Hypertension: New Trials – Best Treatments Karen Moncher, MD Assistant Professor University of Wisconsin School of Medicine and Public Health

Hypertension:New Trials – Best Treatments

Karen Moncher, MD

Assistant Professor

University of Wisconsin School of Medicine and Public Health

Overview

• Epidemiology • Clinical Trials and Trends

– “All things old become new again”

• Management Guidelines– Compelling reasons for treatment– Management based on patient problems and pharmacology

• Patient Adherence

Top 10 HTN RX Problems

10. Lack of Public Awareness 68%

9. Lack of Provider Awareness - Systolic BP

8. Lack of Treatment 54%

7. Lack of Provider Awareness Lifestyle RX

6. Providers / Patients - office BP is higher

5. Thought that BP rise with age is not a risk

Top 10 HTN RX Problems

4. Lack of use of combination therapy, especially with inexpensive thiazide diuretic (concept that thiazide is synergistic with all)

3. Inappropriate choice of antihypertensive agent based on patient

2. Providers and patients underestimate the benefits of RX, assume less Quality of Life

1. Adherence - Adherence - Adherence

-70

-60

-50

-40

-30

-20

-10

0

1970 1974 1978 1982 1986 1990 1994

Year

Per

cen

t d

ecli

ne

White men

White women

Black men

Black women

The decline in age-adjusted mortality for stroke in the total population is 59.0%. *Age-adjusted to the 1940 U.S. census population.

Percent Decline in Age-Adjusted* Mortality Rates for Stroke by Sex and

Race: United States, 1972-94

-60

-50

-40

-30

-20

-10

0

1970 1974 1978 1982 1986 1990 1994Year

Per

cen

t d

ecli

ne

White men

White women

Black men

Black women

The decline in age-adjusted mortality for CHD in the total population is 53.2%.*Age-adjusted to the 1940 U.S. census population.

Percent Decline in Age-Adjusted* Mortality Rates for CHD by Sex and

Race: United States, 1972-94

Incidence of Reported End-Stage Renal Disease Therapy, 1982-1995

50

100

150

200

250

1983 1985 1987 1989 1991 1993 1995

Year

Ra

te p

er

Mill

ion

Po

pu

lati

on

253*

*Provisional data.Adjusted for age, race, and sex.

Demographic Trends

Elderly US population will double “baby boomer” generation

Projected Elderly Population Age 65+ (millions)

0

25

50

75

1990 2000 2010 2020 2030

31 million

12.6% total US population

65 million

21.8% total US population

HypertensionHypertension DyslipidemiaDyslipidemia DiabetesDiabetes

Liao. Liao. Clin Chem.Clin Chem. 1998;44:1799-1808; Spieker et al. 1998;44:1799-1808; Spieker et al. J Hum Hypertens.J Hum Hypertens. 2000;14:617-630; 2000;14:617-630; Belton et al. Belton et al. Circulation.Circulation. 2000;102:840-845; Ross. 2000;102:840-845; Ross. N Engl J MedN Engl J Med. 1999;340:115-126.. 1999;340:115-126.

Risk Factors, Including Hypertension and Dyslipidemia, Promote CVD by Contributing

to Endothelial Dysfunction

Endothelial dysfunctionEndothelial dysfunction

CVDCVD

InflammationInflammation

Leukocyte adhesionLeukocyte adhesion

Endothelial permeabilityEndothelial permeability

Foam cell formationFoam cell formation

T-cell activationT-cell activation

AtherosclerosisAtherosclerosis

Thromboxane AThromboxane A22

Prostaglandin HProstaglandin H22

ProstacyclinProstacyclin

COX-1 ActivityCOX-1 ActivityNO SynthesisNO Synthesis

VasoconstrictionVasoconstriction

ThrombosisThrombosis

SuperoxideSuperoxide

EndothelinEndothelin

VasoconstrictionVasoconstriction

Calcium mobilizationCalcium mobilization

SmokingSmoking

Overview





U.S. Department of Health and Human

Services

National Institutes of Health

National Heart, Lung, and Blood Institute

Major Outcomes in High Risk Hypertensive Patients Randomized to

Angiotensin-Converting Enzyme Inhibitor or Calcium Channel Blocker vs Diuretic

The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT)

The ALLHAT Collaborative Research Group

Sponsored by the National Heart, Lung, and Blood Institute (NHLBI)

ALLHAT

JAMA. 2002;288:2981-2997 Dec. 18, 2002

ALLHAT Trial Design

Randomized, double-blind, multi-center clinical trial

Determine whether occurrence of fatal CHD or nonfatal MI is lower for high-risk hypertensive patients treated with newer agents (CCB, ACE-I, alpha-blocker) compared with a diuretic

Known ASCVD, DM, smoker, LVH, low HDL

42,418 high-risk hypertensive patients ≥ 55 years

ALLHATJAMA 2002 Dec. 18

• 33357 men and women - diverse races• HTN and at least one other CHD risk factor• Compared: Thiazide, Lisinopril, Amlodipine, and

previously stopped doxazosin arm• Primary outcome Fatal CHD or non-fatal MI• Secondary outcomes:

– Total Mortality - CVA– Combined CHD - CHF

ALLHAT Step 1Treatment Protocol

Step 1 Agent Initial Dose* Dose 1* Dose 2* Dose 3*

Chlorthalidone 12.5 12.5 12.5 25

Amlodipine 2.5 2.5 5 10

Lisinopril 10 10 20 40

Doxazosin 1 2 4 8

* mg/day

BP Results by Treatment Group

Compared to chlorthalidone:

SBP significantly higher in the amlodipine group (~1 mm Hg) and the lisinopril group (~2 mm Hg).

Compared to chlorthalidone:

DBP significantly lower in the amlodipine group (~1 mm Hg).

Cumulative Mortality Rate

Years to Death0 1 2 3 4 5 6 7

0

.05

.1

.15

.2

.25

.3

Number at risk: Chlor 15,255 14,933 14,564 14,077 12,480 7.185 3,523 4288 Amlo 9,048 8,847 8,654 8,391 7,442 4,312 2,101 217 Lisin 9,054 8,853 8,612 8,318 7,382 4,304 2,121 144

Cumulative Event Rates for All-Cause Mortality by ALLHAT Treatment Group

HR (95% CI) p value

A/C 0.96 (0.89-1.02) 0.20

L/C 1.00 (0.94-1.08) 0.90

ChlorthalidoneAmlodipineLisinopril

Cumulative Combined CVD Event Rate

Years to Combined CVD Event0 1 2 3 4 5 6 7

0

.1

.2

.3

.4

.5

Number at risk: Chlor 15,255 13,752 12,594 11,517 9,643 5,167 2,362 288 Amlo 9,048 8,118 7,451 6,837 5,724 3,049 1,411 153 Lisin 9,054 7,962 7,259 6,631 5,560 3,011 1,375 139

Cumulative Event Rates for Combined CVD by ALLHAT Treatment Group

RR (95% CI) p value

A/C 1.04 (0.99-1.09) 0.12

L/C 1.10 (1.05-1.16) <0.001


Cumulative CHF Rate

Years to HF0 1 2 3 4 5 6 7

0

.03

.06

.09

.12

.15

Cumulative Event Rates for Heart Failure by ALLHAT Treatment Group

HR (95% CI) p value

A/C 1.38 (1.25-1.52) <.001

L/C 1.19 (1.07-1.31) <.001


Number at risk: Chlor 15,255 14,528 13,898 13,224 11,511 6,369 3,016 384 Amlo 9,048 8,535 8,185 7,801 6,785 3,775 1,780 210 Lisin 9,054 8,496 8,096 7,689 6,698 3,789 1,837 313

Biochemical ResultsChlorthalidone Amlodipine Lisinopril

Serum cholesterol- mg/dL

Baseline 216.1 (43.8) 216.5 (44.1) 215.6 (42.4)

4 Years 197.2 (42.1) 195.6 (41.0)* 195.0 (40.6)*

Serum potassium – mmol/L

Baseline 4.3 (0.7) 4.3 (0.7) 4.4 (0.7)*

4 Years 4.1 (0.7) 4.4 (0.7)* 4.5 (0.7)*

Estimated GFR† – mL/min/1.73m2

Baseline 77.6 (19.7) 78.0 (19.7) 77.7 (19.9)

4 Years 70.0 (19.7) 75.1 (20.7)* 70.7 (20.1)*

* p<.05 compared to chlorthalidone† Ann Intern Med. 1999;130:461-470

ALLHAT Conclusions

Amlodipine (representing CCB), lisinopril (representing ACE-I) and chlorthalidone (representing thiazide-type diuretics) were comparable in preventing major coronary events or increasing overall survival.

Although chlorthalidone did not differ from amlodipine in overall CVD event prevention, it was superior to amlodipine in preventing heart failure.

ALLHAT Conclusions

Chlorthalidone was superior to lisinopril in preventing aggregate CV events, principally stroke, HF, angina, and coronary revascularization

Chlorthalidone was superior to doxazosin (representing alpha-blockers) in preventing CV events, including both HF and other CVD.

Overall Conclusions

ALLHAT

Because of the effectiveness of thiazide-type diuretics in preventing one or more major forms of CVD and their lower cost, they should be the drugs of choice for first-step antihypertensive drug therapy, unless there are other compelling indications.

Isolated Systolic Hypertension

Systolic Pressure 140 mmHg

&

Diastolic < 90 mmHg

JNC VI Report, NIH, JNC VI Report, NIH, NHLBINHLBI

SHEP Study

• Treatment of elderly patients with ISH

• Thiazide diuretic plus atenolol if needed

• Stroke, total mortality, CVD events

• 63% patients had BP controlled with diuretic alone

• CVA reduced 36% (3/100) and CVD events reduced 6 per 100 in 4.5 years

JAMA 1991;265;3255-3264

HTN in the Elderly Trial*

ACE (enalapril) vs. HCTZ • 6083 adults with HTN aged 65 - 84 years• Australia Family Practice clinics• Open-label study in multiple practices• BP reduction was the same: 26/12 mm Hg• All CVD events or death reduced for men (17%

or approximately 4 / 100)• No difference in events for women

NEJM 2003;348:583-592

BP-Lowering Treatment Trialists’ Meta-analysis:Comparisons of Active Treatments and Control

FavorsFavorsActiveActive

FavorsFavorsControlControl

0.5 1.0 2.0

Relative Risk RR (95% CI)RR (95% CI)

StrokeStroke

Coronary heart diseaseCoronary heart disease

Heart failureHeart failure

BP Difference From PlaceboBP Difference From Placebo(SBP/DBP mm Hg)(SBP/DBP mm Hg)

Blood Pressure Lowering Treatment Trialists’ Collaboration. Blood Pressure Lowering Treatment Trialists’ Collaboration. LancetLancet. 2003;362:1527-1535.. 2003;362:1527-1535.

Major CV eventsMajor CV events

CV mortalityCV mortality

Total mortalityTotal mortality

-5/-2-5/-2

-5/-2-5/-2

-5/-2-5/-2

-5/-2-5/-2

0.72 (0.64, 0.81)0.72 (0.64, 0.81) ACEI vs placeboACEI vs placebo -5/-2-5/-2

0.80 (0.73, 0.88)0.80 (0.73, 0.88)-5/-2-5/-2 ACEI vs placeboACEI vs placebo

0.82 (0.69, 0.98)0.82 (0.69, 0.98) ACEI vs placeboACEI vs placebo

ACEI vs placeboACEI vs placebo 0.88 (0.81, 0.96)0.88 (0.81, 0.96)



0.62 (0.47, 0.82)0.62 (0.47, 0.82) CA vs placebo CA vs placebo -8/-4-8/-4

0.78 (0.62, 0.99)0.78 (0.62, 0.99)-8/-4-8/-4 CA vs placeboCA vs placebo

CA vs placeboCA vs placebo 0.82 (0.71, 0.95)0.82 (0.71, 0.95)-8/-4-8/-4

1.21 (0.93, 1.58)1.21 (0.93, 1.58) CA vs placeboCA vs placebo -8/-4-8/-4



0.5 1.0 2.0

BP-Lowering Treatment Trialists’ Meta-analysis: Comparisons of Different Active Treatments

Relative Risk RR (95% CI)RR (95% CI)BP Difference Between RxBP Difference Between Rx

(SBP/DBP mm Hg)(SBP/DBP mm Hg)

FavorsFavorsFirst ListedFirst Listed

FavorsFavorsSecond ListedSecond Listed

Major CV eventsMajor CV events

CV mortalityCV mortality

Total mortalityTotal mortality

1.02 (0.98, 1.07)1.02 (0.98, 1.07)2/02/0 ACEI vs D/BBACEI vs D/BB



1.04 (1.00, 1.09)1.04 (1.00, 1.09)1/01/0 CA vs D/BBCA vs D/BB

1.05 (0.97, 1.13)1.05 (0.97, 1.13)1/01/0 CA vs D/BBCA vs D/BB

0.99 (0.95, 1.04)0.99 (0.95, 1.04)1/01/0 CA vs D/BBCA vs D/BB

0.97 (0.92, 1.03)0.97 (0.92, 1.03)1/11/1 ACEI vs CAACEI vs CA



D=diuretic; BB=D=diuretic; BB=-blocker.-blocker.Blood Pressure Lowering Treatment Trialists’ Collaboration. Blood Pressure Lowering Treatment Trialists’ Collaboration. LancetLancet. 2003;362:1527-1535.. 2003;362:1527-1535.

FavorsFavorsFirst ListedFirst Listed

FavorsFavorsSecond ListedSecond Listed

0.5 1.0 2.0

BP-Lowering Treatment Trialists’ Meta-analysis: Comparisons of Different Active Treatments

Relative Risk RR (95% CI)RR (95% CI)BP Difference Between RxBP Difference Between Rx

(SBP/DBP mm Hg)(SBP/DBP mm Hg)

CA vs D/BBCA vs D/BB 1.33 (1.21, 1.47)1.33 (1.21, 1.47)1/01/0

0.93 (0.86, 1.00)0.93 (0.86, 1.00) CA vs D/BBCA vs D/BB 1/01/0

1.01 (0.94, 1.08)1.01 (0.94, 1.08) CA vs D/BBCA vs D/BB 1/01/0

ACEI vs CAACEI vs CA 0.82 (0.73, 0.92)0.82 (0.73, 0.92)1/11/1

1.12 (1.01, 1.25)1.12 (1.01, 1.25) ACEI vs CAACEI vs CA 1/11/1

0.96 (0.88, 1.04)0.96 (0.88, 1.04) ACEI vs CAACEI vs CA 1/11/1

StrokeStroke

Coronary heart diseaseCoronary heart disease

Heart failureHeart failure

1.09 (1.00, 1.18)1.09 (1.00, 1.18) ACEI vs D/BBACEI vs D/BB 2/02/0



Blood Pressure Lowering Treatment Trialists’ Collaboration. Blood Pressure Lowering Treatment Trialists’ Collaboration. LancetLancet. 2003;362:1527-1535.. 2003;362:1527-1535.

Overview





National Guidelines Recognize the Relationship Between Hypertension and Dyslipidemia

JNC 7 recommends assessing a patient’s lipid profiles when setting appropriate BP treatment goals

NCEP ATP III recognizes hypertension as a major risk factor that modifies lipid goals

When hypertension or dyslipidemia is diagnosed,When hypertension or dyslipidemia is diagnosed,test for the other condition.test for the other condition.

Chobanian et al. Chobanian et al. JAMAJAMA. 2003;289:2560-2572.. 2003;289:2560-2572.Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMAJAMA. . 2001;285:2486-2497.2001;285:2486-2497.

JNC 7: Classification and Management of BP for Adults

BP Classification SBP*

mm Hg DBP*

mm Hg Lifestyle

Modification

Initial Drug Therapy

Without Compelling Indications

With Compelling Indications

Normal <120 and <80 Encourage

Prehypertension 120-139

or 80-89 Yes No antihypertensive drug indicated.

Drug(s) for compelling indications.†

Stage 1 Hypertension

140-159

or 90-99 Yes

Thiazide-type diuretics for most. May consider ACEI, ARB, -blocker, CCB, or combination.

Drug(s) for compelling indications.†

Stage 2 Hypertension

160 or 100 Yes

Two-drug combination for most‡ (usually thiazide-type diuretic and ACEI or ARB or -blocker or CCB).

Other antihypertensive drugs (diuretics, ACEI, ARB, -blocker or CCB) as needed.*Treatment determined by highest BP category.*Treatment determined by highest BP category.

††Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mm Hg. Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mm Hg. ‡‡Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.ARB=angiotensin-II receptor blocker; CCB=calcium-channel blocker.ARB=angiotensin-II receptor blocker; CCB=calcium-channel blocker.Chobanian et al. Chobanian et al. JAMAJAMA. 2003;289:2560-2572.. 2003;289:2560-2572.

Not at Goal Blood Pressure (<140/90 mm Hg) Not at Goal Blood Pressure (<140/90 mm Hg) (<130/80 mm Hg for those with diabetes or chronic kidney disease)(<130/80 mm Hg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Drug(s) for the compelling indications

Other antihypertensive drugs (diuretic, ACEI, ARB, BB, CCB)

as needed

With Compelling Indications

Lifestyle Modifications

Not at Goal Blood Pressure

Optimize dosages or add additional drugs until goal blood pressure is achieved

Consider consultation with hypertension specialist

Stage 2 Hypertension (SBP 160 or DBP 100 mm Hg)

2-drug combination for most (usually thiazide-type diuretic and ACEI, ARB, BB, or CCB)

Stage 1 Hypertension(SBP 140-159 or DBP 90-99 mm Hg)

Thiazide-type diuretics for most May consider ACEI, ARB, BB, CCB,

or combination

Without Compelling Indications

JNC 7 Algorithm for Treatment of Hypertension

Chobanian et al. Chobanian et al. JAMAJAMA. 2003;289:2560-2572.. 2003;289:2560-2572.

Not at Goal Blood Pressure

Algorithm for Treatment of Hypertension

Begin or Continue Lifestyle Modifications

• Lose weight• Limit alcohol• Increase physical

activity• Reduce Sodium

• Maintain potassium, calcium, magnesium

• Stop smoking• Reduce saturated fat,

cholesterol

Laboratory Tests Recommended Before Initiating Therapy

• Urinalysis

• Complete blood count

• Blood chemistry (potassium, sodium, creatinine, and fasting glucose)

• Lipid profile

• 12-lead electrocardiogram

Physical Examination

• Blood pressure readings (2 or more)

• Height, weight, and waist circumference

• Funduscopic examination

• Examination of the neck, heart, lungs, abdomen, and extremities

• S4 IMPORTANT!

• Neurological assessment

Examples of IdentifiableCauses of Hypertension

• Renovascular disease

• Renal parenchymal disease

• Polycystic kidneys

• Aortic coarctation

• Pheochromocytoma

• Primary aldosteronism

• Cushing syndrome

• Hyperparathyroidism

• Exogenous causes

Blood Pressure & Lifestyle

Blood Pressure is highly sensitive to weight loss: 5 - 10# weight loss will often control BP

Dietary Approaches: DASH (SBP 11 DBP 8)6 servings of fruits / vegetableslow sodium (no added salt) low to no alcoholhigh calcium, low fat

NEJM 2001;344:3-9 www.nhlbi.nih.gov/health/public/heart/hbp/dash

Sodium Recommendations

No Added Salt (2400 mg/day)Hypertension, impaired liver function, cardiovascular disease, cardiac failure, and acute and chronic renal failure.

1000 mg* (45 mEq)Cirrhosis of the liver, pulmonary edema, moderate to severe cardiac failure, acute and chronic liver failure.

*For short term use only due to decreased palatability and adherence.

Pharmacologic Treatment

• Decreases cardiovascular morbidity and mortality based on randomized controlled trials.

• Protects against stroke, coronary events, heart failure, progression of renal disease, progression to more severe hypertension, and all-cause mortality.

Initial Drug Choices*Uncomplicated• Diuretics• -blockersWhen other compelling reasons

(or others are contraindicated):• ACE or Calcium Blocker

Algorithm for Treatment ofHypertension

*Based on randomized controlled trials.

Initial Drug Choices*

Algorithm for Treatment of Hypertension (continued)

Compelling Indications • Heart failure

– ACE inhibitors– Diuretics

• Myocardial infarction -blockers (non-ISA)– ACE inhibitors (with systolic dysfunction)

• Diabetes mellitus (type 1) with proteinuria– ACE inhibitors

• Isolated systolic hypertension (older persons) – Diuretics preferred– Long-acting dihydropyridine calcium antagonists

*Based on randomized controlled trials.


Specific indications for the following drugs:

Algorithm for Treatment ofHypertension (continued)

• ACE inhibitors

• Angiotensin II receptor

blockers

• -blockers

• --blockers

• -blockers

• Calcium antagonists

• Diuretics

Specific Drug Indications

• Angina

– -blockers

– Calcium blockers

• Atrial tachycardia and fibrillation

– -blockers

– Non-dihydropyridine calcium antagonists

Some antihypertensive drugs may have favorable effects on co-morbid conditions:

•Heart failure

–Carvedilol

–Losartan

•Myocardial infarction

–Diltiazem

–Verapamil

Specific Indications (continued)

• Cyclosporine-induced hypertension– Calcium blockers

• Diabetes mellitus (1 and 2) with proteinuria– ACE inhibitors (preferred)– Calcium blockers

• Diabetes mellitus (type 2)– Low-dose diuretics

•Dyslipidemia-blockers

•Prostatism (benign prostatic hyperplasia)

-blockers•Renal insufficiency (caution in renovascular hypertension and creatinine 3 mg/dL

- ACE inhibitors

Some antihypertensive drugs may have favorable effects on comorbid conditions:

Patients Undergoing Surgery

• Those not on prior drug therapy may be best treated with cardio-selective-blockers before and after surgery.

• Those with controlled blood pressure should continue medication until surgery and begin as soon after surgery as possible.

Using Thiazide Diuretics

• Can use either HCTZ or chlorthalidone• Use only 12.5 - 25 mg. Daily• Higher doses no more effective, and have more

side effects and electrolyte problems• Do not affect lipids or glucose significantly• Do result in LVH regression• Synergistic with all other classes of medications

– reduce plasma volume

Gout

• Diuretics can increase serum uric acid levels.

• Diuretics should be avoided in patients with gout.

• Diuretic-induced hyperuricemia does not require treatment in the absence of gout or urate stones.

Using ACE Inhibitors

• Patients with:– Diabetes Mellitus– Nephropathy / Albuminuria– Post- MI– Congestive Heart Failure

• Once daily (except captopril)• Use ARB if cough develops• Use with care if hyperkalemia / CRF

Angiotensin Receptor Blocker and Hypertension

LIFE Trial:• Losartan vs. Atenolol (w / HCTZ if needed) for

9193 patients: Hypertension aged 55-80 years• BP decrease 28/9 mmHg both groups• CVD mortality*: 8.7 vs 16.9 (46% reduction)• Stroke*: 10.6 vs 18.9 (40% reduction)• New DM*: 12.6 vs 20.1 (38% reduction)• Total Mortality*: 21.2 vs 30.2 (54% reduction)

* per 1000 patient-yrs JAMA 2002;288:1491

Uses of Calcium Blockers

• Isolated Systolic HTN / Elderly

• African Americans w/better response

• CHD – Angina

• HTN – resistant – especially with a diuretic

• Exercise induced HTN

• Peripheral arterial disease

• Migraine + HTN

Calcium Blockers

A calcium blocker is not a calcium blocker:• AV node inhibitors / modest vasodilators:

– Verapamil– Diltiazem

• Vasodilators: Dihydropyridines– Amlodipine (Norvasc)– Felodipine (Plendil)*Nifedipine: also negative iontrope / adrenergic

Not at Goal Blood Pressure (< 140/90 mm Hg)

No response or troublesome side effects

Inadequate response but well tolerated

Substitute another drug from different class

Add second agent from different class (diuretic

if not already used)


Algorithm for Treatment ofHypertension

Causes for InadequateResponse to Drug Therapy

• Nonadherence to therapy / lifestyle

• Alcohol use

• Volume overload

• ***Failure to add a diuretic***

• Drug-related causes

• Non-steroidal anti-inflammatories

• Identifiable causes of hypertension

Overview





Guidelines for ImprovingAdherence to Therapy

• Close follow-up 4 – 6 weeks

• Prescribe long-acting / once daily medications

• Adjust therapy to minimize adverse affects

• Use synergistic medications

• Utilize other health professionals

• Consider using nurse case management

• Involve the patient in self-care

Advantages of Self-Measurement

• Identifies “white-coat hypertension”

• Assesses response to medication

• Improves adherence to treatment

• Potentially reduces costs

• May confirm HTN to patient and may provide lower readings than those recorded in clinic

Thank you!

Questions?

Additional Slides

A population-wide strategy to

reduce overall blood pressure by

only a few mm Hg could affect

overall cardiovascular morbidity

and mortality as much as or more

than treatment alone.

A Population-Wide Strategy

Lifestyle Modifications

For Prevention and Management

• Lose weight if overweight.

• Limit alcohol intake.

• Increase aerobic physical activity.

• Reduce sodium intake.

• DASH diet*

For Overall and Cardiovascular Health

• Maintain adequate intake of calcium and magnesium.

• Stop smoking.

• Reduce dietary saturated fat and cholesterol.

• Increase fruits/vegetables/fiber and healthy oils

Children and Adolescents

• Blood pressure at 95th or higher percentile is considered elevated.

• Lifestyle modifications should be recommended.

• Drug therapy should be prescribed for higher levels of blood pressure.

• Attempts should be made to determine other causes of high blood pressure and other cardiovascular risk factors.

95th Percentile of Blood Pressure by Selected Ages and Height in Girls

SBP/DBP (mm Hg)

Age 50th Percentile forHeight

75th Percentile forHeight

1 104/58 105/59

6 111/73 112/73

12 123/80 124/81

17 129/84 130/85

95th Percentile of Blood Pressure by Selected Ages and Height in Boys

SBP/DBP (mm Hg)

Age 50th Percentile forHeight

75th Percentile forHeight

1 102/57 104/58

6 114/74 115/75

12 123/81 125/82

17 136/87 138/88

Classification of Blood Pressure for Adults

CategorySBP

(mm Hg)DBP

(mm Hg)

Optimal < 120 and < 80

Normal < 130 and < 85

High-normal 130-139 or 85-89

Hypertension Stage 1 Stage 2 Stage 3

140-159160-179 180

ororor

90-99100-109 110

When SBP and DBP fall into different categories, use the higher category.

Documents

Hypertension: New Trials – Best Treatments Karen Moncher, MD Assistant Professor University of Wisconsin School of Medicine and Public Health