michigan hypertension core curriculum - State of Michigan

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Compelling Indications for Specific Antihypertensive Medication Classes 182 Hypertension Core Curriculum Khaled Ismail, MD Learning Objectives: 1. Learn the various coexisting conditions for which specific classes of antihypertensive drugs are indicated. 2. Understand the evidence supporting the use of different antihypertensive drug classes in patients with these comorbidities. Pretest: 1. A 38 year-old male with a history of type 2 diabetes presents to your office for a routine checkup. His BP is 155/95 mmHg and his last hemoglobin A1C was 8.9%. His BP on a previous visit 6 weeks ago was 150/90 mmHg. He currently takes only insulin. Which medication is the best choice for initial antihypertensive therapy? a. hydrochlorothiazide 25mg b. losartan 50 mg/d plus chlorthalidone 25 mg/d (correct answer) c. metoprolol 25 mg bid d. amlodipine 5 mg/d e. clonidine 0.1mg bid The JNC 7 guidelines published in 2003 identified several “compelling indications” for prescribing certain antihypertensive medication classes. 1 These indications include congestive heart failure (CHF), a history myocardial infarction or stroke, chronic kidney disease, diabetes and an overall elevated risk for coronary artery disease. Large, randomized controlled trials (RCT) have shown survival benefits independent of BP control when treating HF (specifically systolic dysfunction) when beta blockers, angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers are administered. The investigators found a 31% relative risk reduction in all-cause mortality at one year in patients with American Heart Association class 4 heart failure patients treated with enalapril. 2 The ARB valsartan was found to reduce hospitalization due to CHF in patients with class 2 or greater heart failure. 3 Beta-blockers such as extended-release metoprolol have been shown in RCT to significantly reduce mortality. 4,5 The administration of the aldosterone antagonist, spironolactone to patients with classes 3 and 4 heart failure has also been associated with a 30% reduction in mortality. 6 Following myocardial infarction, beta-blockers, ACE inhibitors and aldosterone antagonists have each been associated with significant reductions in mortality (23%, 19%, and 15% respectively). 5,7,8 Thus, in hypertensive patients with systolic heart failure, it is imperative that these drug classes be preferentially used in the prescribed antihypertensive regimens. Numerous prospective studies in animals and humans have shown the renoprotective effects of RAS antagonists in patients with CKD. Thus, these agents are definitely indicated in patients with diabetic and non-diabetic nephropathy. 9,10 It is a mistake, however, to believe that BP control, in most instances, will be obtained without additional antihypertensive agents – most notably diuretics and/or calcium antagonists. Diabetic patients should be treated with RAS antagonists – either an ACE inhibitor or an ARB.
RAS antagonists slow CKD progression, profoundly reduce proteinuria and, at least in some though not all studies, appear to provide protection against cardiovascular events that is not directly linked to BP reductions. For example, the RENAAL trial was an RCT that randomized 1513 patients with diabetes and nephropathy to losartan or placebo. 10 The investigators found a 16% relative risk reduction in the primary composite endpoint of doubling of the serum creatinine, end-stage renal disease or death. Angiotensin converting enzyme inhibitors and ARB are the drugs of choice in recurrent stroke prevention. In RCT, the use of ACE inhibitors or ARB has resulted in 30-50% relative risk reductions in the risk of recurrent stroke. 11-13 Nevertheless, these agents will very likely be utilized along with other antihypertensive drug classes to obtain and persistently maintain BP control. For hypertensive patients with any of the co-morbid conditions for which specific drugs are indicated, BP control to goal is, however, an absolute necessity to confer maximal target-organ protection while preventing undesirable CVD-renal events. Familiarity with the compelling indications for anti-hypertensive medications allows a provider to provide optimal care and to reduce preventable morbidity and mortality. Key Points: 1.) Certain drug classes offer improved cardiovascular and renal morbidity and mortality beyond simple BP control in patients with specific co-morbidities; some drugs with compelling indications, however, do not necessarily confer any special benefit to patients with a given co-morbidity but have rather been proven safe to use in high-risk patients with a given co-morbidity (e.g., diuretics in heart failure) 2.) ACE inhibitors, beta-blockers and aldosterone antagonists are the drugs of choice in patients with congestive heart failure with systolic dysfunction. NKFM & MDCH 183
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MICHIGAN HYPERTENSION CORE CURRICUL
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April 2010 Dear Colleague: In 2005,
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Kevin L. Piggott, MD, MPH, FAAFP Pr
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Blood Pressure Measurement........
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10 Hypertension Core Curriculum Blo
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of the wrist. Additionally, there i
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asis. National guidelines recommend
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Post-Test Questions: 1. High BP is
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18 Hypertension Core Curriculum Ess
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Masked Hypertension is when the off
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TABLE 1. Prevalence of Awareness, T
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Blood Pressure, Circulatory Physiol
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side of the vascular tree. Arterial
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upon the other co-morbidities prese
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Table 3. Clinically Available Clues
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In the setting of chronic hypertens
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34 Hypertension Core Curriculum Tab
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cause greater disruption of CBF aut
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References/Suggested Reading Agabit
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40 Hypertension Core Curriculum Chr
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development of essential HTN can se
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Figures: Figure 1. Pie-chart with m
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Table 2 Table 3 Screening Test for
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References: 1. U.S. Renal Data Syst
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50 Hypertension Core Curriculum Spe
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side effects particularly well. A h
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14. Gaede P, Vedel P, Larsen N, Jen
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Learning Objectives: 56 Hypertensio
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glycemic risk factdors such as hype
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. Weight loss c. Weight gain d. A a
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References: 1. Association AD. All
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64 Hypertension Core Curriculum Spe
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foods and turn out of necessity to
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Figure 1: Table 1. Metabolic Syndro
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9. Singh GK, Kogan MD, Van Dyck PC,
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Incidence and Prevalence The overal
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access to healthy foods than their
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As a part of the approach to managi
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B Hypertensive Adults (rate, percen
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References: 1. Lewington S, Clarke
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82 Hypertension Core Curriculum
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appear to be related to access to c
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CDC MMWR Feb 24, 2006/55(07); 177-1
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Figure 1; Clinical presentation and
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90 Hypertension Core Curriculum Phe
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ANY patient, who develops paroxysma
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Figure 1: 94 Hypertension Core Curr
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Objectives: 96 Hypertension Core Cu
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Definition Prevalence Clinical Feat
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intake. 4 Figure 1; Ion transport i
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loading with 200 mmoles (4.6 grams)
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Figure 3; Endocrine Society See tex
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INTRODUCTION 106 Hypertension Core
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Renal manifestations. Renal ischemi
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to assess renal dimensions and dupl
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stenosis severity. Patients with no
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ARAS, ischemic nephropathy, and imp
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the goals of minimizing injury to t
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hemodynamically impaired renal arte
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e classified as having “renovascu
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disease of the abdominal aorta and
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Table 1. Contemporary evaluation of
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2. Screening tests for RAS RDU, MRA
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Manifestations of vital organ injur
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Table 6. Clinical evaluation of ren
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Page 134 and 135: Table 11. New terminology for renal
Page 136 and 137: References: 1. Murphy TP, Soares G,
Page 138 and 139: 2001;12(6):1235-1241. 40. Subramani
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Page 144 and 145: monitored hypertension screening an
Page 146 and 147: Policy Development: Public health p
Page 148 and 149: Med Clin North Am. Jan 2004;88(1):2
Page 150 and 151: mind they will have no problem iden
Page 152 and 153: Role of Race in the Selection of An
Page 154 and 155: individuals of any race or ethnicit
Page 156 and 157: Older Patients Need Elevated Systol
Page 158 and 159: sister, mother and father. A family
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Page 162 and 163: pulses (lower in the left arm). 4 C
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Page 168 and 169: References: patients. 8 However, th
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Page 176 and 177: interestingly found only a 6.0/4.6
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Page 184 and 185: 3.) Beta-blockers, ACE inhibitors,
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Page 188 and 189: Preparations and Dosage: Oral antih
Page 190 and 191: Preparations and Dosages: The Oral
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Page 208 and 209: Table 2: (JNC VII, 2004) 208 Hypert
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Page 214 and 215: Post-test question: 35y/o male w/ h
Page 216 and 217: Orthostatic Hypotension Pretest que
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Page 222 and 223: References: 1. Hiitola P, Enlund H,
Page 224 and 225: www.neuroanatomy.wisc.edu/.../Image
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4-Direct vasodilators (e.g.minoxidi
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Hypertension. Aug 2003;42(2):161-16
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emergency by virtue of the associat
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PATHOPHYSIOLOGY The underlying mech
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trials included a placebo arm. Seve
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an indication for careful and modes
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ACUTE KIDNEY INJURY (AKI) In additi
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Blood Pressure Research Council, an
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[ACE inhibitors (ACEIs), angiotensi
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y sodium restriction or the use of
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44 months 24 , and were also seen i
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• Hypertension in dialysis patien
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GISEN Group (Gruppo Italiano di Stu
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258 Hypertension Core Curriculum
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DEFINITION AND CLASSIFICATION Hyper
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etween adult socioeconomic position
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women treated with atenolol in earl
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Obstet Gynecol. Dec 12 2008. 5. Vol
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able to dissipate the pressure rise
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Use of Dihydropyridine Calcium Anta
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272 Hypertension Core Curriculum Ca
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Case 4 Hypertensive patient with CK
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Case 6 276 Hypertension Core Curric
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year. Sodium restriction and weight
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What may be causing these new sympt
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