Hypertension management


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Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.

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  • Emerging Treatment Challenges in Hypertension Epidemiologic trends and the guidelines provided by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) 7 can be summarized by a new focus on attaining goal BP, attainment of goal as early as possible, consistency over 24 hours, and goal achievement across both systolic and diastolic BP.
  • Inadequate Control of Hypertension In this study, the care of 800 hypertensive men was evaluated during a 2-year period at 5 VA medical centers in New England. Their average age was 65.5 (± 9.1) years; their average duration of hypertension was 12.6 (± 5.3) years; 92% were white; 33% were taking a single antihypertensive medication; 32% were taking 2 medications; and 27% were taking 3 or more medications. In addition, many had significant comorbidities, including diabetes mellitus (34%), hyperlipidemia (26%), coronary artery disease (37%), and cerebrovascular disease (11%). At the end of the study, patients had been seen an average of  6 times per year in hypertension-related office visits, yet 40% had a blood pressure  160/90 mm Hg, and medications had been increased only 6.7% of the time. (An increase in therapy was either an increase in dose of the existing regimen or addition of new medications.) Fewer than 25% of the patients had what would be considered well-controlled BP (ie, BP <140/90 mm Hg). The presence of coronary artery disease among patients with a BP <165/90 mm Hg was associated with decisions to increase antihypertensive therapy, presumably because many antihypertensive medications serve a dual function and are also used to treat manifestations of coronary disease. Most of the visits were with staff attending physicians; only 19% were with residents. Overall, management of HTN was inadequate despite the availability of easy access to health care and the availability of medications either at no cost or low cost to the patient. The authors concluded, “Many physicians are not aggressive enough in their approach to hypertension.” 1 Reference 1. Berlowitz DR, Ash AS, Hickey EC, et al. Inadequate management of blood pressure in a hypertensive population. N Engl J Med . 1998;339:1957-1963. Slide 4
  • CVF-300044 Healthcare providers often do not initiate or intensify antihypertensive therapy appropriately—despite a better understanding of the prevalence of hypertension, evidence for increased cardiovascular morbidity and mortality associated with uncontrolled hypertension, clear treatment guidelines for diagnosing and reducing high blood pressure, and widespread availability of safe and effective antihypertensive medications. Therapeutic inertia is separate from the patient-related issue of adherence and access to care; it is primarily a problem of the healthcare professional and the healthcare system. Overestimating adherence to guidelines; a perception that control is improving, or it is not improving due to patient non-adherence to non-therapeutic components of the treatment plan (ie, lifestyle changes); concerns about potential drug interactions and side effects despite clinical trial data; lack of education, training, and practice organization on the benefits of treating to therapeutic targets, the practical complexity and need for polypharmacy in treating to target, and the need to structure routine practice to facilitate identification of therapeutic problems are all factors that contribute to therapeutic inertia. Reference: Phillips LS, Branch WT, Cook CB, et al. Clinical inertia. Ann Intern Med. 2001;135:825-834.
  • Clinical Support for Early Onset of BP Effect Results of the recent landmark clinical study, the Valsartan Antihypertensive Long-Term Use Evaluation (VALUE) trial, have indicated that achievement of BP goal early in therapy—in weeks—positively impacts the long-term health of patients. The VALUE trial compared the effects of the calcium channel blocker Norvasc (amlodipine; AMLO) with the angiotensin II receptor blocker (ARB) Diovan (valsartan; VAL) in 15,245 hypertensive patients at risk for cardiovascular complications. The study sought to prove that, at equivalent levels of BP control, a VAL-based regimen would offer superior cardioprotection to an AMLO-based regimen in patients with hypertension. Methods: Patients were randomized to treatment with either VAL 80 mg/d or AMLO 5 mg/d, with a BP goal of <140/90 mm Hg.  If needed, patients were titrated up to VAL 160 mg/d or AMLO 10 mg/d.   If patients still did not meet goal, hydrochlorothiazide (HCTZ) was added, first at 12.5 mg/d, then at 25 mg/d to both patient groups. Endpoints: The primary endpoint of the study was time to first cardiac event (cardiac mortality or morbidity).  Secondary end points included fatal and nonfatal myocardial infarction (MI), fatal and nonfatal stroke, all-cause mortality, and new-onset diabetes. Conclusions: The hypothesis was not proven; no statistically significant difference in cardioprotection was shown between VAL and AMLO.   However, AMLO-based therapy was proven to be significantly more effective in reducing BP, especially during the early phase of treatment at the time of first measurement (Month 1).  The difference was initially 4.0/2.1 mm Hg at 1 month.  The AMLO-based regimen got more patients to the BP goal of <140/90 mm Hg (62%) than the VAL-based regimen (56%). 
  • Thus, the Syst-Eur extension demonstrated that it was not simply the final blood pressure that determined clinical outcome, but the speed with which this control was obtained . The investigators determined that the significant reductions in relative risk achieved at the end of the Syst-Eur extension were entirely due to the early benefit in the patients who received prompt active treatment (treated immediately, compared with those who received active treatment only after the initial trial was unblinded, a median follow-up of 2.0 years). 1 The investigators interpreted these results as supporting the necessity of starting therapy soon after diagnosis of hypertension. More to the point, these results underscore the importance of lowering blood pressure early on . 1. Staessen JA, Thijisq L, Fagard R, et al. Effects of immediate versus delayed antihypertensive therapy on outcome in the Systolic Hypertension in Europe Trial. J Hypertens. 2004;22:847–857.
  • The Treatment of Hypertension in Today's Managed Care Environment
  • AZOR: A CCB/ARB Fixed Combination for the Treatment of Hypertension DSCS07000125 To further support this conclusion, this slide shows the major studies in hypertension that demonstrated that combination therapy improves blood pressure control. The trend line indicates a greater decrease in diastolic blood pressure is demonstrated as the number of antihypertensive agents increases. These studies show that approximately 2-4 antihypertensive agents may be needed to see DBP reductions in the 20-30 mm Hg range. 1. Elliott WJ. Combination drug treatment of hypertension: Have we come full circle? Curr Hypertens Rep. 2002;4:278–285 .
  • Hypertension management

    1. 1. Paradigm Shifts inHypertension Management Dr. Sachin Verma MD, FICM, FCCS, ICFC Fellowship in Intensive Care Medicine Infection Control Fellows Course Consultant Internal Medicine and Critical Care Web:- http://www.medicinedoctorinchandigarh.com Mob:- +91-7508677495
    2. 2. Paradigm Shifts in Hypertension Management1. Hypertension is an important global problem; Controlling it is challenging; All have room for improvement2. Focus on BP goal attainment– sooner rather than later3. Resort to combination therapy readily4. Prevent or reduce target organ damage V052004
    3. 3. Global Burden of Hypertension 2025 Projection Year 2000 Year 2025 • 26.4% of world adult • 29.2% of world adult population population had hypertension will have hypertension • Total of 972 million adults • Total of 1.56 billion adults (60% ↑ overall; 24% ↑ in developed nations, 80% ↑ in developing nations) • Highest prevalence will be in • Highest prevalence is in economically developing established market continents (eg, Asia, Africa) economies (eg, North – will account for 75% of world’s America, Europe) hypertensive patientsKearney PM et al. Lancet. 2005;365:217-223.
    4. 4. Long-Term Antihypertensive Therapy Significantly Reduces CV Events Myocardial Stroke infarction Heart failure 0 –10 –20 Average reduction –30 20%-25% in events (%) –40 35%-40% –50 >50% –60Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet. 2000;355:1955-1964.
    5. 5. Consensus Target BP Levels Since JNC 7 in the Prevention and Management of Ischemic Heart Disease American Heart Association (AHA) Scientific Statement Area of Concern BP Target (mmHg) General CAD prevention <140/90 High CAD risk* <130/80 Stable Angina <130/80 Unstable Angina/NSTEMI <130/80 STEMI <130/80 LV Dysfunction <120/80 *High CAD risk = diabetes mellitus, chronic kidney disease, known CAD, CAD equivalent (carotid artery disease, peripheral artery disease, abdominal aortic aneurysm), or 10-year Framingham risk score >10%Rosendorff et al, Circulation,2007;115: 2761-2788
    6. 6. Inadequate Control of Hypertension • New England VA Study – 800 men; mean age, 66 years, many with comorbid conditions – Mean duration of HTN = 12.6 years – Index visit BP: 146/84 mmHg – Mean of 6.4 hypertension-related visits per year • Followed for two 2 years < 25% reached goal BP < 140/< 90 mm Hg – 40% had BP ≥ 160/≥ 90 mm Hg • Percentage of visits where therapy was increased: – 11.2% overall – 22%, if DBP ≤ 90 mm Hg and SBP ≥ 165 mm Hg – 35% of time when DBP > 90 mmHgBerlowitz et al. N Engl J Med. 1998;339:1957-1963. V052004
    7. 7. Inadequate Control of Hypertension Clinical Inertia • In 75% of visits documenting elevated blood pressure, physicians failed to increase the dose of antihypertensive medications or to try new treatments. • But clinicians did not ignore patients with elevated blood pressure. Follow-up visits occurred 2-3 weeks sooner for patients with poorly controlled hypertension. • Thus, although physicians closely monitored elevated blood pressure, they repeatedly delayed making changes to a patient’s regimen.Berlowitz et al. N Engl J Med. 1998;339:1957-1963. V052004
    8. 8. Therapeutic (Clinical) Inertia? Causes:  Satisfaction with current BP level The failure of  Elevated SBP more acceptable health care  Use of “soft” reasons to avoid providers to intensifying therapy initiate or  Time constraints (15 min visits) intensify  Reluctance to use combination therapies therapy when  Competing priorities indicatedPhillips LS et al. Ann Intern Med. 2001;135:825–834.
    9. 9. Value: Early Onset of BP Effect“The trial gives new insights into the clinicalimportance of the rate of achieving BPcontrol:BP goals need to be reached within arelatively short time (weeks rather thanmonths), at least in patients with hypertensionwho are at high cardiovascular risk.”-VALUE Trial, 2004 Julius S, et al. Lancet. 2004;363(9426):2022-2031.
    10. 10. BP Goal Attainment: JNC VII Expert Roundtable Conclusions“In addition to prescribing the right agent from the start, based on the individual needs of the patient, physicians need to be more aggressive in bringing their patients to goal” -Michael A. Weber, MD; Founder & Past President of The American Society of Hypertension“We want them to attain BP goals while making sure they are adhering to the therapy. The problem is that physicians stopevaluating the patient’s progress toward the targeted BP level” -Jan N. Basile, MD; Review Committee, JNC 7 Adapted from Weber et al., J Clin Hypertens 2004;6:699–705). V112004
    11. 11. The Practical Reality of Combination Therapy Adding another drug provides greater blood pressure reduction than can be achieved by titrating the current drug to a higher dose V052004
    12. 12. Olmesartan Medoxomil/HCTZ Reduction in SeSBP 26.8 27.1 20.6 30 23.0 20.1 16.0 25 15.5 17.4 20 Reduction 17.1 in SeSBP 15 10.7 (mmHg) 10 9.6 40 20 5 3.3 10 Olmesartan 0 0 medoxomil dose 25 12.5 0 (mg/day) HCTZ dose (mg/day)HCTZ = hydrochlorothiazide; SeSBP = seated systolic blood pressureChrysant SG et al. Am J Hypertens 2004; 17(3):252-9.
    13. 13. Need for Combination Therapy 0 Progress HOPE Syst-China -5 PROGRESS-Combo Change in DBP (mm Hg) STOP II-β Syst-EUR RENAAL SHEP -10 IDNT TOMHS EWPHE UKPDS -15 STOP-β INSIGHT ABCD VA II NORDIL -20 HOT <90 HOT <85 -25 HOT <80 VA I -30 0 0.5 1 1.5 2 2.5 3 3.5 4 Number of Antihypertensive AgentsElliott WJ. Curr Hypertens Rep. 2002;4:278–285.
    14. 14. Lifestyle Modifications
    15. 15. Dietary modifications and exerciseLow calorie diets have modest effect on BP inoverweight individuals (avg. 5-6 mm Hg).Aerobic exercise (brisk walking, jogging, or cycling)for 30-60 min., 3-5 times/week, had small effect onBP (2-3 mm Hg). Relaxation therapiesThese activities (stress management, meditation,cognitive therapy, muscle relaxation) reduce byaverage of 3-4 mm Hg.
    16. 16. Limit alcohol consumption Excessive alcohol consumption is associated with raised blood pressure, poorer CV and hepatic health. Reducing alcohol can lower BP 3-4 mm Hg.Limiting excessive consumption ofcoffee/caffeineLimit dietary sodium intake < 6 g/day, modest reduction of 2-3 mm Hg.Encourage smoking cessation
    17. 17. Initiating Treatment
    18. 18. Offer antihypertensive drug treatment to peopleaged under 80 years with Stage 1 hypertensionwho have one or more of the following: Target organ damage Established cardiovascular disease Renal disease Diabetes 10-year CV risk equivalent to 20% or greater.Offer antihypertensive drug treatment to peopleof any age with stage 2 hypertension.
    19. 19. For people aged under 40 years withstage 1 hypertension and no evidence oftarget organ damage, CV disease, renaldisease or diabetesConsider specialist evaluation ofsecondary causes ofhypertension and more detailedassessment of potential targetorgan damage.
    20. 20. The ABCDE algorithm Young subjects (<55 yr) Older subjects (>55 yr) A or B (if associatedStep I A and/or C sympathetic hyperactivity)Step 2 Add C or D or both Add D A and C, and/or D, add BStep 3 A or B, C and/or D, add E or E
    21. 21. What is New in Indian Guidelines on Hypertension - 2013
    22. 22. Due to health related toxic effectsof mercury, mercurysphygmomanometersare being replaced by aneroid anddigital sphygmomanometers.
    23. 23. Use of beta-blockers as first lineagents in hypertension has recededand these are now recommended asagents for use only in younghypertensives with specific indications. For routine patients these are nolonger recommended as first lineagents
    24. 24. Diuretics are now considered at parwith of ACEI’s or ARB’s and calciumchannel blockers and not as preferredagents as in previous guidelines.Chlorthalidone is now available andshown to be better thanHydrochlorothiazide and its usage is tobe preferred.
    25. 25. When blood pressure is high bymore than 20/10 mm of Hg systolicand diastolic it is nowrecommended to start with acombination of drugs.Monotherapy is not going to beeffective in achieving target bloodpressure.
    26. 26. Certain combinations havebeen shown to be betterthan others in recent trials. Specially ACEI’s/ARB’s incombination with CCB’sforms a good combination.
    27. 27. J shaped curve exist specially fornon revascularised coronary arterydisease patients and caution hasbeen advocated in trying to lowerblood pressure to low target levelsspecially in these patients.
    28. 28. A new form of non pharmacological,interventional sympatheticdenervation therapy has becomerecently available and is beingevaluated.
    29. 29. JNC-8:What Might Be Expected
    30. 30. Either a thiazide-type diuretic, CCB,ACEI/ARB will be recommended as initialdrug therapy for most patients.Direct renin inhibitors will be recommendedas an additive• Chlorthalidone or indapamide should behighlighted as the evidence-based thiazidetype diuretic of choice
    31. 31. Summary
    32. 32. It makes less difference which antihypertensiveagent is used, unless the patient has a compellingindication for a specific antihypertensive classIt matters more that BP isappropriately reduced tothe chosen BP goal.
    33. 33. The current recommended BP goals inthose with Diabetes and CKD from theADA, NKF, and JNC 7 is <130/80 mm Hg.
    34. 34. The initial drug chosen will bebroadened to include Thiazide-diuretic,ACEI/ARB, or CCB and mayinclude non-atenolol BB’s.
    35. 35. Most patients will require 2 or moreantihypertensive agents to get BPeffectively controlled which may bebest approached with initial combinationtherapy, either as a fixed-dosecombination (FDC) or as 2 individualinitial agents