Atherosclerotic risk factors-hypertension
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This document summarizes atherosclerotic risk factors related to systemic hypertension. It discusses the epidemiology of hypertension in the US and India. Hypertension is associated with increased risk of cardiovascular disease and peripheral arterial disease. Clinical features may include headaches or strokes. Diagnosis involves taking multiple blood pressure readings on separate occasions. Treatment involves lifestyle modifications and medications like thiazide diuretics, ACE inhibitors, and calcium channel blockers based on guidelines. Emerging therapies for treatment-resistant hypertension include carotid sinus baroreceptor stimulation and renal sympathetic denervation.
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Atherosclerotic risk factors-hypertension
- 1. Atherosclerotic Risk Factors – Systemic Hypertension Dr Rahul Lakshminarayanan, MMC
- 2. • Incidence, Epidemiology • Association of Hypertension with CVD/ Atherosclerosis • Clinical features • Diagnosis • Secondary causes • Pathological mechanisms and effects • Treatment. • Renal artery hypertension
- 3. Epidemiology US statistics Indian statistics Age adjusted prevalence >18 years – 29.1% Prevalence – 29.8 % Prevalence increases with increasing age No sex predilection Race – Increased risk for Blacks , Reduced for Hispanic and Non-Hispanic asian Varying prevalence in rural and urban settings. • J Hypertens. 2014 Jun; 32(6): 1170–11. doi: 10.1097/HJH.0000000000000146 • Hypertension in India: a systematic review and meta-analysis of prevalence, awareness, and control of hypertension • Raghupathy Anchala et al
- 5. • J Hypertens. 2014 Jun; 32(6): 1170–11. doi: 10.1097/HJH.0000000000000146 • Hypertension in India: a systematic review and meta-analysis of prevalence, awareness, and control of hypertension • Raghupathy Anchala et al
- 6. • J Hypertens. 2014 Jun; 32(6): 1170–11. doi: 10.1097/HJH.0000000000000146 • Hypertension in India: a systematic review and meta-analysis of prevalence, awareness, and control of hypertension • Raghupathy Anchala et al
- 7. Association of Hypertension with CVD • Most of the data based on Framingham heart study • < 50 years – DBP strongest predictor • 50-59 years – SBP, DBP, pulse pressure comparable predictors • > 60 years – SBP strongest predictors. • Generally undertreated – • NHANES – 82.7% pts aware, 75.6% under treatment, 51.8% under control • Public health foundation of India - PHFI– • About 33% urban and 25% rural Indians are hypertensive. • Of these, 25% rural and 42% urban Indians are aware of their hypertensive status. • Only 25% rural and 38% of urban Indians are being treated for hypertension. • 11% of rural and 20% of urban Indian hypertensive patients have their BP under control.
- 8. Association of Hypertension with PAD • Framingham heart study – defined PAD as Intermittent claudication • Risk of PAD Increased with SBP, DBP • 2.2 odds ratio for PAD: Symptomatic or ABI • NHANES –National health & Nutrition Examination Survey (2011-12) • Defined PAD as Intermittent claudication • Hypertension- untreated or uncontrolled despite Rx , increased PAD. • Studies with ABPI – Increased association of PAD with SBP elevation. • NHANES • Cardiovascular Heart study • Rotterdam Study of PAD
- 9. Clinical features • Asymptomtatic • Headache, visual disturbances- hemorrhagic stroke • Acute CVA – Ischemic • LVF, arrhythmias, CHF, MI • Atherosclerosis. • Hypertensive emergency
- 10. Association with Lower extremity Arterial disease
- 11. Diagnosis
- 15. Technique of Blood pressure measurement • Average of at least 2 readings, each over 2 visits, at least 1 week apart. • Sitting, back rested- at least 5 mins in a quiet room • Arm at level of heart, Cuff covering 80% circumference of arm. • Free of caffeine or smoking 30 min prior to measurement.
- 16. Ambulatory BP measurement • Hypertension defined as • 24 hr avg > 130/80 mm hg • Daytime avg > 140/85 mm Hg • Useful for: • Masked HTN – Normal BP at physician office, elevated BP at home • White coat hypertension ( WCH): Elevated single reading >140/90, Ambulatory reading <130/80 • Resistant hypertension – uncontrolled hypertension despite >=3 drugs maximal dose (including 1 diuretic). • Episodic hypertension • Autonomic dysfunction • Orthostasis on therapy
- 20. Renal Artery Hypertension • Prospective cohort 629 patients – 33% had RAS, 9 % significant - >=60% • End organ damage of RVD (Reno-vascular disease) more severe due to mitogenic effects of activated RAAS • LVH, stiffness of LV wall predisposition to flash pulm edema • Peripheral vasospasm, increased medial muscle mass – partly reversible.
- 22. Pathologic mechanisms • Association of hypertension with atherosclerosis documented, but molecular mechanisms not established. • Complex interplay. • Animal models – Mouse models with induced hypertension show increased atherosclerotic lesion size. • Some studies show reduction of size with BP, others show no reduction.
- 23. • RAAS & atherosclerosis- • Angiotensin II infusion in mouse models – promotes atherosclerosis independent of BP • Inhibition of RAAS reduced atherosclerosis. • Humans – Hypercholesterolemia increases AT1 expression • Rationale for Statin use with ACE inhibitor therapy – better BP control. • Improved endothelial function • Improved vascular elasticity
- 24. • Endothelial dysfunction and hypertension: • Endothelial dysfunction in coronary renal and peripheral circulation reduced NO expression • Hypothesis of reduced NO causing worsening Hypertension – not proven
- 25. Management
- 26. TRIALS and Guidelines • HOPE study – Heart outcomes prevention evaluation & Appropriate Blood pressure control study ( ABCD) • PAD pts show reduced cardiovascular risk with ACEI (ramipril) – HOPE • Mean 128/75 mm Hg reduced morbidity - ABCD • UK Prospective Diabetes Study Group: - No reduction in risk of PAD. • ACC/AHA guidelines & TASC II - <140/90 mm Hg • JNC 8 – • >60 yrs: <150/90 • <60 yrs : <140/90 mm Hg • SPRINT study – Lower fatal and non fatal cardiovascular events if < 120mm Hg systolic pressure. – Excluded <50yrs, prev CVA, DM.
- 27. Principles • Reduction of BP reduces cardiovascular adverse outcomes. • Benefits also noted in PAD patients • Prehypertension – lifestyle modification. • Hypertension - lifestyle modification first. • If end organ damage / no improvement with lifestyle modification – Medications. • If > 160/100 – dual antihypertensives to be started.
- 29. • Initial drugs of choice – • Thiazide diuretic, • ACE inhibitor, ARBs, • CCBs. • Based on other comorbid illnesses- • CAD/CHF – Loop diuretics, ACEI, B blockers • CKD, DM –ACEI & ARBs
- 32. • Ref – James PA, Ortiz E et al, Evidence based management of hypertension ( JNC8 ), 2014, JAMA, 2014 Feb, 311 (512-20)
- 33. Thiazide diuretics • Act on DCT – inhibit Na-Cl symport. • Effective in low renin level: African-americans, elderly. • ALLHAT trial –RCT, double blind – favored thiazides as first line • Adverse effects – hypokalemia, hyperuricemia, insuline resistance, erectile dysfunction • Hypercalcemia with hypocalciuria – useful in renal stone & osteoporosis • Efficacy reduced – CKD, high salt intake, NSAID use.
- 34. ACE inhibitors • Work synergistically with thiazide diuretics • Useful in AWMI, CHF, LVH, DM, proteinuric renal disease. • Adverse effects – • Dry cough, angioedema, hyperkalemia • Contraindicated in pregnancy. • Can produce AKI.
- 35. Angiotensin receptor blockers • Similar action to ACEI • LIFE trial – Losartan intervention for Endpoint reduction – Losartan vs Atenolol • Ongoing Telmisartan & in combination with Ramipril Global endpoint trial ( ONTARGET) – Telmisartan similar advantage – lesser angioedema. • Combination – no benefit, inc adverse effects. • C/I pregnancy.
- 36. Calcium channel blockers • 2 groups – dihydropyridines, non- dihydropyridines • Dihydropyridines –Amlodipine, Nifedipine • Potent vasodilators • Lower extremity edema. • Non dihydropyridines – Verapamil , Diltiazem • Negative chronotropic and inotropic effect • May show benefit in Claudicants, Raynauds • Use with caution with B blockers and Conduction abnormalities
- 39. • C/I pregnancy – ACEI/ARB, Aliskiren, Triamterene (folate antagonist) • ACEI – Dry cough • Hydralazine – Drug induced Lupus • Methyldopa – hepatotoxicity, hemolytic anemia.
- 40. Emerging therapies • Carotid sinus baroreceptor stimulation • Renal Sympathetic radiofrequency ablation
- 41. Carotid sinus Baroreceptor stimulation • Rheos • Neos
- 43. Renal sympathetic RF ablation • Ardian Simplicity Catheter system – blocks sympathetic afferent and efferent signals to and from. Kidneys • SIMPLICITY 1 & 2 HTN • SIMPLICITY 3 HTN
- 44. Thank you
- 45. References • Rutherford’s Vascular and Endovascular Therapy, 9th Ed. • JNC 8 guidelines- evidence based guidelines for treatment of systemic hypertension.