UNDERSTANDING HYPERTENSION An Introduction to the Significance of

UNDERSTANDING HYPERTENSION An Introduction to the Significance of High Blood Pressure

ESSENTIAL HYPERTENSION, INCLUDING HISTORICAL ITEMS, PERSONAL EXPERIENCE AND TREATMENT SUGGESTIONS Albert J. Miller, M. D. Professor of Clinical Medicine (Cardiology) Feinberg School of Medicine Northwestern University

ASPECTS OF ESSENTIAL HYPERTENSION OFTEN IGNORED High blood pressure is a disease without symptoms n High blood pressure predisposes to serious arterial diseases u Stroke, heart attacks, kidney disease, eye disease, peripheral vascular disease n

THE HISTORY OF THE TREATMENT OF HYPERTENSION

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A REMINDER: B. P. = C. O. x T. P. R.

A DEFINITION of HYPERTENSION: Hypertension is a state of sustained blood pressure elevation from the normal associated with morbidity and mortality from damage to certain body organs A Miller, 1986

WHAT IS THE CAUSE OF HIGH BLOOD PRESSURE? n n Most high blood pressure is due to hormones that arise from the kidneys High blood pressure is not due to being nervous Some families have more high blood pressure than others Certain conditions like obesity, excessive salt intake, and anxiety aggravate high blood pressure

CONCERNING HYPERTENSION AND SYMPTOMS It is important to remember that high blood pressure is rarely associated with symptoms n High blood pressure rarely causes headache, tiredness, chest pain or shortness of breath n When these symptoms occur – we must look for other causes n

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LEFT VENTRICULAR HYPERTROPHY

PRESIDENT FRANKLIN DELANO ROOSEVELT DIED OF A MASSIVE BRAIN HEMORRHAGE APRIL 12, 1945

PRESIDENT ROOSEVELT’S BLOOD PRESSURES: July 1935 n Feb 1941 n Apr 1944 n Nov 1944 n Apr 1945 n 136/78 188/105 226/118 160/150 240/130

THE VOWS I WILL TAKE: I will treat patients with significant hypertension… n With congestive heart failure n With encephalopathy n With angina pectoris n With malignant hypertension n With renal disease 1964

We treat high blood pressure because… It causes damage to body organs n It is a major risk factor for atherosclerosis n It is associated with premature death n

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OVER 60 MILLION AMERICANS HAVE CARDIOVASCULAR DISEASE High BP: 50 million u #1 Cardiovascular Disease n Coronary heart disease: 12. 4 million u Myocardial infarction: 7. 3 million u Angina pectoris: 6. 4 million n Stroke: 4. 5 million n CHF: 4. 7 million n 2001 Heart and Stroke Statistical Update. American Heart Association.

THE TREATMENT OF HYPERTENSION AND COMPLIANCE We need safe medications that can be taken once or twice daily, and which work by counter-acting the excessive systemic arteriolar resistance of essential hypertension without annoying side effects. AJ Miller Treatment of Hypertension Arch Int Med 1977; 137: 1597 -8

TREATMENT OF HIGH BLOOD PRESSURE BEFORE 1977 Treatment consisted of: - Severe dietary restriction of salt Rice diet Weight control and exercise Drugs with many side-effects The drugs made patients feel sick

THE DISCOVERY OF CAPTOPRIL 1977… A specific orally active inhibitor of angiotensin-converting enzyme in man Ferguson, RK, Turini, GA, Brunner, HR, Gavras, H & Mc. Kinstry, DN Lancet 1977; 1: 775 -8

Conclusions n There is strong support from hypertension studies for: u More aggressive treatment goals u Therapy oriented to protect target organs u Recognition of the need for more than one anti-hypertensive drug to achieve new goals

MOST HYPERTENSION IS TREATABLE; SOME FORMS ARE CURABLE RENAL ARTERY STENOSIS u ATHEROSCLEROSIS u MUSCULAR STENOSIS n PHEOCHROMOCYTOMA n HYPOTHYROIDISM n HYPERPARATHYROIDISM n COARCTATION OF THE AORTA n

SOME CONCEPTS OF TREATMENT OF ESSENTIAL HYPERTENSION

A SUGGESTED “IDEAL” INITIAL APPROACH TO TREATING HYPERTENSION n n Start with an ace inhibitor (ACE) or an angiotensin receptor blocker (ARB) Add beta blocker Carvedilol or Labetalol with vasodilating properties Add hydrochlorothiazide if necessary for added blood pressure lowering (or hydrochlorothiazide + triamterine) Salt restriction, weight control, exercise

SUMMARY AND CONCLUSIONS High blood pressure is rarely cured n High blood pressure must be treated to get the pressure to normal levels n High blood pressure requires continued treatment n Persons with high blood pressure should be under a physician’s care n

RESULTS OF STUDIES OF STRESSORS IN HYPERTENSION 24 -hour ambulatory blood pressure monitoring is a valuable diagnostic tool in assessing the blood pressure responses in hypertensive patients. n The modified cold pressor test and the public speaking test are helpful in assessing blood pressure responses to stress n

CARVEDILOL & LABETALOL: BETA BLOCKERS WITH VASODILATING PROPERTIES n n n Both have alpha 1 blocking properties, decrease total peripheral resistance and increase cardiac output Small decrease in heart rate Both decrease work of the heart With comparable dosages, at 1 year both lower systolic and diastolic pressures comparably Both have minimal effects on lipid or glucose levels Lund-Johansem, P J Cardiovasc Pharm, 1988 Data from Smith Kline Beacham Pharm, 1996

INCREASED SYMPATHETIC OUTFLOW IN HYPERTENSIVE PATIENTS n n Lifestyle stresses activate sympathetic nervous system outflow, as demonstrated in our studies and others. Logical treatment approaches should include agents that are vasodilators and block sympathetic outflow: Carvedilol (Coreg) or Labetolol (Normodyne)