Get documents about "High Blood Pressure and Diabetes
Description
Good control of blood pressure, blood pressure of 115/75 mm Hg higher blood pressure than people (more than 160/90 mm Hg) who look 25 years younger.
Document Sample
National Heart, Lung, and Blood
Institute National High Blood Pressure
Education Program
High Blood Pressure U.S. Department of
Health and Human
Services
Seventh Report of the Joint
and Diabetes National Committee on
Prevention, Detection,
by National Institutes
of Health
Evaluation and Treatment
Paula Ackerman, MS, RD, CDE of High Blood Pressure
November 2009
(JNC 7)
National Heart, Lung,
and Blood Institute
www.nhlbi.nih.gov/guidelines/hypertension/index.htm 2
1
Hypertension (HTN) Hypertension (HTN)
Most common primary diagnosis in the US Adults: systolic bp (SBP) > 140 mmHg OR a
diastolic bp (DBP) > 90 mmHg based on 2 separate
Usually develops without signs/symptoms
visits 1 wk apart (unless sbp > 180 or dbp > 110)
1/3 are unaware Systolic bp Diastolic bp
50% of those with 1st MI have HTN Normal < 120 AND < 80
66% of stroke victims have HTN Pre-HTN 120 – 139 or 80–89
Stage 1 HTN 140 – 159 or 90 – 99
Affects more than two-thirds of those over 65 Stage 2 HTN > 160 or > 100
They have the lowest rates of bp control. If SBP and DBP fall into two separate
3 categories, use the higher status. 4
What % of American What % of American
adults have diagnosed adults have diagnosed
HTN (2003-2006)? HTN (2003-2006)?
A. 43% A. 43% (African Americans)
B. 35% B. 35% (Living in Poverty)
C. 31% C. 31%
D. 26% D. 26% (Mexican Americans)
5
www.cdc.gov/bloodpressure/facts.htm 6
Percent of persons with high blood pressure
(Adults aged 20 years and older) 2003
Hypertension (HTN)
Children: defined as an average SBP and/or DBP
> 95%ile based on age, height and gender based
on 3 or more occasions.
Diagnostic Criteria
Normal SBP and/or DBP < 90%ile
Pre-HTN SBP or DBP > 90% and <95%ile
or > 120/80
Stage 1 HTN 95 - 99%ile plus 5 mmHg
Stage 2 HTN > 99%ile plus 5 mmHg
BP Charts for children and teens:
7 http://www.nhlbi.nih.gov/guidelines/hypertension/child_tbl.htm 8
Source: CDC, Behavioral Risk Factor Surveillance System.
In 2002-3, what % of In 2002-3, what % of
children were Dx with HTN? children were Dx with HTN?
A. 1% A. 1% (1989 data)
B. 5% B. 5% (2002 data)
C. 15% C. 15%
D. 25% D. 25% (% of HTN among inner
city and minorities youth in 2003)
9 10
Prevalence Data on BP in Adults
(18 years and older) Diabetes and Hypertension
NHANES Data NHANES III also revealed the following
1988-1994 1999-2000 2003-4 among adults over age 18 with diabetes:
% with elevated bp or taking
73% had HTN
21.7% 26.0% 29.3%
antihypertensive medications
9% of those with HTN were unaware of it.
% with controlled HTN 18% 25.0% 33.1%
43% of those with HTN were untreated
% of persons with diabetes (on
antihypertensive therapy) with 55% of those treated had a bp > 140/90
-- 15.7% 33.2%
controlled blood pressure
National Center for Health statistics. National Health and Nutrition Examination Survey 11 12
(NHANES). Available at www.cdc.gov/nchs/nhanes.htm.
Categories of HTN Consequences of HTN
Primary/Essential (affects 90-95%) Contributes to development and
Most common, cause is unknown progression of chronic complications
Secondary (affects 5-10%) – Cardiovascular disease (Heart failure, CVA, MI)
» #1 killer in PWD: 65%
Due to underlying conditions, meds, drugs
– Kidney Disease
Orthostatic Hypotension
> 20 point drop in sbp OR > 10 point drop – Ophthalmic changes: retinopathy
in dbp within 3 minutes of standing – Peripheral vascular disease
Common in DM: autonomic neuropathy
13 14
BP Measurement and
Diabetes and Hypertension Clinical Evaluation
Improved bp can reduce
Heart failure 50% BP Measurement Techniques
Stroke 35-40% • In-office
MI 20-25% • Ambulatory BP Monitoring
Microvascular complications 33%
• Self-measurement
Progression of kidney failure 70%
UKPDS: Every 10 mmHg reduction in sbp = Classification of BP
12% reduction in DM-related complications
15% reduction in deaths related to DM Follow-up
11% reduction in MI
13% reduction in microvascular complications15 16
BP Measurement Techniques Office BP Measurement
Use properly calibrated and validated instrument.
Client should be seated quietly for 5 minutes in a
In office chair (not on an exam table), feet on the floor,
and arm supported at heart level.
Appropriate-sized cuff should be used to ensure
Ambulatory accuracy.
At least 2 measures should be made, 5 minutes apart
Assess for orthostatic hypotension
Home/Self-measurement
Provide verbal and written results and BP goals.
17 18
Ambulatory BP Monitoring (ABPM) Self-Measurement of BP
Wear monitor for 24 hrs and log daily activities Provides information on:
1. Response to antihypertensive therapy
Recommended for evaluating “white-coat” HTN
in the absence of target organ injury. 2. Improving adherence with therapy
3. Evaluating white-coat HTN
Ambulatory BP values are usually lower than
clinic readings. Home measurement of >135/85 mmHg is
Those with HTN have an average bp >135/85 generally considered to be hypertensive.
(awake) and >120/75 (during sleep).
Home measurement devices should be checked
BP drops by 10-20% during the night; if not, may for accuracy against their provider’s monitor at
signal increased risk for cardiovascular events. least every 6 months.
19 20
Issues of Home Monitoring If a blood pressure cuff is
Before measuring: too small, how will it affect
Avoid tobacco and caffeine (½ hour) the reading?
Sit for 5 min quietly with both feet on floor
and arm supported at heart level
Arm measurements are more accurate than A. Not at all
finger or wrist measurements. B. Reading will be falsely elevated
Place cuff 1” above crease of elbow. C. Reading will be falsely low
Make certain proper cuff size is utilized.
If too small, reading will be falsely elevated
21 22
If a blood pressure cuff is Issues of Home Monitoring
too small, how will it affect The numbers on monitor must be easy to read.
the reading?
If stethoscope must be used, make certain the
person can hear sounds.
A. Not at all Store the monitor away from extreme temps.
B. Reading will be falsely elevated Check tubing for cracks and leaks periodically.
C. Reading will be falsely low Home monitors vary in price (ranging from $20
to hundreds of dollars). The most expensive
23
unit may not be the best or most accurate. 24
Follow-up and Monitoring Follow-up and Monitoring
Routine Tests
Clients should return for follow-up and • Electrocardiogram
adjustment of medications until the BP goal is • Urinalysis
reached. • Blood glucose and hematocrit
• Serum potassium, creatinine or the corresponding
When blood pressure is at goal and stable, estimated GFR and calcium
follow-up should occur ever 3-6 months. • Lipid profile after 9- to 12-hour fast
It is recommended that people with diabetes Optional tests
receive a blood pressure check at every •Urinary albumin excretion or albumin/creatinine ratio
routine diabetes visit. More extensive testing for identifiable causes is not generally
25 indicated unless BP control is not achieved 26
Treatment Overview Goals of Therapy
Goals of therapy Treat to BP <140/90 mmHg
Lifestyle modification In persons with diabetes or chronic kidney
disease, treat to BP < 130/80 mmHg.
Pharmacologic treatment
Reduce CVD and renal morbidity and mortality.
• Algorithm for treatment of hypertension
Achieve SBP goal especially in persons > age 50
years of age.
27 28
What % of those with What % of those with
diabetes (who are treated diabetes (who are treated
for HTN) had a blood for HTN) had a blood
pressure < 130/85 mmHg? pressure < 130/85 mmHg?
A. 12% A. 12%
B. 24% B. 24%
C. 36% C. 36%
D. 48% D. 48%
29 30
Initial Therapy (DM & HTN) Lifestyle Modification
Modification Recommendation Average SBP
reduction
Initial Therapy Weight Reduction Maintain normal body weight 5-10 mmHg per
10 kg wt loss
Normal Encourage lifestyle changes
DASH Eating Plan Adopt meal plan rich in fruits, 8-14 mmHg
Pre-HTN Advise lifestyle changes (3 mo) vegetables, low fat dairy and low in
If not to goal: drug therapy saturated fat and cholesterol
Sodium Restriction Less than 2400 mg per day 2-8 mmHg
Stage 1 HTN Lifestyle and drug therapy
Regular Physical Moderate activity at least 30 4-9 mmHg
Stage 2 HTN Lifestyle and drug therapy Activity minutes most days of the week
Moderation of Men: limit to 2 drinks per day 2-4 mmHg
31 Alcohol Women: limit to 1 drink per day 32
DASH DASH Results
459 adults with sbp < 160; At 8 weeks
dbp of 80-95; BMI < 35 Drop in sbp Drop in dbp
– 27% had HTN; 49% women; 60% African Amer. vs control vs control
– 1/3 with income < 30,000 per year F/V 2.8 mmHg 1.1 mmHg
DASH 5.5 mmHg 3.0 mmHg
3 meal plans
– Typical American diet (control gp)
– Typical American diet + more fruits/veges Changes occurred within 2 weeks
– DASH Was more effective in those with HTN or minority
groups (comparable to first line anti-HTN therapy)
33 34
What % of those Dx What % of those Dx
with Hypertension follow with Hypertension follow
a DASH Meal Plan? a DASH Meal Plan?
A. 19% A. 19% (1999-2004)
B. 26% B. 26% (1988-1994)
C. 35% C. 35%
D. 49% D. 49%
35 36
DASH-Sodium DASH-Sodium Results
412 adults with sbp of 120-159
Lower sodium intakes resulted in lower bp
and dbp of 80-95 mmHg
for the DASH and Control Groups
– 41% had HTN
– 57% African American For those with HTN
– DASH Diet/1500 mg Na had 11.5 mmHg lower
2 meal plans (Typical Diet or DASH) sbp vs control group/3300 mg Na
with 3 sodium levels
For those without HTN
– 3300 mg a day
– 2400 mg a day – DASH Diet/1500 mg Na had 7.1 mmHg lower
sbp vs control group/3300 mg Na
– 1500 mg a day
37 38
Other Other
Cigarette Smoking Soy (Arch Intern Med. 2007; 167:1060-1067)
– Does not impact long term incidence of HTN – ½ c unsalted soy nuts ↓ bp in normotensive (↓ sbp
– Smoking a cigarette can produce an immediate, 6 pts and dbp 2 pts) and hypertensive women (↓ sbp
temporary rise in bp of 5-10 mmHg 15 pts and dbp 6 pts)
Alcohol
Caffeine – Moderate consumption (2 or less for men and
– Does not increase the incidence of HTN 1 or less for women and lighter-weight persons)
– 5 cups of coffee led to a small, temporary rise in bp may help lower bp
– Dose dependent relationship between more alcohol
and bp (2 or more drinks a day ↑ bp 1.5-2 times)
Folic Acid (JAMA. 2005; 293: 320-329)
– 1000 mg qd led to 46% reduction in HTN in women Whole grains
39 40
Whole Grains and Blood Pressure Coffee and Blood Pressure
Risk of Developing High BP
Risk of Developing High BP
1.00
1.00
0.92
0.75
0.77
0.50
0.25
0.00
<0.5 2 to 3 4 or more
n = 27,410
n = 28,926 women, Finnish adults
10-year study Servings of Whole Grains Daily 13.2 year study Coffee Intake (cups/day)
41
American Journal of Clinical Nutrition. 2007;86: 472-479 American Journal of Clinical Nutrition. 2007;86:457-46442
Stepped Care Approach Med Options
Diuretics
Continue Lifestyle Modifications Thiazide: Advantages:
Clorothiazide (Diuril) Inexpensive
Initiate Med Treatment Stage 1 and 2 Chlorthalidone (Hygroton) Very effective in combination with
Hydroclorothiazide (HCTZ) other meds
Increase Dose Indapamide (Lozol)
Methyclothiazide (Enduron) Disadvantages:
– Reach Goal Loop: Frequent urination
electrolyte abnormalities
– Monitor Adverse Effects Bumetanide (Bumex)
May raise BG, lipids and worsen
Furosamide (Lasix)
Ethacrynate (Edecrin) sexual dysfxn (dose dependent)
Add Agent From Different Class Torsemide (Demadex)
Step Down if Possible Potassium-Sparing
Amiloride hydrochloride
Triamterene (Dyrenium)
43 44
Spironolactone (Aldactone)
Med Options Med Options
ACE Inhibitors Angiotensin Receptor Blockers: ARBs
(end in “pril”) (End in “sartan”)
Benazapril (Lotensin) Advantages: Candesartan (Atacand) Advantages:
Captopril (Capoten) Reduces albuminuria & nephropathy Eprosartan (Teveten) Reduces albuminuria &
Enalapril (Vasotec) Irbesartan (Avapro) nephropathy
Fosinopril (Monopril) Disadvantages: Losartan (Cozaar)
Lisinopril (Prinivil, Zestril) cough Olmesartan (Benicar) Disadvantages:
Moexipril (Univasc) Hyperkalemia Cough
asa and NSAIDs may reduce its effects Telmisartan (Micardis) Hyperkalemia
Perindopril (Aceon) Valsartan (Diovan)
Quinapril (Accupril) Kidney and liver failure (rare)
Remipril (Altace)
Trandolapril (Mavik)
45 46
Med Options Med Options
Calcium Channel Blockers: CCBs Beta Blockers (end in “olol”)
(many end in “ipine”) Beta-Adrenergic Blockers Alpha/Beta Adrenergic:
Acebutolol hydrochloride (Sectral) Carvediolo (Coreg)
Dihydropyridine: Advantages: Atenolol (Tenormin) Labetaolol hydrochloride
Amlodipine (Norvasc) Effective Betaxolol hydrochloride (Kerlone) (Trandate, Normodyne)
Felodipine (Plendil) Bisoprolol fumarate (Zebeta)
Disadvantages:
Isradipine (DynaCirc) Carteolol hydrochloride (Cartrol) Advantages:
Dihydropyridines: flushing,
Nicardipine (Cardene) Esmolol hydrochloride (Brevibloc) Low cost
edema, excessive hypotension
Nifedipine (Procardia XL, Adalat) Metoprolol (Lopressor, Toprol XL) Effective after MI
Nimodipine (Nimotop) Non-dihydropyridines: DO Nadolol (Corgard)
Nisoldipine (Sular) NOT use with beta blockers Nebivolol (Bystolic) Disadvantages:
Non-Dihydropyridine: All: grapefruits and grapefruit Penbutolol sulfate (Levatol) May raise BG levels
Diltiazem (Cardizem, Dilacor, juice can affect its action; DO Pindolol (Visken) May mask low BG
Tiazac, Diltia XL) NOT drink alcohol (interferes Propranolol (Inderal) May decrease HDL-chol
Verapamil (Isoptin, Calan, with med and increases SE) Sotalol hydrochloride (Betapace) Sexual dysfunction
Verelan, Covera-HS) 47 Timolol maleate (Blocadren) May worsen asthma 48
Algorithm for Treatment of Hypertension Med Options
Not at Goal Blood Pressure (<140/90 mmHg) with lifestyle changes
(<130/80 mmHg for those with diabetes or chronic kidney disease)
Initial Drug Choices Situation Rec. Drug
If SBP < 20 mmHg above If SBP > 20 mmHg above goal,
goal, ACE or ARB ACE or ARB + Thiazide Diuretic Type 1 or 2 DM, no CV risk ACE or ARB and/or
(titrate up) (titrate up and recheck in 2-3 wks) factors, no proteinuria Thiazide Diuretic
Not at Goal BP Type 1 with proteinuria ACE
Add long-acting Thiazide Add CCB or beta blocker
Diuretic (titrate up). (titrate up) Type 2 with microalbuminuria ACE or ARB
Not at Goal BP Type 2 with renal insufficiency, ARB
macroalbuminuria, nephropathy
Optimize dosages or add additional drugs until goal bp is
met. Consider consultation with hypertension specialist.
49 50
Med Options Monotherapy vs. Combos
Situation Rec. Drug
Pros of combinations
Over age 55 with CV risk factos ACE
– Achieve goal quickly
Those with recent MI ACE – Synergistic efficacy
Type 2 with microalbuminuria ACE or ARB
Type 2 with renal insufficiency, ARB Cons of combinations
macroalbuminuria, nephropathy
– Adverse effects
Those with microalbuminuria or Non-Dihydropyridine
nephropathy and not tolerate Ca Channel blocker – Cost
ACE or ARB
51 52
Treatment Failure Non-compliance factors
Asymptomatic nature of HTN
Inadequate Doses
Med effects
Inadequate or Inappropriate Inconvenient drug dosing
Combinations High cost
Tx non-compliance Lack of social support
Client: apathy, lack of follow-up
53
Provider: apathy, lack of follow-up 54
Supporting Materials Reference Card
For clients and the general public
www.nhlbi.nih.gov/hbp
Search DASH
• “Facts About the DASH Eating Plan”
• “Your Guide to Lowering Blood Pressure”
For health professionals
www.nhlbi.nih.gov/guidelines/hypertension/
JNC7 guide 55 56
Key Messages of JNC7 Key Messages (Continued)
Those with SBP 120–139 mmHg or DBP 80–89
For persons over age 50, SBP is a more
mmHg should be considered prehypertensive
important than DBP as CVD risk factor.
who require health-promoting lifestyle
modifications to prevent CVD.
Starting at 115/75 mmHg, CVD risk doubles with
each increment of 20/10 mmHg throughout the
Thiazide-type diuretics should be initial drug
BP range.
therapy for most, either alone or combined with
other drug classes.
Persons who are normotensive at age 55 have a
90% lifetime risk for developing HTN.
Certain high-risk conditions are compelling
57
. indications for other drug classes. 58
Key Messages (Continued) Key Messages (Continued)
Most will require two or more antihypertensive
Motivation improves when clients have positive
drugs to achieve goal BP.
experiences with, and trust in, the clinician.
If BP is >20/10 mmHg above goal, initiate
Empathy builds trust and is a potent motivator.
therapy with two agents, one usually should be a
thiazide-type diuretic.
The responsible physician’s judgment remains
paramount.
The most effective therapy prescribed by the
careful clinician will control HTN only if patients
are motivated.
59 60
Questions
?????
61
