High Blood Pressure and Diabetes by bestt571


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									                                                                                   National Heart, Lung, and Blood
                                                                                Institute National High Blood Pressure
                                                                                           Education Program

High Blood Pressure                                  U.S. Department of
                                                     Health and Human

                                                                                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

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)
                                                                                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
                                                     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
                                                           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
                           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)

                              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





                                         <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)
                                                         American Journal of Clinical Nutrition. 2007;86: 472-479                                                           American Journal of Clinical Nutrition. 2007;86:457-46442
Stepped Care Approach                                                           Med Options
   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)
 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
                                                                     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

                                                                               Provider: apathy, lack of follow-up            54
Supporting Materials                                       Reference Card
 For clients and the general public
    Search DASH
  • “Facts About the DASH Eating Plan”
  • “Your Guide to Lowering Blood Pressure”

 For health professionals
    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
                                                           .   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
The most effective therapy prescribed by the
careful clinician will control HTN only if patients
are motivated.
                                                      59                                                     60

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