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Systemic Hypertension Craig A Chasen MD FACC
 

Systemic Hypertension Craig A Chasen MD FACC

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    Systemic Hypertension Craig A Chasen MD FACC Systemic Hypertension Craig A Chasen MD FACC Presentation Transcript

    • Systemic Hypertension Craig A Chasen MD FACC Associate Professor of Medicine
    • Overview of Hypertension
      • JNC VI on Prevention, Detection, Evaluation, and Rx of High Blood Pressure (1997)
        • 50 million hypertensive patients in the U.S.
      • National Health and Nutrition Examination Survey III (NHANES III) (1995)
        • only 21% are controlled to <140/90 mm Hg
        • 35% are unaware of their condition
      • High-normal BP is associated with an increased risk of cardiovascular disease
        • N Eng J Med 2001; 345: 1291-7
    • Joint National Committee VI
      • Category Systolic BP Diastolic BP
      • Optimal < 120 < 80
      • High normal 130 – 139 85 - 89
      • Mild HTN 140 – 159 90 - 99
      • Mod HTN 160 – 179 100 - 109
      • Severe HTN > 180 > 110
    • MacMahon et al 1990
      • Diastolic BP increased by 5 mm Hg
        • 34% increase in stroke risk
        • 21% increase in coronary risk
    • Hypertension Adverse Effects: Framingham Study
      • Triples risk of stroke
      • Triples risk of CHF
      • Doubles risk of SCD
      • Doubles risk of MI
    • Increases Risk of CV Event
      • Gender
      • Race
      • Age
      • Pulse pressure
    • Types of Variation in BP
      • Short-term: HR and RR, autonomic NS
      • Daytime: degree of activity
      • Diurnal: BP fall during sleep
      • Seasonal: cold weather increases BP
    • Obtaining BP Measurements
      • Sitting > 5 minutes
      • Appropriate cuff size
      • Cuff level with heart
      • Legs uncrossed
      • Self vs. RN vs. MD*
      * Mancia et al., Hypertension 1987;9:209
    • False BP Elevations
      • Examinee: pain, alcohol, caffeine
      • Equipment: leaky bulb valve, noise
      • Examiner: expectation bias, hearing
      • Examination: cuff uncentered, narrow or
      • low; elbow too low
    • Australian Therapeutic Trial Overall, 80% of the patients with mild-mod. HBP placed on placebo maintained a diastolic BP < 100 mm Hg and, during the average 3-yr follow-up, had no excess CV events. Only 12.2% of the placebo treated patients noted a rise in diastolic BP > 110 mm Hg. Management Committee.Lancet 1980;1:1261
    • Cardiovascular Consequences of Hypertension
      • Increased cardiac afterload leads to LVH
      • Increased LV mass is associated with elevated CV morbidity and mortality independent of other risk factors
      • Pts with BP > 160/95 have CAD, PVD & CVA > 3x than in normotensives
    • BP, Stroke & CHD In nine prospective observational studies and 420,000 patients with DBP ranging from 70 – 110 mm Hg who were followed for 6 – 25 years, the associations (with the above CV events) were “positive, continuous and apparently independent”. MacMahon et al. Lancet 1990;335:765 Kaplan’s Clinical Hypertension 2002
    • Hypertension Treatment and CV Outcomes over 5 Yrs.
      • Reduce BP by 15/6 mm Hg
      • Reduce stroke by 34%
      • Reduce CHD by 19%
    • Patient Evaluation
      • Determine type of hypertension
      • Identify target organ damage
      • Assess risk for early CV event
    • Patient History: I
      • Duration and prior Rx
      • Pharmaceutical profile
      • Family history
      • Symptoms of secondary causes
      • Target organ damage
      • Presence of other risk factors
    • Patient History: II
      • Concomitant Diseases
      • Dietary History
      • Sexual Function
      • Features of Sleep Apnea
      • Ability to modify life-style
    • HBP and Cardiac Risk Factors Kaplan NM. Dis Mon 1992; 38:769-838 50+ Sedentary lifestyle 15 Diabetes 40 Obesity 25 HDL-C < 40 mg/dl 40 LDL-C > 140 mg/dl 35 Smoking Percent Cardiac Risk Factor
    • Physical Examination: I
      • Accurate measure of BP, BMI
      • Fundoscopy
      • Carotid and thyroid abnormalities
      • Heart sounds, rhythm, size
      • Rales, rhonchi on lung exam
    • Physical Examination: II
      • Renal masses, waist circumference
      • Aorta bruits, femoral pulses
      • Peripheral pulses and edema
      • Neurologic assessment, i.e. congnitive
    • Routine Laboratory
      • Hematocrit
      • BMP
      • Urinalysis
      • Lipid profile
      • ECG
    • JNC VI: BP & Rx
    • Lifestyle Changes for HTN :
      • Reduce excess body weight
      • Reduce dietary sodium to < 2.4 gms/day
      • Adequate dietary intake of K, Ca and Mg
      • Limit daily alcohol consumption
      • Moderate aerobic exercise each day
      • Cessation of cigarette smoking
      • Garlic, fish oils, co-enzyme Q ???
    • NIH Consensus Conference on Physical Activity and CV Health (1995)
      • Review of 47 studies of exercise and HTN
      • 70% of exercise groups decreased SBP by an avg. of 10.5 mm Hg from 154
      • 78% of subjects decreased DBP by an avg. of 8.6 mm Hg from 98
      • Beneficial responses are 80 times more frequent than negative responses
      Hagberg, J., et.al., NIH, 1995: 69-71
    • Medical Therapy and Implications for Exercise Training
      • Pharmacologic and nonpharmocologic treatment can reduce morbidity
      • Some antihypertensive agents have side-effects and some worsen other risk factors
      • Exercise and diet improve multiple risk factors with virtually no side-effects
      • Exercise may reduce or eliminate the need for antihypertensive medications
    • Oral Contraceptives and HBP
      • BP rises a little in most women on OCs
      • RR=1.5 for current users vs. never users
        • 41 cases per 10,000 person-years of OC use
      • RR=1.1 for current users vs. previous users
      • ERT is associated with lower BPs
    • Drug Therapy of Hypertension: CV Events Reduction
      • Diuretics
      • BBs
      • ACEIs
      • CCBs
      Randomized controlled trials
    • Slow Breathing
      • Guided slow breathing to < 10 /min
      • 15 minutes, 3-4 times per week
      • Sustained reductions in SBP & DBP
      • FDA approved July 2002
      • J Hum Hypertension 2001;15:263
      • Am J Hypertension 2001;14:74
    • Malignant Hypertension: Treatment I
      • Loop diuretic
      • Nitroprusside*
      • Fenoldopam
      • Labetolol
      • Enalaprilat
    • Malignant Hypertension: Treatment II
      • Esmolol*
      • Hydralazine
      • Nitroglycerin
      • CCBs
      • Phentolamine
    • Hypertension and Pregnancy
      • 5% enter pregnancy with chronic HTN
      • BP > 140/90 @ < 20 wks IUP, > 6 wks PP
      • Drug of choice: alpha-methyldopa
      • 10% develop gestational HTN > 20 wks
      • PE = HTN + proteinuria (300 mg/24 hrs)
      • Eclampsia = PE + seizures
    • Rx of acute, severe HBP in Pre-eclampsia
      • Hydralazine
      • Labetolol
      • Nifedipine
      • Nitroprusside
    • Renovascular Hypertension: Incidence
      • Unselected hypertensives 1%
      • Resistant to 2 drug therapy 10%
      • Severe, rapidly progressive HBP 15%
      • Accelerated-malignant HBP 32%* 4%*
    • Renovascular Hypertension: Clinical Clues & Testing
      • Low suspicion No testing
          • No clinical clues
      • Moderate suspicion Non-invasive
          • Severe HBP (DBP > 120)
          • Abdominal or flank bruit
      • High suspicion Angiography
          • Severe HBP + elevated Cr
          • Malignant HBP
      Mann/Pickering. Ann Int Med 1992;117:845
    • Renovascular Hypertension: Diagnostic Tests
      • Captopril-enhanced renal scan
      • Doppler ultrasonography
      • Gadolinium MRA
      • Spiral CT
      • Angiography
    • EB Pedersen’s Guidelines
      • Moderate or high index of suspicion
      • No to mod. renal failure [Cr < 2.3]
          • Doppler vs. (ACEI) Renography, if ++ then
          • Spiral CT vs. MRA, if ++ then, angiography
      • Severe renal impairment
          • No doppler, no renography
          • MRA preferred, o/w spiral CT or angiography
    • Renovascular Hypertension: Medical Treatment
      • Aggressive BP control
      • Lipid reduction therapy
      • Antiplatelet therapy
    • Renovascular Hypertension: Treatment
      • Renal Artery Revascularization
        • Intolerant of medical Rx
        • Unresponsive to medical Rx
        • Progressive renal impairment
    • Renovascular Hypertension: Treatment In patients with a high likelihood of success and low risk of complications, such as the majority of patients with fibromuscular hyperplasia and uncomplicated atherosclerotic RVHT, it is usually reasonable to proceed directly to revascularization. Block/Pickering. Semin Nephrol 2000;20:474
    • Pheochromocytoma
      • HBP, palpitation, sweating, HA
      • Plasma / spot urine: metanephrines
      • CT scan with adrenal cuts/ MRI
      • If adrenal cuts nl : 131 I–MIBG scan
      • Phentolamine / Phenoxybenzamine
    • Primary Aldosteronism
      • HBP, weakness, alkalosis, hypokalemia
      • Upright PAC/PRA ratio, if > 25, then
      • Saline 500 cc/hr X 4 or NACl 10g/day X 3
      • Adrenal CT + P: 18-OH corticosterone
      • Suppression scintiscan: NP-59 + dexameth
      • Surgical therapy vs. spironolactone
    • Primary Aldosterone Excess
      • Aldosterone producing adenoma
      • Bilateral adrenal hyperplasia
      • Glucocorticoid-remediable
        • chimeric11B-hydroxylase – aldosterone synthase gene
        • Glucocorticoids suppress ACTH
      • Adrenal carcinoma
      • Extra-adrenal tumors
    • Corticosteroid induced HBP
      • Obesity, purple striae, osteopenia, DM
      • Must r/o depression, alcoholism
      • 1 mg dexamethasone (dexa) overnight plasma suppression test
      • Low dose dexa suppression test (urinary); 24-hr urinary free cortisol; plus sleeping midnight plasma cortisol test
    • Localization of Cortisol Excess
      • Localization Pituitary Adrenal Ectopic CTH
      • Corticotropin normal/high Low High
      • CRH Response No response No response
      • Dexa 8 mg Suppression No supp. No suppression
      • Adrenal CT Nl/enlarged Tumor Nl/enlarged
      • Pituitary CT Tumor Normal Normal
      • Inferior petrosal Central/periph No central/peri sinus sampling gradient gradient
    • Secondary Hypertension
      • Hormonal: thyroid, hyperpara, acromegaly
      • Neurologic: brain tumors, quadriplegia
      • Acute physical stress: burns, resp distress
      • Increased volume: EryP Rx, SIADH, PRV
      • Chemical agents: cyclosporine, tacrolimus
      • Sleep apnea
    • Reasons for Decline in CHD deaths from 1980-1990
      • 43% from improved Rxs (i.e. CABG)
      • 29% from secondary prevention (i.e. BP)
      • 25% from primary prevention (i.e. BP)
      Hunink et al JAMA1997;277:535
    • Exaggerated BP Response to Exercise
      • Among normotensive men who had an exercise test between 1971-1982, those who developed HTN in 1986 were 2.4 times more likely to have had an exaggerated BP response to exercise
    • Exaggerated BP Response to Exercise
      • Exaggerated BP was change from rest in SBP >60 mm Hg at 6 METs; SBP > 70 mm Hg at 8 METs; DBP > 10 mm Hg at any workload.
      • CARDIA study: subjects with exaggerated exercise BP were 1.7 times more likely to develop HTN 5 years later
      J Clin Epidemiol 51 (1): 1998
    • Sleep, BP and CV Events
      • Inverted Dippers
      • Non-dippers
      • Excessive Dippers
      • Dippers
    •  
    •  
    •  
    •  
    • Treatment of Orthostatic Hypotension
      • Avoid overtreatment of BP
      • Slow rising from chair/bed
      • Supportive panty hose
      • Avoid dehydration
      • Volume expanders
      • Sympathomimetics
    • NHANES III, phase 2 Hypertension
      • Awareness 68.4%
      • Treated 53.6%
      • Controlled 27.4%
    • Acute BP Response to Exercise