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Changing Strategies Of Treatment Of Hypertension Dr Sunita Dodani Family Medicine Department The Aga Changing Strategies Of Treatment Of Hypertension Dr Sunita Dodani Family Medicine Department The Aga Khan University Karachi, Pakistan

Objectives: At the end of this presentation, we should be able to: Ø Ø Objectives: At the end of this presentation, we should be able to: Ø Ø Ø Learn about recent guidelines of hypertension management. Define hypertension by the JNC-VI guidelines. Discuss the management steps recommended by JNC VI. Define the provider’s role in patient compliance. Controversies of stepped care therapy.

New Guidelines: Ø Ø Joint National Committee (JNC) sixth report on prevention, detection, evaluation New Guidelines: Ø Ø 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.

JNC-VI Guidelines: (Drawn from consensus and evidence - based findings) Ø Discuss hypertension treatment JNC-VI Guidelines: (Drawn from consensus and evidence - based findings) Ø Discuss hypertension treatment in stepwise-manner. Ø Cover treatment strategies in special population like Black Americans, pregnancy and patients with co-morbid conditions.

Definition: Normal pressure into 3 categories. Abnormal pressure into 3 stages for adults > Definition: Normal pressure into 3 categories. Abnormal pressure into 3 stages for adults > 18 and older.

Classification of Blood Pressure for Adults Age 18 and Olders: Category Systolic (mm Hg) Classification of Blood Pressure for Adults Age 18 and Olders: Category Systolic (mm Hg) Optimal Normal High-normal Hypertension <120 <130 130 -139 and or <80 <85 85 -89 140 -159 160 -179 > 180 or or or 90 -99 100 -109 > 110 Stage 1 Stage 2 Stage 3 Diastolic (mm Hg)

Changing Strategies Of Treatment Of Hypertension (Cont’d) Ø Ø Elevated BP (>140/90) on 2 Changing Strategies Of Treatment Of Hypertension (Cont’d) Ø Ø 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 patient’s arm.

Changing Strategies Of Treatment Of Hypertension (Cont’d) Ø BP measurements should be attempted only Changing Strategies Of Treatment Of Hypertension (Cont’d) Ø BP measurements should be attempted only after 5 minutes of rest. Ø BP should be at least 2 minutes apart, averaged, and then repeated if 2 measurements differ by more than 5 mm. Hg. Ø Anxious patient may falsely give high reading (white coat hypertension).

Changing Strategies Of Treatment Of Hypertension(Cont’d) Ø BP rises in most people as they Changing Strategies Of Treatment Of Hypertension(Cont’d) Ø BP rises in most people as they age, BP is not considered a normal part of aging. Ø Isolated systolic hypertension is considered in patients with systolic BP >140 mm. Hg and diastolic BP <90 mm. Hg

Management: Three-pronged approach: Ø Lifestyle modifications. Ø Appropriate medications (based on the patient’s demographic Management: Three-pronged approach: Ø Lifestyle modifications. Ø Appropriate medications (based on the patient’s demographic and medical profile). Ø Professional health care support to foster compliance.

Life Style Modification: Ø Lifestyle modifications for all stages of hypertension and are the Life Style Modification: Ø Lifestyle modifications for all stages of hypertension and are the initial recommendations for both high normal and stage 1 hypertension.

Life Style Modifications (Cont’d): Ø Weight reduction also cholesterol and DM Ø Patients with Life Style Modifications (Cont’d): Ø Weight reduction also cholesterol and DM Ø Patients with abdominal obesity waist size >34 cms Females >39 cms Males Hypertension risk

Exercise: Ø Brisk walking. Ø 30 -45 minutes at 40% - 60% of maximal Exercise: Ø Brisk walking. Ø 30 -45 minutes at 40% - 60% of maximal activity determined by pulse rate (220 - age x 0. 4 & 0. 6).

Changing Strategies Of Treatment Of Hypertension (Cont’d) Ø DASH: Dietary approaches to stop hypertension. Changing Strategies Of Treatment Of Hypertension (Cont’d) Ø DASH: Dietary approaches to stop hypertension. Ø Like DM diet, DASH diet includes a specific number of servings and the weight of servings. Ø Unlike DM Diet, DASH diet does not offer the option of food exchanges. ²Plant food sources ²Only 2 - 3 animal protein servings/day

Changing Strategies Of Treatment Of Hypertension (Cont’d) Ø Ø in Dietary sodium. ± Esp. Changing Strategies Of Treatment Of Hypertension (Cont’d) Ø Ø in Dietary sodium. ± Esp. for African Americans ± Elderly ± DM 75 meq/day of dietary sodium or less ( 5 mm. Hg systolic & 2. 6 mm diastolic). Cessation of smoking. alcohol intake. v v v < 10 oz wine < 2 oz whisky < 24 oz beer

Initial Drug Therapy: Step-wise approach: 1. First line - Diuretic or -blocker. 2. New Initial Drug Therapy: Step-wise approach: 1. First line - Diuretic or -blocker. 2. New agents - Ca channel blocker, ACE inhibitor, vasodilator etc. should be considered if patient is not responsive to initial therapy or has co -morbid conditions. 3. Adrenergic agents should only be used as a last choice b/c of their side effect profile.

Choosing the right medication for your patient: Choice of the treatment regimen depends on: Choosing the right medication for your patient: Choice of the treatment regimen depends on: Ø Degree of BP elevation. Ø Number of associated & concurrent risk factors. Ø Presence of TOD. Ø Clinical CVD or associated clinical conditions (ACC).

Risk Stratification: Risk Factors for Cardiovascular Diseases 1. Used for risk stratification : · Risk Stratification: Risk Factors for Cardiovascular Diseases 1. Used for risk stratification : · Levels of systolic and diastolic BP (Stages 1 -3) · Men > 55 years · Women > 65 years · Smoking · Total Cholestrol > 6. 5 mmol/L · Diabetes · FH of premature CVD Target Organ Damage Associated Clinical (TOD) · LVH (ECG, Echo, XR) Conditions (ACC) Cerebrovascular Disease · 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) Myocardial Infarction Angina Pectoris Coronary revascularization Congestive Heart failure

Risk Stratification (Cont’d): Risk Factors For Cardiovascular Diseases 2. Other factors adversely influencing the Risk Stratification (Cont’d): Risk Factors For Cardiovascular Diseases 2. Other factors 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 Target Organ Damage (TOD) Associated Clinical Conditions (ACC) Renal Diseases: · Generalized or focal narrowing of the retinal arteries ( retinopathy) ·Diabetic nephropathy

Dosage & Combination Therapy Ø Single daily dose interval of 4 - 6 weeks Dosage & Combination Therapy Ø Single daily dose interval of 4 - 6 weeks to observe the full response, unless it is necessary to lower BP more urgently. Ø If drug well tolerated but response is small, the dose or add drugs stepwise until BP control is attained. Ø Treatment can be stepped down later if BP falls substantially below the optimal level. Ø Most hypertensives require a combinations of antihypertensive therapy to achieve optimal control.

Dosage & Combination Therapy (Cont’d): Ø Drugs from different classes generally have additive effect Dosage & Combination Therapy (Cont’d): Ø Drugs from different classes generally have additive effect on BP. Ø Submaximal doses of 2 drugs results in larger response of BP & fewer side effects eg: Diuretic + B-blocker Diuretic + ACE inhibitor Ca-channel blocker + ACE inhibitor Ø Fixed dose combination may be convenient and are acceptable when monotherapy is ineffective

Dosage & Combination Therapy (Cont’d) Ø In Elderly: 1. Initial drug therapy: Diuretics Ca Dosage & Combination Therapy (Cont’d) Ø In Elderly: 1. Initial drug therapy: Diuretics Ca channel blockers

Specific Medication Recommendations For Concurrent Medical Problems: Concurrent Recommended Intermediate Conditions/ Drug Therapy Charactersticks Specific Medication Recommendations For Concurrent Medical Problems: Concurrent Recommended Intermediate Conditions/ Drug Therapy Charactersticks Diabetes with proteinuria ACE Inhibitors Ca antagonists (both types) ACE Inhibitors Diuretics Carvadilol Losartin Isolated Systolic Diuretics Hypertension Ca Antagonists (non-DHP central effects), long acting forms Heart Failure Usually Not Used or Contraindicated Medications ACE Inhibitors Diuretics with care Angiotensin B Blockers Receptor Blockers B Blockers Ca Antagonists ACE Inhibitors B Blockers Angiotensin Receptor Blockers

Specific Medication Recommendations For Concurrent Medical Problems: Concurrent Recommended Conditions/ Drug Therapy Characteristics Myocardial Specific Medication Recommendations For Concurrent Medical Problems: Concurrent Recommended Conditions/ Drug Therapy Characteristics Myocardial Infarction B Blockers (non-ISA) ACE Inhibitors; reduce mortality after MI Intermediate Drug Therapy Diuretics ACE Inhibitors Receptor Blockers Non DHP, Ca. Antagonists, (Diltiazem, Verapamil) Usually Not Contraindicated DHP Ca Antagonists eg nifedipine (immediate release can worsen myocardial ischemia) 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

Specific Medication Recommendations For Concurrent Medical Problems: Specific Medication Recommendations For Concurrent Medical Problems:

Specific Medication Recommendations For Concurrent Medical Problems (Cont’d): Concurrent Conditions/ Characteristics Recommended Drug Therapy Specific Medication Recommendations For Concurrent Medical Problems (Cont’d): Concurrent Conditions/ Characteristics Recommended Drug Therapy Essential or senile tremors BBlockers Intermediate Drug Therapy ACE Inhibitors Receptor Blocker Ca Antagonists Diuretics Hyperthyroidism BBlockers Migraine B Blockers (Non ISA) Calcium Antagonist (non DHP) Diuretics ACE Inhibitors Receptor Blocker DHP Calcium Antagonists Usually not used Contraindicated Medications

Specific Medication Recommendations For Concurrent Medical Problems (Cont’d): Concurrent Recommended Intermediate Usually Not Conditions/ Specific Medication Recommendations For Concurrent Medical Problems (Cont’d): Concurrent Recommended Intermediate Usually Not Conditions/ Used/ Drug Therapy Drug Contraindicated Characteristics Therapy Medications Osteoporosis Thiazides Pre-operative Hypertension BBlockers Diuretics Angiotensin ACE Inhibitors Receptor Blockers ( can’t be given with severe renal impairment) Angiotensin Renal B Blockers Receptor Insufficiency Blockers Ca Antagonists Prostatism (both types)

WHO/ISH Guidelines for Hypertension Management Summary Points: Ø Use of Grades rather than stages, WHO/ISH Guidelines for Hypertension Management Summary Points: Ø Use of Grades rather than stages, otherwise values choosen are same as JNC-VI. Ø Mild, moderate and severe are not used in the WHO-ISH guidelines - they correspond to grades 1, 2 & 3. Ø Term borderline hypertension is subgroup of Grade 1 i. e. Systolic 140 -149 Diastolic 90 -94

British Hypertension Society Guidelines for Hypertension Management: Summary Points: Ø Ø Ø Grades rather British Hypertension Society Guidelines for Hypertension Management: Summary Points: Ø Ø Ø 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.

Indications for specialist referral: Ø Ø Urgent treatment indicated: Malignant hypertension, impending complications. To Indications for specialist referral: Ø Ø Urgent treatment indicated: Malignant hypertension, impending complications. To investigate potential underlying causes of hypertension when initial evaluation suggests this possibility. To evaluate therapeutic problems or failures. Special circumstances: Unusually variable blood pressure, possible white coat hypertension, pregnancy.

Conclusion: Ø Ø Ø New guidelines like JNC-VI, unlike previous guidelines, has introduced the Conclusion: Ø Ø Ø 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…) Ø Ø Ø Diuretics or B-blockers for those as first choice with Conclusion: (Contd…) Ø Ø Ø Diuretics or B-blockers for those as first choice with uncomplicated hypertension. ACE inhibitors for Diabetic patients with proteinuria. ACE inhibitors &/ 0 r 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 treatmen 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.

Figure 1: Stepped Care Algorithm for treatment of Hypertension: Life style modification, Reduce wt Figure 1: Stepped Care Algorithm for treatment of Hypertension: Life style modification, Reduce wt Quit smoking, Regular exc. , Decrease sodium and alcohol Inadequate response Continue lifestyle modification, Initiate pharmacotherapy Inadequate response Increase daily dose Substitute another drug Inadequate response Add 2 nd or 3 rd Drug Add 2 nd drug from diff. class Inadeq, response Refer

Changing Strategies Of Treatment Of Hypertension (Cont’d) Goal: Ø JNC-VI uses a lower goal Changing Strategies Of Treatment Of Hypertension (Cont’d) Goal: Ø JNC-VI uses a lower goal BP (<140/90 mm. Hg) for hypertension in the elderly.

Changing Strategies Diuretics: Of Treatment Of Hypertension (Cont’d) Ø plasma volume. Ø cause peripheral Changing Strategies Diuretics: Of Treatment Of Hypertension (Cont’d) Ø plasma volume. Ø cause peripheral vasodilation. Ø potentiate the effect of other anti-hypertensive drugs. Ø Caution: Renal disease , Gout, DM, Dyslipidemia. Ø Start low dose. -blockers: 1 selective : start low dose & gradually-increase. Ø Should not be used in COPD, CHF or left ventricular function. Ø ACE inhibitors: Ø DM with proteinuria. Ø CHF or myocardial infarction.

Stratifying risk and quantifying prognosis: Stratifying risk and quantifying prognosis:

Which Drug treatment should be used? Class of Compelling Indications Drug Diuretics Heart failure Which Drug treatment should be used? Class of Compelling Indications Drug Diuretics Heart failure b Elderly b Systolic Hypertension Compelling Possible Contra. Indications contraindications b b. Diabetes b. Gout Dyslipidemias b Sexually active males b Dyslipidemia b Athletes b Physically active patients b Peripheral vascular. disease b B Blockers b. Angina b. Post MI b. Tachyarrythmias Heart failure b Pregnancy b Diabetes b Asthma b COPD b Heart Blocks b

Which Drug treatment should be used Class of Drug ACE Inhibitors Compelling Indications Heart Which Drug treatment should be used Class of Drug ACE Inhibitors Compelling Indications Heart Failure b LV. Dysfunction b After MI b Diabetic neph ropathy Calcium b Angina Antagonists b Elderly b Systolic Hypertension Possible Indications Compelling contraindications Possible Contraindications b Pregnancy b Bilateral Renal artery Stenosis b Hyperkalemia b Heart Blocks b Peripheral Vascular Disease Congestive Heart Failure

Which Drug treatment should be used Class of Drug Alpha Blockers Angiotensin II Antagonists Which Drug treatment should be used Class of Drug Alpha Blockers Angiotensin II Antagonists Compelling Possible Indiacations indications Prostrate Hypertrophy b Possible Contraindications Orthostatic hypotension b. Glucose Intolerance b. Dyslipidemias Side Effects Heart Failure with other drugs e. g. ACE inhibitors (cough) b Compelling contraindications Pregnancy b Bilateral Renal artery Stenosis b Hyperkalemia b Heart Blocks b

References: Ø Ø Ø BMJ 1999 Sep 4; 319: 630 - 635 - British References: Ø Ø Ø BMJ 1999 Sep 4; 319: 630 - 635 - British Hypertension Society guidelines for Hypertension management 1999; Summary NEW: 9 - 13 v. 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-V 1 - PDF format from the National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health (NIH) NEW updated URL 2 -11

References (Cont’d): v. NHLBL JNC IV References Sheet. v. National Guideline Clearing House - References (Cont’d): v. NHLBL JNC IV References Sheet. v. National Guideline Clearing House - Brief Summary NEW: 2 - 11. v. Archives of Internal Medicine 1997 Nov 24 BAD LINK NEW URL -waiting for 1997 back issues to be placed on -line ? v. JNC V 1: timing is everything Commentary - The Lancet 15 Nov 97. v JNC - 6 Guidelines Editorial - American Journal of Kidney Diseases May 1998 v. JNC Redux Editorial - American Journal of Kidney Diseases May 1998 v. Treatment of hypertension; insights from the JNC V 1 report. Am Fam Physician 1998 Oct 15; 58 (6; 1323 - 30 Pub. Med abstract)