HYPERTENSION
“DILEMMAS IN TREATMENT”
Dr. N. Dean MBBS FRCP (UK)
Clinical Professor,
Royal Alexandra Hospital
BURDEN
• 1 in 5 adult Canadians have hypertension
• 40% of Canadians at age 55 have
hypertension
• 90% of normotensive persons aged 55-65
developed hypertension in the next 20
year in the Framingham study
2008 Canadian Hypertension Education Program Recommendations
What percent of Canadians have
hypertension?
60
% of Canadians
50
40
30
20
10
0
18-24 25-34 35-44 44-55 56-65 65-74
age
CCHS CMAJ 1992
2008 Canadian Hypertension Education Program Recommendations
Modifiable Risk Factors for IS
Factor Relative Risk Prevalence
Hypertension 4.0 - 5.0 25 - 40
Diabetes 1.5 - 3.0 4-8
Smoking 1.5 - 2.9 20 - 40
Hyperlipidemia 1.0 - 2.0 6 - 50
Atrial fibrillation 5.6 - 17.6 1
Alcohol abuse 1.0 - 4.0 5 - 30
Cardiac disease 2.0 - 4.0 10 - 20
Physical inactivity 2.7 25
Obesity 2 18
Asym Car Sten 2- 3 2-8
Sacco R. Neurology 1995;45:659-663
Treatment of high blood pressure
results in long-term benefit
non-fatal events T = treated
Total no. of
fatal events C = control
individuals affected
1200 1104
934 C 964
1000
835 C
T
800 768
C
T
600 525 560
470
T
400
234
200 140
0
Stroke CHD Vascular deaths
Reduction in odds: 38% ± 4 16% ± 4 21% ± 4
McMahon & Rodgers 1993
2p-value: 65 years of age have hypertension
Hypertensive patients Hypertensive patients
who are treated who are treated
but BP uncontrolled and BP controlled
13%
21%
22% 43%
Patients who are aware
but remain untreated Hypertensive patients
and BP uncontrolled who are unaware
Joffres et al. Am J Hyper 2001;14:1099 –1105
Changes in Diagnosis of Hypertension in Canada
Hypertension Diagnosis by Gender
Post 1999 compared
20
to pre 1999
1999
Females
• Marked increase
Percentage of Population
Males & in the rate of
Females diagnosis of
Males hypertension
15 • Closing of the
gender gap
10
1992 1994 1996 1998 2000 2002 2004
NPHS, CCHS
Year Onysko J, Hypertension 2006;48:853-60
Changes in Treatment of Hypertension in Canada
Hypertension Treatment by Gender Post 1999 compared
20
to pre 1999
Females • Doubling of the rate
Percentage of Population
Males & Females of treatment of
15
Males hypertension
• Closing of the
gender gap
10
5
1992 1994 1996 1998 2000 2002 2004 NPHS, CCHS
Year Onysko J, Hypertension 2006;48:853-60
Changes in proportion of aware hypertensive
Canadians not treated with antihypertensive drugs
Hypertensives who were Aware but not treated Post 1999 compared
by Gender
to pre 1999
40
• Marked decrease in
proportion of aware
Percentage of Population
hypertensives that
30
are untreated
• Closing of the
gender gap
20
Females
Males &
Females
Males
10
1992 1994 1996 1998 2000 2002 2004 NPHS, CCHS
Year Onysko J, Hypertension 2006;48:853-60
DIURNAL VARIATION IN BP?
Nocturnal dipping and AM surge
190
+20% Systolic
170 +38%
Blood Pressure (mm Hg)
150
130
110
+57% +38%
90 Diastolic
70
0 3 6 9 12 15 18 21
Clock Time (hours)
Millar-Craig M. Lancet 1978;i:795
Diurnal /Circadian variation in
disease presentation
• Based on meta-analysis of
studies:
–5-12 AM (awakening hours)
• ~50% higher risk of Stroke
• ~40% higher risk of
Myocardial Infarction
• ~30% higher risk of Sudden
Cardiac Death
Patients with significant AM BP surge
have increased risk of stroke (ischemic or hemorrhagic)
with worse prognosis
Patients with nocturnal BP increase (Risers)
have increased risk of stroke and MI
with worse prognosis
Question
• In Hypertensive individuals we should
aim for BP control in :
a) AM
b) PM
c) 24 hour
WHAT IS THE OPTIMAL BP?
Impact of High-Normal Blood Pressure on the Risk of
Cardiovascular Disease
CUMULATIVE INCIDENCE OF CV EVENTS IN MEN WITHOUT HYPERTENSION ACCORDING TO BASELINE BLOOD PRESSURE
N Engl J Med 2001;345:1291-7
I. Indications for Pharmacotherapy
Usual blood pressure threshold values for initiation of
pharmacological treatment of hypertension
Condition Initiation
SBP or DBP mmHg
• Systolic or Diastolic hypertension 140/90
• Diabetes
130/80
• Chronic Kidney Disease
II. Goals of Therapy
Blood pressure target values for treatment
of hypertension
Condition Target
SBP and DBP mmHg
Isolated systolic hypertension 20 mmHg systolic
or >10 mmHg diastolic above target
Long-
Thiazide Beta-
ACE-I ARB acting
blocker*
CCB
* BBs are not indicated as first line therapy for age 60 and above
ACEI and ARB are contraindicated in pregnancy and caution is required
in prescribing to women of child bearing potential
Treatment Algorithm for Isolated Systolic Hypertension without
Other Compelling Indications
TARGET 20%)
• Morning Surges
Clinic, Home, Ambulatory (ABP) Blood Pressure
Measurement equivalence numbers
A clinic blood pressure of 140/90 mmHg
has a similar risk of a:
Description Blood Pressure mmHg
Home pressure average 135 / 85
Daytime average ABP 135 / 85
24-hour average ABP 130 / 80
Case 3
• 60 year old male of african – american
back ground . Known high BP. On
Lisinopril . BP always in the range of
150-160 / 90-100.
• Treatment ?
Stroke – Subgroup Comparisons –
RR (95% CI)
Total 0.93 (0.82, 1.06) Total 1.15 (1.02, 1.30)
Age = 65 0.93 (0.81, 1.08) Age >= 65 1.13 (0.98, 1.30)
Men 1.00 (0.85, 1.18) Men 1.10 (0.94, 1.29)
Women 0.84 (0.69, 1.03) Women 1.22 (1.01, 1.46)
Black 0.93 (0.76, 1.14) Black 1.40 (1.17, 1.68)
Non-Black 0.93 (0.79, 1.10) Non-Black 1.00 (0.85, 1.17)
Diabetic 0.90 (0.75, 1.08) Diabetic 1.07 (0.90, 1.28)
Non-Diabetic 0.96 (0.81, 1.14) Non-Diabetic 1.23 (1.05, 1.44)
0.50 1 2 0.50 1 2
Amlodipine Better Chlorthalidone Better Lisinopril Better Chlorthalidone Better
P = .01 for interaction
Considerations Regarding the Choice of First-
Line Therapy
• Use caution in initiating therapy with 2 drugs where substantive
blood pressure lowering is more likely or more poorly tolerated
(e.g. those with postural hypotension).
• ACE inhibitors and ARBs are contraindicated in pregnancy and
caution is required in prescribing to women of child bearing
potential.
• Beta adrenergic blockers are not recommended for patients age
60+ without another compelling indication.
• Diuretic-induced hypokalemia should be avoided through the
use of potassium sparing agent if required.
• ACE-I are not recommended (as monotherapy)
for black patients without another compelling indication.
CAUSES OF TREATED BUT
UNCONTROLLED BP?
Case 5
• 50 year old hypertensive lady. On 3 BP
lowering meds but BP uncontrolled. Non
compliant with meds !!
Adherence to anti-hypertensive management can be
improved by a multi-pronged approach
• Assess adherence to pharmacological and non-
pharmacological therapy at every visit
• Teach patients to take their pills on a regular
schedule associated with a routine daily activity e.g.
brushing teeth.
• Simplify medication regimens using long-acting
once-daily dosing
• Utilize fixed-dose combination pills
• Utilize unit-of-use packaging e.g. blister packaging
Adherence to anti-hypertensive management can be improved
by a multi-pronged approach
• Encourage greater patient responsibility/autonomy in
regular monitoring of their blood pressure
• Educate patients and patients' families about their
disease/treatment regimens verbally and in writing
Exogenous factors which can induce /
aggravate BP
• NSAIDs , Coxibs
• Corticosteroids and anabolic steroids
• OCP and sex hormones
• Decongestants
• Erythropoietin
• MAOIs
Other substances and conditions
• Licorice
• Cocaine
• Salt
• Excessive alcohol
• Sleep apnea
Case 4
• 60 year old male. Heavy smoker.
Diabetes. Dyslipidemia. High BP and on
Ramipril, HCT, Diltiazem. B/L carotid
bruit. Worsening renal function over the
last 6 months.
• Thoughts ?
Renovascular Hypertension
Patients presenting with two or more of the following clinical
clues listed below suggesting renovascular hypertension
should be investigated.
i) sudden onset or worsening of hypertension and > age 55
or 220 mm Hg or mean arterial pressure >
130
or DBP >120 mm Hg. ( AHA guide lines)
• Candidate for thrombolysis : SBP < 185 mm Hg
and
DBP <110 mm Hg
More aggressive treatment of BP in patients with ICH
Most patients can be treated with oral agents.
IV Labetalol and Nitroprusside in more urgent
situations
Avoid SL calcium channel blockers.