Nuevos conceptos en HTA

Dr. Christian Amurrio Gonzales

Objetivo 1
Diagnostico correcto Preguntas adicionales:
El paciente toma alguna sustancia que puede influir

sobre su presion arterial? Hay otras enfermedades presentes que pueden tener impacto sobre su riesgo cardiovascular? Hay evidencia de dao a organo-blanco por hipertension sostenida?

Table : Prescription medications that elevate blood pressure

Corticosteroids

NSAIDs
Cyclosporine Tacrolimus Erythropoietin Tricyclic antidepressants Venlafaxine (Effexor) MAO inhibitors Oral contraceptives ***

Table : Classification of blood pressure1

Systolic BP, mm Hg
BP Classification Normal Prehypertension Stage 1 hypertension Stage 2 hypertension <120 120-139 140-159 >160 <80 80-89 90-99 >100

Diastolic BP, mm Hg

Riesgos asociados con HTA enf. Cardiovascular [aortic aneurysm and aortic dissection enf. Cerebrovascular enfermedad renal-terminal insuficiencia cardiaca congestica

La curva J
Coronary perfusion occurs during diastole, and

there is concern that as diastolic pressure is brought to ever lower levels, coronary perfusion will be compromised and cardiovascular mortality will increase. INVEST trial
"in view of the uncertainty on this issue, it would

seem prudent to counsel that in patients with an elevated DBP and occlusive CAD with evidence of myocardial ischemia, the BP should be lowered slowly, and caution is advised in inducing falls of DBP below 60mm HG if the patient has diabetes

 Every 5mm Hg increase in diastolic blood pressure and

every 10mm Hg increase in systolic blood pressure is associated with a 28% increase in the risk of death from coronary heart disease, even in individuals who are not classified as hypertensive.
Systolic blood pressure has been shown to be a

stronger predictor

Objetivo 2
Table : Objectives of evaluation of the newly-diagnosed hypertensive

Examples
Objective Identification of other cardiovascular risk factors Diabetes Hypercholesterolemia Tobacco Positive family history Renal artery stenosis Obstructive sleep apnea Cushing's disease Conn's syndrome

Identification of possible secondary causes

Identification of possible target organ damage

Left ventricular hypertrophy Chronic kidney disease

Table : Physical evidence of target organ damage

Physical finding
Hypertensive retinopathy18

Comments
Examples Arteriovenous nicking "Copper-wiring" Retinal hemorrhages

Vascular bruits

Examples: Carotid bruits Renal artery bruits Femoral artery bruits

LV heave on physical exam; EKG may show evidence of hypertrophy or strain Examples: S3 gallop Pulmonary rales Elevated JVP Peripheral edema Inquire about intermittent claudication; consider obtaining ankle/brachial indices Consider evaluation of cerebrovascular circulation

Left ventricular hypertrophy Left or right ventricular failure

Diminished pedal pulses Neurologic abnormalities (i.e. stroke)

Table 6: Commonly recommended tests in the newly diagnosed hypertensive1, 19

Test EKG Comment May demonstrate evidence of LVH, conduction abnormalities, ischemia or infarction, all of which will demonstrate target organ damage and alter not only the initial choice of therapy, but also the time course of instituting therapy

Basic metabolic panel

Demonstrates pre-treatment sodium and potassium, which will affect initial choice of therapy along with providing a possible clue to a secondary cause of hypertension (e.g. hyperaldosteronism). Ca++ The BUN and creatinine will demonstrate the presence or absence of target organ damage, and also guide initial choice of therapy (thiazides do not work well if the creatinine is above 1.5 -2 mg/dL; a loop diuretic should be considered if a diuretic is needed. ACE-inhibitors do not work well if the creatinine is above 3mg/dL). Guidelines for antihypertensive therapy for diabetics and those with renal disease are among the most aggressive; thus the creatinine and glucose provided with the basic metabolic panel will alter therapy. Provides evidence of target organ damage that will guide initial management (e.g. proteinuria).
Indicated for risk stratification for coronary artery disease. Elevated LDL cholesterol is an independent risk for the development of coronary artery disease, and will need to be evaluated in most individuals diagnosed with hypertension To exclude polycythemia as a possible cause of hypertension

Urinalysis
Lipids

Complete blood count

Table : Lifestyle modification and impact on blood pressure1

Modification Recommendations Maintain normal body weight (BMI 18.5-24.9) Consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat Reduce dietary sodium intake to no more that 2.4 g sodium or 6g sodium chloride Engage in regular aerobic physical activity such as brisk walking (30mins, most days/week) Limit consumption to no more than 2 drinks/day (men) or 1 drink/day (women and lighter weight persons) Approximate Systolic Blood Pressure Reduction

Weight reduction

5-20mm Hg/10kg weight loss

Adopt DASH eating plan

8-14mm Hg

Dietary sodium reduction

2-8mm Hg

Physical activity

4-9mm Hg

Moderation of alcohol consumption

2-4mm Hg

Objetivo 3 Tx farmacolgico inmediato?

The individual who presents with an elevated blood

pressure who has no target organ damage or other cardiovascular risks The level of blood pressure elevation will also impact your decision. and without hypertension.

Salt restriction lowers blood pressure in patients with In one study, individuals who lost as little as 2.4kg

had a 77% reduction in the odds of developing hypertension seven years later.

DASH and TONE

Objetivo 4 HTA secundaria

Table : Red flags for secondary hypertension

Evaluation component History

Finding Onset of HTN age <30 or >50 History of well-controlled HTN, now poorly controlled Flash pulmonary edema Episodic hypertension Daytime somnolence; loud snoring

Potential implication Prevalence of secondary causes higher in this population Suggests secondary cause, especially renal artery stenosis Suggests renal artery stenosis Suggests pheochromocytoma Suggests obstructive sleep apnea Suggests obstructive sleep apnea Suggests hyperthyroidism Suggests Cushing's Suggests Cushing's Suggests Cushing's Suggests renal artery stenosis Suggests polycystic kidney disease Suggests coarctation of the aorta Suggests anemia, hyperthyroidism, aortic insufficiency, arteriovenous fistula, Paget's disease of bone

Physical exam

Obesity Thyroid goiter Moon facies Dorsal fat pad Purple striae Vascular bruits Abdominal mass Decreased pulses in lower extremities Isolated systolic hypertension

Labs

Hypokalemia

Suggests Cushing's, hyperaldosteronism, renal artery stenosis

Suggests hyperparathyroidism Suggests Cushing's, hyperaldosteronism, possibly obstructive sleep apnea Suggests polycythemia

Hypercalcemia Metabolic alkalosis Elevated hematocrit

HTA resistente y refractaria

History: onset of HTN before 30 or after 50; h/o

well controlled HTN now out of control; flash pulmonary edema; episodic HTN; daytime somnolence, loud snoring; uncontrolled BP despite 3 meds at or near maximal dose (including a diuretic) dorsal fat pad; purple striae; vascular bruits; abdominal mass; decreased pulses lower extremities alkalosis; elevated hematocrit

Physical: Obesity; thyroid goiter; moon facies;

Labs: Hypokalemia; hypercalcemia; metabolic

Figure 1: Considerations in resistant hypertension

Table: Review of causes of secondary hypertension

Cause Renal parenchymal disease Renal artery stenosis Clues Microalbuminuria; proteinuria; nocturia; edema Flash pulmonary edema; multiple vascular risks; previously well-controlled hypertension, now poorly controlled; vascular bruits; hypokalemia; renal insufficiency on ACE-I Women between ages 15 and 50; beaded appearance on renal angiogram Daytime somnolence; loud snoring; met. alkal Sustained or episodic hypertension with headache, palpitations, diaphoresis Hypokalemia; metabolic alkalosis Dorsal fat pad; moon facies; purple striae; truncal obesity; proximal muscle weakness; metabolic alkalosis; hypokalemia Hypercalcemia; "bones, stones, abdominal groans" Systolic hypertension, tachycardia, weight loss, exophthalmos, goiter, thyroid bruit. Cold intolerance; constipation; mental slowing; diastolic hypertension; lateral thinning of eyebrows; periorbital edema; delayed relaxation of reflexes

Fibromuscular dysplasia Obstructive sleep apnea Pheochromocytoma Hyperaldosteronism ( Conn syndrome) Hypercortisolism (including Cushing syndrome)

Hyperparathyroidism Hyperthyroidism Hypothyroidism

Table 10: AHA recommendations for blood pressure targets in cardiac disease17
Area of concern
General CAD prevention High CAD risk

TargetBP
<140/90 <130/80

Comments
Start 2 agents if SBP >160 of DBP > 100 High CAD risk = DM, CKD, known CAD, CAD equivalent condition (i.e. carotid artery disease, peripheral vascular disease, abdominal aortic aneurysm) or 10-year Framingham Risk >10% Beta-blocker and ACEI or ARB should be included in regimen

Stable angina

<130/80

UA/NSTEMI

<130/80

Beta-blocker and ACEI or ARB should be included in regimen if hemodynamically stable

Beta-blocker and ACEI or ARB should be included in regimen if hemodynamically stable ACEI or ARB and beta-blocker and aldosterone antagonist and thiazide or loop diuretic should be included in regimen; hydralazine/isosorbide dinitrate should also be included in African Americans

STEMI

<130/80

Left ventricular dysfunction

<120/80

Objetivo 6 Medicamento adecuado

The single most important aspect in

treating a patient with hypertension is the level of blood pressure control.

However, the agent(s) chosen to

achieve blood pressure control may provide additional benefit in specific clinical conditions

ALLHAT
Men and women aged 55 or older with blood pressure

greater than 140/90 and at least one other cardiovascular risk factor were randomized to receive treatment with either a diuretic (chlorthalidone), an alpha-blocker (doxazosin), a calcium channel blocker (amlodipine) or an ACE-inhibitor (lisinopril). Beta blockers were not included. Goal blood pressure reduction for all groups was set at BP<140/90.
The primary outcome was combined fatal CHD or non-

fatal myocardial infarction. Before the study was completed, an interim analysis of results found that the doxazosin group (as compared to the chlorthalidone group) had a higher incidence of stroke (relative risk 1.19), combined cardiovascular disease (relative risk 1.25) and most dramatically, congestive heart failure

 Clinical outcomes of those patients treated with

chlorthalidone were compared to those treated with amlodipine or lisinopril. Chlorthalidone proved superior to the other agents in lowering blood pressure, reducing clinical events, and was better tolerated than the other agents. As compared to amlodipine, chlorthalidone was associated with 25% fewer cases of heart failure, although other clinical outcomes were not statistically different. As compared to lisinopril, chlorthalidone was better tolerated and resulted in better blood pressure control. In addition, the lisinopril group had a greater risk of stroke, heart failure, angina, and coronary revascularization as compared to chlorthalidone. The authors concluded that "thiazide-type diuretics should be considered first for pharmacologic therapy in patients

Table : Indicaciones convincentes

High-risk condition with compelling indication CHF

Diuretic recommen ded

Beta-blocker recommende d

ACEI recomme nded

ARB recomm ended

CCB recomm ended

Aldosterone antagonist recommended

Post-MI

High CAD risk

**

DM

CKD

Recurrent CVA prevention

**ACCOMPLISH ACE-inhibitor/dihydropyridine CCBbenazepril/amlodipine <20% VS. benazepril/hydrochlorothiazide

Table : Secondary considerations of antihypertensive agents

Diuretics Drug of choice for hypertension without compelling indications for another drug Thiazide diuretics may have beneficial effects on calcium metabolism Low dose diuretics may be of benefit in patients with diabetes Thiazide diuretics may precipitate gout

Beta-blockers

Drug of choice for preoperative hypertension Increasingly useful in cardiovascular risk reduction in noncardiac surgery Drug of choice for hypertension associated with hyperthyroidism Useful for migraine prophylaxis Acceptable for use during pregnancy (other acceptable agents: methydopa; vasodilators)

ACE-inhibitors

Absolutely contraindicated in pregnancy A 35% increase in creatinine is acceptable when initiating therapy with ACE-inhibitors May be less effective for blood pressure control in African Americans, who are also more likely to develop angioedema in response to ACE-I

Angiotensin-receptor blockers (ARBs)

Not currently a first line agent; Used when ACE indicated but not tolerated Evidence continues to increase that they are equivalent to ACE-I in benefits to kidneys in diabetics Absolutely contraindicated in pregnancy As with ACE-I, a 35% increase in creatinine may be seen when initiating therapy

Calcium channel blockers

May be of particular use when treating isolated systolic hypertension in the elderly May be more effective for blood pressure control in African Americans May be used for migraine prophylaxis Non-dihydropyridine CCBs (e.g. verapamil) third choice in diabetic nephropathy if ACE or ARB not tolerated55 Non-dihydropyridine CCBs may also delay progression of proteinuria in other causes of chronic kidney disease 56 In the absence of benefit in specific clinical scenarios, calcium channel blockers are now considered thirdline agents, after therapy with diuretics, betablockers, and/or ACE-inhibitors

Alpha blockers

Should not be used as monotherapy for the treatment of hypertension May help treat symptoms in men with benign prostatic hypertrophy

Aldosterone antagonists

Includes spironolactone and eplerenone (brand name Inspra) Defined role in management of CHF Both cause hyperkalemia Spironolactone associated with sexual side effects, seen less with eplerenone

GRACIAS

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