2 nd most common reason for visit All family physicians should be experts at HTN.
Hypertension is an important contributing risk factor for morbidity and mortality from both cardiovascular (CV) and renal disease. Hypertension is one of the most significant contributing factors to the development of CV and renal disease. Complications of hypertension include coronary artery disease, congestive heart failure, stroke, renal disease (including end-stage renal disease), and peripheral vascular disease. These diseases account for significant disability, loss of productivity, and decreased quality of life for many Americans. National High Blood Pressure Education Program Working Group. National High Blood Pressure Education Program Working Group report on primary prevention of hypertension. Arch Intern Med. 1993;153:186-208.
Hypertension Current Practice
Prevalence of Cardiovascular Disease 10 20 30 40 50 60 High BP CAD CHF Stroke Other 50,000,000 12,200,000 4,600,000 4,400,000 2,800,000 Prevalence (millions) BP=blood pressure, CAD=coronary artery disease, CHF=congestive heart failure Estimated Number of Persons With Cardiovascular Disease in the US <ul><li>American Heart Association ® . 2000 Heart and Stroke Statistical Update. 1999. </li></ul>(24%)
Hypertension <ul><li>Hypertension is the most common public health problem in developed countries </li></ul><ul><li>Called Silent Killer </li></ul><ul><li>No cure is available, but prevention and management decrease the incidence of hypertension and disease sequelae </li></ul><ul><li>Definition: Persistently high arterial blood pressure, defined as systolic blood pressure above 140 mm Hg and/or diastolic blood pressure above 90 mm Hg </li></ul>
Hypertension: The Silent Killer Facts & Figures <ul><li>50 million Americans & 1 billion worldwide affected </li></ul><ul><li>Most common primary care diagnosis (35 million visits annually) </li></ul><ul><li>Normotensive at age 55 have 90% lifetime risk of Hypertension </li></ul><ul><li>Continuous & consistent relationship with CVD </li></ul><ul><ul><li>Between ages 40-70, starting from 115/75 </li></ul></ul><ul><ul><li>CVD risk doubles with each increment of 20/10 </li></ul></ul>
<ul><li>Essential hypertension </li></ul><ul><ul><li>90% </li></ul></ul><ul><ul><li>No underlying cause </li></ul></ul><ul><li>Secondary hypertension </li></ul><ul><ul><li>Underlying cause </li></ul></ul>Types of Hypertension
Identifiable Causes of Hypertension <ul><li>Sleep apnea </li></ul><ul><li>Drug-induced or related causes </li></ul><ul><li>Chronic kidney disease </li></ul><ul><li>Primary aldosteronism </li></ul><ul><li>Renovascular disease </li></ul><ul><li>Chronic steroid therapy and Cushing’s syndrome </li></ul><ul><li>Pheochromocytoma </li></ul><ul><li>Coarctation of the aorta </li></ul><ul><li>Thyroid or parathyroid disease </li></ul>JNC 7 Express. JAMA. 2003 Sep 10; 290(10):1314
Hypertension: A Significant CV and Renal Disease Risk Factor National High Blood Pressure Education Program Working Group. Arch Intern Med. 1993;153:186-208.
CV Mortality Risk Doubles with Each 20/10 mm Hg BP Increment* *Individuals aged 40-69 years, starting at BP 115/75 mm Hg. CV, cardiovascular; SBP, systolic blood pressure; DBP, diastolic blood pressure Lewington S, et al. Lancet . 2002; 60:1903-1913. JNC VII. JAMA. 2003. CV mortality risk SBP/DBP (mm Hg) 0 1 2 3 4 5 6 7 8 115/75 135/85 155/95 175/105
SBP Reductions as Little as 2 mm Hg Reduce the Risk of CV Events by Up to 10% <ul><li>Meta-analysis of 61 prospective, observational studies </li></ul><ul><li>1 million adults </li></ul><ul><li>12.7 million person-years </li></ul>Lewington S et al. Lancet. 2002;360:1903-1913. 2 mm Hg decrease in mean SBP 10% reduction in risk of stroke mortality 7% reduction in risk of ischemic heart disease mortality
BP Control Rates Trends in awareness, treatment, and control of high blood pressure in adults ages 18–74 Sources: Unpublished data for 1999–2000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6. National Health and Nutrition Examination Survey, Percent II 1976–80 II (Phase 1) 1988–91 II (Phase 2) 1991–94 1999–2000 Awareness 51 73 68 70 Treatment 31 55 54 59 Control 10 29 27 34
Blood Pressure Classification JNC 7 Definition Hypertension 2003;42:1206-52 Blood Pressure (mm Hg) Category Systolic Diastolic <120 and <80 Normal 120-139 or 80-89 Prehypertension 140-159 or 90-99 Stage 1 hypertension ≥ 160 or ≥100 Stage 2 hypertension
"The Goal is to Get to Goal!” JNC VII recommended BP goals Hypertension -PLUS- Diabetes or Renal Disease < 140/90 mmHg < 130/80 mmHg
New Features and Key Messages <ul><li>For persons over age 50, SBP is a more important than DBP as CVD risk factor </li></ul><ul><li>Starting at 115/75 mmHg, CVD risk doubles with each increment of 20/10 mmHg throughout the BP range. </li></ul><ul><li>Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN. </li></ul><ul><li>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>
4-Year Progression To Hypertension: The Framingham Heart Study (<120/80 mm Hg) (130/85 mm Hg) (130-139/85-89 mm Hg) Vasan, et al. Lancet 2001;358:1682-86 Participants age 36 and older
ASH Writing Group: Proposed New Definition of Hypertension <ul><li>Hypertension is a progressive cardiovascular syndrome arising from complex and interrelated etiologies. Early markers of the syndrome are often present before blood pressure elevation is sustained; therefore, hypertension cannot be classified solely by discrete blood pressure thresholds. Progression is strongly associated with functional and structural cardiac and vascular abnormalities that damage the heart, kidneys, brain, vasculature and other organs and lead to premature morbidity and death. </li></ul>ASH Writing Group 2005.
† CVD designation is determined by the constellation of risk factors, early disease markers, and target-organ disease. CVD, cardiovascular disease. ASH Writing Group Definition and Classification of Hypertension Classification Normal Stage 1 hypertension Stage 2 hypertension Stage 3 hypertension Descriptive Category Normal BP or rare blood pressure elevations AND No identifiable CVD † Occasional or intermittent BP elevations OR Early CVD † Sustained BP elevations OR Progressive CVD † Marked and sustained BP elevations OR Advanced CVD † Cardiovascular Risk Factors None or few Several Many Many Early Disease Markers None Usually present Overtly present Overtly present with progression Target-organ Disease None None Early signs present Overtly present with or without CVD events
Patient Evaluation <ul><li>Two consecutive blood pressure measurements </li></ul><ul><li>Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guides treatment </li></ul><ul><li>Reveal identifiable causes of high BP </li></ul><ul><li>Assess the presence or absence of target organ damage and CVD </li></ul>
BP Measurement Techniques http://hin.nhlbi.nih.gov/nhbpep_slds/menu.htm; Accessed October 20, 2003; 8:15AM Method Brief Description In-office Two readings, 5 minutes apart. Sitting in chair, not on exam table. Confirm elevated reading in contralateral arm. Self-measurement Provides information on response to therapy. May help improve adherence to therapy and evaluate “white-coat” HTN. Ambulatory BP monitoring Indicated for evaluation of “white-coat” HTN. Can be used to confirm self-measurement when inconsistent with in-office measurement. Reimbursable.
Self-Measurement of BP <ul><li>Improves awareness and adherence </li></ul><ul><li>Instruction on proper use and technique should be provided </li></ul><ul><li>Home measurements of >135/85 mmHg (or 125/75 in diabetes or renal disease) are considered hypertensive </li></ul><ul><li>At least 50% of measurements should be at or below goal </li></ul><ul><li>Home measurement devices should: </li></ul><ul><ul><li>Have an arm cuff </li></ul></ul><ul><ul><li>Be checked in office regularly </li></ul></ul>
Lifestyle Modifications <ul><li>Lose weight if overweight </li></ul><ul><li>Limit alcohol intake </li></ul><ul><li>Increase aerobic physical activity </li></ul><ul><li>Reduce sodium intake </li></ul><ul><li>Maintain adequate intake of potassium </li></ul><ul><li>Maintain adequate intake of calcium and magnesium </li></ul><ul><li>Stop smoking </li></ul><ul><li>Reduce dietary saturated fat and cholesterol </li></ul>For Prevention and Management For Overall and Cardiovascular Health
Impact of a 5 mmHg Reduction Hypertension 2003;289:2560-2572. Overall Reduction Stroke 14% Coronary Heart Disease 9% All Cause Mortality 7%
Dietary Approaches to Stop Hypertension (DASH) <ul><li>Diet high in fruits and vegetables and low-fat dairy products lowers blood pressure (11 mmHg SBP/ 5 mmHg DBP lower than traditional US diet), including more than a sodium-restricted diet. </li></ul><ul><li>Recommends 7-8 servings/day of grain/grain products, 4-5 vegetable, 4-5 fruit, 2-3 low- or non-fat dairy products, 2 or less meat, poultry, and fish. </li></ul><ul><li>NEJM 1997; 366: 1117-24. </li></ul>
Old Paradigm BP Cholesterol Disease Disease Treatment Treatment Normal Normal GOAL : Target Response
Current Paradigm DISEASE BP Cholesterol GOAL : Target Response TREATMENT
Classification and Management of BP for adults *Treatment determined by highest BP category. † Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension. ‡ Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg. BP classification SBP* mmHg DBP* mmHg Lifestyle modification Initial drug therapy Without compelling indication With compelling indications Normal <120 & <80 Encourage Prehypertension 120–139 or 80–89 Yes No antihypertensive drug indicated. Drug(s) for compelling indications. ‡ Stage 1 Hypertension 140–159 or 90–99 Yes Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination. Drug(s) for the compelling indications. ‡ Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. Stage 2 Hypertension > 160 or > 100 Yes Two-drug combination for most † (usually thiazide-type diuretic and ACEI or ARB or BB or CCB).
Anti Hypertensive drug classes The A, B, C, D approach
Anti Hypertensive drug classes <ul><li>ACEi – Angiotensin converting enzyme inhibitors - let us call them ‘A’ </li></ul><ul><li>ARB – Angiotensin Receptor Blockers – Let us call them also as ‘A’ </li></ul><ul><li>BB – Beta Receptor Blockers – let us call them ‘B’ </li></ul><ul><li>CCB – Calcium channel blockers – let us call them ‘C’ </li></ul><ul><li>Diuretics – let us call them ‘ D ’ </li></ul>
AB/CD Rule – HT Treatment AGE Younger (< 55) ACEi, Beta-blocker Ca++-blocker, Diuretic) (AB/CD = Dickerson et al. Lancet 353:2008-11;1999 Older (> 55) ACEi / ARB BB A + B A + B + D Diuretic CCB D + C + A D + C I II III III II I Resistant HT / Intolerance Add / substitute alpha blocker Re-consider 2 0 causes trial of spironolactone IV: V:
Compelling Indications for Individual Drug Classes Compelling Indication Initial Therapy Clinical Trial Basis ACC/AHA Heart Failure Guideline, MERIT-HF, COPERNICUS, CIBIS, SOLVD, AIRE, TRACE, ValHEFT, RALES ACC/AHA Post-MI Guideline, BHAT, SAVE, Capricorn, EPHESUS ALLHAT, HOPE, ANBP2, LIFE, CONVINCE THIAZ, BB, ACEI, ARB, ALDO ANT BB, ACEI, ALDO ANT THIAZ, BB, ACE, CCB Heart failure Post myocardial infarction High CAD risk
Follow up and Monitoring <ul><li>Patients should return for follow-up and adjustment of medications until the BP goal is reached. </li></ul><ul><li>More frequent visits for stage 2 HTN or with complicating co morbid conditions. </li></ul><ul><li>Serum potassium and creatinine monitored 1–2 times per year. </li></ul><ul><li>After BP at goal and stable, followup visits at 3- to 6-month intervals. </li></ul><ul><li>Co morbidities, such as heart failure, associated diseases, such as diabetes, and the need for laboratory tests influence the frequency of visits. </li></ul>
Summary <ul><li>Lifestyle modifications are important for the prevention of hypertension </li></ul><ul><li>The goal is to get to goal: </li></ul><ul><ul><li>Initial therapy with a thiazide is indicated for most </li></ul></ul><ul><ul><li>Consider compelling indications </li></ul></ul><ul><ul><li>Initiate low dose combination therapy if BP >20/10 mmHg above goal </li></ul></ul><ul><li>Consider the physiologic site of action of agents when choosing combination therapy </li></ul>