Treatment of Hypertension Treatment of Hypertension

1. Treatment of Hypertension
Jai Radhakrishnan, M.D.
Division of Nephrology
Based on the Seventh Report of the
Joint National Committee on
Prevention, Detection ,Evaluation and Treatment
of High Blood Pressure (JNC-7)

2. Objectives
Define hypertension
Principles of treatment
Special groups

3. Slide Source
HypertensionOnline
www.hypertensiononline.org
0
20
40
60
80
Prevalence of Hypertension in the USPrevalence of Hypertension in the US
Percent hypertensive
18-29
Based on NHANES III (phase 1 and 2)
Hypertension defined as blood pressure ³140/90 mmHg or treatment
30-3940-4950-5960-6970-7980+
Age
3 %
9 %
18 %
38 %
51 %
66 %
72 %
JNC-VI. Arch Intern Med. 1997;157:2413 -2446. www.hypertensiononline.org

4. Blood Pressure Classification
>100>160Stage 2 HTN
90-99140-159 orStage 1 HTN
80-89120-139 orPrehypertension
<80<120 andNormal
DBPSBP
BP
CLASSIFICATION

5. Why Treat Hypertension ?
To decrease:
Cerebrovascular Accidents 35-40%
Coronary events 20-25%
Heart failure 50%
Progression of renal disease
Progression to severe hypertension
All cause mortality

6. Awareness, Treatment and Control of
Blood Pressure 1976-2000 (NHANES)
0
10
20
30
40
50
60
70
80
1976-19801988-19911991-19941999-2000
Awareness
Treatment
Control

7. Factors to Consider in Treating
Hypertension
Repeat readings
r/o secondary causes
Estimate CV risk status
Co-morbid conditions
Lifestyle changes
Drugs

8. “Secondary” Hypertension
Difficult to control
Sudden onset of HTN
Well controlled-> difficult to
control
Severe hypertension
History/physical/labs

9. Initial Workup of
Secondary HTN
Renal parenchymal disease
 UA, spot urine protein/creatinine, serum creatinine, USG.
Renovascular
 Captopril scan
Coarctation
Lower Extremity BP
Primary aldosteronism
Serum and urinary K
Plasma renin and aldosterone ratio
Pheochromocytoma
Spot urine for metanephrine/creatinine

10. Laboratory Tests in
Uncomplicated HTN
ECG
Urine analysis
Blood glucose, hematocrit
Basic metabolic panel
Lipid profile after 9-12 hour fast
Urine microalbumin

11. Estimate Risk Status
Hypertension
Smoking
Obesity (BMI > 30kg/m
2
)
Dyslipidemia
Diabetes
Microalbuminuria or GFR <60ml/min
Age > 55 (men), 65 (women)
Family history of CVD
(Men< 55, Women <65)
Metabolic Syndrome

12. Target Organ Damage
Heart Disease
CAD (Angina, myocardial infarction, coronary
revascularization
Left Ventricular Hypertrophy
Heart Failure
Stroke/TIA
Chronic kidney disease
Peripheral arterial disease
Retinopathy

13. Goals of Therapy
BP <140/90 mmHg
BP <130/80 mmHg in patients
with diabetes or chronic kidney disease.
Achieve SBP goal especially in persons
>50 years of age.

14. Lifestyle Modification
Approximate SBP reduction
(range)
Modification
5–20 mmHg/10 kg weight lossWeight reduction
8–14 mmHgAdopt DASH eating plan
2–8 mmHgDietary sodium reduction
4–9 mmHgPhysical activity
2–4 mmHgModeration of alcohol
consumption

15. Drugs for Hypertension
Diuretics
Thiazide
Loop diuretics
Aldosterone antagonists
K-sparing
Adrenergic inhibitors
Peripheral agents
Central (α-agonists)

alpha -blockers*
beta-blockers
Alpha+beta-blockers
Direct Vasodilators *
Calcium channel
blockers
Dihydropyridine
Non dihydropyridine
ACE-inhibitors
Angiotensin-II blockers
* Usually not monotherapy

17. 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
Drug(s) for the compelling
indications
Other antihypertensive drugs
(diuretics, ACEI, ARB, BB, CCB)
as needed.
With Compelling
Indications
Lifestyle Modifications
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)
Stage 1 Hypertension
(SBP 140–159 or DBP 90–99
mmHg)
Thiazide-type diuretics for most.
May consider ACEI, ARB, BB, CCB,
or combination.
Without Compelling
Indications
Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved.
Consider consultation with hypertension
specialist.

18. Classification and Management
of BP for adults
*Treatment determined by highest BP category.
†
Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.
‡
Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.
Two-drug combination
(usually thiazide and
ACEI or ARB or BB or
CCB).
Yes or
>100
>160 Stage 2
Hypertension
Other
antihypertensive
drugs (diuretics,
ACEI, ARB, BB,
CCB) as needed.
Thiazide-type diuretics
for most. May consider
ACEI, ARB, BB, CCB, or
combination.
Yes or 90–
99
140–
159
Stage 1
Hypertension
Drug(s)No antihypertensive drug
indicated.
Yes or 80–
89
120–
139
Pre-
hypertension
NoneNoneEncourage <80 <120 Normal
Compelling
indications
Without compelling
indication
Initial drug therapy
LifestyleDBP SBPBP Class

19. Heterogeneity of “Essential”
Hypertension
0%
20%
40%
60%
80%
100%
Patient 1 Patient 2 Patient 3
Sodium
Sympathetic N.S.
Renin-Angiotensin

20. Special Considerations
Compelling Indications
Special populations

21. HTN with COPD and MI
A 55 year old patient with COPD and HTN (controlled
with nifedipine) is admitted with severe chest pain
x24 hrs.
BP is 170/100 and she has a soft S3 gallop.
ECG shows an anterior wall MI.
She is not a candidate for thrombolysis. ECHO shows an
ejection fraction of 35%.
How will you manage her hypertension?

22. Compelling Indications for
Certain Drug Classes

23. HTN with CAD
Beta blockers: cardioprotective
(reinfarction, arrhythmias and sudden
death)
ACE inhibitors: MI with systolic
dysfunction- heart failure and mortality
improved

24. Renal Insufficiency
A 30 year old patient with IDDM is referred
with difficult-to-control HTN on diltiazem and
clonidine.
Exam reveals BP=190/100 and 3+ edema.
Labs: Creatinine = 2.2 mg/dL
Serum K = 5.1 meq/L
24 hour protein = 5 g

25. Hypertension with Renal Insufficiency
Goal BP <130/80
ACE-inhibitors/angiotensin receptor blockers
should be used if no contraindications
Most patients have volume overload:
Diuretics should be included in the regimen.
Thiazides ineffective if S Creat>2.5

26. A 40 year old previously healthy male is brought to the E.R. with 3
days of progressive shortness of breath and has experienced
blurred vision in both eyes.
Physical exam:
Blood pressure 230/140. Lethargic.
Eye exam: Papilledema
Chest: Bibasilar crackles
Cardiac: S1S2S4
Neuro: Bilateral upgoing plantars:
Extr: 2+ edema
Labs: K=3.4, BUN=35, Creatinine: 2.2
CXR: Pulmonary edema
Urine: 10-15 red cells, 2+ albumin.

27. Hypertensive Urgencies and
Emergencies
HYPERTENSIVE EMERGENCIES
Require immediate blood pressure reduction (not necessarily
to normal range) to prevent or limit target organ damage.
HYPERTENSIVE URGENCIES
Require reduction of blood pressure within a few hours

28. Emergencies
& Urgencies
HYPERTENSIVE
EMERGENCIES
Require immediate
blood pressure
reduction (not
necessarily to normal
range) to prevent or
limit target organ
damage.
HYPERTENSIVE
URGENCIES
Require reduction of
blood pressure within a
few hours

29. Parenteral Drugs For Treatment of
Hypertensive Emergencies
VASODILATORS
Nitroprusside
Fenoldopam
Nitroglycerine
Enalaprilat
Nicardipine
Hydralazine
ADRENERGIC
INHIBITORS
Labetalol
Esmolol
Phentolamine

30. Pregnancy and Hypertension
A 24 year old primiparous woman is seen in the
obstetric clinic at 30 weeks gestation.
BP: 160/100, 2 + pedal edema
Otherwise unremarkable physical exam.
Urine shows 1000 mg of protein. Other labs: N
After 2 days of bed rest BP remains 160-170/100

31. Drug Therapy of the Hypertensive
Pregnant Patient
Methyldopa: Drug of choice.
Beta blockers (not early pregnancy).
Hydralazine is the parenteral drug of
choice.
Most agents if used prior to pregnancy
may be continued
(except ACE-I OR A-II BLOCKERS)

32. Resistant Hypertension
Improper BP measurement
Excess sodium intake
Inadequate diuretic therapy
Medication
• Inadequate doses
• Drug actions and interactions (e.g., nonsteroidal anti-inflammatory
drugs (NSAIDs), illicit drugs, sympathomimetics, oral contraceptives)
• Over-the-counter (OTC) drugs and herbal supplements
Excess alcohol intake
Identifiable causes of HTN

33. Conclusions
The initial approach to hypertension should start with ruling out secondary
causes, detecting and treating other cardiovascular risk factors, and
looking for target organ damage.
Treatment should always include lifestyle changes.
Medication use should be guided by the severity of HTN and the
presence of “compelling” indications.
Thiazide-type diuretics should be initial drug therapy for most, either
alone or combined with other drug classes.
Most patients will require two or more antihypertensive drugs

34. Conclusions
HTN is a risk factor for mortality and
cardiovascular and renal disease
HTN is common but not controlled.
Target BP 140/90 (130/80 in DM, CKD)
Remember Compelling Indications

35. www.nhlbi.nih.gov/