1、Management of Hypertension,David Putnam, MD Albany Medical College September 21, 2000,The decline in age-adjusted mortality for stroke in the total population is 59.0%. *Age-adjusted to the 1940 U.S. census population.,Percent Decline in Age-Adjusted* Mortality Rates for Stroke by Sex and Race: Unit
2、ed States, 1972-94,The decline in age-adjusted mortality for CHD in the total population is 53.2%. *Age-adjusted to the 1940 U.S. census population.,Percent Decline in Age-Adjusted* Mortality Rates for CHD by Sex and Race: United States, 1972-94,Incidence of Reported End-Stage Renal Disease Therapy,
3、 1982-1995,253*,*Provisional data. Adjusted for age, race, and sex.,Prevalence of Heart Failure, by Age, 1976-80 and 1988-91,1988-91,1976-80,Hypertension,One of the most well established and important risk factors for CVD Most recent surveys show that HTN remains largely untreated and uncontrolled,A
4、wareness, Treatment, and Control of High Blood Pressure in Adults*,Hypertension,JNC-VI has provided widely used definitions of high blood pressure categories Relationship between SBP and DBP and CVD is strong, graded, and continuous SBP is a better predictor of CVD at all ages but particularly in ol
5、der age groups,Blood Pressure Measurement,Patients should be seated with back supported and arm bared and supported. Patients should refrain from smoking or ingesting caffeine for 30 minutes prior to measurement. Measurement should begin after at least 5 minutes of rest. Appropriate cuff size and ca
6、librated equipment should be used. Both SBP and DBP should be recorded. Two or more readings should be averaged.,Advantages of Self-Measurement,Identifies “white-coat hypertension” Assesses response to medication Improves adherence to treatment Potentially reduces costs Usually provides lower readin
7、gs than those recorded in clinic (hypertension is defined as SBP 135 or DBP 85 mm Hg),Ambulatory Measurement,Ambulatory monitoring can provide: readings throughout day during usual activities readings during sleep to assess nocturnal changes measures of SBP and DBP load Ambulatory readings are usual
8、ly lower than in clinic (hypertension is defined as SBP 135 or DBP 85 mm Hg),Classification of Blood Pressure for Adults,Recommendations for Followup Based on Initial Measurements,Evaluation Objectives,To identify known causes To assess presence or absence of target organ damage and cardiovascular d
9、isease To identify other risk factors or disorders that may guide treatment,Evaluation Components,Medical history Physical examination Routine laboratory tests Optional tests,Medical History,Duration and classification of hypertension Patient history of cardiovascular disease Family history Symptoms
10、 suggesting causes of hypertension Lifestyle factors Current and previous medications,Physical Examination,Blood pressure readings (2 or more) Verification in contralateral arm Height, weight, and waist circumference Funduscopic examination Examination of the neck, heart, lungs, abdomen, and extremi
11、ties Neurological assessment,Laboratory Tests and Other Diagnostic Procedures,Determine presence of target organ damage and other risk factors Seek specific causes of hypertension,Laboratory Tests Recommended Before Initiating Therapy,Urinalysis Complete blood count Blood chemistry (potassium, sodiu
12、m, creatinine, and fasting glucose) Lipid profile (total cholesterol and HDL cholesterol) 12-lead electrocardiogram,Optional Tests and Procedures,Creatinine clearance Microalbuminuria 24-hour urinary protein Serum calcium Serum uric acid Fasting triglycerides LDL cholesterol Glycosolated hemoglobin,
13、Thyroid-stimulating hormone Plasma renin activity/ urinary sodium determination Limited echocardiography Ultrasonography Measurement of ankle/arm index,Hypertension,Secondary Causes,Examples of Identifiable Causes of Hypertension,Renovascular disease Renal parenchymal disease Polycystic kidneys Aort
14、ic coarctation,Pheochromocytoma Primary aldosteronism Cushing syndrome Hyperparathyroidism Exogenous causes,HTN: Renal Artery Stenosis,Onset of HTN before age 30 or after age 55 in absence of family history of HTN Abdominal bruit Accelerated or resistant HTN Renal failure of uncertain cause Acute re
15、nal failure induced by ACE Diagnosis: captopril renal flow scan,HTN: Hypersecretion of Aldosterone,Suspect in patients with spontaneous hypokalemia Unilateral adenoma more common in women Bilateral adrenal hyperplasia more common in men Diagnosis: Measurement of PRA and plasma or 24-hour urine aldos
16、terone after 2 days of high sodium diet,HTN: Pheochromocytoma,Suspect in patients with episodic headaches, tachycardia, diaphoresis with labile HTN Diagnosis: resting supine plasma catecholeamine levels 2000 pg/ml Urine metanephrine and VMA less sensitive but very specific,Hypertension,Risk Stratifi
17、cation,HTN: Major Risk Factors,Smoking Dyslipidemia Diabetes mellitus Sex (men and postmenopausal women) Family history of cardiovascular disease: women 65 yr or men 55 yr,Hypertension: CAD Risk Factors,Estimated that 90% of patients with hypertension have other risk factors for CAD,Target Organ Dam
18、age Clinical Cardiovascular Disease,Heart diseases Left ventricular hypertrophy Angina or prior MI Prior coronary revascularization Heart failure Stroke or TIA Nephropathy Peripheral artery disease Retinopathy,HTN: LVH,LVH is the most important risk factor for cardiovascular events that we have Epid
19、emiological data indicate that LVH is an ominous harbinger of cardiovascular disease in the hypertensive patient,Fundoscopic Exam,Risk Stratification,Hypertension,Treatment,Goal of Hypertension Prevention and Management,To reduce morbidity and mortality by the least intrusive means possible. This ma
20、y be accomplished by achieving and maintaining: SBP 140 mm Hg DBP 90 mm Hg controlling other cardiovascular risk factors,Treatment Strategies and Risk Stratification,Not at Goal Blood Pressure,Algorithm for Treatment of Hypertension,HTN: TONE Study,Randomized, controlled study 875 men/women aged 60
21、to 80 years old SBP10# ) Sodium reduction and weight loss,HTN: TONE Study,Results BP lower and decreased BP meds in weight loss group and sodium reduction group,Initial Drug Choices,Algorithm for Treatment of Hypertension,Not at Goal Blood Pressure ( 140/90 mm Hg)lower goals for patients with diabet
22、es or renal disease,Begin or Continue Lifestyle Modifications,Not at Goal Blood Pressure,Initial Drug Choices,Uncomplicated,Compelling Indications,Not at Goal Blood Pressure,Algorithm for Treatment of Hypertension (continued),Start at low dose and titrate upward.Low-dose combinations may be appropri
23、ate.,Specific Indications,Classes of Antihypertensive Drugs,ACE inhibitors Adrenergic inhibitors Angiotensin II receptor blockers Calcium antagonists Direct vasodilators Diuretics,Initial Drug Choices*,UncomplicatedDiuretics-blockers,Algorithm for Treatment of Hypertension (continued),*Based on rand
24、omized controlled trials.,JNC VI Treatment Algorithm,Treatment of Hypertension,HTN,CHD,Medical Problems,HTN: Pharmacologic Rx Compelling Indications,Diabetes mellitus Heart failure Post-myocardial infarction Isolated systolic HTN and HTN in older patients,HTN: Patients with DM,ACE inhibitors are a g
25、ood first choice Calcium channel antagonists and low dose diuretics are a good second choice ARBs may be considered as an alternative to ACE inhibitors but renal protection is still unproven Beta blockers may mask hypoglycemia but can be used safely,HTN: Patients with CHF,ACE inhibitors preferred wi
26、th systolic dysfunction ARBs may be an alternative to ACE inhibitors but mortality reduction remains unproven Diuretics Beta blockers in low doses Amlodipine/Felodipine may be used safely with systolic dysfunction,HTN: Patients Post-MI,Beta blockers ACE inhibitors with LV dysfunction,HTN: Older Pati
27、ents,Extremely common Present in more than 60% of Americans age 60 and older SBP a better predictor of events then DBP Elevated pulse pressure a predictor of increased risk,HTN: Older Patients,Primary HTN is the most common form Some patients have pseudohypertension due to excessive vascular stiffne
28、ss Orthostasis is more common,Systolic HTN: European Trial,4695 patients aged 60 years or older SBP 160 to 219 mmHg w/ DBP 95 mmHg Dihydropyridine with possible addition of enalapril and HCTZ Median follow-up of 2 yearsLancet 1997;350:757-64.,Systolic HTN: European Trial,Hypertension in the Elderly,
29、HTN: Older Patients,Thiazide diuretics recommended first Dihydropyridine calcium antagonists recommended as an alternative agent Beta blockers are not as effective ( JAMA 1998(JUN);279:1903-1907 ),HTN: Pharmacologic Rx Specific Indications,Coronary artery disease LVH Renal Disease Dyslipidemia,HTN:
30、Patients with CAD,Beta blockers, calcium channel antagonists Avoid short-acting calcium channel antagonists Beta blockers post MI ACE inhibitors with LV dysfunction,HTN: Patients with LVH,Major independent risk factor for cardiac events Observational data indicate that regression of LVH associated w
31、ith reduction in cardiac events,HTN: LVH,HTN: Patients with LVH,All antihypertensive agents except direct acting vasodilators reduce LVH ACE inhibitors, ARBs, calcium antagonists may be better at reversing LVH,HTN: Patients with Renal Insuficiency,Goal BP of 125/75 in patients with 1g/d of proteinur
32、ia Goal BP of 130/85 in patients with 1g/d of proteinuria ACE inhibitors have additional renoprotective effects,HTN: Patients with Dyslipidemia,Beta blockers may increase Trig and reduce HDL-C Alpha blockers may decrease Chol, and increase HDL-C ACE, ARBs, and calcium antagonists tend to have a neut
33、ral effect,HTN: Patients with Dyslipidemia,In most cases dietary modification will correct any drug effect on dyslipidemia,Other Situations,African Americans Oral Contraceptives Hormone Replacement Therapy Pregnancy,Hypertension: African Americans,Prevalence of HTN among the highest in the world Dev
34、elops earlier in life Average blood pressures are much higher Higher rates of Stage 3 HTN,Hypertension: African Americans,80% higher stroke rate mortality 50% higher heart disease mortality rate 320% greater rate of hypertension-related end-stage renal disease,Hypertension: African Americans,Diureti
35、cs should be agent of first choice Calcium antagonists and alpha-beta blockers are also effective Beta blockers and ACE inhbitors are less effective,HTN: Oral Contraceptives,HTN 2 to 3 times more common in women taking oral contraceptives Advisable to stop contraceptives In certain cases may need to
36、 continue and treat hypertension,HTN: Hormone Replacement Therapy,Presence of HTN is not a contraindication to postmenopausal estrogen therapy BP does not increase significantly in most women A few women may experience a rise in BP,Pregnant Women,Chronic hypertension is high blood pressure present b
37、efore pregnancy or diagnosed before 20th week of gestation. Preeclampsia is increased blood pressure that occurs in pregnancy (generally after the 20th week) and is accompanied by edema, proteinuria, or both. ACE inhibitors and angiotensin II receptor blockers are contraindicated for pregnant women.
38、 Methyldopa is recommended for women diagnosed during pregnancy.,Antihypertensive Drugs Used in Pregnancy,Antihypertensive Drugs Used in Pregnancy (continued),HTN: Pregnancy Beta Blockers,Review of 312 pregnancies complicated by HTN in the UK Atenolol associated with significantly lower birth weight
39、sAm J HTN 1999;12:541-547,Sleep Apnea,Obstructive sleep apnea is more common in patients with hypertension and is associated with several adverse clinical consequences. Improved hypertension control has been reported following treatment of sleep apnea.,HTN: HOT Study,Lowest risk for major cardiovasc
40、ular events seen at DBP of 82.6 mm Hg 51% reduction in major cardiovascular events in diabetics with DBP 80 mm Hg vs 90 mm Hg,Special Considerations in Selecting Drug Therapy,Demographics Coexisting diseases and therapies Quality of life Physiological and biochemical measurements Drug interactions E
41、conomic considerations,Drug Therapy,A low dose of initial drug should be used, slowly titrating upward. Optimal formulation should provide 24-hour efficacy with once-daily dose with at least 50% of peak effect remaining at end of 24 hours. Combination therapies may provide additional efficacy with f
42、ewer adverse effects.,Combination Therapies,-adrenergic blockers and diuretics ACE inhibitors and diuretics Angiotensin II receptor antagonists and diuretics Calcium antagonists and ACE inhibitors Other combinations,Followup,Follow up within 1-2 months after initiating therapy. Recognize that high-r
43、isk patients often require high dose or combination therapies and shorter intervals between changes in medications. Consider reasons for lack of responsiveness if blood pressure is uncontrolled after reaching full dose. Consider reducing dose and number of agents after1 year at or below goal.,Causes for Inadequate Response to Drug Therapy,Pseudoresistance Nonadherence to therapy Volume overload Drug-related causes Associated conditions Identifiable causes of hypertension,HTN: Prescribing Patterns,“Judge a man by his questions rather than by his answers.”Voltaire,
