Hypertension diagnosis and management

Hypertension causes and investigation and management according to jnc7 nad 8

1. diagnosis and management of hypertension PRESENTED BY DR SHASHANK AGRAWAL MEDICINE JR 2 Moderated by Dr M.P RAWAL M.D MEDICINE

2. Factors Influencing Blood Pressure Blood Pressure = Cardiac Output x Systemic Vascular Resistance

3. Factors Influencing BP Heart rate Vasoconstriction/ vasodilation Fluid volume overload Renin-angiotensin Aldosterone ADH

4. Hypertension defination Hypertension is defined as Systolic blood pressure > 140 mm of Hg Diastolic blood pressure > 90 mm of Hg

5. BP Classification SBP mmHg DBP mmHg Normal < 120 and < 80 Pre-hypertension* 120-139 or 80-89 Stage 1 Hypertension 140-159 or 90-99 Stage 2 Hypertension > 160 or > 100 Isolated systolic hypertension grade 1 Grade ii 140 – 159 > 160 < 90 < 90 Hypertension classification

6. Primary ( essential ) hypertension elevated BP with unknown cause 90% to 95% of all cases Secondary hypertension elevated BP with a specific cause 5% to 10 % in adults Continue..

7. Primary hypertension contributing factors : - increase sinus node activity DM increase sodium intake excessive alcohol intake continue..

8. Aetiology of Systemic Hypertension Secondary HTN (05%) A. Renal (80%) AGN CGN , Polycyst . K.D Renal Artery stenosis B. Endocrine Adrenal Primary aldosteronism Cushing’s syndrome Pheochromocytoma Acromegaly Exogenous hormone Oral contraceptive Glucocorticoids Hypothyroidism & Hyperparathyroidism Continue…

9. Others Coarctation of the aorta Pregnancy Induced HTN (Pre- eclampsia ) Sleep Apnea Syndrome .

10. Hypertensive Crisis Hypertensive Urgencies : No progressive target-organ dysfunction. (Accelerated Hypertension) Hypertensive Emergencies : Progressive end-organ dysfunction. (Malignant Hypertension)

11. Hypertensive Urgencies Severe elevated BP > 180 /110 mm of Hg Without progressive end-organ dysfunction. Examples : Highly elevated BP without severe headache, shortness of breath or chest pain. Usually due to under-controlled HTN.

12. Hypertensive Emergencies Severely elevated BP (> 220 / 140 mmHg ). With progressive target organ dysfunction. Require emergent lowering of BP. Examples : Severely elevated BP with: Hypertensive encephalopathy Acute left ventricular failure Acute MI or unstable angina pectoris Dissecting aortic aneurysm

13. Risk Factors for Primary Hypertension Age (> 55 for men; > 65 for women) Alcohol Cigarette smoking Diabetes mellitus Elevated serum lipids Excess dietary sodium Gender

14. Risk Factors for Primary Hypertension Family history Obesity (BMI > 30) Ethnicity (African Americans) Sedentary lifestyle Socioeconomic status Stress

15. • Frequently asymptomatic until severe and target organ disease has occurred Fatigue, reduced activity tolerance Dizziness Palpitations, angina Dyspnea Hypertension Clinical Manifestations

16. Diseases Attributable to Hypertension HYPERTENSION Gangrene of the Lower Extremities Heart Failure Left Ventricular Hypertrophy Myocardial Infarction Coronary Heart Disease Aortic Aneurym Blindness Chronic Kidney Failure Stroke Preeclampsia/Eclampsia Cerebral Hemorrhage Hypertensive encephalopathy

17. Hypertension: Complications Complications are primarily related to development of atherosclerosis (“hardening of arteries”), or fatty deposits that harden with age

18. Renal Parenchymal Disease Common cause of secondary HTN (2-5 %) HTN is both cause and consequence of renal disease Multifactorial cause for HTN including disturbances in Na/water balance, vasodepressors/ prostaglandins imbalance

19. Renovascular HTN Atherosclerosis 75-90% ( more common in older patients) Fibromuscular dysplasia 10-25% (more common in YOUNG /WHITE / FEMALE ) Other Aortic/renal dissection Takayasu’s arteritis Thrombotic/cholesterol emboli CVD Post transplantation stenosis Post radiation

20. Target Organs CVS (Heart and Blood Vessels) The kidneys Nervous system The Eyes

21. Effects On CVS Ventricular hypertrophy, dysfunction and failure. Arrhithymias Coronary artery disease, Acute MI Arterial aneurysm, dissection, and rupture.

22. Effects on The Kidneys Glomerular sclerosis leading to impaired kidney function and finally end stage kidney disease. Ischemic kidney disease especially when renal artery stenosis is the cause of HTN

23. Nervous System Stroke, intracerebral and subaracnoid hemorrhage. Cerebral atrophy and dementia

24. The Eyes Retinopathy, retinal hemorrhages and impaired vision. Vitreous hemorrhage, retinal detachment Neuropathy of the nerves leading to extraoccular muscle paralysis and dysfunction

25. Retina Normal and Hypertensive Retinopathy Normal Retina Hypertensive Retinopathy A: Hemorrhages B: Exudates (Fatty Deposits) C: Cotton Wool Spots (Micro Strokes) A B C

26. Stage I- Arteriolar Narrowing Arteriolar Narrowing

27. Stage II- AV Nicking AV Nicking AV Nicking AV Nicking

28. AV Nicking

29. Stage III- Hemorrhages (H), Cotton Wool Spots and Exudates (E) H E

30. Stage IV- Stage III+Papilledema

31. Measuring Blood Pressure Patient seated quietly for at least 5minutes on a chair , arm supported at heart level An appropriate-sized cuff (cuff bladder encircling at least 80% of the arm) At least 2 measurements

32. 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) Ambulatory BP Monitoring - information about BP during daily activities and sleep Range is > 125 /80 mm of Hg Continue…

33. Non pharmacological Treatment of hypertension Avoid harmful habits ,smoking , alcohol Reduce salt and high fiber diets Loose weight , if obese Regular exercise DASH diet

34. Jnc 8 recomendation General population > 60 yr B.P - < 150 /90 General population < 60 yr B.P < 140 /90 Population > 18 yr with CKD B.P < 140 /90 Population > 18 yr with or with out diabetes B.P < 140 /90

35. Treatment recomendation Non black including diabetes initial treatment - CCB, ACEI, ARBs , DIURETICS IN BLACK POPULATION – DIURETIC, CCB IN > 18 yr age with CKD – ACEI , ARBs

36. Comparisons to Other Guidelines BP Goal JNC-7 JNC-8 ASH/ISH ESC/ESH Age < 60 <140/90 <140/90 <140/90 <140/90 Age 60-79 <140/90 <150/90 <140/90 <140/90 Age 80+ <140/90 <150/90 <150/90 <150/90 Diabetes <130/80 <140/90 <140/90 <140/85 CKD <130/80 <140/90 <140/90 <130/90

37. Antihypertensive Drugs Continue…. AT 1 receptor ARB

38. Hypertensive drug classification

39. Diuretics Example: Hydrochlorothiazide , chlorothiazide , Indapamide , amiloride , triametrine , spironolactone , Act by decreasing blood volume and cardiac output Drugs of choice in elderly hypertensives S ide effects- Hypokalaemia Hyponatraemia Hyperlipidaemia Hyperuricaemia (hence contraindicated in gout) Hyperglycaemia (hence not safe in diabetes) Not safe in renal and hepatic insufficiency

40. Beta blockers Example: Atenolol, Metoprolol , nebivolol , Block b 1 receptors on the heart Block b 2 receptors on kidney and inhibit release of renin Drugs of choice in patients with co-existent CHD Side effects- lethargy, impotency, bradycardia Not safe in patients with co-existing asthma and diabetes Have an adverse effect on the lipid profile

41. Calcium channel blockers Example: Amlodipine Block entry of calcium through calcium channels Cause vasodilation and reduce peripheral resistance Drugs of choice in elderly hypertensives and those with co-existing asthma Neutral effect on glucose and lipid levels Side effects Flushing, headache, Pedal edema

42. ACE inhibitors Example : Ramipril , Lisinopril , Enalapril Inhibit ACE and formation of angiotensin II and block its effects Drugs of choice in co-existent diabetes mellitus, Heart failure Side effects- dry cough, hypotension, angioedema

43. Angiotensin II receptor blockers Example: Losartan , candesartan , valsartan Block the angiotensin II receptor and inhibit effects of angiotensin II Drugs of choice in patients with co-existing diabetes mellitus Side effects- safer than ACEI, hypotension,

44. Alpha blockers Example: prazosin , doxazosin Block a -1 receptors and cause vasodilation Reduce peripheral resistance and venous return Exert beneficial effects on lipids and insulin sensitivity Drugs of choice in patients with co-existing BPH Side effects- Postural hypotension,

45. Centrally acting drugs Example – clonidine , Alpha-methyldopa MOA – convert NA to alpha methyl NA which act on alpha 2 receptor in brain – decrease in adrenergic discharge – fall in PVR – fall in B.P D.O.C in hypertension in pregnancy.

46. Algorithm for Treatment of Hypertension Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease ) Initial Drug Choices With Compelling Indications Lifestyle Modifications Without Compelling Indications

47. Stage 1 Hypertension (SBP 140–159 or DBP 90–99 mmHg) Thiazide -type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination . Stage 2 Hypertension (SBP > 160 or DBP > 100 mmHg) 2-drug combination for most (usually thiazide -type diuretic and ACEI, or ARB, or BB, or CCB) Drug(s) for the compelling indications Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed . Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist .

48. Choice of Drug Condition Preferred drugs Other drugs Drugs to be that can be used avoided Asthma Calcium channel a -blockers/Angiotensin-II b -blockers blockers receptor blockers/Diuretics/ ACE-inhibitors Diabetes a -blockers/ACE Calcium channel blockers Diuretics/ mellitus inhibitors/ b -blockers Angiotensin-II receptor blockers High cholesterol a -blockers ACE inhibitors/ A-II b -blockers/ levels receptor blockers/ Calcium Diuretics channel blockers Elderly patients Calcium channel  -blockers/ACE- (above 60 years) blockers/Diuretics inhibitors/Angiotensin-II receptor blockers/  - blockers BPH a -blockers b -blockers/ ACE inhibitors/ Angiotensin-II receptor blockers/ Diuretics/ Calcium channel blockers

49. Antihypertensive therapy: Side-effects and Contraindications (Contd .) Class of drug Main side-effects Contraindications/ Special Precautions Calcium channel blockers Pedal edema, Headache (e.g. Amlodipine Diltiazem ) Hypersensitivity, Bradycardia , Conduction disturbances, CHF, LV dysfunction. a -blockers Postural hypotension Hypersensitivity (e.g. prazosin ) ACE-inhibitors Cough, Hypotension, Hypersensitivity, Pregnancy, (e.g. Lisinopril ) Angioneurotic edema Bilateral renal artery stenosis Angiotensin-II receptor Headache, Dizziness Hypersensitivity, Pregnancy, blockers (e.g. Losartan) Bilateral renal artery stenosis

50. Condition Pregnancy Coronary heart disease Congestive heart failure Preferred Drugs Nifedipine , labetalol , hydralazine , beta-blockers, methyldopa, prazosin Beta-blockers, ACE inhibitors, Calcium channel blockers ACE inhibitors, beta-blockers

51. Causes of Resistant Hypertension Improper BP measurement Excess sodium intake Inadequate diuretic therapy Medication Inadequate doses Drug actions and interactions (e.g., (NSAIDs), illicit drugs, sympathomimetics, OCP) Over-the-counter drugs and some herbal supplements Excess alcohol intake Identifiable causes of HTN