Slide #6: This chart summarizes the guidelines for defining stages of hypertension. This new classification scheme was identified by the JNC in 2003 and created to assist in the identification individuals at risk for developing hypertension that my be able to prevent progression through lifestyle modifications (Brashers, 2006). If a patient’s systolic pressure and diastolic pressure fall into different categories, the higher category is used to classify the patient. The majority of hypertension cases (95%) are considered to be “primary” or “essential” hypertension (Brashers, 2006). The many causes of primary hypertension will be addressed later in this presentation. Secondary hypertension represents approximately 5% of the hypertension cases. Secondary hypertension can be caused by renal parenchymal disease, renal vascular disease, adrenocortical disease (such as Cushing’s disease or hyperaldosteronism), pheochromocytoma, hyperthyroidism, hyperparathyroidism, and medications such as oral contraceptives (Brashers, 2006).
Slide #14: Review history carefully for signs of underlying pathology indicative of secondary HTN. Hypertension is generally asymptomatic, until vascular changes to the heart, kidneys, eyes, and brain begin to occur. Patients with severe hypertension may complain of headaches or blurry vision. Physical exam: Abdomen -assess for masses, bruits of abdominal aorta, renal, femoral, and carotid arteries. Assess for indications of Cushing's disease and manifestation of pheochromocytoma. Funduscopic - assess for retinal vessel damage, blurry vision. Carefully assess Vascular, Cardiac, Pulmonary, Neurological, and extremities for symptoms such as headache, dizziness, edema, epistaxis, confusion, fatigue, and nocturia Lab tests: Urinalysis- may reveal blood cells or protein, indicating renal compromise. Glucose may be present indicating diabetes mellitus Blood Chemistry - BUN, and creatinine will give and indication of renal function. Glucose testing will reveal any diabetes. Hypokalemia will indicate adrenal dysfunction. CBC may reveal polycythemia or anemia ECG- ischemia and left ventricular hypertrophy. Renal ultrasound- renal perfusion Vascular studies- tissue perfusion, blockages Chest x-ray- may demonstrate cardiomegaly
Slide #13: It is important to make a diagnosis of hypertension according to established standards, such as those outlined previously by JNC VII. Keys to assessment and the goals of evaluation for hypertension are to establish the true diagnosis of HTN, rule out secondary HTN, assess for end-organ damage, and overall cardiovascular and neurovascular risk. In order to rule out an isolated incident of increased blood pressure, or “white coat syndrome”, a 24-hour blood pressure monitor may be considered. Unlike disorders of organ structures that are diagnosed by methods such as x-rays and tissue examination, hypertension and other blood pressure disorders are determined by repeated blood pressure measurement. Of those not taking antihypertensive medications, diagnosis should be based on the average of at least two or more blood pressure readings taken at each of two or more visits, after initial screening. (Mattson Porth, 2004, 281-281) An important consideration in the proper diagnosis of true hypertension is to assure the equipment is appropriate. The equipment must be maintained, calibrated and of the appropriate size. The individual taking the readings should be trained in blood pressure measurement (Mattson Porth, 2004). In order to confirm or exclude secondary hypertension, lab tests, diagnostic testing or x-rays may be performed. If secondary hypertension is present, these tests will assist in determining the extent of compromise of the affected organ.
Slide #18: Untreated, resistant or uncontrolled hypertension can result in these complications. Mild hypertension left untreated can progress into severe or malignant hypertension. Hypertension is usually asymptomatic until it reaches severe stages (Brashers, 2006).
Slide #16: Dozens of anti-hypertensive drugs are available. Most fall into the following categories: Diuretics rid the body of extra water and salt. Diuretics are usually the first-line treatment for high blood pressure (Groer, 2001). Thiazide diuretics inhibit sodium reabsorption, and decreased water reabsorption which decreases cardiac output and lowers peripheral vascular resistance (Groer). Thiazide diuretics are often uses in combination with beta blockers. Loop diuretics such as furosemide are often used in patients with renal dysfunction. These diuretics decrease water reabsorption and cardiac output through inhibiting Na+, K+, and Cl- co-transport in the loop of Henle (Groer). Spirolactone is a potassium-sparing agent that reduces loss of K+ in the urine (a side effect of thiazide and loop diuretics) through antagonizing aldosterone. Spirolactone is also useful in patients with renal impairment (Groer). Beta-blockers (Atenolol, Nadolol, Propranolol) block the effects of adrenaline and ease the heart's pumping action. As the name implies, beta blockers block beta-adrenergic receptors and reduces cardiac output as well as renin (Groer, 2001). Angiotensin converting enzyme (ACE) inhibitors reduce the angiotensin II, a major vasoconstrictor and also reduces aldosterone (Groer, 2001). Ace inhibitors are uses as a first-line medication for diabetics with proteinuria, as well as patient with heart failure who have not had successful control with diuretics and beta blockers (Groer). Calcium-channel blockers (CCBs) decrease the contractions of the heart and widen blood vessels. CCBs cause vasodilation by blocking calcium current in L channels of coronary and peripheral vessels. CCBs are used if beta blockers and diuretics are not effective, also used in systolic HTN in the elderly (Groer, 2001). Angiotensin-receptor blockers (ARBs) block angiotensin, another chemical that constricts the arteries. ARBs work by removing angiotensin II from its receptor which caused vasodilation and a drop in peripheral vascular resistance (Groer, 2001). ARBs are used primarily in patients that do not tolerate ACE inhibitors. Alpha blockers cause vasodilation through the blocking of post synaptic alpha receptors on vascular smooth muscles. Alpha blockers are available, in either short-acting or long-acting forms. Alpha blockers relax certain muscles and help small blood vessels remain open. They work by keeping the hormone norepinephrine (noradrenaline) from stimulating the muscles in the walls of smaller arteries and veins. This stimulation makes the vessel walls constrict. Blocking that effect causes the vessels to remain open and relaxed. This improves blood flow and lowers blood pressure. Because alpha blockers also relax smooth muscle cells throughout the body, these medications help improve urine flow in older men with prostate problems. (Mayo Clinic, 2006, 1). Vasodilators (Apresoline)- dilates blood vessels and work directly on the muscles in the walls of your arteries, preventing the muscles from tightening and the walls from narrowing. As a result, blood flows more easily through your arteries, your heart doesn't have to pump as hard and blood pressure is reduced (Mayo Clinic, 2006, 1). In about half of patients a single-drug regimen can control mild to moderate hypertension. More severe hypertension often requires a combination of two or more drugs. Each drug has specific benefits, but their effects may vary depending on the individual patient.
Slide #15: Primary goal is to reduce cardiovascular and renal morbidity and mortality. Other keys to management are: prevention-- which includes patient education and life-style modification (diet and exercise) and medication. Life-style modifications are the first-line interventions in the management of blood pressure. Life-style modifications include patient education, diet, and exercise. These modifications may aid in prevention or slowing of disease progression. Life-style modifications are important even if medication interventions are also implemented. Hypertension should not be treated as an isolated disease, a full assessment of the cardiac system and risk factors should be completed. Again, secondary causes of hypertension should also be excluded. Life-style changes important in the management of hypertension are weight management or reduction, reduced sodium intake, smoking cessation, moderation of alcohol consumption, stress management, and regular physical exercise. Weight management can have a significant effect on hypertension. Each 1.8 kg of weigh loss can produce a reduction in hypertension by 1 mm Hg (Groer, 2001). It is recommend that individuals have a body mass index of 18.5 to 24.9 (United States Department of Health and Human Services [USDHHS], 2007). Weight loss improves insulin resistance and decreases cardiovascular and metabolic requirements through the reduction of body mass. Dietary changes for hypertensive include education and implementation of the DASH (dietary approaches to stop hypertension) diet. The DASH diet may be implemented for patients with hypertension or prehypertension for improvement in blood pressure as well as weight loss. The diet emphasizes increasing the consumption of fruits and vegetables, low-fat or non-dairy, lean meats, fish and poultry. It also recommends sodium intake on two levels (1500 mg up to 2300 mg), according to the patient’s degree of hypertension. According to the authors sodium intake should never exceed 2300 mg (National Institute of Health [NIH], 2006). The average American consumes 3300 mg to 4200 mg of sodium per day (National Institute of Health [NIH], 2006). The Dash diet was the foundation on which the USDA food pyramid was based (National Institute of Health [NIH], 2006). Decreased sodium intake results in reduced potassium excretion (associated with diuretic use), and reduced calcium loss in the urine. Smoking is a major risk factor in hypertension and cardiovascular disease and progression (NIH, 2006). Each cigarette smoked produced an immediate rise in blood pressure and lasts 15-30 minutes (Groer, 2001). Smoking makes the hypertensive patient resistant to drug therapy (Groer). It is imperative for the hypertensive patient to quit smoking in order to assist in blood pressure control. Nicotine patches do not have the same effects on blood pressure as cigarettes and therefore may be a helpful intervention in smoking cessation (Groer). Hypertension is higher among those that consume more than three alcoholic drinks per day (considered to be heavy use) than those that do not use alcohol (McCance & Huether, 2006). It is noted that moderate alcohol consumption (2-4 drinks per week) appears to lower blood pressure and results in lower mortality than either heavy alcohol users or non-users (McCance & Huether). Stress reduction is recommended to assist is blood pressure management. The more appropriate term might be stress management. Patients may benefit from learning techniques to deal with stress, such as relaxation techniques. Relaxation provides a transitory drop in blood pressure, more long-term effects on hypertension have been reported with biofeedback techniques (Groer, 2001). “ Sedentary individuals have a 1.5 times increased risk of HTN” (Groer, 2001, 301). It is recommended that hypertensive patients engage in moderate exercise, such as brisk walking, , for 30-45 minutes most days of the week (Groer). Regular exercise directly lowers blood pressure, and may also aid in weight loss. This is a two-fold benefit in regard to control and maintenance of hypertension. Exercise, especially combined with the added benefit of weight loss may reduce BP to a level that may reduce of eliminate the necessity of pharmaceutical management (Groer).
Slide #20: Hospitalization is warranted and should be considered if any of the following are present: very high BP, severe headache, chest pain, neurologic symptoms, altered mental status, acutely worsening renal failure, S & S of hypertensive emergency (Brashers, 2006).
Presentation Htn Elderly
HYPERTENSION IN ELDERLY <ul><li>Dr. Kunal Kothari </li></ul><ul><li> Emeritus Professor of Medicine and Clinical Cardiology </li></ul><ul><li> Director Primary Health Care and Strategic initiative </li></ul>
<ul><li>Sphygmanometer- size of the cuffs </li></ul><ul><li>Food </li></ul><ul><li>Exercise </li></ul><ul><li>Caffeine </li></ul><ul><li>Smoking </li></ul>200 140 160 120 180 20 40 60 80 100 0 A softer blowing sound A sharp thump A softer thump A blowing or whooshing sound K1 K2 K3 K4 K5
Benefits of Lowering Blood Pressure Antihypertensive Therapy has been associated with reductions in: <ul><li>Stroke Incidence (35-40 %). </li></ul><ul><li>MI (20-25 %). </li></ul><ul><li>Heart Failure ( averaging > 50 %). </li></ul>
Guidelines <ul><li>The Seventh Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII) uses the following guidelines to define HTN in adults: </li></ul>90-99 or 140-159 Stage 1 hypertension > 100 or > 160 Stage 2 hypertension 85-89 or 120-139 Pre-hypertension <80 and <120 Normal Diastolic Systolic Category
Pseudo Hypertension <ul><li>Recording of high B.P. but do not have </li></ul><ul><li>Common cause of this is brachial artery compression </li></ul>
WHITE COAT HYPERTENSION <ul><li>BP recording in office or clinic is high while at home is normotensive </li></ul><ul><li>"white coat" hypertension appear to have no greater risk than people with normal blood pressure ( Aug. 2, 2005, American college of cardiology ) </li></ul>
MASKED HYPERTENSION Proposed the term masked hypertension Pickering et al (Hypertension 2002;102:1139-44) Documented by Ohkubo et al (N Engl J Medicine 2003;348:2407-15)
MASKED HYPERTENSION <ul><li>HYPERTENSION IS NOT DETECTED BY THE ROUTINE METHODS. "UNDETECTED AMBULATORY HYPERTENSION" </li></ul><ul><li>UNUSUALLY HIGH AMBULATORY PRESSURE OR A LOW CLINIC PRESSURE ON THAT PARTICULAR OCCASION </li></ul><ul><li>SHOW MORE EXTENSIVE TARGET ORGAN DAMAGE THAN TRUE NORMOTENSIVE SUBJECTS </li></ul>
Blood Pressure in 347,978 men aged 35-57 screened for MRFIT <110 110-119 120-129 130-139 140-149 150-159 >160 % of Men Systolic pressure mmHg ¼ ½ ¼
Lifetime Risk of Developing Hypertension in Middle Aged (Vasan et al, JAMA 2002; 287: 1010 ) <ul><li>Risk for Hypertension in a 55 year old </li></ul><ul><li>Time, yr Women Men </li></ul><ul><li>52% 56% </li></ul><ul><li>72% 78% </li></ul><ul><li>83% 88% </li></ul><ul><li>25 91% 93% </li></ul>
Diagnostic Evaluation of the Hypertensive Patient- How much is enough? <ul><li>How high is the blood pressure? </li></ul><ul><li>Why is it high? </li></ul><ul><li>What is the risk? </li></ul>
Differential Diagnosis <ul><li>Rule out isolated incident of increased blood pressure. </li></ul><ul><li>Rule out secondary hypertension related to: </li></ul><ul><li>Renal disease </li></ul><ul><li>Cushing's disease </li></ul><ul><li>Pheochromocytoma </li></ul><ul><li>Hyperthyroidism </li></ul><ul><li>Hyperparathyroidism </li></ul>
Complications <ul><li>Complications as a result of HTN include: </li></ul><ul><li>Stroke </li></ul><ul><li>Dementia </li></ul><ul><li>Myocardial Infarction </li></ul><ul><li>Congestive Heart Failure </li></ul><ul><li>Retinal Vasculopathy </li></ul><ul><li>Aortic Dissection </li></ul><ul><li>Renal Disease or Failure </li></ul>
Management <ul><li>Primary goal is to reduce cardiovascular and renal morbidity and mortality. </li></ul><ul><li>Other keys to management are: </li></ul><ul><li>Prevention </li></ul><ul><li>Patient education </li></ul><ul><li>Life-style modification </li></ul><ul><li>Medication </li></ul>
Hospitalization should be considered if <ul><li>Very high BP </li></ul><ul><li>Severe headache </li></ul><ul><li> Chest pain </li></ul><ul><li>Neurologic symptoms </li></ul><ul><li>Altered mental status </li></ul><ul><li>Acutely worsening renal failure </li></ul><ul><li>S & S of hypertensive emergency </li></ul>
DOES ELDERLY HYPERTENSION HAVE SPECIFIC CHARACTERISTICS?
CHARACTERISTICS OF HYPERTENSION IN THE ELDERLY Increased Systolic blood pressure and pulse pressure Left ventricular mass and wall thickness Arterial stiffness Calculated total peripheral resistance Decreased Cardiac output and heart rate Renal blood flow, plasma renin activity, and angiotensin II levels Arterial compliance and blood volume Diastolic blood pressure Black H. JCH 2003; 5:12
Bar graph shows change in mean arterial blood pressure used to define salt responsivity as a function of age in normotensive [open bars] and hypertensive [color bars] subjects. Change in Mean Arterial Blood Pressure Weinberger M. Hypertens 1991; 18:69
Effect of 30 minute walk 3 days a week Age 70 - 79 Systolic Diastolic Exercise Group Baseline 156 ± 10 mm Hg 86 ± 8 mm Hg 3 months 151 ± 15 mm Hg 80 ± 6 mm Hg Control Group Baseline 153 ± 7 mm Hg 85 ± 8 mm Hg 3 months 156 ± 10 mm Hg 85 ± 6 mm Hg Conone et al. Med Scl in Sports and Exercise. 1991
What is the effect of drug therapy related to age? Are the recommendations different?
<ul><li>Algorithm for Management of the Elderly - </li></ul><ul><li>Primarily Systolic Hypertension </li></ul><ul><li>1) Lifestyle changes </li></ul><ul><li>Low dose diuretic (12.5 mg HCTZ) </li></ul><ul><li>CCB B-Blocker ACE or ARB </li></ul><ul><li>3) Stop, Look & Listen before dosages </li></ul><ul><li>Let the Baroreceptors reset </li></ul><ul><li>4) Rx until goal achieved </li></ul>+ + + + +
ALLHAT <ul><li>The Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) suggests that low dose thiazide diuretics have a better cardiovascular protective effect </li></ul>
Result Highlights <ul><li>21% reduction in relative risk death from any cause </li></ul><ul><li>64% reduction relative risk heart failure </li></ul><ul><li>39% reduction relative risk of death from stroke </li></ul>
Syst-Eur <ul><li>A study called the Systolic-Hypertension Trial in Europe (Syst-Eur) showed that aggressive treatment of hypertension reduces the risk of stroke by 42% and dementia is prevented. </li></ul>
Trials Examining Treatment of Hypertension in the Elderly EWPHE MRC-Elderly SHEP STOP-H Syst-China Syst-Eur (N = 840) (N = 4396) (N = 4736) (N = 1627) (N = 2394) (N = 4695) Stroke reduction, % -36 -25 -33 -47 -38 -42 CAD change, % -20 -19 -27 -13 +6 -26 CHF reduction, % -22 Not stated -55 -51 -58 -27 % of Patients receiving 35 52 (b-blocker) 44 67 11-26 26-36 combination drug therapy 38 (diuretic) Prisant, Moser M. Arch Int Med 2000; 160:284
Independent Predictors of Using Antihypertensives Medications in 2000 Variable Adjusted OR (95% CI) of Using Antihypertensives Comorbid conditions Asthma/COPD 0.43 (0.40-0.47) Depression 0.50 (0.45-0.55) GI disorders 0.59 (0.54-0.64) Osteoarthritis 0.63 (0.59-0.67) Cardiovascular conditions Coronary artery disease 1.31 (1.23-1.40) Cerebrovascular disease 1.03 (.97-1.10) Congestive heart failure 1.05 (0.99-1.11) Diabetes 1.16 (1.10-1.22) Wang PS et al. Hypertension 2005; 46:273-279
Barriers to Optimal Control of Hypertension Inaccurate measurement of blood pressure (BP) Focusing on diastolic BP rather than systolic BP goal Failure to consider absolute global risk Failure to advocate lifestyle modifications Failure to use polypharmacy Failure to use effective drug combinations Failure to titrate doses upward Fear of reaching excessively low diastolic BP The patient with truly resistant hypertension Behavioral barriers Franklin S. JCH 2006; 8:524
REDUCTION OF STROKES WITH BP LOWERING - SHEP TRIAL No. of Patients: 4736 Follow-up: 4.5 years 37% in ischemic strokes 47% in lacunar infarcts 54% in hemorrhagic strokes Lower BPs - fewer strokes Am J Hypertension 2000;13:724-733
Hypertension in the Very Elderly Trial NEJM 2008;358(18):1887-1898 <ul><li>Double blind, placebo-controlled </li></ul><ul><li>International, multicenter </li></ul><ul><li>3845 patients </li></ul><ul><li>Mean age 83.6 yrs </li></ul><ul><li>BP range 160-219/90-109 </li></ul><ul><li>Mean BP 173.0/90.8 </li></ul><ul><li>f/u median of 1.8 yrs </li></ul><ul><li>Primary endpoints – fatal or non fatal stroke </li></ul><ul><li>Indapamide 1.5mg </li></ul><ul><li>Perindopril prn (2mg or 4mg) </li></ul><ul><li>Mean BP fall 15.0/6.1 at 2 yrs </li></ul>
Result Highlights <ul><li>21% reduction in relative risk death from any cause </li></ul><ul><li>64% reduction relative risk heart failure </li></ul><ul><li>39% reduction relative risk of death from stroke </li></ul>
GOALS OF TREATMENT <ul><li>To achieve a target BP of <140/ 90 mm Hg. </li></ul><ul><li>In patients with Hypertension & Diabetes or Renal disease, BP Goal is < 130/80 mm Hg. </li></ul><ul><li>To reduce cardiovascular morbidity & mortality. </li></ul>
Thiazide Related Gout <ul><li>Thiazide related hyperuricemia is dose related </li></ul><ul><li>HDFP Trial: 15 episodes of gout over 5 years in 3693 patients treated with chlorthalidone 25-100mg (equivalent to 50-200 mg HCTZ) </li></ul><ul><li>Low dose thiazide (HCTZ 12.5-25 mg) is not contraindicated in gout </li></ul>
Treatment Recommendations for the Elderly in JNC 7 <ul><li>Recommendations are no different according to age for: </li></ul><ul><ul><li>BP classification </li></ul></ul><ul><ul><li>BP goals </li></ul></ul><ul><ul><li>Lifestyle interventions </li></ul></ul><ul><ul><li>Selection of medications </li></ul></ul>
<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 </li></ul><ul><li>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>JNC 7: New Features and Key Messages
<ul><li>Thank You </li></ul><ul><li>Dr. Kunal Kothari </li></ul><ul><ul><ul><li>Emeritus Professor of medicine and Clinical Cardiology </li></ul></ul></ul><ul><ul><ul><li>Director Primary Health care and Strategic initiative </li></ul></ul></ul>