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Hypertension

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Title: PowerPoint Presentation Author: Daniel Varghese Last modified by: Humayun Chaudhry Created Date: 7/4/2001 11:11:26 PM Document presentation format – PowerPoint PPT presentation

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Title: Hypertension


1
Hypertension
  • Howard L. Sacher, D.O.
  • Long Island Cardiology and Internal Medicine

2
Learning Objectives
  • To know how to detect and diagnose hypertension
    and its secondary causes.
  • To become familiar with updated recommendations
    for classifying hypertensive patients.
  • To understand the pharmacologic options for
    treating hypertension and their appropriate use.
  • To grasp the importance of counseling patients on
    lifestyle modification to help control
    hypertension

3
Hypertension
  • Hypertension is the most well established and
    important risk factor for
  • 1 Cardiovascular disease
  • 2 Cerebrovascular events
  • 3 Congestive Heart Failure (CHF)
  • 4 End stage renal disease (ESRD)

4
Hypertension (cont)
  • There have been enormous advances in our
    understanding of the value of treating
    hypertension over the past three decades, yet the
    most recent surveys show that hypertension
    remains largely untreated and uncontrolled

5
Hypertension (cont)
  • The relationship between systolic and diastolic
    blood pressure is strong, graded and continuous
  • The higher the BP, the higher the risk
  • Systolic BP is a better predictor of
    cardiovascular disease at all ages but
    particularly in the older age group
  • Diastolic BP does not rise with age after the
    fifth decade, a time when isolated systolic BP
    begins to increase sharply in prevalence

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Patient Evaluation
  • Repeat BPs
  • Teach Patients to take BPs
  • Promotes participation by patient
  • May reduce costs by reducing visits
  • Ambulatory BP monitoring
  • BP
  • Evaluate diurnal variations
  • Patient at a greater risk for end organ disease

10
Patient Evaluation (cont)
  • History medication , lifestyle habits such as
    diet, exercise, smoking history, family history
    and review of symptoms that may reflect secondary
    hypertension, target organ disease or co-morbid
    conditions

11
Patient Evaluation (cont)
  • Physical Exam
  • BP standing and sitting in both arms and legs
  • Looking for patients with orthostatic hypotension
    over 60
  • Coarctation of the aorta in younger patients
  • Peripheral vascular disease
  • Fundoscopic exam looking for evidence of
    hypertensive retinopathy

12
Patient Evaluation (cont)
  • Evaluation of the Heart
  • S4 decreased LV function compliance precedes
    systolic dysfunction or S3 gallop
  • Evidence of CHF
  • Rales (Crackles)
  • Hepatomegaly
  • Peripheral Edema
  • Neurological exam for evidence of Cerebrovascular
    disease

13
Patient Evaluation (cont)
  • Laboratory Evidence
  • Complete blood count (CBC)
  • Renal failure and polycythemia
  • Chemistries Na, K, creatinine, fasting
    glucose and lipid profile
  • K - low in hyperaldosteronism, high in renal
    failure
  • Urinalysis
  • 12 lead EKG
  • LVH, Ischemia

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17
Pheochromocytoma
  • Pheochromocytoma
  • Catacholamine producing tumors can occur in the
    adrenal gland or anywhere along the
    neuroectodermal crest 10 of adults have
    multiple tumors
  • Triad
  • Episodic Headaches
  • Tachycardia
  • Diaphoresis with labile hypertension
  • Associated with multiple endocrine neoplastic
    (MEN) syndromes, neurofibromatosis, and Van
    Hipple Landau syndrome

18
Pheochromocytoma
  • Diagnosis
  • Postural hypertension
  • Resting tachycardia
  • Café au lait spots
  • Resting supine catacholamine levels gt 2000 pg/ml
    (nep, ep)
  • Clonidine suppression test
  • Lowers catacholamine levels in essential HTN but
    not pheochromocytoma
  • Glucagon (2mg IV) increases plasma catecholamines
    at least three fold or gt2000 1 to 3 minutes after
    administration in patients with pheochromocytoma

19
Pheochromocytoma
  • Tumor Localization accomplished by
  • CT scan
  • MRI
  • Radioisotope uptake studies
  • Treatment
  • Surgical removal of tumor
  • Alpha and beta adrenergic blockers are useful for
    chronic management or non-surgical cases (alpha
    blockers commonly used)

20
Hyperaldosteronism
  1. Spontaneous hypokalemia while on diuretics and
    potassium supplements
  2. Primary Hyperaldosteronism
  3. Small unilateral adenoma (lt1cm) is more common
    in women
  4. Bilateral adrenal hyperplasia is more common in
    men
  5. Diagnosis
  6. Measure 24 hour urinary aldosterone measurements
    for two days on high sodium diet (gt!4g/ 24 hours)
  7. Increased aldosterone with low levels of plasma
    renin activity
  8. Adenomas detected by MRI

21
Hyperaldosteronism (cont)
  • Treatment
  • Surgery for small solitary adenomas
  • Medical treatment for adrenal hyperplasia
  • Diuretics and vasodilators
  • Aldosterone antagonists do not reduce BP
    adequately but may be needed to correct
    hypokalemia

22
Renal Artery Stenosis
  • More commonly found stage 3 or resistant
    hypertension
  • When bilateral can have reduced kidney function
  • Clinical clues to renovascular disease
  • Onset before age 30 or recent onset of
    significant high BP after age 55
  • Abdominal bruit if diastolic and lateralized
  • Accelerated or resistant high blood pressure
  • Recurrent flash pulmonary edema
  • Renal failure with normal sediment
  • Co-exiting ASVD especially in long smokers
  • Acute renal failure particularly after ACE I or
    Angiotensin receptors blockers

23
Renal Artery Stenosis (cont)
  • Diagnosis
  • Captopril enhances radionuclide renal scan
  • Duplex doppler flow studies
  • MRI and MRA
  • Definitive diagnosis angiography
  • Treatment
  • Revascularization
  • Fibromuscular dysplasia Percutaneous
    transluminal renal angioplasty (PTRA) is
    comparable to surgery
  • Atherosclerotic renal artery stenosis ideal for
    PTCA with stenting if renal function normal
  • Surgery or PTCA with stenting to preserve renal
    function

24
  • LVH with left atrial enlargement

25
  • HTN 2nd to RAS

26
  • HTN 2nd to Fibromuscular Dysplasia

27
10-Minute Break
28
JNC - VI
  • Joint National Committee (JNC) on the Detection,
    Evaluation and Control of High Blood Pressure
  • Emphasis risk stratification for cardiovascular
    disease
  • Smoking
  • Dyslipidemia
  • Diabetes Mellitus
  • Old age
  • Male sex
  • Post-Menopausal
  • Family History of cardiovascular disease

29
At any given level of SBP the absolute risk of a
coronary event increases dramatically as compared
to those with no risks
30
Classifying patients with HTN with consideration
to target end organ damage/clinical
cardiovascular disease (TOD/CCD)
31
Lifestyle Modifications
  • Weight redistribution lowers BP but also has
    effect on lipids and glucose metabolism
  • There is a Metabolic Syndrome
  • Obesity
  • High BP
  • Hyperlipidemia
  • Insulin resistance or Diabetes
  • Reduction of dietary sodium
  • Correlation between dietary sodium and blood
    pressure most patients benefit from reducing
    intake to below 2400mg/day, 6 g salt. Also
    enhances the efficacy of anti-hypertensive agents
    and may reduce potassium effect of diuretic
    agents and minimize hypokalemia. (i.e. processed
    foods)

32
Lifestyle Modifications (cont)
  • Alcohol
  • 1 ounce of ethanol
  • 24 ounces of beer
  • 10 ounces of wine
  • 2 ounce of 100 proof whisky
  • Tobacco
  • Aerobic Exercise

33
Diabetic Hypertensive patients
  • Blood glucose controlled
  • Weight loss
  • Aerobic exercise
  • Angiotensin Converting Enzyme (ACE) Inhibitors or
    Angiotensis Receptor Blockers (ARB)
  • Treatment to lower BP using ACE-I and ARB
  • Microvascular retinopathy, nephropathy
  • Macrovascular CAD, angina, AAA, CVA
  • BP goals lt or to 120 / 80

34
Congestive Heart Failure
  • Treatment
  • ACE I
  • ARB
  • Diuretics
  • B-Blockers
  • Digitalis
  • Monitor for
  • Orthostatic hypotension
  • Renal function
  • K levels

35
Post-Myocardial Infarction
  • Treatment
  • ß-Blockers
  • ACE- I in patients with systolic dysfunction
  • Diltiazem or Verapamil in patients with non
    Q-wave infarction may be used if B-blocker
    ineffective or contraindicated

36
Isolated Systolic Hypertension (ISH) and
Hypertension in older patients
  • Higher risk for cardiovascular disease
  • Lifestyle modifications
  • Decreased vascular compliance due to loss of
    arterial elasticity associated with aging
  • Drug of choice
  • Low dose thiazide diuretics
  • Be concerned about postural hypotension or
    cognitive dysfunction (central alpha 2 agonists)

37
Ischemic Heart Disease
  • Treatment
  • B-Blockers
  • Calcium channel blockers as a second choice if
    beta blockers are contraindicated or both drugs
    can be used together to achieve BP goals
  • Treat risk factors
  • High lipids
  • Diabetes or Insulin resistance
  • Weight loss
  • ACE-Inhibitors

38
Renal Disease
  • Aggressive treatment to lower BP
  • lt or 130/85
  • Goal will slow rate of disease progression
  • ACE inhibitors are drugs of choice but must be
    used with caution if creatinine gt3 mg/dl and are
    not used when renovascular hypertension is
    suspected
  • Thiazide diuretics are not effective if serum
    creatinine is gt 2.5 mg/dl and loop diuretics are
    required

39
African-Americans and HTN
  1. High prevalence
  2. Occurs earlier, more severe and is associated
    with higher risks of cardiovascular disease
  3. Stroke and heart disease mortality rates 80 and
    50 higher respectively
  4. End stage renal disease 320 higher
  5. Lifestyle modifications
  6. Diuretics are drugs of choice for uncomplicated
    hypertension
  7. Ca channel blockers and alpha blockers are also
    effective
  8. All other drugs can be used to achieve BP goals

40
Women and HTN
  • Same therapy as men
  • If on OCP stop and monitor BP
  • During pregnancy ACE-I and ARB should be stopped
  • Alpha-Methyldopa during pregnancy

41
Patients Undergoing Surgery
  • If BP is gt 180/110, patient must be treated to
    reduce the risk of perioperative ischemic events
  • Cardio-selective beta-blockers, unless
    contraindicated, are drugs of choice
  • Hypertensive patients who are well controlled
    prior to surgery should be continued on their own
    regimen as soon as possible after surgery

42
Meta-analysis on the various first line drug
treatments
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BP gt 95th percentile is considered elevated in
children
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Hypertensive Emergencies
  • Reduce mean arterial pressure (MAP) no more than
    25 (minutes to several hours) and then to
    160/100 mmHg avoiding excessively rapid falls
    that may precipitate cerebral or coronary
    ischemia
  • Sublingual nifedipine is not recommended because
    of the relatively high risk for these adverse
    events

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Patient Education and Lifestyle modifications
  • Lose excess weight.
  • Cut the fat.
  • Limit alcohol intake.
  • Exercise regularly.
  • Reduce sodium intake.
  • Stop smoking.

55
Follow-up
  • Once stable, patients should be re-evaluated at
    least every 3 to 6 months
  • Review compliance, effectiveness and adverse
    reactions
  • Quality of life issues should be considered,
    including sexual function
  • At least annual evaluation of urinalysis,
    creatinine and potassium are appropriate,
    generally as part of a screening laboratory panel
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