1、The Pharmacists Role in Treating Hypertension,Thomas Owens, MD Saint Francis University CERMUSA,Objectives,Enhance your understanding of hypertension to include cardiovascular risks, management, and goals for individual patientsReview and discuss the current pharmacotherapy standards of care for hyp
2、ertensionDescribe the pharmacists role in counseling patients on hypertensive medications,Hypertension 140/90 mm Hg,United States: 65 million adultsRisk factors include: Stroke, myocardial infarction, heart failure, peripheral vascular disease, aortic dissection, chronic renal failureHypertension pr
3、ice tag: $59.7 billion,Wexler & Feldman, 2005,Hypertension,Typical onset second decade of lifePrimary Hypertension identifiable behaviorsSecondary Hypertension more discrete,Cecil, 2004,Ethnic Groups,African Americans 43% female & 39% male Ratio 1:3 Increase in sodium sensitivity? Caucasians 28% fem
4、ale 29% male Mexican Americans Ratio 1:4 or 1:5,DASH Diet,Cecil, 2004,Dietary Sodium Intake,Salt Hypothesis?Strong genetic underpinning,ADA, 2005,Metabolic Syndrome,Risk of Hypertension increases with BMIObesity accounts for 50% to 60% of new cases of hypertension,Cecil, 2004,Potential Causes of Hyp
5、ertension,Expanded plasma volume plus sympathetic over activity Peripheral vasoconstriction Renal salt retention Renal water retention,Sleep Apnea,, 2007,Cecil, 2004,Blood Pressure Equation,Blood Pressure = Cardiac Output x Peripheral Vascular Resistance,Most pharmacologic agents lower,Some pharmaco
6、logic agents lower,Some pharmacologic agents lower both,Cecil, 2004,Genetics of High BP,Sympathetic up-regulation leads to a cascade of events Peripheral vascular resistanceGenetic factors 30% of cases 2x as likely if parents have hypertension,D, 2007; ADA, 2003,Systolic & Diastolic ?,What is more i
7、mportant? Depends on ageLive long enough almost all develop systolic hypertension,120 80,systolic,diastolic,Cecil, 2004,Age Dependant Rise in BP,(Whelton & Rocella, 1995),Framingham Study (age: 50-79),(Khan, Wong, Larson, & Levy, 1999),Systolic Hypertension,Decreased distensibility of large arteries
8、Majority of uncontrolled hypertension Due to focus on diastolic BP,Cecil, 2004,Risk of cardiovascular mortality by systolic BP,(National High Blood Pressure Education Program Working Group, 1993),Hypertension Study Results,Hypertension is excess of 140/90 mm Hg Studies found Increase risk when above
9、 115 mm Hg systolic or 75 mm Hg diastolic High normal BP had twice increased risk for cardio disease More studies are needed to fully understand,Cecil, 2004,The Silent Killer,1/3 of adults do not know they have hypertension Hypertension: 60% are treated 45% of treated remain uncontrolledDespite over
10、 75 different antihypertensive agents in 9 different classes!,Cecil, 2004,Reclassification of BP Stages,Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC)New category “pre-hypertension” Pharmacotherapy not recommended Lifestyle modification reco
11、mmended!,Cecil, 2004; JNC, 2007,JNC Drug Therapy Recommendations,recommendation (healthy),130/80 (w/ heart and kidney disease or diabetes mellitus),JNC, 2007,Modest reduction in BP = big benefits !,Decrease 5 mm Hg decreases risks Small changes can have a big difference Results of studies Systolic s
12、urge 34 mm Hg = 3x increase of stroke Systolic 135 mm Hg = 74% increase of cardio event,Cecil, 2004; JNC, 2007,Clinical Presentation,No specific signs or symptoms Possible symptoms Occipital headache, dizziness, tinnitus, dimmed vision, palpitations, fatigue Physical Exam May reveal evidence,Cecil,
13、2004,Hypertensive Retinopathy,Grades of hypertensive retinopathy shown(Forbes, Jackson, 2003),Electrocardiogram (ECG or EKG),GOOD (Normal),BAD (Antero-Septal MI),physiol.umin.jp/cardiovasc, 2007,Counseling Patients: Proper BP Readings,At least 30 minutes before NO Caffeine, decongestants, oral contr
14、aceptives, alcohol, tobacco Sit down for at least 5 minutes,Cecil, 2004; ADA, 2005,Counseling Patients: Proper Fit of BP Cuff,Length of bladder of the cuff at least 80% circumference of arm,Bladder of cuff at least 40% circumference of arm,Place the center of the bladder over the brachial artery,Pum
15、p until radial pulse disappears, then continue for additional 30 mm Hg,Help Patients Understand: White Coat Hypertension,Anxiety of going to doctor office raises BP Recommend self-monitoring Daytime: 135/85 mm Hg Nighttime: 120/70 mm Hg 24 hr: 130/80 mm HgFollow patients every 6 months for possible
16、progression to persistent hypertension,Cecil, 2004,Closely Monitor Medications with High-Risk Patients,Cecil, 2004,Counseling Patients: Causes of Organ Damage,Counseling Patients: Treatment,JNC, 2005,Counseling Patients: Lifelong Treatment,Objective: reduce BP and metabolic abnormalities Pharmacothe
17、rapy & lifestyle modification Reduce sodium intake Weight loss Exercise Moderating alcohol Reduce systolic BP by 21 to 55 mm Hg,Cecil, 2004,Counseling Patients: Dietary Changes,Losing only 10 to 12 lbs lowers BP by 10/5 mm Hg Reduce daily salt 10 to 6 grams Teach patients to read food labels DASH Di
18、et www.nhlbi.nih.gov/health/public/heart/dash,Cecil, 2004,Counseling Patients: Health Behaviors,JNC, 2005,Counseling Patients: Helpful Resources,,Barriers to Successful Health Behavior Modifications,Lack of education Lack of access to safe places to exercise Added salt in prepared foods and restaura
19、nt meals Higher cost of foods low in saltPatient self-management is realistic and feasible!,Cecil, 2004,Pharmacologic Therapy,Scientific proof lowering BP reduces organ damage Certain classes of antihypertensive agents exert organoprotective effects Not all medications equal,Cecil, 2004; JNC, 2005,M
20、ajor Challenges for Science,Identify the key gene-environment interactionsEliminate the patient and medical provider barriers,ADA, 2003,Counseling Patients: Target Blood Pressure,Most patients below 140/90 mm Hg Patients w/ diabetes or chronic disease 130/80 mm Hg Help patients self-monitor BP 1/3 d
21、o not know they are hypertensiveResearch studies on targeting BP,Cecil, 2004,Improve Hypertension Control Rates,Titrating blood pressure medications to achieve target goalsMost patients require 2 or 3 antihypertensive medicationsPatient compliance with multi-drug regimens,ADA, 2005,Patient Complianc
22、e and Quality of Life,Hypertension requires lifelong treatment Medications can produce side effects Men often concerned with sexual dysfunction Patients with controlled BP, rate a significantly higher quality of life,Cecil, 2004,Patient Compliance Principles,Titrating medical therapy based on home r
23、eadings Long-acting preparations w/ once daily dosing Low dose combinations of medications from different drug classes Fixed-dose combinations to reduce overall number of pills,JNC, 2005,Drug Therapy,Old method: high-dose monotherapy Recent studies (ex. ALLHAT) At least 2 medications of different cl
24、asses to treat mild hypertension 3 or 4 different medications to treat more difficult cases Thiazide-type antihypertensive medications cost-effective Initial treatment: Beta blockers, Angiotensin-converting enzyme (ACE) inhibitors, Angiotensin receptor blockers, Calcium antagonists,Cecil, 2004,Stage
25、 2 Drug Therapy,JNC recommends: 2 drug combination Additional medications needed for each 10 mm Hg of systolic BP above goal Great majority should include low-dose diuretic High-risk conditions (heart failure/diabetes) Angiotensin-converting enzyme inhibitors (ACE-Is) Angiotensin receptor blockers (
26、ARBs),Cecil, 2004,Cardio Events in Hypertensive Patients,Verdecchia, Carin, Circo,2001,Left Ventricular Hypertrophy,, 2007,Counseling Patients: Contradictions & Side Effects,Considerations For Individualizing Antihypertensive Drug Therapy,Hypertensive Sub-Populations,Hypertensive patients with nephr
27、osclerosisDiabetic hypertensive patientsHypertensive patients with coronary artery diseaseIsolated systolic hypertension in older personsHypertensive disorders of women Oral contraceptives Pregnancy,Cecil, 2004,Hypertension Case Study,How would we modify his treatment since he did not change his health behaviors (and he is diabetic)?,Thank you for attending,
