Hypertension

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The Silent Killer
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Hypertension
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By Hai Ho, MD
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My doctor thought that blood pressure of
150/95was pretty good
I have hypertension
My doctor would not treat me because I was an
unassigned patient
My doctor thought I was OK, because I was
asymptomatic
My doctor maintained hypertension in the elderly
to prevent orthostatic hypotension
My doctor gave me the latest medication
recommended by a drug rep
My doctor thought that hypertension is a part of
aging because of stiff arteryies
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Myocardial infarction and congestive heart failure
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Cerebral Vascular Accident
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Renal Insufficiency Failure
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Why Do We Have To Talk About Hypertension again?
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Prevent
Black Out
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Goals

• What is hypertension?
• Why we do what we do?

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Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High
Blood PressureJNC 6 in 1997
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Recall
JNC 7
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Candidates
Intimidator
Sybaritor
Eliminator
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Hypertension is weapons of mass destruction, and
we need to take a preemptive strike against this
terrorist.
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Hypertension affect

• 50 million people in the U.S
• 1 billion people in the world

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Hypertension is a part of the normal aging
process?

• Myth

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Facts

• Two-third of patients with hypertension are over
  age 65
• Normotensive patients age 55 have a 90 lifetime
  risk of developing hypertension

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What is hypertension?

• Blood pressure
• 140/90 mmHg
• On 2 different occasions

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Prehypertension

• Systolic blood pressure 120-139 mmHg
• Diastolic blood pressure 80-89 mmHg

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Risk of Prehypertension

• For patients age 40-70 with blood pressure range
  115-185/75-115 mmHg
• With each incremental increase of 20 mmHg in
  systolic blood pressure and 10 mmHg in diastolic
  blood pressure, risk of cardiovascular disease
  doubles

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Moral of the story
Treat hypertension aggresively
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How Blood Pressure is Measured?

• Sit Relax for at least 5 minutes
• Arm bared and at heart level
• Bladder within the cuff at least 80 of arm
  circumference
• Average of ? 2 readings 2 minutes apart

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Ambulatory vs. Office Measurement?

• Lower than office measurement
• Consider hypertension if mean blood pressure
  gt135/85 mmHg

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Work-up Goals

• Identify secondary causes of hypertension
• Identify cardiovascular risk factors and
  concomitant disorders
• Assess target-organ damage and cardiovascular
  disease

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Secondary Causes of Hypertension?

• Drugs
• Sleep apnea
• Chronic renal disease
• Primary aldosteronism
• Cushing syndrome
• Pheochromocytoma
• Coarctation of the aorta
• Thyroid or parathyroid disease

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Major Cardiovascular Risk Factors?

• Cigarette smoking
• Obesity (BMI 30)
• Physical inactivity
• Dyslipidemia
• Diabetes mellitus
• Microalbuminuria or estimated GFR lt60 mL/min
• Age gt55 for men and gt65 for women
• Family history of premature cardiovascular
  disease men lt55 years or women lt65 years

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Target-Organ Damage?

• Cardiac LVH, MI, CHF
• Stroke
• Chronic kidney disease
• Peripheral arterial disease
• Retinopathy

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What is the most common cause of hypertension?

• Essential hypertension

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What Is The Most Common Presentation?

• Asymptomatic

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History What Could Cause Elevated Blood Pressure?

• Medications OCP, pseudoephrine, NSAID
• Diet High sodium, alcohol
• Illicit drugs
• Smoking
• Psychosocial Stress, work

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Axis of Evil

• Hypertension
• Diabetes mellitus
• Hyperlipidemia

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History What are the cardiovascular risk factors?

• Metabolic syndrome
• Blood pressure 130/85
• Glucose intolerance with FBS 110 mg/dL
• Triglyceride gt150 mg/dL or HDL lt40 mg/dL in males
  and lt50 mg/dL in females
• Abdominal obesity with waist circumference gt102
  cm for males and gt89 cm for female
• Past Medical History
• Coronary or cerebral vascular diseases
• Renal disease

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History What are the symptoms of target organ
damage?

• Increased intracranial pressure headache, blurry
  vision, confusion
• Heart chest pain

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Physical Exam?

• Fundoscopic Hypertensive retinopathy
• Carotid bruit Atherosclerosis
• JVD Congestive Heart Failure
• Thyroid gland Hyperthyroidism
• Heart S3S4 in congestive heart failure
• Lungs Rales in congestive heart failure
• Abdominal bruit Renovascular stenosis
• Extremities Edema in congestive heart failure,
  decreased femoral pulse in aortic coarctation

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Diagnostic Tests?

• Chemistry
• Sodium and potassium high cortisol or
  aldosterone
• Bun and creatinine kidney function
• Glucose diabetes mellitus
• Calcium - hyperparathyroidism
• Fasting lipid panel

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Diagnostic Tests

• CBC
• Urinalysis
• Proteinuria
• Hematuria glomerulonephritis
• EKG
• Cardiomegaly

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Blood Pressure Goal?
General lt140/90 mm Hg Diabetes mellitus and renal
disease lt 130/80
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How Hypertension Is Treated?
I would audit the PDR and get rid of wasteful
medications
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How hypertension should be managed?

• Lifestyle modification
• Medications

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Lifestyle Modification
BMI lt 27
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Lifestyle Modification Weight Reduction
Exercise, Exercise, Exercise
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Lifestyle Modification Diet
DASH Dietary Approach to Stop Hypertension
High in fruits, vegetables, low-fat dairy foods,
protein, fiber, potassium, calcium, and magnesium
Low in fat and cholesterol
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Lifestyle Modification Diet
Limit the salt to lt 2.5 gm sodium or lt 6 gm
sodium chloride per day
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Lifestyle Modification Alcohol
Beer 2 oz or 2 cans
Wine 10 oz or 1 glass
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Which Medication Should Be Started?
Viagra
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How do we pick medications?

• Recurrent Themes
• Target organ damage
• Cardiovascular risk factors and concomitant
  disorders

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Which medications should be used for
uncomplicated hypertension?
Diuretics
Beta-Blockers
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Diuretics

• FOR????
• Gout
• Potassium

Side Note Minimal effects on dyslipidemia and
glucose intolerance
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Beta-blockers
No, no.

• Asthma/COPD
• Depression
• Peripheral vascular disease
• Class IV congestive heart failure

Side Note Minimal effects on dyslipidemia and
glucose intolerance
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Which medication should be used in diabetics?
Pick one.
ce-Inhibitors or ARB
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ACE-inhibitors
Side Effect?
Hyperkalemia Renovascular stenosis
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Which Medications Should Be Used In Ischemic
Heart Disease?
ce-Inhibitors
Beta-Blockers
Calcium-channel blockers
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Calcium-channel Blockers
In what condition????

• Angina pectoris
• Non Q-wave MI
• MI without left ventricular dysfunction

Only nondihydropyridines diltiazem verapamil
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Calcium-channel Blocker Cautions
Side Effect?
Pitting edema Impotence (no illustration)
Do not use short-acting calcium-channel blockers
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Which medications should be used in CHF?
ce-Inhibitors
Loop diuretics aldosterone blockers
Beta-Blockers
Angiotensin receptor blockers
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Which medication should be used in renal
insufficiency?
ce-Inhibitors
Limitation Hyperkalemia
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Which medication should be used in BPH?
Alpha-blockers
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Combination Therapy

• Most patients need 2 drugs
• If blood pressure gt20 mmHg systolic or 10 mmHg
  diastolic, initiate 2 drugs

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Combination drugs

• ACE-I and CCB
• ACE-I and diuretics
• ARB and diruetics
• ?-blockers and diuretics
• Central acting drug and diuretics
• Diuretics and diuretics

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Hypertensive Emergency Urgency

• Emergency
• Encephalopathy Headache, nausea, vomiting,
  intracranial hemorrhage
• Heart Acute MI or left ventricular dysfunction,
  dissecting aortic aneurysm
• Urgency
• No acute target organ damage

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Hypertensive Emergency

• Control blood pressure within minutes to 2 hours
• Gradual reduction in blood pressure to avoid MI
  and CVA 25 or 20 mm Hg initially and slowly to
  160/100 mm Hg
• Medications Sodium nitroprusside esmolol
  because of quick onset of action and short
  duration (minutes)

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Hypertensive Urgency

• Control blood pressure within 24 hours
• Gradual reduction of blood pressure
• Medications Oral (not sublingual)
  calcium-blockers, beta-blockers, ace-inhibitors,
  ?2-blockers

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Hypertension
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Why hypertension again?
Confusion ?????????
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MD, BS, MS, DDS, OCP
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Hypertension
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Basic and Practical Approach to Hypertension
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Remember this basic dictum cold turkey

• Blood pressure ? 140/90 mmHg is NOT
• Stable or controlled

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Sophisticated Classification
Category Systolic (mm Hg) Diastolic (mm Hg)
Optimal lt120 lt 80
Normal lt130 lt85
High-normal 130-139 85-89
Hypertension
Stage 1 140-159 90-99
Stage 2 160-179 100-109
Stage 3 ?180 ?110