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Hypertension the silent killer


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Published in: Health & Medicine

Hypertension the silent killer

  1. 1. HTN The Silent Killer ADA 2013 guidelinesSTEMI 2013 guidelines BHS 2011 guidelines Dr Ihab Suliman 25/3/2013
  2. 2. Leading risks for premature deathHYPERTENSION 1Tobacco Use 2Alcohol 3Cholesterol 4Overweight 5 (World Health Organization 2002)
  3. 3. HTN: KEY CONTRIBUTOR TO DIABETES COMPLICATIONSFramingham Study: DM ⊕ HTN vs DM alone Relative Risk of Complication Total mortality ↑ 72% CVD events ↑ 57%• HTN → 44% of deaths and 41% of CVD events in DM! ‒ ↑ risk of nephropathy/retinopathy/neuropathy 60-100% Hypertension 2011; 57:891 Lancet 2012; 380:601
  4. 4. HTN PREVALENCE: GENERAL vs DM POPULATIONS north american data UTAH BP ≥ 140/90 BP ≥ 130/80General population 30% --- • Age ≥ 60y 67% --- • White 29% --- • Black 41% --- • Hispanic 26% --- ---Persons with DM 67% 76%  HTN is more than twice as common in DM! JACC 2012; 60:599 Diabetes Care 2011; 34:1597 Am J Med 2009; 122:443 Utah State Health Department, 2012
  5. 5. Background• Each 2 mmHg rise in systolic blood pressure associated with increased risk of mortality: – 7% from heart disease – 10% from stroke.
  6. 6. Properly Measured Cuff Size Bilateral Confirm with Manual No recent caffeine or Smoking
  7. 7. How many BP readings?1. 3 – in sinus rhythm2. more if there are multiple ectopics or AF
  8. 8. DefinitionsStage 1 hypertension:CBP >140/90 and ABPM or HBPM >135/85 mmHgStage 2 hypertension:CBP >160/100 and ABPM or HBPM daytime >150/95 mmHgSevere hypertension:C SBP >180 or C DBP >110 mmHg
  9. 9. DiagnosisIf C.B.P. >140/90 mmHg, offer ABPM to confirm thediagnosisABPM:–at least two measurements per hour, at least 14measurementsHBPM:–two consecutive seated measurements, at least 1 minuteapart–BP twice a day for at least 4 days–measurements on the first day are discarded
  10. 10. Monitoring drug treatment Use C.B.P. measurements to monitor response to treatment. Aim for target <140/90 mmHg in people <80y <150/90 mmHg in people aged >80y For people with ‘white-coat effect’* consider ABPM or HBPM as an adjunct to C.B.P. to monitor response to treatment. Aim for ABPM/HBPM target <135/85 mmHg in people <80y <145/85 mmHg in people >80y*White-coat effect: a discrepancy of more than 20/10 mmHgbetween clinic BP and average daytime ABP or average HBP at thetime of diagnosis.
  11. 11. HTN: DOMINANT CONTRIBUTOR TO GLOBAL MORTALITYIncreases RR by 2.0-4.0 fold for: • CAD, stroke, HF, PAD • Renal failure, AF, dementia, ↓ cognitionAttributable risk for HTN: • Stroke 62% • MI 25% • CKD 56% • Premature death 24% • HF 49%Aftermath: • Shortens lifespan 5y • $93.5 billion/y in U.S. Circulation 2012; 125:e12 J Hum Hypertension 2008; 22:63 Hypertension 2007; 50:1006
  12. 12. Definitions from BHS 2011 Stage 1 hypertension:• Clinic blood pressure (BP) is 140/90 mmHg or higher and• ABPM or HBPM average is 135/85 mmHg or higher. Stage 2 hypertension:• Clinic BP 160/100 mmHg is or higher and• ABPM or HBPM daytime average is 150/95 mmHg or higher.
  13. 13. Monitoring drug treatment (1)Use clinic blood pressure measurements to monitor response to treatment. Aim for target blood pressure below: 140/90 mmHg in people aged under 80 150/90 mmHg in people aged 80 and over
  14. 14. Choosing drugs for patients newly diagnosed with hypertension BHS Guidelines (2011) 55 years or older Younger than 55 years Or black patientsAbbreviations: of any ageA: ACE-I (orARB if ACE A C Step 1intolerant)C: CCB A+C Step 2D: thiazidetype diuretic A+C+D Step 3 Add •further diuretic therapy •Or alpha blocker Step 4 •Or Beta Blocker •Consider seeking specialist advice
  15. 15. CCBs - Pharmacokinetics  High oral absorption, but high first pass metabolism (except amlodipine) – individual variation and highly plasma protein bound  Extensively distributed in tissues and metabolized in liver and excreted in urine, eliminated in 22-6 Hrs (except amlodipine) Drug Bioavailability Vd (L/kg) Active Elim half life(hr) % metabolite Verapamil 15-30 5.0 Y 4-6 Diltiazem 40-60 3.0 Y 5-6 Nifedepine 30-60 0.8 M 2-5 Felodipine 15-25 10.0 None 12-18 Amlodipine 60-65 21.0 None 35-45
  16. 16. Case 55 years old obese Diabetic with Type 2 DM, SBP is consistently above 150 mmHg, the best initial treatment will be ??? 1-HCTZ 12.5 mg po daily. 2-Atenolol 50 mg po daily. 3-Lisinopril 10 mg po daily
  17. 17.  Lisinopril 10 mg po daily is chosen You FU the patient by A-POTASSIUM B-RENIN C-CREATININE D-ECG E— A&C F-A,B,C,D
  18. 18.  E— A&C The patient after starting Lisinopril will be seen after with Basic Screen A- one week then 3 monthy B- every 3 months C- within 3 days then 3months
  19. 19.  A- one week then 3 monthy
  20. 20.  45 years old male with DM , Prior history of IHD, Last echo report EF 45%, SBP 155, Creatinine 140, potassium 4, started on lisinopril 10 mg po daily, after 3 month on a routine visit SBP 115, creatinine 155, potassium is 4.5 , No chest Pain or SOB, the next step will be ????
  21. 21.  A- DIC Lisinopril & Start Amlor . B- refer to cardiology. C-No change & B D- DIC lisinopril & start ARBs E- Start Aliskiren
  22. 22.  70 years old female with no prior active cardiac problems, Informed in a private clinic about being Hypertensive, 3 separate visits, SBP 160- 170 ,what is the next step?? A-life style modfication. B-single agent anti hypertensive C- combination of two anti hypertensive agents. D- a diagnosis of HTN cannot be made at this time.
  23. 23.  C- combination of two anti hypertensive agents.
  25. 25. Recommendations: Hypertension/Blood Pressure Control Screening and diagnosis  Blood pressure should be measured at every routine visit  Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day (B) ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S28-S29.
  26. 26. Recommendations: Hypertension/Blood Pressure Control Treatment (1)  Patients with a blood pressure (BP) >120/80 mmHg should be advised on lifestyle changes to reduce BP (B)  Patients with confirmed BP ≥140/80 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely subsequent titration of pharmacological therapy to achieve BP goals (B) ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S29.
  27. 27. Recommendations: Hypertension/Blood Pressure Control  Lifestyle therapy for elevated BP (B)  Weight loss ifoverweight  DASH-style dietary pattern including reducing sodium, increasing potassium intake  Moderation of alcohol intake  Increased physical activity ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S29.
  28. 28. Recommendations: Hypertension/Blood Pressure Control Pharmacological therapy for patients with diabetes and hypertension (C)  A regimen that includes either an ACE inhibitor or angiotensin II receptor blocker; if one class is not tolerated, substitute the other Multiple drug therapy (two or more agents at maximal doses) generally required to achieve BP targets (B) Administer one or more antihypertensive medications at bedtime (A) ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S29.
  29. 29. Recommendations: Hypertension/Blood Pressure Control  If ACE inhibitors, ARBs, or diuretics are used, kidney function, serum potassium levels should be monitored (E)  In pregnant patients with diabetes and chronic hypertension, blood pressure target goals of 110– 129/65–79 mmHg are suggested in interest of long-term maternal health and minimizing impaired fetal growth; ACE inhibitors, ARBs, contraindicated during pregnancy (E) ADA. VI. Prevention, Management of Complications. Diabetes Care 2013;36(suppl 1):S29.
  30. 30. Renal Sympathetic Activation: Afferent Nerves Kidney as Origin of Central Sympathetic DriveVasoconstrictionAtherosclerosis Hypertrophy Sleep Arrhythmia Insulin Disturbances Renal Afferent Oxygen Consumption Resistance Nerves ↑ Renin Release  RAAS activation ↑ Sodium Retention ↓ Renal Blood Flow 37
  31. 31. Anatomical Location of RenalSympathetic Nerves • Arise from T10-L1 • Follow the renal artery to the kidney • Primarily lie within the adventitia
  32. 32. Anatomical Location of RenalSympathetic Nerves • Arise from T10-L1 • Follow the renal artery to the kidney • Primarily lie within the adventitia Vessel Lumen Media Adventitia Renal Nerves
  33. 33. RF Ablation Approach to RenalSympathetic Denervation Electrode Insulated arch wire Symplicity® Catheter System, Ardian, Inc., Palo Alto, CA, USA
  34. 34. Treatment by Renal RF Catheter
  35. 35. ‫وفي النهاية‬‫، نسأل ا أن يعلمنا ما ينفعنا‬ ‫،وأن ينفعنا بما علمنا‬ ‫وأ علما‬