hypertension

1. Treatment of Hypertension
Based on the Seventh Report of the
Joint National Committee on
Prevention, Detection ,Evaluation and Treatment
of High Blood Pressure (JNC-7)
Jai Radhakrishnan, M.D.
Division of Nephrology

2. Objectives
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 Define hypertension
Principles of treatment
Special groups

3. Slide Source
HypertensionOnline
www.hypertensiononline.org
20
40
60
80
Prevalence of Hypertension in the US
Percent
hypertensive
Based on NHANES III (phase 1 and 2)
Hypertension defined as blood pressure 140/90 mmHg or treatment
0
18-29 30-39 40-49 60-69 70-79 80+
50-59
Age
3 %
9 %
18 %
51 %
38 %
66 %
72 %
JNC-VI. Arch Intern Med. 1997;157:2413-2446. www.hypertensiononline.org

4. Blood Pressure Classification
BP
CLASSIFICATION
SBP DBP
Normal <120 and <80
Prehypertension 120-139 or 80-89
Stage 1 HTN 140-159 or 90-99
Stage 2 HTN >160 >100

5. Why Treat Hypertension ?
 To decrease:
35-40%
20-25%
50%
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 Cerebrovascular Accidents
Coronary events
Heart failure
Progression of renal disease
Progression to severe hypertension
All cause mortality

6. Awareness, Treatment and Control of
Blood Pressure 1976-2000 (NHANES)
80
70
60
50
40
30
20
10
0
1976-1980 1988-1991 1991-1994 1999-2000
Awareness
Treatment
Control

7. Factors to Consider in Treating
Hypertension
 Repeat readings
r/o secondary causes
Estimate CV risk status
Co-morbid conditions
Lifestyle changes
Drugs
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8. “Secondary” Hypertension
 Difficult to control
Sudden onset of HTN
Well controlled-> difficult to
control
Severe hypertension
History/physical/labs
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

9. Initial Workup of
Secondary HTN
 Renal parenchymal disease
 UA, spot urine protein/creatinine, serum creatinine, USG.
 Renovascular
 Captopril scan
 Coarctation
 Lower Extremity BP
 Primary aldosteronism
 Serum and urinary K
Plasma renin and aldosterone ratio

 Pheochromocytoma
 Spot urine for metanephrine/creatinine

10. Laboratory Tests in
Uncomplicated HTN
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 ECG
Urine analysis
Blood glucose, hematocrit
Basic metabolic panel
Lipid profile after 9-12 hour fast
Urine microalbumin

11. Estimate Risk Status
 Hypertension
Smoking
Obesity (BMI > 30kg/m2)
Dyslipidemia
Diabetes
Microalbuminuria or GFR <60ml/min
Age > 55 (men), 65 (women)
Family history of CVD
(Men< 55, Women <65)
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Metabolic Syndrome

12. Target Organ Damage
 Heart Disease

CAD (Angina, myocardial infarction, coronary
revascularization
Left Ventricular Hypertrophy
Heart Failure

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 Stroke/TIA
Chronic kidney disease
Peripheral arterial disease
Retinopathy
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


13. Goals of Therapy
BP<140/90mmHg
BP<130/80mmHginpatients
withdiabetesor chronickidneydisease.
AchieveSBPgoal especiallyinpersons
>50yearsof age.

14. Lifestyle Modification
Modification Approximate SBP reduction
(range)
5–20 mmHg/10 kg weight loss
Weight reduction
8–14 mmHg
Adopt DASH eating plan
2–8 mmHg
Dietary sodium reduction
4–9 mmHg
Physical activity
2–4 mmHg
Moderation of alcohol
consumption

15. Drugs for Hypertension
 Diuretics
 Thiazide
Loop diuretics
Aldosterone antagonists
K-sparing
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 Adrenergic inhibitors
 Peripheral agents
Central (α-agonists)
alpha -blockers*
beta-blockers
Alpha+beta-blockers
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 Direct Vasodilators *
Calcium channel
blockers
Dihydropyridine
Non dihydropyridine
ACE-inhibitors
Angiotensin-II blockers
*Usually not monotherapy

17. Algorithm for Treatment of Hypertension
Not at Goal Blood Pressure (<140/90 mmHg)
(<130/80 mmHg for those with diabetes or chronic kidney disease)
Initial Drug Choices
Drug(s) for the compelling
indications
Other antihypertensive drugs
(diuretics, ACEI, ARB, BB, CCB)
as needed.
With Compelling
Indications
Lifestyle Modifications
Stage 2 Hypertension
(SBP >160 or DBP >100 mmHg)
2-drug combination for most
(usually thiazide-type diuretic and
ACEI, or ARB, or BB, or CCB)
Stage 1 Hypertension
(SBP 140–159 or DBP 90–99
mmHg)
Thiazide-type diuretics for most.
May consider ACEI, ARB, BB, CCB,
or combination.
Without Compelling
Indications
Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved.
Consider consultation with hypertension
specialist.

18. Classification and Management
of BP for adults
BP Class SBP DBP Lifestyle
Initial drug therapy
Without compelling
indication
Compelling
indications
Normal <120 <80 Encourage None None
Pre-
hypertension
120–
139
or 80–
89
Yes No antihypertensive drug
indicated.
Drug(s)
Stage 1
Hypertension
140–
159
or 90–
99
Yes Thiazide-type diuretics
for most. May consider
ACEI, ARB, BB, CCB, or
combination.
Other
antihypertensive
drugs (diuretics,
ACEI, ARB, BB,
CCB) as needed.
Stage 2
Hypertension
>160 or
>100
Yes Two-drug combination
(usually thiazide and
ACEI or ARB or BB or
CCB).

19. Heterogeneity of “Essential”
Hypertension
20%
0%
40%
60%
100%
80%
Patient 1 Patient 2 Patient 3
Sodium
Sympathetic N.S.
Renin-Angiotensin

20. Special Considerations
Compelling Indications
Special populations

21. HTN with COPD and MI
A 55 year old patient with COPD and HTN (controlled
with nifedipine) is admitted with severe chest pain
x24 hrs.
BP is 170/100 and she has a soft S3 gallop.
ECG shows an anterior wall MI.
She is not a candidate for thrombolysis. ECHO shows an
ejection fraction of 35%.
How will you manage her hypertension?

22. Compelling Indications for
Certain Drug Classes

23. HTN with CAD

 Beta blockers: cardioprotective
(reinfarction, arrhythmias and sudden
death)
ACE inhibitors: MI with systolic
dysfunction- heart failure and mortality
improved

24. Renal Insufficiency
 A 30 year old patient with IDDM is referred
with difficult-to-control HTN on diltiazem and
clonidine.
 Exam reveals BP=190/100 and 3+ edema.
 Labs: Creatinine = 2.2 mg/dL
Serum K = 5.1 meq/L
24 hour protein = 5 g

25. Hypertension with Renal Insufficiency
 Goal BP <130/80
ACE-inhibitors/angiotensin receptor blockers
should be used if no contraindications
Most patients have volume overload:
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 Diuretics should be included in the regimen.
Thiazides ineffective if S Creat>2.5

26. A 40 year old previously healthy male is brought to the E.R. with 3
days of progressive shortness of breath and has experienced
blurred vision in both eyes.
Physical exam:
Blood pressure 230/140. Lethargic.
Eye exam: Papilledema
Chest: Bibasilar crackles
Cardiac: S1S2S4
Neuro: Bilateral upgoing plantars:
Extr: 2+ edema
Labs: K=3.4, BUN=35, Creatinine: 2.2
CXR: Pulmonary edema
Urine: 10-15 red cells, 2+ albumin.

27. Hypertensive Urgencies and
Emergencies
 HYPERTENSIVE EMERGENCIES
 Require immediate blood pressure reduction (not necessarily
to normal range) to prevent or limit target organ damage.
 HYPERTENSIVE URGENCIES
 Require reduction of blood pressure within a few hours

28. Emergencies
& Urgencies
 HYPERTENSIVE
EMERGENCIES
 Require immediate
blood pressure
reduction (not
necessarily to normal
range) to prevent or
limit target organ
damage.
 HYPERTENSIVE
URGENCIES
 Require reduction of
blood pressure within a
few hours

29. Parenteral Drugs For Treatment of
Hypertensive Emergencies
VASODILATORS
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 Nitroprusside
Fenoldopam
Nitroglycerine
Enalaprilat
Nicardipine
Hydralazine
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ADRENERGIC
INHIBITORS
 Labetalol
Esmolol
Phentolamine

30. Pregnancy and Hypertension
A 24 year old primiparous woman is seen in the
obstetric clinic at 30 weeks gestation.
BP: 160/100, 2 + pedal edema
Otherwise unremarkable physical exam.
Urine shows 1000 mg of protein. Other labs: N
After 2 days of bed rest BP remains 160-170/100

31. Drug Therapy of the Hypertensive
Pregnant Patient
 Methyldopa: Drug of choice.
Beta blockers (not early pregnancy).
Hydralazine is the parenteral drug of
choice.
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 Most agents if used prior to pregnancy
may be continued
 (except ACE-I OR A-II BLOCKERS)

32. Resistant Hypertension
 Improper BPmeasurement
 Excesssodiumintake
 Inadequatediuretictherapy
 Medication
• Inadequatedoses
•Drugactions andinteractions (e.g., nonsteroidal anti-inflammatory
drugs(NSAIDs),illicit drugs,sympathomimetics,oralcontraceptives)
• Over-the-counter (OTC)drugsandherbalsupplements
 Excessalcohol intake
 Identifiablecausesof HTN

33. Conclusions
 Theinitial approachtohypertension shouldstartwithruling outsecondary
causes,detecting andtreatingother cardiovascular risk factors,and
lookingfor target organdamage.
 Treatmentshouldalways include lifestyle changes.
 MedicationuseshouldbeguidedbytheseverityofHTNandthe
presenceof “compelling” indications.
 Thiazide-type diureticsshouldbeinitial drugtherapy for most,either
aloneor combinedwithother drugclasses.
 Mostpatientswill requiretwoor moreantihypertensive drugs

34. Conclusions
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 HTN is a risk factor for mortality and
cardiovascular and renal disease
HTN is common but not controlled.
Target BP 140/90 (130/80 in DM, CKD)
Remember Compelling Indications

35. www.nhlbi.nih.gov/