Office Evaluation of Office Evaluation of HypertensionHypertension

December 2, 2008December 2, 2008

PrevalencePrevalence

Why do we (physicians) Why do we (physicians) get so excited about get so excited about

controlling hypertension?controlling hypertension? Coronary artery diseaseCoronary artery disease StrokeStroke End-stage renal diseaseEnd-stage renal disease Congestive heart failureCongestive heart failure

Isolated systolic and Isolated systolic and systolic / diastolic systolic / diastolic

hypertension in the elderlyhypertension in the elderly

Hypertension is the most common Hypertension is the most common disease specific reason for disease specific reason for Americans to visit a physicianAmericans to visit a physician

Present in over 50% of all Present in over 50% of all Americans over the age of 60Americans over the age of 60

Short-term benefit of treatment is Short-term benefit of treatment is greater than in young people greater than in young people because of overall greater because of overall greater cardiovascular riskcardiovascular risk

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Bethesda, Md: NationalInstitutes of Health, National Heart, Lung, and Blood Institute. 2003; NIH Publication 03-5231.

Classification of blood Classification of blood pressurepressure

Normal BP: systolic < 120 and Normal BP: systolic < 120 and diastolic <80diastolic <80

Pre-hypertension: systolic 120-139 Pre-hypertension: systolic 120-139 or diastolic 80-89or diastolic 80-89

Classification of blood Classification of blood pressurepressure

Stage 1: systolic 140-159 or Stage 1: systolic 140-159 or diastolic 90-99diastolic 90-99

Stage 2: systolic > 160 or diastolic Stage 2: systolic > 160 or diastolic > 100> 100

Lower Blood Pressure is Lower Blood Pressure is BetterBetter

Not symptomatically hypotensiveNot symptomatically hypotensive Treated Blood Pressure must take Treated Blood Pressure must take

into account the risk of medicationsinto account the risk of medications Low diastolic pressures are probably Low diastolic pressures are probably

a marker for decreased arterial a marker for decreased arterial compliance in patients over age 65 compliance in patients over age 65 years (Hardening of the arteries)years (Hardening of the arteries)

Initial evaluationInitial evaluation

BP should be elevated on 2 BP should be elevated on 2 separate occasions: office, home, separate occasions: office, home, ambulatory monitorambulatory monitor

Rule out secondary causes Rule out secondary causes (correctable) of hypertension(correctable) of hypertension

Evaluate for end-organ damageEvaluate for end-organ damage Evaluate the patient’s overall Evaluate the patient’s overall

cardiovascular risk statuscardiovascular risk status

Secondary HypertensionSecondary Hypertension

Renovascular hypertension Renovascular hypertension (secondary hyperaldosteronism)(secondary hyperaldosteronism)

Primary hyperaldosteronismPrimary hyperaldosteronism Primary hyperparathyroidismPrimary hyperparathyroidism Cushing’s diseaseCushing’s disease PheochromocytomaPheochromocytoma

Secondary HypertensionSecondary Hypertension

Primary renal diseasePrimary renal disease HypothyroidismHypothyroidism Oral contraceptivesOral contraceptives Sleep apneaSleep apnea Coarctation of the aortaCoarctation of the aorta

Secondary HypertensionSecondary Hypertension

Renovascular hypertension Renovascular hypertension (secondary hyperaldosteronism)(secondary hyperaldosteronism)

Renovascular Renovascular hypertensionhypertension

Most common cause of secondary Most common cause of secondary hypertensionhypertension

Incidence 10-45% in severe or Incidence 10-45% in severe or refractory hypertensionrefractory hypertension

Clinical symptoms include ischemic Clinical symptoms include ischemic loss of renal function and loss of renal function and otherwise unexplained sudden otherwise unexplained sudden onset pulmonary edemaonset pulmonary edema

Atherosclerotic DiseaseAtherosclerotic Disease

Fibromuscular dysplasiaFibromuscular dysplasia

Secondary HypertensionSecondary Hypertension

Renovascular hypertension Renovascular hypertension (secondary hyperaldosteronism)(secondary hyperaldosteronism)

Primary hyperaldosteronismPrimary hyperaldosteronism Primary hyperparathyroidismPrimary hyperparathyroidism Cushing’s diseaseCushing’s disease PheochromocytomaPheochromocytoma

HyperaldosteronismHyperaldosteronism

Primary Hyperaldo-most common, Primary Hyperaldo-most common, prevalence around 1-2%prevalence around 1-2%

Aka Conn’s Syndrome (1955)Aka Conn’s Syndrome (1955) Hypertension, hypokalemiaHypertension, hypokalemia Adrenal adenoma, bilateral adrenal Adrenal adenoma, bilateral adrenal

hyperplasiahyperplasia

Cushing’s SyndromeCushing’s Syndrome

Excess glucocorticoid-either Excess glucocorticoid-either exogenous or endogenousexogenous or endogenous

Hypertension results from the Hypertension results from the mineralocorticoid effect of the mineralocorticoid effect of the excess glucocorticoidsexcess glucocorticoids

PheochromocytomaPheochromocytoma

Very rareVery rare Episodic headache, sweating and Episodic headache, sweating and

tachycardiatachycardia 50% have paroxysmal HTN, the 50% have paroxysmal HTN, the

rest apparently have “essential” rest apparently have “essential” HTNHTN

HistoryHistory

Features of Essential Features of Essential Hypertension without End Hypertension without End

organ damageorgan damage NoneNone

Initial evaluationInitial evaluation

BP should be elevated on 2 BP should be elevated on 2 separate occasions: office, home, separate occasions: office, home, ambulatory monitorambulatory monitor

Rule out secondary causes Rule out secondary causes (correctable) of hypertension(correctable) of hypertension

Evaluate for end-organ damageEvaluate for end-organ damage Evaluate the patient’s overall Evaluate the patient’s overall

cardiovascular risk statuscardiovascular risk status

Cardiovascular risk factorsCardiovascular risk factors

SmokingSmoking Diabetes mellitusDiabetes mellitus DyslipidemiaDyslipidemia Physical inactivityPhysical inactivity Chronic kidney diseaseChronic kidney disease

Symptoms of target organ Symptoms of target organ damagedamage

HeadacheHeadache Transient weakness or blindnessTransient weakness or blindness Loss of visual acuityLoss of visual acuity Chest painChest pain DyspneaDyspnea ClaudicationClaudication

Aggravating factorsAggravating factors

Drugs: estrogens, adrenal steroids, Drugs: estrogens, adrenal steroids, sympathomimetics, and NSAIDSsympathomimetics, and NSAIDS

Diet: salt, alcohol, caffeine, and Diet: salt, alcohol, caffeine, and weightweight

Family historyFamily history RaceRace Sleep apneaSleep apnea

Symptoms of secondary Symptoms of secondary causescauses

Muscle weaknessMuscle weakness Spells of tachycardia, sweating, Spells of tachycardia, sweating,

and tremorand tremor Thinning of the skinThinning of the skin Flank painFlank pain

Clues to the presence of Clues to the presence of Secondary HypertensionSecondary Hypertension

Young age of onsetYoung age of onset Sudden onset of HTNSudden onset of HTN Uncontrolled/Refractory HTNUncontrolled/Refractory HTN Malignant HTN (End organ Malignant HTN (End organ

damage)damage) Features of a recognized Features of a recognized

underlying causeunderlying cause

Physical examPhysical exam

Is there evidence for end-Is there evidence for end-organ damage?organ damage?

RetinopathyRetinopathy Heart rhythm, extra soundsHeart rhythm, extra sounds Bruits (renal artery variety may Bruits (renal artery variety may

suggest a secondary cause)suggest a secondary cause) PulsesPulses EdemaEdema RalesRales

LaboratoryLaboratory

Electrolytes (Na+, K+, Cl-, CO2-)Electrolytes (Na+, K+, Cl-, CO2-)

CreatinineCreatinine

UrinalysisUrinalysis

Other testsOther tests

Lipid profileLipid profile

EKGEKG

EchocardiogramEchocardiogram

Tests to pursue secondary Tests to pursue secondary causes of hypertensioncauses of hypertension

Serum renin and aldosteroneSerum renin and aldosterone 24 hour urine collection for 24 hour urine collection for

metanephrinesmetanephrines Dexamethasone suppression testDexamethasone suppression test Serum calciumSerum calcium Renal angiogram Renal angiogram

TreatmentTreatment

Lifestyle modificationLifestyle modification

Weight loss for the overweightWeight loss for the overweight Increased aerobic physical activityIncreased aerobic physical activity Moderate sodium restrictionModerate sodium restriction Moderate alcohol consumptionModerate alcohol consumption Minimize caffeine consumptionMinimize caffeine consumption

Pharmacologic treatmentPharmacologic treatment

Low renin*older*thin*black

- thiazide diuretics- calcium channel blockers- alpha blockers

Essential Hypertension High renin*younger*overweight

- beta blockers- angiotensin converting enzyme inhibitors- angiotensin II receptor antagonists

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Bethesda, Md: NationalInstitutes of Health, National Heart, Lung, and Blood Institute. 2003; NIH Publication 03-5231.

Other agentsOther agents

Alpha 2 central blockersAlpha 2 central blockers

Direct vasodilatorsDirect vasodilators

Sympathetic blockersSympathetic blockers

Thiazide diureticsThiazide diuretics

Mechanism of action is unclear but probably is Mechanism of action is unclear but probably is a combination of mild plasma volume a combination of mild plasma volume decrease plus decreased intracellular calcium decrease plus decreased intracellular calcium concentration leading to vasodilationconcentration leading to vasodilation

CheapCheap

EffectiveEffective

Very low incidence of side effects at low dosesVery low incidence of side effects at low doses

Thiazide diuretics provide Thiazide diuretics provide cardioprotection in:cardioprotection in:

Left ventricular hypertrophyLeft ventricular hypertrophy Type 2 diabetes mellitusType 2 diabetes mellitus Previous myocardial infarctionPrevious myocardial infarction Previous strokePrevious stroke Current cigarette smokingCurrent cigarette smoking HyperlipidemiaHyperlipidemia Atherosclerotic cardiovascular Atherosclerotic cardiovascular

diseasedisease

Angiotensin converting enzyme Angiotensin converting enzyme inhibitors: agents of choice in inhibitors: agents of choice in

hypertension and ….hypertension and ….

Congestive heart failureCongestive heart failure ST elevation myocardial infarctionST elevation myocardial infarction Non-ST elevation anterior Non-ST elevation anterior

myocardial infarctionmyocardial infarction Diabetes mellitusDiabetes mellitus Proteinuric chronic renal failureProteinuric chronic renal failure

Angiotensin converting Angiotensin converting enzyme inhibitors and enzyme inhibitors and

angiotensin receptor blockers angiotensin receptor blockers used together are indicated used together are indicated

in:in:

Congestive heart failureCongestive heart failure

Proteinuric chronic renal failureProteinuric chronic renal failure

Angiotensin converting Angiotensin converting enzyme inhibitors act enzyme inhibitors act

by ...by ...

Decreasing angiotensin IIDecreasing angiotensin II Increasing kinin levels (block Increasing kinin levels (block

kininase activity)kininase activity) Decrease aldosteroneDecrease aldosterone Increase insulin sensitivityIncrease insulin sensitivity

Angiotensin II receptor Angiotensin II receptor antagonistsantagonists

Impair binding of angiotensin II to Impair binding of angiotensin II to AT1 receptorsAT1 receptors

No cough (no increased kinin No cough (no increased kinin levels)levels)

No reduction in AT2 receptor No reduction in AT2 receptor activity (arterial hypertrophy, activity (arterial hypertrophy, improved left ventricular activity improved left ventricular activity after ischemia)after ischemia)

Angiotensin receptor Angiotensin receptor antagonistsantagonists

Production of angiotensin II in the heart Production of angiotensin II in the heart may be through another enzyme may be through another enzyme (chymase), therefore AII receptor (chymase), therefore AII receptor antagonists may be more effective than antagonists may be more effective than ACE inhibitors locallyACE inhibitors locally

No change in insulin sensitivity (kinin No change in insulin sensitivity (kinin mediated)mediated)

Indications for and efficacy of ARB’s are Indications for and efficacy of ARB’s are not different from ACE inhibitorsnot different from ACE inhibitors

Direct Renin InhibitorsDirect Renin Inhibitors

Aliskiren approved by the FDA in Aliskiren approved by the FDA in August 2007August 2007

Inhibits renin production in the JG Inhibits renin production in the JG cellscells

Trade name TekturnaTrade name Tekturna Studies ongoing, not yet in Studies ongoing, not yet in

widespread clinical usewidespread clinical use

Beta blockers (without Beta blockers (without intrinsic sympathomimetic intrinsic sympathomimetic activity) are indicated in:activity) are indicated in:

Post myocardial infarctionPost myocardial infarction Stable patients with congestive Stable patients with congestive

heart failureheart failure Rate control in atrial fibrillationRate control in atrial fibrillation Control of angina pectorisControl of angina pectoris

Calcium channel blockersCalcium channel blockers

DihydropyridinesDihydropyridines

VerapamilVerapamil

DiltiazemDiltiazem

Calcium channel blockers: no Calcium channel blockers: no absolute indication in absolute indication in

treatment of hypertension treatment of hypertension but are helpful in:but are helpful in:

Rate control in atrial fibrillationRate control in atrial fibrillation

Control of angina pectorisControl of angina pectoris

May be preferred in obstructive May be preferred in obstructive airway diseaseairway disease

Dihydropyridines: side Dihydropyridines: side effectseffects

HeadacheHeadache DizzinessDizziness FlushingFlushing Edema (due to a redistribution of Edema (due to a redistribution of

fluid from vascular to interstitial fluid from vascular to interstitial space)space)

PregnancyPregnancy

Alpha Methyl DopaAlpha Methyl Dopa LabetalolLabetalol CCBCCB Diuretics +/-Diuretics +/- No ACE-I or ARBNo ACE-I or ARB