MANAGEMENT OF HT BY DR.ARSHAD FUAD () () () MBCHB, FIBMS )MEDICINE(, CABM ()MEDICINE(, FIBMS)CARDIOLOGY Treatment
Overview Goals of therapy Lifestyle modification Pharmacologic treatment Algorithm for treatment of hypertension "The Goal is to Get to Goal! Hypertension -PLUSDiabetes or Renal Disease < 140/90 mmHg
Measurements and goals < 130/80 mmHg should be provided to the patient verbally and in writing at each office visit Lifestyle Interventions Implementation of lifestyles that favorably affect blood pressure has implications for both the prevention and the treatment of hypertension.
Health-promoting lifestyle modifications are recommended for individuals with prehypertension and as an adjunct to drug therapy in hypertensive individuals. Lifestyle Modification Modification Weight reduction Approximate SBP reduction (range) 520 mmHg/10 kg weight loss
Moderation of alcohol consumption 24 mmHg Dietary Approaches to Stop Hypertension Lowers systolic BP in normotensive patients by an average of 3.5 mm
Hg In hypertensive patients by 11.4 mm Hg Copies available from NHLBI website http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/ DASH Eating Plan Low in saturated fat, cholesterol, and total fat Emphasizes fruits, vegetables, and low fat diary products
Reduced red meat, sweets, and sugar containing beverages Rich in magnesium, potassium, calcium, protein, and fiber 3 -1.5 g sodium per day Can reduce BP in 2 weeks Sacks FM. NEJM. 2001; 344:3-10. Sample Menu Breakfast
1 whole-wheat bagel 2 tablespoons peanut butter 1 medium orange 1 cup fat-free milk Decaffeinated coffee Lunch Spinach salad made with 4 cups of fresh spinach leaves, 1 sliced pear, 1/2 cup mandarin orange sections, 1/3 cup unsalted peanuts and 2 tablespoons reduced-fat red wine vinaigrette
12 reduced-sodium wheat crackers 1 cup fat-free milk Dinner Herb crusted baked cod 1 cup bulgur
1/2 cup fresh green beans, steamed 1 sourdough roll with 1 teaspoon trans-free margarine 1 cup fresh berries with chopped mint Herbal iced tea Algorithm for Treatment of Hypertension Lifestyle Modifications Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease) Initial Drug Choices Without Compelling
(SBP >160 or DBP >100 mmHg) 2-drug combination for most ( thiazide-type diuretic, ACEI, or ARB, or BB, or CCB) Not at Goal Blood Pressure Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist. Drug(s) for the compelling indications
Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed. 2013 ESC/ESH Hypertension Guidelines update Possible combinations of classes of antihypertensive drugs Classification and Management of BP for adults BP classification
Normal SBP* mmHg DBP* mmHg Lifestyle modification <120
and <80 Encourage Initial drug therapy Without compelling indication With compelling indications Prehypertension 120139 or 8089
Yes No antihypertensive drug indicated. Stage 1 Hypertension Yes Thiazide-type diuretics, ACEI, Drug(s) for the ARB, BB, CCB, or
compelling combination. indications. Other antihypertensive Two-drug combination for drugs (diuretics, ACEI, most (thiazide-type diuretic, ARB, BB, CCB) as ACEI or ARB or BB or CCB). needed. Stage 2 Hypertension 140159 or 9099
>160 or >100 Yes *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.
Drug(s) for compelling indications. Pharmacologic Therapy Drug therapy is recommended for individuals with blood pressures 140/90 mmHg. The degree of benefit derived from antihypertensive agents is related to the magnitude of the blood pressure reduction. Benefits of Lowering BP Lowering systolic blood pressure by 1012 mmHg and diastolic blood pressure by 56 mmHg
Average Percent Reduction Stroke incidence 3540% Myocardial infarction Heart failure50% 2025% Diuretics Low-dose thiazide diuretics often are used previously as first-line agents alone or in combination with other antihypertensive drugs.
Thiazides inhibit the Na+/Cl pump in the distal convoluted tubule and hence increase sodium excretion. In the long term, they also may act as vasodilators. Thiazides are safe, efficacious, inexpensive, and reduce clinical events. They provide additive blood pressurelowering effects when combined with beta blockers, angiotensin-converting enzyme inhibitors (ACEIs), or angiotensin receptor blockers (ARBs). In contrast, addition of a diuretic to a calcium channel blocker is less effective. Usual doses of hydrochlorothiazide range from 6.2550 mg/d. The preferred are Chlorthalidone 6.25-50 mg/dl & indapamide 1.5 mg Owing to an increased incidence of metabolic side effects (hypokalemia, insulin resistance, increased cholesterol), higher doses generally are not recommended.
Indications: HF Stroke Loop diuretics generally are reserved for hypertensive patients with reduced glomerular filtration rates [reflected in serum creatinine >220 mol/L (>2.5 mg/dL)], CHF, or sodium retention and edema Low-dose eplerenone (6.25 to 25 mg/day) or spironolactone (6.25 to 12.5 mg/day) can be effective in treatment of primary
hypertension, particularly low-renin hypertension in African Americans. Angiotensin-Converting Enzyme Inhibitors These inhibit the conversion of angiotensin I to angiotensin II and are usually well tolerated. They are particularly useful in diabetics with nephropathy, where they have been shown to slow disease progression, and in those patients with symptomatic or asymptomatic left ventricular dysfunction, where they have been shown to improve survival. Electrolytes and creatinine should be checked before and 1-2 weeks after commencing therapy.
Side-effects include first-dose hypotension, cough, rash, hyperkalaemia and renal dysfunction. The most common side effect of ACE inhibitors is a dry cough. Patients may complain not of a cough but rather of having to clear the throat or loss of voice later in the day. These symptoms occur in 3 to 39% of patients, resolve in a few days after the drug is discontinued, and can be eliminated by switching the patient to an ARB. The incidence is higher in African Americans than in whites and is highest in Asians. Angiotensin II receptor antagonists This group of agents selectively block the receptors for
angiotensin II. They share many of the actions of ACE inhibitors but, since they do not have any effect on bradykinin, do not cause a cough. They are currently used for patients who cannot tolerate ACE inhibitors because of persistent cough. Angioneurotic oedema and renal dysfunction are encountered less with these drugs than with ACE inhibitors. Indications of both: HF MI Diabetes
CKD Stroke Beta-adrenoceptor blockers B-Adrenergic receptor blockers lower blood pressure by decreasing cardiac output, due to a reduction of heart rate and contractility. They are no longer a preferred initial therapy for hypertension. Indications: Angina MI HF
Tachycardia The major side-effects of this class of agents are bradycardia, bronchospasm, cold extremities, fatigue, bad dreams and hallucinations. Atenolol has been shown to reduce brachial arterial pressure but not aortic pressure, which is more significant in causing strokes and heart attacks. Atenolol is now not a preferred drug for hypertension. Calcium-channel blockers These agents effectively reduce blood pressure by causing arteriolar dilatation, and some also reduce the
force of cardiac contraction. Like the beta-blockers, they are especially useful in patients with concomitant ischaemic heart disease. The major side-effects are particularly seen with the short-acting agents and include headache, sweating, swelling of the ankles, palpitations and flushing. Indications: Angina Alpha-blockers By blocking the interaction of norepinephrine on vascular -adrenergic receptors, these drugs cause peripheral vasodilation, thereby lowering blood
pressure. they are effective third- or fourth-line therapy for difficult hypertension and are particularly useful in older men with prostatism. Indications: Prostatism Phenoxybenzamine remains the drug of choice for preoperative management of pheochromocytoma Renin inhibitors Aliskerin is the first orally active renin inhibitor which directly inhibits plasma renin activity: it reduces the negative feedback by which angiotensin II inhibits renin
release. It has been used in combination with ACE inhibitors and angiotensin receptor blockers with a significant reduction in blood pressure. Side-effects are few but hypokalaemia occurs. Centrally acting drugs Reserpine is used in a low dose of 0.05 mg/day, which provides almost all its antihypertensive action with fewer sideeffects than higher doses. It has a slow onset of action (measured in weeks). Methyldopa is still widely used despite central and potentially serious hepatic and blood side-effects. It acts
on central 2-receptors, usually without slowing the heart. Clonidine provide all the benefits of methyldopa with none of the rare (but serious) autoimmune reactions. vasodilators These include hydralazine (up to 100 mg daily) and minoxidil (up to 50 mg daily). Both are extremely potent vasodilators that are reserved for patients resistant to other forms of treatment. Hydralazine can be associated with tachycardia, fluid retention and a systemic lupus erythematosus-like syndrome.
Minoxidil can cause severe oedema, excessive hair growth and coarse facial features. If these agents are used, it is usually in combination with a beta-blocker. Acute Severe Hypertension Twenty-five percent of all emergency department patients present with an elevated blood pressure . Hypertensive emergencies are acute, often severe, elevations in blood pressure, accompanied by acute (or rapidly progressive) target organ dysfunction, such as myocardial or cerebral ischemia or infarction, pulmonary edema, or renal failure.
Hypertensive urgencies are severe elevations in blood pressure without severe symptoms and without evidence of acute or progressive target organ dysfunction. The key distinction depends on the state of the patient and the assessment of target organ damage, not just the absolute level of blood pressure. The full-blown clinical picture of a hypertensive emergency is a critically ill patient who presents with a blood pressure above 220/140 mm Hg, headaches, confusion, blurred vision, nausea and vomiting, seizures, pulmonary edema, oliguria, and grade 3 or grade 4 hypertensive retinopathy .
Hypertensive emergencies require immediate intensive care unit (ICU) admission for intravenous therapy and continuous blood pressure monitoring; In most other hypertensive emergencies, the goal of parenteral therapy is to achieve a controlled and gradual lowering of blood pressure. A good rule of thumb is to lower the initially elevated arterial pressure by 10% in the first hour and by an additional 15% during the next 3 to 12 hours to a blood pressure of no less than 150/90mm Hg. Blood pressure can be reduced further during the next 48 hours.
hypertensive urgencies often can be managed with oral medications and appropriate outpatient follow-up in 24 to 72 hours. Most patients who present to the emergency department with hypertensive urgencies either are nonadherent with their medical regimen or are being treated with an inadequate regimen. To expedite the necessary changes in medications, outpatient follow-up should be arranged within 72 hours Resistant Hypertension
(Refractory hypertension) Defined as persistence of usual blood pressure above 140/90 mm Hg despite treatment with full doses of three or more different classes of medications including a diuretic in rational combination, resistant hypertension is the most common reason for referral to a hypertension specialist. In practice, the problem usually falls into one of four categories: (1) pseudoresistance, (2) an inadequate medical regimen, (3) nonadherence or ingestion of pressor substances, or (4) secondary hypertension. Pseudoresistant hypertension is caused by white coat aggravation
Adjuvant drug therapy Aspirin. Antiplatelet therapy is a powerful means of reducing cardiovascular risk but may cause bleeding, particularly intracerebral haemorrhage, in a small number of patients. The benefits are thought to outweigh the risks in hypertensive patients aged 50 or over who have well-controlled BP and either target organ damage, diabetes or a 10-year coronary heart disease risk of 15% (or 10-year cardiovascular disease risk of 20%). Statins. Treating hyperlipidaemia can produce a substantial reduction in cardiovascular risk. These drugs are strongly indicated in patients who have established vascular disease, or hypertension with a high ( 20% in 10 years) risk of developing cardiovascular disease
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