert their major effect at the level of the resistance vessels (small arteries), these disorders also reduce the ability of large vessels to distend, a deleterious effect that is reversible with lowering of BP and LDL-C. Some studies have shown a BP-reducing effect of statins in patients with untreated hypertension as well as in those treated with angiotensin-converting enzyme inhibitors (ACEIs) or calcium channel blockers (CCBs) and suggest that statins may act synergistically with antihypertensive agents. John S, Schmieder RE. Potential mechanisms of impaired endothelial function in arterial hypertension and hypercholesterolemia. Curr Hypertens Rep. 2003;5:199-207. Sander GE, Giles TD. Hypertension and lipids: lipid factors in the hypertension syndrome. Curr Hypertens Rep. 2002;4:458-463. Spieker LE, Noll G, Ruschitzka FT, Maier W, Lüscher TF. Working under pressure: the vascular endothelium in arterial hypertension. J Hum Hypertens . 2000;14:617-630. Giannattasio C, Mancia G. Arterial distensibility in humans: modulating mechanisms, alterations in diseases and effects of treatment. J Hypertens. 2002;20:1889-1899. Borghi C, Dormi A, Veronesi M, Immordino V, Ambrosioni E. Use of lipid-lowering drugs and blood pressure control in patients with arterial hypertension. J Clin Hypertens . 2002;4:277-285.
  • Partners in Healthcare Education, LLC 2009 Neaton et al analyzed data from 316,099 white men aged 35 to 57 years screened for the Multiple Risk Factor Intervention Trial (MRFIT) to assess the combined influence of BP, serum cholesterol level, and smoking on age-adjusted CHD mortality per 10,000 person-years. One of the more interesting findings was the combined effect of SBP ≥142 mm Hg and total serum cholesterol level  245 mg/dL, which was associated with a death rate of 33.7. This represented a greater than 2-fold increase in risk compared with persons in the same SBP quintile (≥142 mm Hg) and a cholesterol level of 182 mg/dL. It represented nearly a tripling of the risk in persons with SBP of 118 to 124 mm Hg and a cholesterol level  245 mg/dL. For both smokers and nonsmokers, in each SBP quintile, CHD death rates increased with increasing serum cholesterol; similarly, in each serum cholesterol quintile, the rates increased with increasing SBP (shown in green). The graph also shows that 2 moderately elevated risk factors can present a higher risk for a fatal CHD event than 1 severely elevated risk factor (shown in blue). These findings of the association of BP and cholesterol as predictors of CHD strongly support intensified efforts to prevent the development of these risk factors in all age groups.   Neaton JD, Wentworth D, for the Multiple Risk Factor Intervention Trial Research Group. Serum cholesterol, blood pressure, cigarette smoking, and death from coronary heart disease: overall findings and differences by age for 316,099 white men. Arch Intern Med . 1992;152:56-64.
  • Partners in Healthcare Education, LLC 2009 An estimated 27 million American adults have hypertension and dyslipidemia concurrently. Both conditions are important independent risk factors for CVD, and their effects are additive. Yet the presence of both simultaneously has been diagnosed in only 9 million individuals, or one third of the population at risk. About 6 million persons with the hypertension/dyslipidemia syndrome are being treated for only 1 of the 2 conditions, which means that only 3 million persons are being treated for both. A mere 300,000 of these at-risk individuals are reaching the goals for both BP and lipids. This generalized undertreatment clearly calls for testing for both conditions in the context of overall risk and initiating more aggressive therapy to bring both BP and lipids in line with national guidelines. American Heart Association. Heart Disease and Stroke Statistics – 2003 Update. Dallas, Tex: American Heart Association; 2002. Working Group Report on Management of Patients with Hypertension and High Blood Cholesterol. Bethesda, Md: National Heart, Lung, and Blood Institute; 1990. NIH Pub. No. 90-2361. Working Group Report on Management of Patients with Hypertension and High Blood Cholesterol. National Education Programs Working Group Report on the Management of Patients with Hypertension and High Blood Cholesterol. Ann Intern Med. 1991;114:224-237.  Meigs JB, D'Agostino RB Sr, Wilson PWF, Cupples LA, Nathan DM, Singer DE. Risk variable clustering in the insulin resistance syndrome: the Framingham Offspring Study. Diabetes. 1997;46:1594-1600.
  • Summary: Hypertension is associated with increased cardiovascular morbidity and mortality, leading to an estimated direct and indirect cost of $63.5 billion in 2006. Cardiovascular morbidity and mortality are high among patients with hypertension, which is evident in as many as 69% of patients suffering a first heart attack and 74% of those with congestive heart failure (CHF). In fact, according to a 2006 report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee, approximately 91% of patients with CHF had hypertension before the development of heart failure. 1 This same report indicates that among the 2.4 million deaths that occurred in the United States in 2003, 2 approximately 277,000 were attributable to high blood pressure. The estimated direct and indirect costs of hypertension in 2007 total $66.4 billion. 1 References Rosamond W, Flegal K, Friday G, et al. Heart disease and stroke statistics—2007 update. Circulation . 2007;115:1-103. Centers for Disease Control and Prevention. Number of deaths, death rates, and age-adjusted death rates, by race and sex: United States, 1940, 1950, 1960, 1970, and 1980-2003. Available at: http://www.cdc.gov/nchs/fastats/pdf/mortality/nvsr54_13_t01.pdf. Accessed January 29, 2007.
  • Partners in Healthcare Education, LLC 2009 Although hypertension is the most common primary diagnosis in the United States, the current control rate for hypertension (~ 30%) is still below the goal of 50% set by the national prevention initiative, Healthy People 2010. Nevertheless, patients with hypertension are more likely to be treated and controlled with medication than are those with dyslipidemia. Based on ATP III guidelines and NHANES III data, approximately 40% of adults aged  20 years require fasting lipoprotein analysis whereas <60% of persons with high cholesterol have been diagnosed with dyslipidemia. Patients’ noncompliance is a likely reason for inadequate lipid-lowering treatment. Their noncompliance with lipid-lowering therapies may be due to the length of therapy or complexity of therapy if multiple medications are required. Patients may also be reluctant to adhere to pharmacologic therapy if the condition appears to be asymptomatic. Additionally, inadequate lipid-lowering treatment may be due to poor compliance by healthcare providers. This may include a tendency to see more urgency in treating hypertension than other CVD risk factors, poor adherence to treatment guidelines, and reluctance to appropriately modify pharmacologic regimens to achieve therapy goals. The NCEP ATP III and JNC 7 guidelines encourage physicians, nurse practitioners, nurses, physician assistants, dietitians, and pharmacists to work as a team in educating, treating, and following up patients. Braunstein JB, Cheng A, Cohn G, Aggarwal M, Nass CM, Blumenthal RS. Lipid disorders: justification of methods and goals of treatment. Chest. 2001;120:979-988. Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560-2572. National Cholesterol Education Program. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel [ATP] III). Final Report. Bethesda, Md: National Heart, Lung, and Blood Institute; 2002. NIH Publication No. 02-5215. Sempos CT, Cleeman JI, Carroll MD, et al. Prevalence of high blood cholesterol among US adults: an update based on guidelines from the second report of the National Cholesterol Education Program Adult Treatment Panel. JAMA. 1993;269:3009-3014.
  • SLIDE SUMMARY: PHYSIOLOGICALLY, THE RENIN ANGIOTENSIN SYSTEM HELPS TO REGULATE BLOOD PRESSURE AND BLOOD VOLUME BY RESPONDING TO EXTRACELLULAR FLUID VOLUME AND BLOOD PRESSURE REDUCTIONS The diagram shows the cascade of events characteristic of the physiologic operation of the renin angiotensin system Reductions in blood volume and arterial pressure, perhaps caused by dehydration or blood loss, result in decreased firing of low- and high-pressure baroreceptors. This causes an increase in renal sympathetic nerve activity, which, together with decreases in renal artery pressure, glomerular filtration rate, and macula densa salt load, stimulates renin secretion 1 Renin secretion initiates processes resulting in increased plasma concentrations of angiotensin II, which causes vasoconstriction, renal sodium reabsorption, and thirst (stimulating fluid intake). These processes lead to restoration of blood volume and blood pressure 1 Reid IA. The renin-angiotensin system: physiology, pathophysiology, and pharmacology. Adv Physiol Edu . 1998;20:S236-S245.
  • Slide Summary According to a meta-analysis of over 60 prospective studies, the risk of cardiovascular disease doubles with each rise of 20 mm Hg in systolic blood pressure (BP) and 10 mm Hg in diastolic BP. Background In a meta-analysis of 61 prospective, observational studies conducted by Lewington et al involving one million adults with no previous vascular disease at baseline, the researchers found that between the ages of 40-69 years, each incremental rise of 20 mm Hg systolic BP and 10 mm Hg diastolic BP was associated with a twofold increase in death rates from ischemic heart disease and other vascular disease. The researchers also noted that when attempting to predict vascular mortality risk from a single BP measurement, the average of systolic and diastolic BP was “slightly more informative” than either alone, and that pulse pressure was “much less informative.” The seventh report Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) notes this study result as yet more information linking hypertension to high risk for cardiovascular events. Lewington S, Clarke R, Qizilbash H, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet . 2003;361:1903-1913. JNC 7. JAMA. 2003;289:2560-2572.
  • Partners in Healthcare Education, LLC 2009 The most important departure from JNC 6 in JNC 7 is a new category designated prehypertension (SBP of 120-139 mm Hg or DBP of 80-89 mm Hg) . The addition of this category emphasizes the importance of preventing BP from reaching hypertensive levels (>140/90 mm Hg). Patients with prehypertension are considered to have twice the risk of progressing to clinical hypertension than those with lower values. In addition, stages 2 and 3 hypertension of JNC 6 have been combined based on the recognition that BP ≥160/100 mm Hg should be treated aggressively, generally with 2 drugs upon diagnosis rather than a stepwise approach. JNC 7 emphasizes elevated SBP as a more accurate predictor of cardiovascular risk than elevated DBP in persons older than 50 years. Beginning at a BP of 115/75 mm Hg, CVD risk doubles with each increment of 20/10 mm Hg; individuals who are normotensive at age 55 years have a 90% lifetime risk for developing hypertension. The JNC 7 report is available online at http://www.nhlbi.gov/guidelines/hypertension/express.pdf. Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289:2560-2572. National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure . Bethesda, Md: National Heart, Lung, and Blood Institute; 2003. NIH Publication No. 03-5233.
  • Partners in Healthcare Education, LLC 2009 Health-promoting lifestyle modification(s) should be applied in persons with prehypertension as primary prevention. These nonpharmacologic treatments, such as diet and exercise, should also be encouraged in patients with all stages of hypertension, as they may enhance the efficacy of antihypertensive agents and minimize risk factors associated with hypertension. While lifestyle modifications are helpful, pharmacologic therapy is usually needed to treat high BP. Most patients with hypertension require  2 antihypertensive agents to achieve goal BP (<140/90 mm Hg, or <130/80 mm Hg for patients with diabetes or chronic kidney disease). A thiazide-type diuretic is recommended as initial therapy for uncomplicated hypertension, either alone or in combination with an antihypertensive agent from another class (ACEI, angiotensin receptor blocker [ARB], β- blocker, or CCB). A drug from a different class should be added if the first drug is insufficient for achieving goal BP. Patients whose BP is >20/10 mm Hg above goal should receive pharmacologic therapy, either singly or in a fixed-dose combination.    National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure . Bethesda, Md: National Heart, Lung, and Blood Institute; 2003. NIH Publication No. 03-5233.
  • There have been many outcome trials performed with ACE inhibitors showing positive cardiovascular and renal outcomes suggesting that agents that affect the RAAS system are beneficial in reducing mortality and morbidity.
  • Similarly the ARBs, the newest class of antihypertensive agents, have shown they are also beneficial in improving renal and cardiovascular outcomes. Lending further credence to the fact that interruption of the RAAS system is beneficial in patients with hypertension.
  • Summary: Diuretics, ACEIs, and ARBs activate the RS; renin inhibition does not Although angiotensin-converting enzyme (ACE) inhibition reduces levels of angiotensin (Ang) II (by preventing the formation of Ang II from Ang I), angiotensin-converting enzyme inhibitor (ACEI) therapy is associated with a reactive rise in plasma renin activity and plasma Ang I levels, perhaps due to the negation of the short feedback loop wherein Ang II inhibits renin secretion by AT 1 receptor stimulation. Such a process may overcome the effects of ACE inhibition 1 Far from blocking the formation of circulating Ang II, angiotensin receptor blocker (ARB) therapy is associated with elevated plasma Ang II concentrations, driven by a rise in plasma renin activity linked to inhibition of AT 1 -mediated negative feedback on renin release 2,3 Direct renin inhibitors block the formation of Ang I, and thus Ang II becomes unavailable to maintain its vasopressor and volume-regulatory effects on the circulation Thus, renin inhibitors decrease PRA in addition to systemic blood pressure and systemic vascular resistance 7 References Johnston CI. Angiotensin II type 1 receptor blockade: a novel therapeutic concept. Blood Pressure. 2000;9(suppl 1):9-13. Widdop RE, Matrougui K, Levy BI, Henrion D. AT 2 receptor-mediated relaxation is preserved after long-term AT 1 receptor blockade. Hypertension. 2002;40:516-520. Fabiani ME, Johnston CI. AT1 receptor antagonists as antihypertensive agents. In: Epstein M, Brunner HR, eds. Angiotensin II Receptor Antagonists . Philadelphia, Pa: Hanley & Belfus, Inc; 2001:263-278. Lin C, Frishman WH. Renin inhibition: a novel therapy for cardiovascular disease. Am Heart J . 1996;131:1024-1034.
  • Partners in Healthcare Education, LLC 2009 Patients with prehypertension or hypertension who have compelling indications (specific high-risk conditions) require therapy with specific antihypertensive agents (ACEIs, ARBs, β -blockers, CCBs). Compelling indications include heart failure, post-MI, high CHD risk, diabetes, chronic kidney disease, and prevention of recurrent stroke. The selections of agents for patients with these high-risk conditions are based on favorable outcome data from clinical trials. Also in these patients, however, a combination of agents may be required to lower BP. Other management considerations include medications already being taken by the patient, tolerability, and desired BP targets.    National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure . Bethesda, Md: National Heart, Lung, and Blood Institute; 2003. NIH Publication No. 03-5233.
  • Slide Summary The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) acknowledges the evidence from recent clinical trials (eg the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial [ALLHAT]) that most patients with hypertension will require two or more drugs to reach target blood pressure (BP) levels. Further, JNC 7 recommends that combination therapy be considered as initial therapy where BP is greater than 20/10 mm Hg above goal. Background JNC 7 notes the increased cardiovascular risk due to hypertension, and in its recommendations has set out guidelines aimed at effective and timely ways of achieving goal BP in hypertensive patients. The JNC authors recommend that initial combination therapy be considered as optimal therapy in patients who are greater than 20/10 mm Hg from goal BP. JNC 7. JAMA. 2003;289:2560-2572. ALLHAT Investigators. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor, or calcium channel blocker vs diuretic. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA . 2002;288:2981-2997.
  • Slide Summary The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) recommends that combination therapy be considered as initial therapy where BP is greater than 20/10 mm Hg above goal. The JNC 7 authors note that a failure to tailor antihypertensive therapy to assist patients to meet BP goals, either by titration or the addition of medications, is a problem among some clinicians that requires urgent attention. Background The JNC 7 authors recommend that clinicians consider factors that affect patient adherence to therapeutic regimens – eg, cultural differences, beliefs, and previous experience with the health care system – when determining hypertensive therapy. The JNC 7 report also notes that physicians may need assistance in monitoring that their hypertensive patients are reaching goal BP. This assistance may come from electronic or paper decision support systems, flow charts, feedback reminders, and the involvement of other members of the health care team including nurses and pharmacists. JNC 7. JAMA. 2003;289:2560-2572.
  • Slide Summary In 6 large double-blind, placebo-controlled studies, more than one agent was required to achieve desired target blood pressure (BP) goals. Background This slide shows evidence from 6 large placebo-controlled trials [1-6] demonstrating that when target BP values were set for subjects, 2 or more agents were required to achieve these goals [7]. In the Hypertension Optimal Treatment (HOT) study, for example, 68% of subjects required more than one agent [4]. 41% of subjects were taking felodipine plus an ACE inhibitor, and 28% were taking felodipine plus a beta blocker. In the United Kingdom Prospective Diabetes Study (UKPDS) [1], 29% of subjects required 3 or more agents to achieve a BP of <150/85 mm Hg at 9 years after randomization. 1. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ . 1998;317:703-713. 2. Estacio RO, Schrier RW. Antihypertensive therapy in type 2 diabetes: implications of the Appropriate Blood pressure Control in Diabetes (ABCD) trial. Am J Cardiol . 1998;82(9B):9R-14R. 3. Lazarus JM, Bourgoignie JJ, Buckalew VM, et al, for the Modification of Diet in Renal Disease Study Group. Achievement and safety of a low blood pressure goal in chronic renal disease. Hypertension. 1997;29:641-650. 4. Hansson L, Zanchetti A, Carruthers SG, et al, for the HOT Study Group. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet . 1998;351:1755-1762. 5. Kusek JW, Lee JY, Smith DE, et al. Effect of blood pressure control and antihypertensive drug regimen on quality of life: the African American Study of Kidney Disease and Hypertension (AASK) Pilot Study. Control Clin Trials . 1996;16(suppl 4):40S-46S. 6. Lewis EJ, Hunsicker LG, Clarke WR, et al. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med. 2001;345:851-860. 7. Bakris GL, Williams M, Dworkin L, et al, for the National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group. Preserving renal function in adults with hypertension and diabetes: a consensus approach. Am J Kidney Dis. 2000;36:646-661.
  • Partners in Healthcare Education, LLC 2009
  • Partners in Healthcare Education, LLC 2009
  • Partners in Healthcare Education, LLC 2009
  • Transcript

    • 1. Partners in Healthcare Education, LLC 2009 1 Hypertension: A Focus on JNC VII Wendy L. Wright, MS, RN, ARNP, FNP, FAANP Adult/Family Nurse Practitioner Owner – Wright & Associates Family Healthcare, PLLC Partner – Partners in Healthcare Education, LLC
    • 2. Partners in Healthcare Education, LLC 2009 2 Objectives • Upon completion of this lecture, the participant will be able to: – Identify the various classifications of prehypertension, Stage I and Stage 2 hypertension – Discuss nonpharmacologic treatment options for the patient with hypertension – Discuss pharmacologic treatment options for the patient with hypertension
    • 3. Partners in Healthcare Education, LLC 2009 3 CVD Is the Most Common Health Problem in the United States More than 60 million Americans (>20%) have some form of cardiovascular disease Adapted from American Heart Association. Heart Disease and Stroke Statistics – 2003 Update. Dallas, Tex; 2002.
    • 4. CVD disease mortality trends for males and femalesCVD disease mortality trends for males and females (UnitedUnited States: 1979-2004).States: 1979-2004). SSource: NCHS and NHLBI.ource: NCHS and NHLBI. 400 450 500 550 79 80 85 90 95 00 04 DeathsinThousands Years Males Females CVD disease mortality trends for males and females 4 Wright, 2009
    • 5. Partners in Healthcare Education, LLC 2009 5 Evolution in Understanding Cardiovascular Disease: Total Risk Perspective Cardiovascular Disease Is an Interplay of Risk Factors Age Gender Smoking Dyslipidemia Hypertension Diabetes Mellitus Kannel WB. Am J Hypertens. 2000;13:3S-10S; Poulter N. Am J Hypertens. 1999;12:92S-95S.
    • 6. Partners in Healthcare Education, LLC 2009 6 Hypertension and Dyslipidemia Contribute to Atherogenesis Endothelial Dysfunction CVD Hypertension Dyslipidemia Atherosclerosis Smooth Muscle Cell Contraction Impaired Bioavailability of Nitric Oxide Impaired Vasodilation
    • 7. Partners in Healthcare Education, LLC 2009 7 Impact of Elevated SBP and Total Cholesterol on CHD Mortality in MRFIT Age-Adjusted CHD Death Rates Per 10,000 Person-Years Cholesterol Quintile (mg/dL) SBP Quintile (mm Hg) MRFIT = Multiple Risk Factor Intervention Trial. Adapted from Neaton JD et al. Arch Intern Med. 1992;152:56-64. 33.7 21 17.1 12.7 12.2 22.6 12.3 8.3 9.6 5.9 17.7 10.9 8.5 6.3 5.5 16.7 7.9 7.9 6 4.3 13.7 5 5.6 3.4 3.1 ≥142 132-141 125-131 118-124 <118 <182 182-202 203-220 221-244 ≥245
    • 8. Partners in Healthcare Education, LLC 2009 8 Hypertension and Dyslipidemia: A Significantly Undertreated Syndrome Adapted from American Heart Association. Heart Disease and Stroke Statistics—2003 Update; CDC; NHANES III (1988-1994). 27 Million Affected by Both Hypertension and Dyslipidemia 9 million diagnosed with both 3 million treated for both 300,000 at both goals (~ 1%) 14.7 million undiagnosed
    • 9. 9 Impact of Hypertension • 50 million individuals in the United States have hypertension1 • 277,000 deaths annually in US due to hypertension2 1 American Association of Clinical Endocrinologists Medical Guidelines For Clinical Practice for the Diagnosis and Treatment of Hypertension. Endocrine Practice, Vol 12 No. 2 March/April 2006 2 National Center for Health Statistics. Health, United States, 2005, with Chartbook on the Health of Americans. Hyattsville, Maryland: 2004. Available at: http://www.cdc.gov/nchs/hus.htm
    • 10. Hypertension Remains One of the Most Important Multipliers of CV Risk BP >140/90 mm Hg is associated with: • 277,000 deaths in 2003 BP, blood pressure; CHF, congestive heart failure; MI, myocardial infarction. Rosamond W et al. Circulation. 2007;115:1-103.
    • 11. Partners in Healthcare Education, LLC 2009 11 It is currently estimated that… • 90% of normotensive 55 year olds will develop hypertension at some point in his/her lifetime
    • 12. Partners in Healthcare Education, LLC 2009 12 Hypertension: Controlled or Not? Prevalence(%) Hypertension 0 20 40 60 80 Controlled on medication Uncontrolled on medication Diagnosed Adapted from NHANES III Morning Examination Subset: Hypertension (June 1998);
    • 13. Partners in Healthcare Education, LLC 2009 13 Statistics of Interest • 53% of patients with hypertension are being treated with medications • Of those treated, 29% have their blood pressure < 140/90 Lookinland, S. and Beckstrand, R. Evidence-Based Treatment of Hypertension: JNC 7 Guidelines Provide an Updated Framework; Advance for Nurse Practitioners, Sept 2003.
    • 14. 14 Hypertension and Management: Old School Hypertension = Systemic disease Hemodynamics altered Treat the blood pressure Therapeutic options Beta Blockers ACE ARB Diuretics CCB Others Adapted from Vascular Biology Working Group, University of Florida College of Medicine, Carl Pepine, MD, Director
    • 15. 15 Hypertension and Management: New School Hypertension = Disease of the blood vessels Vascular biology altered Treat the vasculature Therapeutic options Beta Blockers ACE ARB Diuretics CCB Others Adapted from Vascular Biology Working Group, University of Florida College of Medicine, Carl Pepine, MD, Director
    • 16. Physiology of the Renin Angiotensin System Ang, angiotensin. Reid IA. Adv Physiol Edu. 1998;20:S236-S245. ↓ BLOOD PRESSURE BLOOD VOLUME Activation of Baroreceptor Reflexes ↑ Renal Sympathetic Nerve Activity Beta-adrenergic Stimulation ↑ RENIN SECRECTION ↓ Renal Artery Pressure Renal Baroreceptor ↑ BLOOD PRESSURE BLOOD VOLUME Systemic Vasoconstriction ↑ Plasma Ang II ↑ Aldosterone Secretion ↑ Plasma Ang I
    • 17. 17 RAAS and Adipose Tissue • All components of the RAAS system are expressed in adipose tissue, especially the visceral adipose tissue1,2,3 • Visceral adipose tissue of patients with insulin resistance and Type 2 diabetes is dysfunctional and is a source of chronic low-grade inflammation4 1 Sowers, James R. Insulin Resistance and Hypertension Physiol Heart Circ Physiol. 2004;286: H1597-H1602 2 Ashish, A, El-Atat, R, et al. Hypertension and Obesity Recent Prog Horm Res. 2004;59:169-205. 3 Kershaw EE, Flier JS. Adipose Tissue as an Endocrine Organ Clin Endocrinol Metab. 2004; 98:2548-2556..
    • 18. 18 RAAS and Endothelial Dysfunction • Growing body of evidence – Promotion of endothelial dysfunction – Microalbuminuria1,2 • RAAS Inhibition (ACE, ARB and Direct Renin Inhibitor) – Decreased incidence of new onset Type 2 diabetes – Improvement in CVD outcomes3 Higashi, Y, Sasaki S, Nakagawa K, et al. Endothelial Function and Oxidative Stress In Renovascular Hypertension N Engl J Med 2002;346:1954-1962.
    • 19. 19 Today – The Hypertensive Patient Exhibits... • More insulin resistance • More hyperinsulinemia • Dyslipidemia • Microalbuminuria • Obesity ...as compared to nonhypertensive patients! Reaven GM. Banting lecture 1988. Role of insulin resistance in human. Disease Diabetes. 1988.37;1595-1607.
    • 20. 20 Cardiovascular Disease Hypertension Diabetes Blocking the RAAS has been shown to be beneficial in…
    • 21. Partners in Healthcare Education, LLC 2009 21 JNC VII: Messages to Clinicians JAMA. 2003:289:2560-2577.
    • 22. Partners in Healthcare Education, LLC 2009 22 New Messages JNC VII • The risk of CVD, beginning at 115/75 mm Hg, doubles with each increment of 20/10 mm Hg. JAMA. 2003:289:2560-2577.
    • 23. 23 CV Disease Risk Doubles with Each 20/10 mm Hg BP Increment* *Individuals aged 40-70 years, starting at BP 115/75 mm Hg. CV, cardiovascular; SBP, systolic blood pressure; DBP, diastolic blood pressure CV disease risk SBP/DBP (mm Hg) 0 1 2 3 4 5 6 7 8 115/75 135/85 155/95 175/105 1. Lewington S, Cardiovascular Issues in Ageing Pilots. et al. Lancet. 2002; 60:1903-1913 2. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, And Treatment of High Blood Pressure. http://jama.ama-assn.org/cgi/content/full/289.19.2560v1. Assessed 5-1-08
    • 24. Partners in Healthcare Education, LLC 2009 24 Diagnosis • 2 readings; separated apart • Patient should not ingest caffeine or smoke for 30 minutes before readings • Patient should sit for 5 minutes with arm at heart level before blood pressure is checked
    • 25. Partners in Healthcare Education, LLC 2009 25 JNC 7: New Blood Pressure Classification Blood Pressure Classification SBP* DBP* (mm Hg) Normal <120 and <80 Prehypertension 120-139 or 80-89 Stage 1 hypertension 140-159 or 90-99 Stage 2 hypertension ≥160 or ≥100 *Treatment determined by highest BP category (SBP or DBP). Adapted from Chobanian AV et al. JAMA. 2003;289:2560-2572; NHBPEPCC. 2003. NIH Publication No. 03-5233.
    • 26. Partners in Healthcare Education, LLC 2009 26 Prehypertension • Individuals with a systolic BP of 120- 139 mm HG or a diastolic BP or 80- 89 mm HG should be considered as pre-hypertensive and lifestyle modification initiated.JAMA. 2003:289:2560-2577.
    • 27. Partners in Healthcare Education, LLC 2009 27 Most Cases of Hypertension • Primary hypertension – Also called essential – Responsible for 90-95% of all hypertension diagnoses
    • 28. Partners in Healthcare Education, LLC 2009 28 Consider Secondary Causes of HTN • Sleep apnea • Drug-induced or drug related – Including OTC medications • Chronic kidney disease – Polycystic kidneys • Renal artery stenosis • Primary aldosteronism • Renovascular disease • Chronic steroid therapy and Cushing’s disease • Pheochromocytoma • Coarctation of the Aorta • Thyroid or parathyroid disease JAMA. 2003:289:2560-2577.
    • 29. Partners in Healthcare Education, LLC 2009 29 What about White-Coat Hypertension? • Patient involvement in the measurement of his/her blood pressure is recommended, particularly for those individuals whose blood pressure is normal out of the office but consistently elevated in the office • The office blood pressure of elders is 5 mm Hg higher than their ambulatory blood pressure • Older the individual, the greater the discrepancy between home and office blood pressures • No longer considered a benign condition JAMA. 2003:289:2560-2577.
    • 30. 30 Initial Work-up • History and review of systems – Medications and risk factors • Consider home blood pressure readings with validated blood pressure cuff • Laboratory workup: CBC, BUN, Creatinine, Glucose, Lipids, GFR, urine - protein • EKG and/or Echocardiogram, if indicated • Urine for microalbuminuria Pickering, TG, Hall JE, et al. AHA Scientific Statement: Recommendations for Blood Pressure Measurement in Humans and Experimental Animals. Part 1: Blood Pressure Measurement in Humans Hypertension. 2005;45:142-161.
    • 31. Partners in Healthcare Education, LLC 2009 31 Treatment of Hypertension
    • 32. Partners in Healthcare Education, LLC 2009 32 How Helpful is control of BP? In stage 1 HTN, combined with additional CVD risk factors, achieving a sustained 12 mmHg reduction in SBP over 10 years will prevent 1 death for every 11 patients treated. JAMA. 2003:289:2560-2577.
    • 33. 33 Benefits of Lowering Blood Pressure Average Percent Reduction Stoke: 35% - 40% MI: 20% - 25% CHF: 50% The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, And Treatment of High Blood Pressure. http://jama.ama-assn.org/cgi/content/full/289.19.2560v1. Assessed 5-1-08
    • 34. Partners in Healthcare Education, LLC 2009 34 Treatment Goals • < 140/90 mm Hg for those with no complications • < 130/80 mm Hg for those with diabetes or CRF (per ADA) • < 130/80 mm Hg – all individuals per NKF
    • 35. Partners in Healthcare Education, LLC 2009 35 JNC 7: Algorithm for Treatment of Hypertension Prehypertension (SBP 120-139 mm Hg or DBP 80-89 mm Hg) Not at Goal BP (<140/90 mm Hg, or <130/80 mm Hg for patients with diabetes or chronic kidney disease) Without Compelling Indications With Compelling Indications Prehypertension Stage 1 Hypertension (SBP 140-159 or DBP 90-99 mm Hg) Thiazide-type diuretics for most; may consider ACEI, ARB, BB, CCB, or combination. Stage 2 Hypertension (SBP ≥160 or DBP ≥100 mm Hg) 2-drug combinations for most (usually thiazide-type diuretics and ACEI, or ARB, or BB, or CCB). Drug(s) for compelling indications Other antihypertensive drugs (diuretic, ACEI, ARB, BB, CCB) as needed. Adapted from NHBPEPCC. 2003. NIH Publication No. 03-5233. LIFESTYLE MODIFICATIONS If not at goal BP, optimize dosages or add additional drugs until goal BP is achieved. Consider consultation with hypertension specialist. INITIAL DRUG CHOICES
    • 36. Partners in Healthcare Education, LLC 2009 36
    • 37. Partners in Healthcare Education, LLC 2009 37 New Messages JNC VII • The most effective therapy prescribed by the most careful clinician will control hypertension….only if the patient is motivated. JAMA, May 21, 2003 Vol 289;No 19.
    • 38. Partners in Healthcare Education, LLC 2009 38 Lifestyle Modifications to Manage Hypertension Modification Recommendation Systolic Diastolic Chgs Weight Reduction BMI 18.5-24.9 5-20mm/10 kg wt loss Adopt DASH eating Diet rich in fruits 8-14 mm Hg vegetables and low fat with reduced saturated and total fat Dietary Sodium 2.4g Na 2-8 mm Hg Physical Inactivity Brisk exercise 30” day 4-9 mm Hg most days of week Moderation of Alcohol intake 2 drinks day max 2-4 mm Hg 24 oz beer; 10 oz wine 2 oz 100 proof whiskey JAMA. 2003:289:2560-2577.
    • 39. Partners in Healthcare Education, LLC 2009 39 Lifestyle Modifications • Dietary sodium reduction – Most helpful in African Americans and patients with diabetes – Recommend limiting sodium to < 2000 mg/day for these individuals • Average individual ingests 4000 mg / day – ACE inhibitors and diuretics work best with a relatively low sodium diet
    • 40. Partners in Healthcare Education, LLC 2009 40 How Successful Is It? • Combination of the DASH diet and a dietary sodium reduction to 1600 mg/day is as effective as 1 medication
    • 41. Partners in Healthcare Education, LLC 2009 41 Alcohol Intake • Limit alcohol intake to < 30 mL or 1 ounce of ethanol/day – Translation: 2 ounces of whiskey – 10 ounces of wine – 24 ounces of beer • Excessive amounts increases treatment resistance • Also increases risk of a CVA** Women: ½ this amount
    • 42. Partners in Healthcare Education, LLC 2009 42 Electrolytes • Diets high in potassium, calcium and magnesium are associated with a lower blood pressure • JNC VII recommends an adequate dietary intake of these but does not recommend supplementing from an outside source to lower blood pressure
    • 43. Partners in Healthcare Education, LLC 2009 43 Additional Recommendations • Omega-3 fatty acids may lower blood pressure • Caffeine may increase it but tolerance often develops – Most studies do not support a relationship between hypertension and caffeine • Smoking: discontinuation is important • Exercise: 30 minutes daily recommended
    • 44. Partners in Healthcare Education, LLC 2009 44 Pharmacologic Treatments
    • 45. Partners in Healthcare Education, LLC 2009 45 New Messages JNC VII • Thiazide diuretics should be used in drug treatment for patients with uncomplicated hypertension. JAMA. 2003:289:2560-2577.
    • 46. Partners in Healthcare Education, LLC 2009 46 Thiazide Diuretics • Dosing: – Start @ 12.5 mg of HCTZ – Increase to 25 mg at 6 weeks • Benefits – 55% reduction in CHF – 37% reduction in CVA – 27% reduction in cardiac events • If not adequately controlled, add additional agents
    • 47. 47 Diuretic Precautions • Electrolyte imbalances • Syncope/presyncope when combined with ACE/ARB • Hemoconcentration • Decrease in urate excretion • Worsening of insulin resistance at higher doses • Fatigue Product inserts accessed 04-20-2008
    • 48. 48 Angiotensin Converting Enzyme (ACE) Inhibitors •Increased nitrous oxide at vessel for vasodilatation •Improved glucose disposal •Reduction in LV geometry changes •Reduction in inflammation •Stabilization of fibrous cap of lipid lesion •Decreased proteinuria •Improves endothelial function •Reduced mortality in patients with CHF •Decreases post-MI mortality Sato Atsuhisa, Pleiotropic effects of angiotensin-converting enzyme inhibitors; differentiation Among ace inhibitors may lead to further organ protection. Abstr 21st Sci Meet Int Soc Hypertens 2006. 423(2006)
    • 49. 49 ACE Inhibitor Trials 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 2000 2001 CONSENSUS I ValHeFT II SOLVD treatment SAVE AIRE TRACE SMILE CATS CONSENSUS II GISSI-3 ISIS-4 PEACE HOPE Latini, et al. Curr Perspect. 1995;92:3132-7 CCS-1 CHF Anterior AMI AMI CAD LVD Post-AMI
    • 50. 50 ACE Inhibitors Precautions • Hyperkalemia • Increase in creatinine • May improve insulin sensitivity • Decrease in serum Na+ may result in syncope and dizziness when used with diuretics Product inserts accessed 04-20-2009 • Angioedema • Cough
    • 51. 51 Effects on Hypoglycemia • Several studies have shown the ability of ACE inhibition to improve glycemic control – even decrease the risk of hypoglycemia in patients using sulfonylureas. Thamer M, Ray NF, Taylor T. Association between antihypertensive drug use and hypoglycemia: A case-control study of diabetic users of insulin or sylfonylureas. Clin Therapeutics 1999; 21:1387
    • 52. 52 But… ACE Inhibitors Are Highly Effective..
    • 53. 53 ** ** ** **** ** ** ** * = p<0.001 versus placebo* = p<0.001 versus placebo Plasma ACEPlasma ACE (mmol/ml/min)(mmol/ml/min) Plasma ANG IIPlasma ANG II (pg/ml)(pg/ml) ** Placebo 4h 24h 1 2 3 4 5 6Placebo 4h 24h 1 2 3 4 5 6 HospitalHospital MonthsMonths Modified fromModified from Journ Cardiovasc PharmJourn Cardiovasc Pharm 1982; 966-721982; 966-72 Long Term Effect of Enalapril (20mg) on Plasma ACE and Angiotensin II Vascular Biology Working Group, University of Florida College of Medicine, Carl Pepine, MD, Director
    • 54. 54 If you block the receptor site, you don’t have to worry about the angiotension levels… AT1
    • 55. 55 Angiotensin Receptor Blockers
    • 56. 56 Angiotension Receptor Blockers (ARB’s) • Utilized since April 1995 • Blocks uptake at receptor site • Angiotension II produced in locations other than in the lungs • BP decreased by reducing vascular tone and enhancing NA+ and water clearance
    • 57. 57 Metabolic Effects of ARB’s • Angiotensin II Receptor Blockers • Metabolically neutral • No impact on lipids • No impact on insulin • No impact on K+ • Lowers uric acid levels • Minimal side effect profile Product Inserts accessed 04-20-2009
    • 58. 58 ARB Trials 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 ValHeFTELITE I ELITE II IDNT RENAAL IRMA II OPTIMAAL LIFE VALIANT VALUE CHARM MARVAL ON TARGET CHF CV MI Renal/CV Renal IPreserve
    • 59. ACE vs ARB ONTARGET Trial Goal: 1. Assess the effects of ACE VS ARB in terms of efficacy 2. Assess if the combination ACE & ARB was superior Results: Telmisartan was found to be “noninferior” to ramipril in patients with vascular disease or high risk diabetes Combination of these two agents was associated with more adverse events without an increase in benefit. 59 Yusuf, S, Teo KK, Pogue, J et al for the ONTARGET investigators. Telmisartan, ramipril, or both in patients At high risk for vascular events N Engl J Med 2008;358:1547-1559.
    • 60. 60 Beta Blockers •Reduction in blood pressure •Decreased contractility •Decreased heart rate •Decreased myocardial oxygen demand •Reduction in LVH •Reduced arrhythmias The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, And Treatment of High Blood Pressure. http://jama.ama-assn.org/cgi/content/full/289.19.2560v1. Assessed 5-1-08
    • 61. 61 Beta Adrenergic Receptors • 3 receptors are found in human cardiac myocytes that are coupled to a positive inotropic response and cell growth. – Beta1 – Beta2 – Alpha1 Hunt, et al. ACC/AHA 2005 Chronic Heart Failure Guideline Update. JACC.2005; 46:1116-43.
    • 62. Beta Blocker Trials SHEP Systolic Hypertension in the Elderly Program Step Approach Chlorthalidone/Atenolol Reduced incidence of major CV events and CVA; chlorthalidone decreased CHF STOP HTN 2 Swedish Trial in Old Persons with Hypertension Beta Blocker Vs CCB VS ACE on CV Morbidity ACE /BB similar efficacy in preventing CV mortality. CAPPP Captopril Prevention Project Beta Blocker + Diuretic vs Captopril Captopril not better than conventional HTN Rx in prevention of CV morbidity and mortality; Diabetic patients on captopril did better than BB +Diuretics in decreasing morbidity 62
    • 63. 63 Calcium Channel Blockers
    • 64. 64 Calcium Channel Blockers • Effectively treat systolic hypertension • May be superior to other antihypertensives for stroke prevention • Effective in patients with: – Comorbid conditions (Raynauds, migraine)1 • Particularly effective in – Elderly and African American’s2 1. Materson BJ, Reda DJ, eta l. Single drug therapy for hypertension in men. A comparison of six Antihypertensive agents with placebo. N Engl J Med. 1993;328:914-921. 2. Tuomilehto J, Rastenyte D, et al. Effects of calcium channel blockade in older patients with Diabetes and hypertension. N Engl J med. 1999;340:677-684.
    • 65. The Calcium Blockers Dihydropyridines – Studies of DPH’s effects on proteinuria have produced conflicting results – NKF recommends that in patients who have diabetes and kidney disease, DPH’s should only be used in combination with and ACE or ARB Nondihydropyridines – Regression of proteinuria – Combination of Verapamil + ACE, reduction in proteinuria can be greater than achievable with verapamil alone. – NKF now recommends adding a NDH to treat hypertension with an ACE inhibitor or an ARB to slow the progression of kidney disease. 65 Thornley-Brown D, et al for the African American Study of Kidney Disease and Hypertension Study Group. Differing effects of antihypertensive drugs on the incidence Of Diabetes mellitus among patients with hypertensive kidney disease. Arch Intern Med. 2006;166(7):797-805. National Kidney Foundation. K/DOQI clinical practice guidelines on hypertension and antihypertensive agents in chronic kidney disease. Am J Kidney Dis. 2004; 43(suppl 1):S1-S290.
    • 66. 66 Alpha Blockers
    • 67. 67 Alpha Blockers • Block postsynaptic Alpha1 Receptors • Results in vasodilatation • Relatively inexpensive • Fair tolerability; May cause postural effects • Additive agent for older men to decrease BPH symptomatology • Add-on agent only • Should never be used as monotherapy due to increased risk of stroke and CHF The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, And Treatment of High Blood Pressure. http://jama.ama-assn.org/cgi/content/full/289.19.2560v1. Assessed 5-1-08
    • 68. 68 Centrally Acting Blockers
    • 69. 69 Centrally Acting Agents • Stimulates central alpha2 receptors which results in: – Inhibiting efferent sympathetic activity • Additive agents • Should be used 3rd or 4th line – Examples: Clonidine (catapress, catapress TTS); methyldopa • Caution: sedation, orthostatic hypotension The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, And Treatment of High Blood Pressure. http://jama.ama-assn.org/cgi/content/full/289.19.2560v1. Assessed 5-1-08
    • 70. 70 Direct Vasodilators
    • 71. 71 Direct Vasodilators • Direct smooth muscle vasodilatation, primarily arteriolar • Two agents – Apresoline (Hydralazine) – Minoxidil **Precautions include: tachycardia, significant peripheral edema and hair growth **Agents to reduce heart rate may be needed The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, And Treatment of High Blood Pressure. http://jama.ama-assn.org/cgi/content/full/289.19.2560v1. Assessed 5-1-08
    • 72. 72 Aldosterone Agonists
    • 73. 73 • Spironolactone (Aldactone) • HCTZ / spironolactone (Aldactazide) • Eplerenone (Inspra) Aldosterone Antagonists
    • 74. 74 Aldosterone as a Therapeutic Target • Aldosterone promotes: – Retention of sodium – Loss of magnesium and potassium – Sympathetic activation – Parasympathetic inhibition – Baroreceptor dysfunction – Impaired arterial compliance Mac Fadyen RJ, et al Aldosterone blockade reduces vascular collagen turnover, improves heart rate variability and reduces early morning rise in heart rate in heart failure patients. Cardiovasc Res 1997;35:30-34.
    • 75. 75 • May be recommended in the following individuals: – Post MI – NYHA Class III or IV – Ejection fraction of < 35% – Serum creatinine of < 2.5 mg/dl – K+ < 5.0 mmol/L Mardi Gomberg-Maitland, Baran DA, Fuster, V. Treatment of Congestive Heart Failure Guidelines for the Primary Care Physician and Heart Failure Specialist. Arch Intern Med 2001;161:324-352et al. ACC/AHA 2005 Chronic Heart Failure Guideline Update. JACC.2005; 46:1116-43. Aldosterone Antagonists
    • 76. 76 Precautions • Must monitor electrolytes • Must obtain baseline renal function • Should discontinue the K+ supplement • Should limit to use in severe heart failure and post MI patients Clavell, Alfredo L. Common Mistakes made in the Treatment of Congestive Heart Failure. Success with Failure: New Strategies for Evaluation and Treatment of CHF. Whistler BC, Canada 8-2000.
    • 77. 77 New Classes/Agents
    • 78. 78 Direct Renin Inhibitor Renin is the enzyme at the beginning of the RAAS, one of the key regulating centers for blood pressure. Blocking this enzyme can decrease the downstream impact of the RAAS system. Suppression of the RAAS has been shown to treat hypertension and reduce target organ damage.
    • 79. Direct Renin Inhibition Inhibits the Entire Renin System1-4 Class ACEI ARB Direct Renin Inhibitor (DRI) PRA Ang I Ang II Increased peptide levels have not been shown to overcome the blood pressure–lowering effect of these agents. ACEI, angiotensin-converting enzyme inhibitor; Ang, angiotensin; ARB, angiotensin receptor blocker; PRA, plasma renin activity. 1.Johnston CI. Blood Press Suppl. 2000;1:9(suppl 1):9-13. 2.Widdop RE et al. Hypertension. 2002;40:516-520. 3.Fabiani ME et al. Angiotensin II Receptor Antagonists. 2001:263-278. 4.Lin C et al. Am Heart J. 1996;131:1024-1034.
    • 80. Aliskiren  Dosage: –150 mg or 300 mg once daily  Indications: –Adults with hypertension –May be administered with any other antihypertensive Product Insert, 2007
    • 81. Partners in Healthcare Education, LLC 2009 81 New Messages JNC VII • Certain high risk conditions are compelling indications for the initial use of other antihypertensive drug classes. – Angiotensin-converting enzyme inhibitors – Angiotensin-receptor blockers – Beta blockers – Calcium channel blockers JAMA. 2003:289:2560-2577.
    • 82. Partners in Healthcare Education, LLC 2009 82 JNC 7: Compelling Indications for Individual Antihypertensive Drug Classes Compelling Indication* Recommended Drugs DIURETIC BB ACEI ARB CCB Aldo ANT Heart failure • • • • • Post-MI • • • High coronary disease risk • • • • Diabetes • • • • • Chronic kidney disease • • Recurrent stroke prevention • • *Compelling indications for antihypertensive drugs are based on benefits from outcome studies or existing clinical guidelines; the compelling indication is managed parallel with the BP. ACEI = angiotensin converting enzyme inhibitor; ARB = angiotensin receptor blocker; Aldo ANT = aldosterone antagonist; BB = beta-blocker; CCB = calcium channel blocker. Adapted from NHBPEPCC. 2003. NIH Publication No. 03-5233.
    • 83. 83 Combination Therapy
    • 84. 84 When you put your hand in the cabinet…
    • 85. 85 JNC 7 (2003) Combination Therapy •Most hypertensive patients will require two or more antihypertensive medications to achieve goal BP (<140/90 mm Hg or <130/80 mm Hg in patients with diabetes/renal disease) •Initiating therapy with combination therapy should be considered when BP is >20/10 mm Hg above goal. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, And Treatment of High Blood Pressure. http://jama.ama-assn.org/cgi/content/full/289.19.2560v1. Assessed 5-1-08
    • 86. 86 •“When BP is more than 20/10 mm Hg above goal, consideration should be given to initiating therapy with two drugs, either as separate prescriptions or in fixed-dose combinations.” •“Failure to titrate or combine medications, despite knowing the patient is not at goal BP, represents clinical inertia and must be overcome.” JNC 7 (2003) Combination Therapy The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, And Treatment of High Blood Pressure. http://jama.ama-assn.org/cgi/content/full/289.19.2560v1. Assessed 5-1-08
    • 87. 87 AASK MAP <92 Target BP (mm Hg) Multiple Antihypertensive AgentsMultiple Antihypertensive Agents Are Needed to Achieve Target BPAre Needed to Achieve Target BP No. of antihypertensive agents 1 UKPDS DBP <85 ABCD DBP <75 MDRD MAP <92 HOT DBP <80 Trial 2 3 4 DBP, diastolic blood pressure; MAP, mean arterial pressure; SBP, systolic blood pressure. Bakris GL et al. Am J Kidney Dis. 2000;36:646-661. Lewis EJ et al. N Engl J Med. 2001;345:851-860. IDNT SBP <135/DBP <85
    • 88. Partners in Healthcare Education, LLC 2009 88
    • 89. Partners in Healthcare Education, LLC 2009 89 Target Organ Damage • Heart – LVH, Angina, CHF, MI • Brain – Stroke or TIA – Dementia • Chronic Kidney Disease • Peripheral Vascular Disease • Retinopathy JAMA. 2003:289:2560-2577.
    • 90. Partners in Healthcare Education, LLC 2009 90 Pick the agent wisely • Benefits are not the same in antihypertensive therapy at the same commensurate blood pressure control. American Heart Association Scientific Sessions 2003; November 9-12, 2003, Orlando, Florida, USA.
    • 91. Partners in Healthcare Education, LLC 2009 91 Additional Considerations for the Patient with Hypertension
    • 92. Partners in Healthcare Education, LLC 2009 92 New Messages JNC VII • In presenting the NEW JNC VII, the committee recognizes that the responsible practitioner’s judgment remains paramount. JAMA. 2003:289:2560-2577.
    • 93. Partners in Healthcare Education, LLC 2009 93 Summary • Hypertension is highly prevalent and is a significant risk factor for CHD • Current guidelines recognize the importance of assessing multiple cardiovascular risk factors in patients with hypertension • Health-promoting lifestyle modifications are an important part of prevention and treatment of hypertension • Antihypertensive therapy reduces CHD risk • ≥2 antihypertensive agents are usually required to achieve BP goals in patients with hypertension
    • 94. Partners in Healthcare Education, LLC 2009 94 Thank You! I Would Be Happy To Entertain Any Questions
    • 95. Partners in Healthcare Education, LLC 2009 95 Wendy L. Wright, ARNP Adult/Family Nurse Practitioner www.4healtheducation.com WendyARNP@aol.com

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