HYPERTENSION Background for understanding the Hypertension literature Case

HYPERTENSION Background for understanding the Hypertension literature. Case presentation Approach to Treatment Jeffrey J. Kaufhold, MD Nephrology 2009

HYPERTENSION SUMMARY l Background for understanding the literature of Hypertension l Review of Joint National Commission Recommendations (VII) 2003 l Clinical Evaluation and Case histories.

Nat’l Health & Nutrition Exam Survey NHANES JNC 7 Dec 2003

$Case Presentation 56 y. o. A. A. male prior weight lifter presents for refractory$

Case Presentation 56 y. o. A. A. male prior weight lifter presents for refractory HTN. Normal labs and UA. Normal CXR and EKG. Meds: Clonidine 0. 2 BID ACE inhibitor Diltiazem 300 mg daily

Case Presentation Physical Exam: BP 170 / 110 Edema 2 + Pulse 85

Case Presentation Special populations help define your approach. African Americans: CHF Diabetics:

Case Presentation Special populations help define your approach. African Americans: Volume Mediated, Low renin low Aldo. CHF: ACE, Diuretics, B-blocker Diabetics: ACE or ARB.

Case Presentation 56 y. o. A. A. male with edema, HTN Normal labs and UA. Normal CXR and EKG. Meds: Clonidine 0. 2 BID ACE inhibitor Diltiazem 300 mg daily Whats Missing? ? ?

$Case Presentation 56 y. o. A. A. male with refractory HTN. Meds: Clonidine 0.$

Case Presentation 56 y. o. A. A. male with refractory HTN. Meds: Clonidine 0. 2 BID ACE inhibitor - Stopped Diltiazem 300 mg daily I added HCTZ 50 mg daily.

$Case Presentation 56 y. o. A. A. male with refractory HTN. Meds: Clonidine 0.$

Case Presentation 56 y. o. A. A. male with refractory HTN. Meds: Clonidine 0. 2 BID Diltiazem 300 mg daily HCTZ 50 mg daily. Still swelling, BP a little better. 156 / 100.

$Case 56 y. o. AA male with refractory HTN. I changed diuretics to Lasix$

Case 56 y. o. AA male with refractory HTN. I changed diuretics to Lasix and Zaroxolyn. I get a call 3 days later: Swellings gone, but I can’t get out of bed – too dizzy!

$Case Presentation 56 y. o. A. A. male with refractory HTN. Meds: Lasix 40$

Case Presentation 56 y. o. A. A. male with refractory HTN. Meds: Lasix 40 mg BID Zaroxolyn 5 mg weekly No swelling, BP 126 / 80. Pt reports joint pain and swelling. What test do you order next?

Case Uric acid level is 12 Creatinine 1. 4 K 3. 8 Glucose 244 (nonfasting)

Case Pt stopped his meds due to the pain, and symptoms improved. BP climbed to 200/110 Headaches, visual blurring, DOE, dizzy.

Malignant HTN Mortality of 50% within 2 years! Usual mode of exit was Heart Failure, stroke or Renal failure. Marked by severe hypertension with end organ damage Hypertensive emergency = high BP with sx Hypertensive urgency= high BP no sx.

Malignant HTN End Organ Damage: Renal failure CHF with Pulmonary Edema Stroke (esp with bleeding), Encephalopathy Retinopathy Flame Hemorrhages, Papilledema

Malignant HTN End Organ Damage: Retinopathy Flame hemorrhage Keith and Wagoner, 1974 Cotton wool spot papilledema

Malignant Hypertension Treatment Goals: Get BP down to safe level, not “normal” (brain needs to autoregulate blood flow) Target 25 % reduction or SBP < 170, DBP<105 within 6 hours. Control symptoms, especially SOB, CP

Malignant Hypertension Treatment Principles: ICU monitoring consider Art line if cuff BP readings are suspect. Use agents which are safe and rapidly titratable depending on response Get pt OFF IV therapy as soon as possible and on Oral meds.

Malignant Hypertension I. V. Treatment: Nipride drip Start 0. 25 to 0. 5 microgm/kg/min up to 2 mcg/kg/min max dose about 8 mcg/kg/min Limited by what toxicity? Who is at risk for this toxicity? Symptoms of toxicity? Treatment of Toxicity?

Malignant Hypertension I. V. Treatment: Nitroglycerine drip 5 mcg/min (no kg in here) up to 100 mcg/min (have gone as high as 200 in some cases) Same dose for Angina, (preferred treatment in cases with CP)

Malignant Hypertension I. V. Treatment: Labetolol drip give 20 mg IV slow push, followed by drip at 0. 5 to 2 mg/min use with caution in pts with bradycardia, CHF, Asthma, Crystal Meth use Probably treatment of choice in pt with Bblocker withdrawal syndrome

Malignant Hypertension I. V. Treatment: Nicardipine drip 5 -15 mg/hr Longer half-life so slower titration and won’t clear rapidly

Malignant Hypertension I. V. Treatment: Esmolol drip (Brevibloc) 80 mg IVP followed by 150 -300 mcg/kg/min infusion useful for suppression of arrhythmias, use in OR with anesthesia

Malignant Hypertension I. V. Treatment: Corlepam/fenoldepam dopamine congener start at dose of 0. 1 mcg/kg/min titrate up 1 -2 mcg/kg/min as needed contraindicated in pt with glaucoma. Preserves Renal Perfusion Expensive! to

Malignant Hypertension I. V. Treatment: Phentolamine 5 -15 mg IV bolus every 5 -15 min or drip of 1 mg/min Alpha blockade, so especially useful in cases with pheochromocytoma, Tyramine-Cheese reaction with MAO-inhibitor

Case Started Allopurinol for gout. Pt started exercising and watching diet. Sugars normalized without treatment.

Hypertension Literature Summary l Malignant Hypertension - 1958 Kincaid-Smith and others DBP > 130 l VA Cooperative Studies - 1967 DBP 115 -129 mm Hg - 1970 DBP 90 -114 mm Hg

HYPERTENSION Literature Summary l US Public Health Service 1977 Prospective placebo controlled trial for DBP 90 -115 mm Hg l HDFP 1979 Introduced concept of Stepped Care l Oslo Study 1980 Treatment of Mild Hypertension l Medical Research Clinics (MRC) 1985 Single blind and community based.

HYPERTENSION PARALLEL WORK l 1948 to 1972 Framingham Study 20 year follow-up on 5000 pts l 1982 MRFIT Randomized primary prevention trial Lower than expected rate of mortality in controls led to NS reduction. l 1984 LRC (Lipid Research Clinics) Treatment of hyperlipidemia reduced risk of heart disease, all-cause mortality not effected.

HYPERTENSION Recent Works l 1985 HDFP follow-up Study Long term surveillence for drug side effects: 9 -25 % l 1992 Gurwitz Ann Int Med Antihypertensive therapy and the initiation of Tx for DM. Diabetes and HTN are linked, drugs and diabetes are NOT. l 1993 VA Cooperative Study, Materson, NEJM Compares 6 agents. Efficacy in 55 % range. Drug intolerance 6 to 14 %.

Joint National Commission JNC 1 JNC 2 JNC 3 JNC 4 JNC 5 JNC 6 JNC 7 1980 1984 1986 1988 1993 1997 2003 founded on HDFP Intro of ACE, alpha B. Special situations Many agents 1 st line Back to stepped care. ACE for Diabetics

HYPERTENSION JNC V l "Because diuretics and B-Blockers are the only classes of drugs that have been used in long-term controlled trials and shown to reduce morbidity and mortality, they are recommended as first- choice agents unless they are contraindicated or unacceptable, or unless there are special indications for other agents. "

HYPERTENSION JNC VII Outline l Epidemiology of HTN l Evaluation of HTN l NON Pharmacologic treatments: Wt loss, diet, exercise, alcohol l Drug treatment l Special Issues in HTN

Stages of Hypertension Normal < 120 / 80 Prehypertension 120 -139 / 80 -89 Stage 1 140 -159 / 90 -99 Stage 2 > 160 / >100

Treatment of Hypertension Single agent – HCTZ for most pts. B-Blocker for females/ high heart rate. Stage 2 I start with DHP CCB (procardia XL) plus one or both of above. Resistant HTN I look for CLASSES of agents

Classes of Antihypertensives Diuretics Rate control agents BBlocker, Verapamil, Diltiazem ACE/ ARB’s Vasodilators Dihydropyridines, Hydralazine, Alpha blockers, Minoxidil Central agents: clonidine, aldomet.

Nephrology level htn I tell the pt that will need to control the main route plus the main detours causing the HTN. Rate control (pulse < 78) Diuretic Vasodilator DHP CCB, Hydralazine, Cardura, Minoxidil. ACE / ARB (accept 30% increase in creat if BP responds)

Refer to Nephrologist If unable to control on 3 drug regimen which includes Rate control, diuretic. If you are considering Minoxidil If creatinine climbs more than 30 % or if creatinine is over 2. 0.