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Clinical Evaluation
BP Measurements
Benefits Of Lowering BP
CVD Risk Factors
BP Goal
Choice Of Drug Therapy
Learning Objectives
At the end of this presentation, participants will be
able to-
1) appreciate the goals of anti-htn therapy
2) understand anti-htn choices
The treatment of hypertension is the most common reason
for office visits of adults to physicians in the United States
and for use of prescription drugs
In 1999-2000 there was approximately about 58 to 65 million
hypertensives in the United States, compared to only 43.2
million in1988-1991 NHANES-III survey .
Despite the prevalence of hypertension and its associated
complications, control of the disease is far from adequate .
Data from NHANES show that only 34 percent of persons
with hypertension have their blood pressure under control,
defined as a level below 140/90 mmHg
HTN: management
52 yo male with no significant PMH comes for a physical
check up and his BP was 160/90. What it is the target BP?
What is the choice of therapy? Two months later 180/100?

54 yo male with PMH of HTN, DM, CKD(stage III) , goal

BP? choice for the drug therapy?

70 you male with PMH of HTN, CAD, DM, LVSD(EF 30%)?

Goal BP? Drug therapy?

Publication of many new studies.

Need for a new, clear, and concise guideline
useful for clinicians.
Need to simplify the classification of BP.
New Facts

For persons over age 50, SBP is a more important than DBP as CVD risk

Starting at 115/75 mmHg, CVD risk doubles with each increment of

20/10 mmHg throughout the BP range.

Persons who are normotensive at age 55 have a 90% lifetime risk for
developing HTN.

Those with SBP 120139 mmHg or DBP 8089 mmHg should be

considered prehypertensive who require health-promoting lifestyle
modifications to prevent CVD.
BP Measurement
Method Brief Description
In-office Two readings, 5 minutes apart, sitting in
chair. Confirm elevated reading in
contralateral arm.
Ambulatory BP monitoring Indicated for evaluation of white-coat HTN.
Absence of 1020% BP decrease during
sleep may indicate increased CVD risk.
Self-measurement Provides information on response to therapy.
May help improve adherence to therapy and
evaluate white-coat HTN.
Office BP Measurement
Patient should be seated quietly for 5 minutes in a chair
(not on an exam table), feet on the floor, and arm supported at heart
Appropriate-sized cuff should be used to ensure accuracy.
At least two measurements should be made.
Clinicians should provide to patients, verbally and in writing, specific BP
numbers and BP goals.
Ambulatory BP Monitoring

evaluation of white-coat HTN in the absence of target organ injury.

Ambulatory BP values are usually lower than clinic readings.
Awake, individuals with hypertension have an average BP of >135/85
mmHg and during sleep >120/75 mmHg.
BP drops by 10 to 20% during the night; if negative, may indicate
possible increased risk for cardiovascular events.
Self-Measurement of BP

Provides information on:

1. Response to antihypertensive therapy
2. Improving adherence with therapy
3. Evaluating white-coat HTN

Home measurement of >135/85 mmHg is generally considered to be


Home measurement devices should be checked regularly.

Blood Pressure Grades
BP Classification SBP mmHg DBP mmHg

Normal <120 and <80

Prehypertension 120139 or 8089

Stage 1 Hypertension 140159 or 9099

Stage 2 Hypertension >160 or >100

Benefits of Lowering BP

Average Percent Reduction

Stroke incidence 3540%

Myocardial infarction 2025%

Heart failure 50%

Benefits of Lowering BP

In stage 1 HTN and additional CVD risk factors, achieving

a sustained 12 mmHg reduction in SBP over 10 years will
prevent 1 death for every 11 patients treated.
CVD Risk Factors
Cigarette smoking
Obesity* (BMI >30 kg/m2)
Physical inactivity
Diabetes mellitus
Microalbuminuria or estimated GFR <60 ml/min
Age (older than 55 for men, 65 for women)
Family history of premature CVD
(men under age 55 or women under age 65)
*Components of the metabolic syndrome.
CVD Risk

HTN prevalence ~ 50 million people in the United


Each increment of 20/10 mmHg doubles the risk of

CVD across the entire BP range starting from 115/75
Target Organ Damage
Left ventricular hypertrophy
Angina or prior myocardial infarction
Heart failure
Stroke or transient ischemic attack
Chronic kidney disease
Peripheral arterial disease
Causes of Hypertension
Sleep apnea
Drug-induced or related causes
Chronic kidney disease
Primary aldosteronism
Renovascular disease
Chronic steroid therapy and Cushings syndrome
Coarctation of the aorta
Thyroid or parathyroid disease
Goals of therapy
Lifestyle modification
Pharmacologic treatment
Algorithm for treatment of hypertension
Classification and management of BP for adults
Followup and monitoring
Goals of Therapy

Reduce CVD and renal morbidity and mortality.

Treat to BP <140/90 mmHg or BP <130/80 mmHg in patients

with diabetes or chronic kidney disease or <120/80 if LVD.

Achieve SBP goal especially in persons >50 years of age.

Lifestyle Modification:
effect on BP
Modification Approximate SBP reduction

Weight reduction 520 mmHg/10 kg weight loss

Dietary sodium reduction 28 mmHg

Physical activity 49 mmHg

Moderation of alcohol 24 mmHg

Choice of drug therapy

Thiazide-type diuretics should be initial drug therapy for most, either

alone or combined with other drug classes.

Certain high-risk conditions are compelling indications for other drug


Most patients will require two or more antihypertensive drugs to

achieve goal BP.

If BP is >20/10 mmHg above goal, initiate therapy with two agents,

one usually should be a thiazide-type diuretic.
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)
(< 120/80 with LVD)

Initial Drug Choices

Without Compelling With Compelling

Indications Indications

Stage 1 Hypertension Stage 2 Hypertension Drug(s) for the compelling

(SBP 140159 or DBP 9099 (SBP >160 or DBP >100 mmHg) indications
mmHg) 2-drug combination for most Other antihypertensive drugs
Thiazide-type diuretics for most. (usually thiazide-type diuretic and (diuretics, ACEI, ARB, BB, CCB)
May consider ACEI, ARB, BB, CCB, ACEI, or ARB, or BB, or CCB) as needed.
or combination.

Not at Goal
Blood Pressure

Optimize dosages or add additional drugs

until goal blood pressure is achieved.
Consider consultation with hypertension
Followup and Monitoring

Patients should return for follow up and adjustment of medications

until the BP goal is reached.

More frequent visits for stage 2 HTN or with complicating comorbid


Serum potassium and creatinine monitored 12 times per year.

Special Indications for
Individual Drug Classes
Special Indication Initial Therapy Options Clinical Trial Basis
Heart failure THIAZ, BB, ACEI, ARB, ACC/AHA Heart Failure
Postmyocardial BB, ACEI, ALDO ANT ACC/AHA Post-MI
infarction Guideline, BHAT, SAVE,
Capricorn, EPHESUS


Special Indications for
Individual Drug Classes
Compelling Indication Initial Therapy Options Clinical Trial Basis

Diabetes THIAZ, BB, ACE, ARB, NKF-ADA Guideline,

Chronic kidney disease ACEI, ARB NKF Guideline,
Captopril Trial,
Recurrent stroke THIAZ, ACEI PROGRESS
Special indication: Left
Ventricular Dysfucntion

LVD is an independent risk factor that increases the risk of


GOAL BP:<120/80

Avoid direct vasodilators: hydralazine and minoxidil.

Hypertension in Older
More than two-thirds of people over 65 have HTN.

This population has the lowest rates of BP control.

Treatment, including those who with isolated systolic HTN, should

follow same principles outlined for general care of HTN.

Lower initial drug doses may be indicated to avoid symptoms;

standard doses and multiple drugs will be needed to reach BP targets.
Considerations in
Antihypertensive Drug Choices
Potential favorable effects
Thiazide-type diuretics useful in slowing demineralization in
BBs useful in the treatment of atrial tachyarrhythmias/fibrillation,
migraine, thyrotoxicosis (short-term), essential tremor, or perioperative
CCBs useful in Raynauds syndrome and certain arrhythmias.
Special consideration in
Antihypertensive Drug Choices
Potential side effects
Thiazide diuretics should be used cautiously in gout or a history of
significant hyponatremia.
BBs should be generally avoided in patients with asthma, reactive
airways disease, or second- or third-degree heart block.
ACEIs and ARBs are contraindicated in pregnant women or those likely
to become pregnant.
ACEIs should not be used in individuals with a history of angioedema.
Aldosterone antagonists and potassium-sparing diuretics can cause
BP goal: no CVD : <140/90
CKD, DM : <130/80
LVD : < 120/80
If Systolic>20 0r Diastolic>10 use 2 agents
Choice of therapy:
1st line: Thiazide diuretics
Post-MI (anterior wall):
BB, spironolactone antagonists
Stroke: Thiazide and ACEI
A 58-year-old man is evaluated for a 3-month history of intermittent cough and
shortness of breath with exertion. He has a history of hypertension and type 2
diabetes mellitus but no history of coronary artery disease. His medications include
extended-release metoprolol, aspirin, metformin, and atorvastatin.
On examination, blood pressure is 165/92 mm Hg and heart rate is 88/min. Jugular
venous distention is 5 cm above the clavicle at a 45-degree incline. Faint crackles are
present at the bases of both lungs, cardiac rhythm is regular, an S3 is present as is a
small amount of peripheral edema. Electrocardiogram shows normal sinus rhythm and
voltage criteria for left ventricular hypertrophy. Laboratory results include potassium
4.2 meq/L (4.2 mmol/L), and creatinine 1.0 mg/dL (88.42 mol/L). An echocardiogram
is ordered and furosemide is prescribed, and the patient returns the following week
with resolution of his symptoms. His blood pressure at this visit is 130/78 mm Hg, his
heart rate is 65/min, jugular venous distention is at the level of the clavicle at a 45-
degree incline, his chest is clear to auscultation, the S3 is absent, and there is no
peripheral edema. The echocardiogram shows left ventricular hypertrophy, reduced
systolic function (left ventricular ejection fraction 40%), and inferior wall hypokinesis.
Which of the following is the most appropriate medication change at this time?
a)No change
b)Change metop to coreg
c)Start lisinopril
d)Start digoxin
e)Start spironolactone
A 57-year-old woman is evaluated for intermittent claudication of the
left calf that she has had for 5 years. The symptoms reproducibly occur after she walks
100 yards and resolve after 5 minutes of rest. The patient has an 80 pack-year smoking
history but no longer smokes; she also has hypertension, type 2 diabetes mellitus,
hypercholesterolemia, and chronic stable angina. Her medications are include atenolol,
atorvastatin, aspirin, lisinopril, and insulin.
On physical examination, the blood pressure is 142/94 mm Hg bilaterally and heart rate is
66/min. Carotid arteries are brisk, with a right carotid artery bruit. The lungs are clear to
auscultation and percussion. There is an S4 and nonradiating 2/6 early systolic murmur at
the left lower sternal border. Examination of the abdomen is normal. There is a left femoral
artery bruit, with absent pulses in the left foot and trace pulses in the right foot.
What is the target blood pressure in this patient?
b)< 140/90
55-year-old man with hypertension and diabetic nephropathy comes for a follow-up visit. He was
diagnosed with type 2 diabetes mellitus 10 years ago. He has no shortness of breath or edema.
Medications are glipizide, 5 mg twice daily; pioglitazone, 30 mg/d; metoprolol, 100 mg/d; fosinopril, 80
mg/d; hydrochlorothiazide, 25 mg/d; atorvastatin, 40 mg/d; and aspirin, 81 mg/d.
On physical examination, pulse rate is 55/min and blood pressure is 145/85 mm Hg. He is obese.
Retinal microaneurysms are present. On cardiac examination, there is a regular sinus rhythm with no
murmurs. The lungs are clear to auscultation. There is trace pedal edema.
Laboratory Studies Creatinine
1.0 mg/dL (88.42 mol/L)
Sodium 140 meq/L (140 mmol/L)
Potassium 4.0 meq/L (4.0 mmol/L)
Chloride 106 meq/L (106 mmol/L)
Bicarbonate 24 meq/L (24 mmol/L)
24-Hour urine protein excretion 6 g/24 h
Urinalysis 4+ protein, 12 erythrocytes and 8 leukocytes/hpf
On abdominal ultrasound, the right kidney is 12 cm and the left kidney is 12.2 cm. There is normal
echogenicity and no hydronephrosis, masses, or stones.
Which of the following is the most appropriate next step in this patient's management?
a)Increase hydrochlorothiazide dose to 50 mg/d
b)Add amlodipine
c)Add losartan
d)Add prazosin
e)Increase metoprolol dose to 150 mg/d
A 45-year-old woman is referred for evaluation for a blood pressure measurement of
150/94 mm Hg. Her husband is a nurse and regularly measures her blood pressure at
home. Her usual home blood pressure measurement is between 110/76 mm Hg and
120/80 mm Hg. She does not smoke cigarettes. Her mother has hypertension.
On physical examination, her average blood pressure is 148/98 mm Hg. Results of
laboratory studies, including the creatinine level, are normal.
In addition to counseling regarding lifestyle modifications, which of the following is the most
appropriate management for this patient?

a)Begin hydrochlorothiazide
b)Begin enalapril
c)Perform ambulatory blood pressure monitoring
d)Continue home blood pressure measurement
65-year-old woman is evaluated for resistant hypertension. Despite use of antihypertensive therapy
for over 20 years, her blood pressure usually is approximately 160/90 mm Hg. For several years she
has been taking amlodipine, 10 mg/d, and metoprolol, 100 mg/d. However, her regimen recently was
changed to lisinopril, 20 mg/d, and sustained-release verapamil, 180 mg/d.
On physical examination, pulse rate is 68/min and blood pressure is 178/100 mm Hg. On cardiac
examination, the point of maximal impulse is prominent and displaced laterally. The lungs are clear to
auscultation. The remainder of the examination is normal.
Laboratory Studies
Blood urea nitrogen 18 mg/dL (6.43 mmol/L)
Creatinine 0.9 mg/dL (79.58 mol/L)
Sodium 147 meq/L (147 mmol/L)
Potassium 3.3 meq/L (3.3 mmol/L)
Chloride100 meq/L (100 mmol/L)
Bicarbonate 28 meq/L (28 mmol/L)
An echocardiogram reveals increased left ventricular mass.
Which of the following is the most appropriate next step in this patient's management?
a)Magnetic resonance angiography
b)Hydrochlorothiazide, 25 mg/d
c)Aldosteronerenin ratio
d)CT scanning