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Dr Sunita Dodani
Family Medicine Department The Aga Khan University Karachi, Pakistan
Learn about recent guidelines of hypertension management. Define hypertension by the JNC-VI guidelines. Discuss the management steps recommended by JNC VI. Define the providers role in patient compliance. Controversies of stepped care therapy.
New Guidelines:
Joint National Committee (JNC) sixth report on prevention, detection, evaluation and treatment of high blood pressure (JNC-VI) - 1997. WHO/International Society of Hypertension (ISH), Guidelines of Hypertension Management for Primary Care Physicians - 1999. British Hypertension Society Guidelines for Hypertension Management - 1999. Local: First report of National Task Force on Hypertension, Pakistan Hypertension League - 1998.
Discuss hypertension treatment in stepwise-manner. Cover treatment strategies in special population like Black Americans, pregnancy and patients with co-morbid conditions.
Definition:
Normal pressure into 3 categories.
Elevated BP (>140/90) on 2 or more visits with BP taken 2 or more times on each visit and then averaged. Seated in a chair with arm supported at heart level. Must not smoke or drink caffeine for 30 minutes prior to measuring the BP. Cuff size should encircle 80% of the patients arm.
BP measurements should be attempted only after 5 minutes of rest. BP should be at least 2 minutes apart, averaged, and then repeated if 2 measurements differ by more than 5 mmHg. Anxious patient may falsely give high reading (white coat hypertension).
BP rises in most people as they age, BP is not considered a normal part of aging. Isolated systolic hypertension is considered in patients with systolic BP >140 mmHg and diastolic BP <90 mmHg
Management:
Three-pronged approach:
Lifestyle modifications.
Appropriate medications (based on the patients demographic and medical profile). Professional health care support to foster compliance.
modifications for all stages of hypertension and are the initial recommendations for both high normal and stage 1 hypertension.
Patients
waist size >34 cms Females >39 cms Males Hypertension risk
Exercise:
Brisk
walking.
30-45
minutes at 40% - 60% of maximal activity determined by pulse rate (220 - age x 0.4 & 0.6).
Like DM diet, DASH diet includes a specific number of servings and the weight of servings. Unlike DM Diet, DASH diet does not offer the option of food exchanges. Plant food sources Only 2 - 3 animal protein servings/day
in Dietary sodium. Esp. for African Americans Elderly DM 75 meq/day of dietary sodium or less ( 5 mmHg systolic & 2.6 mm diastolic). Cessation of smoking. alcohol intake.
< 10 oz wine < 2 oz whisky < 24 oz beer
Choosing the right medication for your patient: Choice of the treatment regimen depends on:
Degree of BP elevation. Number of associated & concurrent risk factors. Presence of TOD. Clinical CVD or associated clinical conditions (ACC).
Risk Stratification:
Risk Factors for
Cardiovascular Diseases Target Organ Damage Associated Clinical
(TOD)
Proteinuria & / or slight Ischemic stroke Cerebral hemorhage elevation of plasma Transient ischemic attack creatinine 1 . 2 2 mg/dl (106- 177 mmol/L)
Heart Disease:
Ultrasound or radiological evidence of atherosclerotic plaques (carotid, illiac & f emoral arteries, aorta)
Cardiovascular Diseases
adversely influencing the prognosis
Reduced HDL Raised LDL Microalbuminuria in diabetes Impaired GTT Obesity Sedentary life style Raised fibrinogen High risk socioeconomic & ethnic group High risk geographic region
2. Other factors
Renal Diseases:
(TOD)
Generalized or focal narrowing of the retinal arteries ( retinopathy)
Single daily dose interval of 4 - 6 weeks to observe the full response, unless it is necessary to lower BP more urgently. If drug well tolerated but response is small, the dose or add drugs stepwise until BP control is attained. Treatment can be stepped down later if BP falls substantially below the optimal level. Most hypertensives require a combinations of antihypertensive therapy to achieve optimal control.
Elderly:
ACE Inhibitors Diuretics with care Angiotensin B Blockers Receptor Blockers B Blockers Ca Antagonists
ACE Inhibitors Diuretics Carvadilol Losartin Isolated Systolic Diuretics Hypertension Ca Antagonists (non-DHP central effects), long acting forms Heart Failure
Diuretics Angiotensin B Blockers African American race Calcium Antagonists Receptor Blockers ACE Inhibitors (both types) Atrial Tachycardia/ Fibrillation
B Blockers Ca Antagonists (Both Types) Diuretics ACE Inhibitors Angiotensin. Receptor Blockers
Diabetes Mellitus
Low dose diuretics ACE Inhibitors B Blockers (careful Receptor Blockers monitoring) Ca antagonists (both types) Angiotensin ACE Inhibitors B Blockers Receptor Blockers Ca Antagonists (both types) Diuretics with care
Dyslipidemia
Hyperthyroidism BBlockers Migraine B Blockers (Non Diuretics ISA) ACE Inhibitors Calcium Receptor Blocker Antagonist DHP Calcium (non DHP) Antagonists
Diuretics Angiotensin ACE Inhibitors Receptor Blockers ( cant be given with severe renal impairment) Angiotensin Renal B Blockers Receptor Insufficiency Blockers Ca Antagonists
(both types)
Grades rather than stages are used to classify hypertension. Uses coronary heart disease risk accessors or risk charts. Isolated systolic hypertension defined as systolic > 160 and diastolic < 90. Use of aspirin (primary prevention ) in hypertension patients. Use of statins in patients with hypertension.
Conclusion:
New guidelines like JNC-VI, unlike previous guidelines, has introduced the concept of aggressive blood pressure control at optimal levels. For elderly patients , the achievement of at least 140/90 mm Hg or below blood pressure is acceptable. Life style modification alone for those patients at relatively low overall risk for cardiovascular diseases and with drugs for those at higher risk.
Conclusion: (Contd)
Diuretics or B-blockers for those as first choice with uncomplicated hypertension. ACE inhibitors for Diabetic patients with proteinuria. ACE inhibitors &/ 0r diuretics for patients with heart failure & systolic dysfunction. Long-acting dihydropyridine Ca antagonist for systolic hypertension in the elderly. Follow-up during evaluation & stabilization of treatment should be frequent to monitor BP and other risk factors. Follow-up is important to establish good relationship with patient and to educate the patient.
Inadeq, response
Refer
Changing Strategies
Of Treatment Of Hypertension (Contd)
Goal:
JNC-VI uses a lower goal BP (<140/90 mmHg) for hypertension in the elderly.
Changing Strategies Diuretics: Of Treatment Of Hypertension (Contd) plasma volume. cause peripheral vasodilation. potentiate the effect of other anti-hypertensive drugs. Caution: Renal disease , Gout, DM, Dyslipidemia. Start low dose.
-blockers:
1 selective : start low dose & gradually-increase. Should not be used in COPD, CHF or left ventricular function.
ACE inhibitors:
DM with proteinuria. CHF or myocardial infarction.
2. 1 - 2 risk factors Medium risk 3. 3 or more risk High risk factors or diabetes or TOD 4. ACC v. High risk
v. High risk
v.High risk
B Blockers
Angina Post
MI Tachyarrythmias
Calcium
Antagonists
Prostrate Hypertrophy
Glucose
Intolerance Dyslipidemias
Angiotensin II Antagonists
Side Effects Heart Failure with other drugs e.g. ACE inhibitors (cough)
References:
BMJ 1999 Sep 4; 319:630- 635 - British Hypertension Society guidelines for Hypertension management 1999; Summary NEW: 9 - 13 Editorial - British guidelines on managing hypertension World Health Organization- International Society of Hypertension - 1999 WHO-ISH Guidelines for the management of Hypertension - Journal of Hypertension (see on line articles, Volume 17, Issue 2, pages 151 - 183, February 1999). The Sixth Report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure JNC-V1- PDF format from the National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health (NIH) NEW updated URL 2-11
References (Contd):
NHLBL JNC IV References Sheet. National Guideline Clearing House - Brief Summary NEW: 2 - 11. Archives of Internal Medicine 1997 Nov 24 BAD LINK NEW URL -waiting for 1997 back issues to be placed on-line ? JNC V1: timing is everything Commentary - The Lancet 15 Nov 97. JNC - 6 Guidelines Editorial - American Journal of Kidney Diseases May 1998 JNC Redux Editorial - American Journal of Kidney Diseases May 1998 Treatment of hypertension; insights from the JNC V1 report. Am Fam Physician 1998 Oct 15; 58 (6; 1323 - 30 - PubMed abstract)