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  1. 1. HYPERTENSION<br />
  2. 2. Hypertension <br />5th leading cause of morbidity in the Philippines (2005)<br />Prevalence of 6.2% in the Filipino elderly<br />
  3. 3. The Seventh Report of the Joint National Committee onPrevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)<br />
  4. 4. <ul><li>For persons over age 50, SBP is a more important than DBP as CVD risk factor.
  5. 5. Starting at 115/75 mmHg, CVD risk doubles with each increment of 20/10 mmHg throughout the BP range.
  6. 6. Persons who are normotensive at age 55 have a 90% lifetime risk for developing HPN.
  7. 7. Those with SBP 120–139 mmHg or DBP 80–89 mmHg should be considered prehypertensive who require health-promoting lifestyle modifications to prevent CVD.</li></ul>Key Messages<br />
  8. 8. Key Messages<br /><ul><li>Thiazide-type diuretics should be initial drug therapy for most, either alone or combined with other drug classes.
  9. 9. Certain high-risk conditions are compelling indications for other drug classes.
  10. 10. Most patients will require two or more antihypertensive drugs to achieve goal BP.
  11. 11. If BP is >20/10 mmHg above goal, initiate therapy with two agents, one usually should be a thiazide-type diuretic.</li></li></ul><li>Key Messages<br /><ul><li>The most effective therapy prescribed by the careful clinician will control HPN only if patients are motivated.
  12. 12. Motivation improves when patients have positive experiences with, and trust in, the clinician.
  13. 13. Empathy builds trust and is a potent motivator.
  14. 14. The responsible physician’s judgment remains paramount.</li></li></ul><li>BP MEASUREMENT AND CLINICAL EVALUATION<br />
  15. 15. Definition of Hypertension<br />BP of 140/90 recorded on at least two separate occasions<br />
  16. 16. CVD Risk<br /><ul><li>The BP relationship to risk of CVD is continuous, consistent, and independent of other risk factors.
  17. 17. Each increment of 20/10 mmHg doubles the risk of CVD across the entire BP range starting from 115/75 mmHg.
  18. 18. Prehypertension signals the need for increased education to reduce BP in order to prevent hypertension.</li></li></ul><li>Benefits of Lowering BP<br />Average <br /> Reduction<br /> Stroke incidence 35–40% <br /> Myocardial infarction 20–25% <br /> Heart failure 50%<br />
  19. 19. BP Measurement Techniques<br />
  20. 20. Office BP Measurement<br /><ul><li>Use auscultatory method with a properly calibrated and validated instrument.
  21. 21. Patient should be seated quietly for 5 minutes in a chair (not on an exam table), feet on the floor, and arm supported at heart level.
  22. 22. Appropriate-sized cuff should be used to ensure accuracy.
  23. 23. At least two measurements should be made.
  24. 24. Clinicians should provide to patients, verbally and in writing, specific BP numbers and BP goals. </li></li></ul><li>Ambulatory BP Monitoring<br /><ul><li>Warranted for evaluation of “white-coat” HPN in the absence of target organ injury.
  25. 25. Ambulatory BP values are usually lower than clinic readings.
  26. 26. Awake individuals with hypertension have an average BP of >135/85 mmHg and during sleep >120/75 mmHg.
  27. 27. BP drops by 10 to 20% during the night; if not, signals possible increased risk for cardiovascular events.</li></li></ul><li>Self-Measurement of BP<br /><ul><li>Provides information on:</li></ul>Response to antihypertensive therapy<br />Improving adherence with therapy <br />Evaluating white-coat HPN<br /><ul><li>Home measurement of >135/85 mmHg is generally considered to be hypertensive.
  28. 28. Home measurement devices should be checked regularly.</li></li></ul><li>Patient Evaluation<br />Objectives: <br />Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guides treatment. <br />Reveal identifiable causes of high BP.<br />Assess the presence or absence of target organ damage and CVD.<br />
  29. 29. History<br />Age of onset<br />Other co-morbid conditions<br />Ingestion of medications/supplements<br />Family history <br />
  30. 30. CVD Risk Factors<br /><ul><li>Hypertension*
  31. 31. Cigarette smoking
  32. 32. Obesity* (BMI >30 kg/m2)
  33. 33. Physical inactivity
  34. 34. Dyslipidemia*
  35. 35. Diabetes mellitus*
  36. 36. Microalbuminuria or estimated GFR <60 ml/min
  37. 37. Age (older than 55 for men, 65 for women)
  38. 38. Family history of premature CVD (men under age 55 or women under age 65)</li></ul>*Components of the metabolic syndrome.<br />
  39. 39. Medications that may induce/worsen hypertension<br />Sodium-containing antacids<br />NSAIDs, Cyclooxygenase 2 inhibitors<br />Sympathomimetics (decongestants, anorectics)<br />Oral contraceptives<br />Corticosteroids<br />Cyclosporine, tacrolimus<br />Erythropoietin<br />Licorice (including some chewing tobacco)<br />
  40. 40. Physical Examination<br />Truncal obesity, moon face, acne, other features of Cushing’s syndrome<br />Sweaty palms, fine tremors, brisk DTRs, new onset AF<br />Dry skin, hair loss, bradycardia<br />Abdominal bruits<br />Palpable bilateral flank mass<br />Tachycardia, labile BP<br />
  41. 41. Target Organ Damage<br /><ul><li>Heart
  42. 42. Left ventricular hypertrophy
  43. 43. Angina or prior myocardial infarction
  44. 44. Prior coronary revascularization
  45. 45. Heart failure
  46. 46. Brain
  47. 47. Stroke or transient ischemic attack
  48. 48. Chronic kidney disease
  49. 49. Peripheral arterial disease
  50. 50. Retinopathy</li></li></ul><li>Identifiable Causes of Hypertension<br /><ul><li>Sleep apnea
  51. 51. Drug-induced or related causes
  52. 52. Chronic kidney disease
  53. 53. Primary aldosteronism
  54. 54. Renovascular disease
  55. 55. Chronic steroid therapy and Cushing’s syndrome
  56. 56. Pheochromocytoma
  57. 57. Coarctation of the aorta
  58. 58. Thyroid or parathyroid disease</li></li></ul><li>Laboratory Tests<br />Routine Tests:<br />12-L ECG<br />Urinalysis<br />Blood glucose, Hematocrit<br />Serum Potassium<br />Creatinine (estimated GFR)<br />Calcium<br />Lipid profile (HDL, LDL, Triglycerides)<br />
  59. 59. Laboratory Tests<br />Optional Tests:<br />Urinary albumin excretion<br />Albumin/Creatinine ratio<br />Work-up for other identifiable causes of Hypertension if BP control is not achieved.<br />
  60. 60. TREATMENT<br />
  61. 61. Goals of Therapy<br />Reduction of cardiovascular and renal morbidity and mortality<br />Target BP:<br />< 140/90<br />< 130/80 (diabetes, renal disease)<br />
  62. 62. Lifestyle Modification<br />
  63. 63. Lifestyle Modification<br />Maintain normal body weight (BMI = 18.5 to 24.9)<br />Diet rich in fruits, vegetables, low fat dairy products with reduced content of saturated and total fat<br />Reduce dietary sodium intake<br />Regular aerobic physical activity<br />Moderate alcohol consumption (men ≤ 2 drinks/day; women ≤ 1 drink/day)<br />
  64. 64. With Compelling Indications<br />Without Compelling Indications<br />Drug(s) for the compelling indications <br />Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. <br />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)<br />Stage 1 Hypertension(SBP 140–159 or DBP 90–99 mmHg) Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination.<br />Not at Goal Blood Pressure<br />Optimize dosages or add additional drugs until goal blood pressure is achieved.Consider consultation with hypertension specialist.<br />Algorithm for Treatment of Hypertension<br />Lifestyle Modifications<br />Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease)<br />Initial Drug Choices<br />
  65. 65. Classification and Management of BP for adults<br />*Treatment determined by highest BP category.<br />†Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.<br />‡Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg. <br />
  66. 66. Follow-up and Monitoring<br /><ul><li>Patients should return for follow-up and adjustment of medications until the BP goal is reached (monthly)
  67. 67. More frequent visits for stage 2 HPN or with complicating comorbid conditions.
  68. 68. Serum potassium and creatinine monitored 1–2 times per year.</li></li></ul><li>Follow-up and Monitoring<br /><ul><li>After BP is at goal and stable, follow-up visits at 3 to 6 month intervals.
  69. 69. Co-morbidities, such as heart failure, associated diseases such as diabetes, and the need for laboratory tests influence the frequency of visits. </li></li></ul><li>Special Considerations<br /><ul><li>Compelling Indications
  70. 70. Other Special Situations
  71. 71. Minority populations
  72. 72. Obesity and the metabolic syndrome
  73. 73. Left ventricular hypertrophy
  74. 74. Peripheral arterial disease
  75. 75. Hypertension in older persons
  76. 76. Postural hypotension
  77. 77. Dementia
  78. 78. Hypertension in women
  79. 79. Hypertension in children and adolescents
  80. 80. Hypertension urgencies and emergencies</li></li></ul><li>Compelling Indications for Individual Drug Classes<br />
  81. 81. Compelling Indications for Individual Drug Classes<br />
  82. 82. Left Ventricular Hypertrophy<br /><ul><li>LVH is an independent risk factor that increases the risk of CVD.
  83. 83. Regression of LVH occurs with aggressive BP management: weight loss, sodium restriction, and treatment with all classes of drugs except the direct vasodilators hydralazine and minoxidil.</li></li></ul><li>Peripheral Arterial Disease (PAD)<br /><ul><li>PAD is equivalent in risk to ischemic heart disease.
  84. 84. Any class of drugs can be used in most PAD patients.
  85. 85. Other risk factors should be managed aggressively.
  86. 86. Aspirin should be used. </li></li></ul><li>Hypertension in the Elderly<br /><ul><li>More than two-thirds of people over 65 have HPN.
  87. 87. This population has the lowest rates of BP control.
  88. 88. Treatment, including those who with isolated systolic HPN, should follow same principles outlined for general care of HPN.
  89. 89. Lower initial drug doses may be indicated to avoid symptoms; standard doses and multiple drugs will be needed to reach BP targets. </li></li></ul><li>Postural Hypotension<br /><ul><li>Decrease in standing SBP >10 mmHg, when associated with dizziness/fainting, more frequent in older SBP patients with diabetes, taking diuretics, venodilators, and some psychotropic drugs.
  90. 90. BP in these individuals should be monitored in the upright position.
  91. 91. Avoid volume depletion and excessively rapid dose titration of drugs.</li></li></ul><li>Dementia<br /><ul><li>Dementia and cognitive impairment occur more commonly in people with HPN.
  92. 92. Reduced progression of cognitive impairment occurs with effective antihypertensive therapy.</li></li></ul><li>Hypertension in Women<br /><ul><li>Oral contraceptives may increase BP, and BP should be checked regularly. In contrast, HRT does not raise BP.
  93. 93. Development of HPN—consider other forms of contraception.
  94. 94. Pregnant women with HPN should be followed carefully. Methyldopa, BBs, and vasodilators, preferred for the safety of the fetus. ACEI and ARBs contraindicated in pregnancy. </li></li></ul><li>Children and Adolescents<br /><ul><li>HPN defined as BP—95th percentile or greater, adjusted for age, height, and gender.
  95. 95. Use lifestyle interventions first, then drug therapy for higher levels of BP or if insufficient response to lifestyle modifications.
  96. 96. Drug choices similar in children and adults, but effective doses are often smaller.
  97. 97. Uncomplicated HPN not a reason to restrict physical activity.</li></li></ul><li>Hypertensive Urgencies and Emergencies<br /><ul><li>Patients with marked BP elevations and acute TOD (e.g., encephalopathy, myocardial infarction, unstable angina, pulmonary edema, eclampsia, stroke, head trauma, life-threatening arterial bleeding, or aortic dissection) require hospitalization and parenteral drug therapy.
  98. 98. Patients with markedly elevated BP but without acute TOD usually do not require hospitalization, but should receive immediate combination oral antihypertensive therapy.</li></li></ul><li>Additional Considerations in Antihypertensive Drug Choices<br />Potential favorable effects<br /><ul><li>Thiazide-type diuretics useful in slowing demineralization in osteoporosis.
  99. 99. BBs useful in the treatment of atrialtachyarrhythmias/fibrillation, migraine, thyrotoxicosis (short-term), essential tremor, or perioperative HTN.
  100. 100. CCBs useful in Raynaud’s syndrome and certain arrhythmias.
  101. 101. Alpha-blockers useful in prostatism.</li></li></ul><li>Additional Considerations in Antihypertensive Drug Choices<br />Potential unfavorable effects<br /><ul><li>Thiazide diuretics should be used cautiously in gout or a history of significant hyponatremia.
  102. 102. BBs should be generally avoided in patients with asthma, reactive airway disease or 2nd or 3rd degree heart block.
  103. 103. ACEIs and ARBs are contraindicated in pregnant women or those likely to become pregnant.
  104. 104. ACEIs should not be used in individuals with a history of angioedema.
  105. 105. Aldosterone antagonists and potassium-sparing diuretics can cause hyperkalemia.</li></li></ul><li>Improving Hypertension Control<br />
  106. 106. Strategies for Improving Adherence to Regimens<br /><ul><li>Clinician empathy increases patient trust, motivation, and adherence to therapy.
  107. 107. Physicians should consider their patients’ cultural beliefs and individual attitudes in formulating therapy.</li></li></ul><li>Causes of Resistant Hypertension<br /><ul><li>Improper BP measurement
  108. 108. Excess sodium intake
  109. 109. Inadequate diuretic therapy
  110. 110. Medication
  111. 111. Inadequate doses
  112. 112. Drug actions and interactions (e.g. NSAIDs, illicit drugs, sympathomimetics, oral contraceptives)
  113. 113. OTC drugs and herbal supplements
  114. 114. Excess alcohol intake
  115. 115. Identifiable causes of HPN</li></li></ul><li>