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Management of Hypertension

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Management of Hypertension

  1. 1. HYPERTENSIONHYPERTENSION AND ITSAND ITS MANAGEMENTMANAGEMENT Dr. Md.Toufiqur Rahman MBBS, FCPS, MD,FACC, FESC, FRCP, FSCAI,FAPSIC, FAPSC, FCCP Associate Professor of Cardiology National Institute of Cardiovascular Diseases Sher-e-Bangla Nagar, Dhaka-1207 Consultant, Medinova, Malbagh branch.
  2. 2. Hypertension A World Wide Epidemic Nearly 1 billion hypertensive in the world Hypertension is poorly controlled, with less than 25% controlled in developed countries and less than 10% in developing countries. Hypertension which is responsible for 3 million death annually. May 14th is World Hypertension Day
  3. 3. Prevalence ofPrevalence of HypertensionHypertension 131 144 302 584 240 0 100 200 300 400 500 600 PrevalenceRate/1000 1 India (2000) Bangladesh (2002) Malaysia (2002) China (2002) USA (2002)
  4. 4. Hypertension is a hemodynamic disorder A well accepted definition of hypertension was suggested by Evans and Rose: “Hypertension should be defined in the terms of blood pressure level above which investigation and treatment do good more than harm” A patient is said to be hypertensive when his SBP≥ 140 mm Hg & DBP ≥ 90 mm Hg provided that the patient is not on antihypertensive drugs. Hypertension: DefinitionHypertension: Definition
  5. 5. Varieties OF HTNVarieties OF HTN Labile HTN Isolated diastolic hypertension Isolated systolic hypertension Malignant or accelerated Hypertension Refractory/ Resistant hypertension Hypertensive emergencies/ urgencies
  6. 6. Classification of BP for AdultsClassification of BP for Adults JNC-VI;1997JNC-VI;1997 BP Classification Systolic BP Diastolic BP Optimal <120 and <80 Normal <130 and <85 High Normal 130-139 or 85-89 Stage 1 HT 140-159 or 90-99 Stage 2 HT 160-179 or 100-109 Stage 3 HT ≥ 180 or ≥ 110 BP Classification Systolic BP Diastolic BP Normal <120 and <80 Prehypertension 120-139 or 80-89 Stage 1 HT 140-159 or 90-99 Stage 2 HT ≥ 160 or ≥ 100 JNC-VII;2003JNC-VII;2003
  7. 7. Classification of BP LevelsClassification of BP Levels ESH-ESC Guidelines, 2003 BP Classification Optimal Normal High Normal Grade 1 HT (mild) Grade 2 HT (moderate) Grade 3 (severe) Isolated systolic HT Systolic BP <120 120-129 130-139 140-159 160-179 >180 >140 Diastolic BP <80 80-84 85-89 90-99 100-109 >110 <90
  8. 8. Regulation of BP BP = CO X PVR SV HR
  9. 9. Haemodynamic Pattern inHaemodynamic Pattern in HypertensionHypertension Young : ↑ BP = ↑CO X TPR Middle Aged : ↑ BP = CO X TPR Elderly : ↑ BP = ↓ CO X ↑ ↑ TPR
  10. 10. Aetiology of SystemicAetiology of Systemic HypertensionHypertension A) Essential or Primary HTN (95%) A. ↑ Age B. Genetic • Both parents (45%) • Single (25%) C. Environment • Diet Fat Salt alcohol • Obesity • Physical inactivity • Stress • Smoking D. Hormonal
  11. 11. Aetiology of SystemicAetiology of Systemic HypertensionHypertension B) Secondary HTN (05%) A. Renal (80%) • AGN • CGN, • CPN, • Polycyst. K.D • Renal Artery stenosis B. Endocrine • Adrenal • Primary aldosteronism • Cushing’s syndrome  Pheochromocytoma • Acromegaly • Exogenous hormone • Oral contraceptive) • Glucosteroids • Hypothyroidism & • Hyperparathyroidism Continue…
  12. 12. C) Others  Coarctation of the aorta  Pregnancy Induced HTN (Pre-eclampsia)  Sleep Apnea Syndrome. Aetiology of SystemicAetiology of Systemic HypertensionHypertension
  13. 13. Clinical ManifestationClinical Manifestation • Asymptomatic in the majority of patients. Can remain undetected for many years • Headache may occur when SBP rises above 200mmHg or when blood pressure is rapidly elevated.
  14. 14. Measuring Blood PressureMeasuring Blood Pressure • Patient seated quietly for at least 5minutes in a chair, with feet on the floor and arm supported at heart level •An appropriate-sized cuff (cuff bladder encircling at least 80% of the arm) •At least 2 measurements Continue…
  15. 15. Measuring Blood PressureMeasuring Blood Pressure • Systolic Blood Pressure is the point at which the first of 2 or more sounds is heard • Diastolic Blood Pressure is the point of disappearance of the sounds (Korotkoff 5th) Continue…
  16. 16. Measuring Blood PressureMeasuring Blood Pressure • Ambulatory BP Monitoring - information about BP during daily activities and sleep. • Correlates better than office measurements with target-organ injury. Continue…
  17. 17. Complication of HypertensionComplication of Hypertension 1. Cardiac : LVH LVF •Systolic •Diastolic IHD Arrhythmias 2. Vascular Peripheral arterial disease •Aortic dissection 3. Cerebral Stroke TIA Encephalopathy 4. Renal Nephropathy Renal failure 5. Eye Retinopathy
  18. 18. The scope of the problemThe scope of the problem – Heart Attack (MI) – Heart Failure – Stroke – Kidney Disease THEREFORE EARLY DIAGNOSIS IS ESSENTIAL TO MINIMISE CARDIOVASCULAR RISK AND DAMAGE TO TARGET ORGANS
  19. 19. Hypertension even today is aHypertension even today is a triple paradox which is :triple paradox which is : Easy to diagnose OFTEN remains undetected Simple to treat OFTEN remains untreated Despite availability of potent drugs, treatment all too OFTEN is ineffective
  20. 20. The "Rule of Halves" inThe "Rule of Halves" in HypertensionHypertension Only 1/2 have been diagnosed Only 1/2 of those diagnosed have been treated Only 1/2 of those treated are adequately controlled Only 12.5% overall are adequately controlled Not diagnosed Not treated Not controlled Controlled
  21. 21. Evaluation of hypertensive patientsEvaluation of hypertensive patients Objectives: To know accurate and representative measurement of BP To identity any known cause of Hypertension To assess presence or absence of TOD To assess response to therapy To identity cardiovascular risks factor To know concomitant disorders Continue….
  22. 22. Evaluation of hypertensive patientsEvaluation of hypertensive patients Evaluation by Medical history Physical Examination Laboratory investigation  Routine tests  Optional tests.
  23. 23. Effects of Antihypertensive Drug Treatment onEffects of Antihypertensive Drug Treatment on CV Mortality and MorbidityCV Mortality and Morbidity Combined result from 17 randomized, placebo-controlled treatment trials; decreased in events-treated compared to control Arch Intern Med.1993;153: 578-581and JACC,1996; 27:121478 -52% -38% -35% -25% -16% -60% -50% -40% -30% -20% -10% 0% CHF Strokes (fatal/nonfatal) LVF CVD Deaths CVD events (fatal/nonfatal Management of HTNManagement of HTN
  24. 24. 140 120 100 80 60 40 20 0 50 40 30 20 10 0 Historical Lessons About HypertensionHistorical Lessons About Hypertension Hypertension Increases Morbidity and Mortality Men Women CHDIncidenceRate/1000 personsperyear THE FRAMINGHAM STUDY Cumulativefatal& NonfatalEndpoints Treatment Decreases Morbidity and Mortality Men Women Placebo Active Treatment THE VET.ADM. STUDY II Ann Inter Med. 1961; 55:33-50 JAMA. 1970;213:1143-1152 Normotension Hypertension
  25. 25. Implication of reduction in Diastolic BP forImplication of reduction in Diastolic BP for Primary PreventionPrimary Prevention 30 20 %Reduction Change in DBP 0 -10 -20 -30 -40 -50 7.5 mm Hg 5-6 mm Hg 2 mm Hg -21 -46 -16 -38 -6 -15 CHD Stroke Cook, et al. Arch Int med. 1995; 155:711-109
  26. 26. Millimeters Matter……Millimeters Matter…… “ A 2-mm Hg reduction in DBP would result in… a 6% reduction in the risk of CHD and a 15% reduction in the risk of stroke and TIAs” Cook, et al. Arch Int med. 1995; 155:711-109
  27. 27. Impact of High Normal BP on CVImpact of High Normal BP on CV Disease Risk in MenDisease Risk in Men High Normal 130-139/ 85-89 mm Hg Normal 120-129/ 80-84 mm Hg Optimal <120/ 80 mm Hg CumulativeIncidence(%) Time (Years) N Engl J Med. 2001;345:1291-97
  28. 28. Benefits of Lowering BPBenefits of Lowering BP Average percent reduction Stroke reduction 35-40% Myocardial infarction 20-25% Heart failure 50%
  29. 29. Goals of TherapyGoals of Therapy • Reduction of cardiovascular and renal morbidity and mortality. 1 • The primary focus should be on achieving the systolic BP goal. • Systolic BP and diastolic BP to targets < 140/90 mmHg = decrease in CVD complications. • In patients with hypertension with diabetes or renal disease, the BP goal is < 130/80 mmHg 1 1 JNC - VII Report, JAMA , 2003;289:2560-2572
  30. 30. JNC VII Algorithm for Treatment of Hypertension JNC - VII Report, JAMA , 2003;289:2560-2572 Lifestyle Modifications Not at Goal BP (< 140/90 mmHg or < 130/80 mmHg for Those with Diabetes or Chronic Kidney Disease Initial Drug Choices
  31. 31. Lifestyle Modification: 1Lifestyle Modification: 1 ⇒ Socioeconomic condition in the world suggest that prevention through Lifestyle Modifications is the universal “vaccine” against Hypertension ⇒Weight Reduction – Maintain normal body weight • BMI: 18.5 – 24.9 • BP reduction: 5-20 mmHg/10 kg loss ⇒DASH Eating Plan – Dietary Approaches to Stop Hypertension • Fruits, Vegetables, Low-fat dairy • Reduce saturated and total fat • 8-14 mmHg BP reduction
  32. 32. Lifestyle Modification: 2Lifestyle Modification: 2 ⇒Dietary Sodium Reduction •2.4 grams Sodium or 6 grams Sodium Chloride •2-8 mmHg BP reduction ⇒Physical Activity –Regular aerobic physical activity •4-9 mmHg BP reduction
  33. 33. Lifestyle Modification: 3Lifestyle Modification: 3 ⇒Smoking Cessation •Any independent chronic effect of smoking on BP is small •Smoking cessation does not decrease BP •BUT total cardiovascular risk is increased by smoking. Therefore hypertensives who smoke should be counselled on smoking cessation
  34. 34. Antihypertensive Drugs Continue…. AT1 receptor ARB
  35. 35. Antihypertensive Drugs
  36. 36. JNC VII Algorithm for Treatment of Hypertension Hypertension without compelling indications Hypertension with compelling indication (Systolic Bp 140-159 mmHg or Diastolic BP 90-99 mmHg) Thiazide-Type Diuretics for Most May Consider ACE inhibitor, ARB, ß- blocker, CCB or combination Systolic Bp >160 mmHg or Diastolic BP > 100 mmHg) 2- Drug Combination for Most (Usually Thiazide - Type Diuretic and ACE Inhibitor or ARB or ß-blocker, CCB) Drug (s) for the Compelling Indications Other Anithypertensive Drugs (Diuretics, ACE inhibitor, ARB, ß- blocker, CCB) as Initial Drug Choices
  37. 37. ChoiceChoice of antihypertensiveof antihypertensive • Diuretics, beta-blockers, calcium antagonists, ACE-inhibitors, angiotensin receptor antagonists) are suitable for the initiation and maintenance of therapy • Choice: → Previous experience of the patient → Cost → Risk profile, target organ damage, clinical cardiovascular or renal disease or diabetes or lung disorder → Patient’s preference • Long acting preparations providing 24-h efficacy on a once daily basis (2003 European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension. Journal of Hypertension 2003 vol21 no6 p1011-1063).
  38. 38. Special ConsiderationsSpecial Considerations Guideline Basis for Compelling Indications for Individual Drug Classes High Risk Conditions With Compelling Indication Heart failure Post-myocardial infarction High coronary disease risk Diabetes Chronic Kidney Disease Recurrent stroke prevention Recommended Drugs Diuretic β-blocker ACE inhibitor ARB CCB Aldosterone Antagonist JNC - VII Report, JAMA , 2003;289:2560-2572
  39. 39. Choice Between MonotherapyChoice Between Monotherapy and Combination therapyand Combination therapy
  40. 40. Possible Combination ofPossible Combination of Antihypertensive AgentsAntihypertensive Agents Diuretics Beta Blocker ∝-Blocker ACE inhibitor CCBs ARBs EHS-ESC Guidelines, 2003;
  41. 41. Indications and Contraindications forIndications and Contraindications for the Major Classes of Antihypertensiuethe Major Classes of Antihypertensiue DrugsDrugs Class Conditions favouring the use Compelling contraindications Possible contraindications ACEIs CHF LV dysfunction Post-MI Nondiabetic nephropathy Type 1 diabetic nephropathy Protienuria Pregnancy Hyperkalaemia Bilateral RAS ARBs Type 2 diabetic nephropathy Diabetic microalbuminuria Proteinuria LVH ACE inhibitor cough Pregnancy Hyperkalaemia Bilateral RAS a-Blockers Prostatic hyperplasia (BPH) Hyperlipidaemia Orthostatic hypotension CHF EHS-ESC Guidelines, 2003;
  42. 42. EVOLUTION OF HYPERTENSIONEVOLUTION OF HYPERTENSION MANAGEMENTMANAGEMENT JNC I 1977 JNC II 1980 JNC III 1984 JNC IV 1988 JNC V 1993 JNC VI 1997 JNC VII 2003 High Dose diuretic High Dose diuretic Lower Dose diuretic Or β-blocker Lower Dose diuretic Or β-blocker Or ACEI Or CCB Lower Dose diuretic Or β-blocker Or ACEI Or CCB α-blocker Or α / β blocker • Individulised Therapy •Single-agent titration preferred •Loe-dose combo therapy as a secondary option •Focus on Systolic BP Control •Thiazide- type diuretics preferred as initial drug treatment •Emphasis on combinatio n therapy High-dose Monotherapy Low-dose Combination
  43. 43. Management of HTN in SpecialManagement of HTN in Special SituationSituation 1. Hypertension Crises Hypertension Emergencies Hypertension Urgencies 2. Refractory/ Resistant hypertension 3. HTN in Pregnancy 4. HTN with coexisting Cardiovascular & other disorders 4. Management of Secondary HTN
  44. 44. Resistant Hypertension • Not uncommon : 15-20% • Persistence of elevated systo-diastolic pressure in spite of at 3 anti-hypertensive drugs ( including diuretics) • Pre-requisites: Exclusion of pseudo-hypertension; white-coat hypertension,use of not-appropriate cuffs.
  45. 45. Resistant hypertension: Causes • Insufficient patient compliance • Inability to follow prescribed life-style modifications ( weight loss, increased alcohol consumption) • Use of offending drugs: steroids,NSAID • Obstructive Sleep apnoea syndrome • Volume overload
  46. 46. Therapeutic intervention • Exclude undiagnosed secondary hypertension • Compliance of drugs • Adherence to life style changes • Consider use of 3 or more anti-hypertensive drugs • Consider the use of drugs such as spironolactone
  47. 47. Failure of reduction of DBP<90 mm Hg despite the use of three or more drugs which include a diuretic Resistant hypertension Braunwald’s Heart Disease, 2005
  48. 48. Volume overload & pseudotolerance “White coat” Pseudohypertension in the elderly Excess sodium intake Inadequate diuretic therapy Volume retention Drug related Dosage too low Inappropriate combination Drug interaction Associated conditions Smoking Obesity Excess alcohol Sleep apnea Secondary hypertension Resistant hypertension Causes: Braunwald’s Heart Disease, 2005
  49. 49. Current recommendations for primary prevention of hypertension involve:  a population based approach, and  an intensive targeted strategy focused on individuals at high risk for hypertension. Primary Prevention of Hypertension Hypertension Primer, AHA, 2004
  50. 50. Conclusion • Hypertension is easy to diagnose and easy to treat • Aim of the management is to save the target organ from the deleterious effect • Pharmacological armament of antihypertensive drugs so rich that we have wide range of options. And this makes the physicians comfortable in varied situations. Conversely one needs to be judicious regarding the choice of the drug • Besides pharmacology we have other choices and one has to be acquainted with that choice • Primary prevention of hypertension should be highlighted and it should get more priority than it is getting now.
  51. 51. Hypertension - a worldwide epidemic It’s a disease which is responsible for 3 million death annually About 15-20% of Bangladeshi population is suffering from Hypertension HTN is very poorly controlled - < 25% in developed & < 10% in developing countries Early diagnosis & management can prevent end organ damage from HTN Target goal of BP in hypertensive patients:- < 140/90 mm Hg < 130/80 mm Hg for patients with DM & renal disease Lifestyle modification is the universal “Vaccine” against Hypertension ConclusionConclusion
  52. 52. Thank you !Thank you !

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