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1、What Is Hypertension?,JNC 7 Definitions,Chobanian AV,et al.Hypertension 2003;42:1206-52,*Individuals aged 40-69 years,starting at blood pressure 115/75 mm Hg.CV,cardiovascular;DBP,diastolic blood pressure;SBP,systolic blood pressure.Chobanian AV et al.JAMA.2003;289(19):2560-2572.Lewington S et al.La
2、ncet.2002;360(9349):1903-1913.,Cardiovascular Mortality Risk Doubles With Each 20-mm Hg SBP or 10-mmHg DBP Increment*,Cardiovascularmortalityrisk,2x,4x,8x,Non-Hispanic White,Non-Hispanic Black,Mexican American,Men(age,years),Hypertension*Prevalence(%),0,20,40,60,80,100,Women(age,years),0,20,40,60,80
3、,100,Hypertension*Prevalence(%),*Hypertension defined as a BP of 140/90 mm Hg or reported use of antihypertensives.Error bars indicate 95%confidence intervals.Data are weighted to the US population.Hajjar I,Kotchen TA.JAMA.2003;290:199-206.,Prevalence of Hypertension Increases with Age:NHANES 1999-2
4、000 Data,NHANES=National Health and Nutrition Examination Survey.Fields,LE et al.Hypertension.2004;44:398-404.,Increasing Prevalence of Hypertension:Rise From 1988 to 2000(NHANES),0,0.5,1,1.5,2,2.5,3,3.5,4,4.5,5,Non-Hispanic Whites,Non-Hispanic Blacks,MexicanAmericans,%Increase(19881994 to 19992000)
5、,Ethnic/Racial Differences inPrevalence of Hypertension,Blacks have a higher prevalence and incidence of hypertension than whites.Most studies in the United Kingdom and the United States report a higher prevalence and lower awareness of hypertension in black people than in white people.In Mexican-Am
6、ericans,the prevalence and incidence of hypertension is similar to or lower than in whites.NHANES III reported an age-adjusted prevalence of hypertension at 20.6%in Mexican-Americans and 23.3%in non-Hispanic whites.,Group HTN PrevalenceWhite 21.2%Black/African-American 29.2%Hispanic/Latino 19.6%Asia
7、ns 16.9%Native Hawaiian/other Pacific Islander 20.7%American Indians/Alaska Natives 25.4%,American Heart Association Heart Disease and Stroke Statistics 2007,Hypertension Prevalence by Ethnic/Minority Groups,Contributing Factors:Social,Environmental,or Genetic?,Environmental factors ultimately relat
8、ed to race(e.g.socioeconomic disadvantage,less access to health care)play roles in causing and sustaining hypertension 1,2 Despite similar African heritage,Africans living in Africa or West Indies have much less hypertension than African Americans 3,4 In rural Africa,hypertension prevalence is very
9、low and blood pressure does not rise with age as it does in all ethnic groups in US 3,1 Cooper RS,Rotimi CN,Ward R.The puzzle of hypertension in African-Americans.Sci Am.1999;280:5662.2 Geronimus AT,Bound J,Waidmann TA,et al.Excess mortality among blacks and whites in the United States.N Engl J Med.
10、1996;335(21):15521558.3 Cooper R,Rotimi C,Ataman S,et al.The prevalence of hypertension in seven populations of west African origin.Am J Public Health.1997;87:160168.4 Ordunez-Garcia PO,Espinosa-Brito AD,Cooper RS,et al.Hypertension in Cuba:evidence of a narrow black-white difference.J Hum Hypertens
11、.1998;12:111116.,BP Reductions as Small as 2 mm Hg Reduce Risk of CV Events by Up to 10%,Meta-analysis of 61 prospective,observational studies1 million adults12.7 million person-years,Prospective Studies Collaboration.Lancet.2002;360:1903-1913.,2 mm Hg decrease in mean SBP,10%reduction in risk of st
12、roke mortality,7%reduction in risk of CHD mortality,BPLTTC Meta-analysis:Stroke and CHD,Blood Pressure Lowering Treatment Trialists Collaboration.Lancet.2003;362:1527-1535.,JNC7 Algorithm forTreatment of Hypertension,Not at Goal BP 140/90 mm Hg for most 130/80 for those with diabetes or CKD,Initial
13、Drug Choices,Drug(s)for compelling indications+BP meds as needed,Compelling Indications,Lifestyle Modifications,Stage 2 BP 160/100 2-drug combo for most(diuretic+ACEI,or ARB,or BB,or CCB),Stage 1 140-159/90-99 Diuretics for most;consider ACEI,ARB,B,CCB,No Compelling Indications,Not at Goal BP,Optimi
14、ze dosages or add drugs until goal BP is achieved.Consider hypertension specialist consult.,Chobanian AV,et al.JAMA.2003;289:2560-2572.,ACEI=ACE inhibitorCCB=calcium channel blockerARB=angiotensin receptor blockerB=-blockerCKD=chronic kidney disease,JNC 7 Compelling Indications,Chobanian AV,et al.JA
15、MA.2003;289:2560-2572.,Heart failurePost-MIHigh CHD riskDiabetesChronic kidneydiseaseRecurrent strokeprevention,B,ACEI,ARB,CCB,AA,Diuretic,AA=aldosterone antagonist,AHA Perspective/Hypertension Management and BP Goals Summary of Main Recommendations,adapted from Rosendorff C,et al.Circulation 2007;1
16、15:published online,Lose weight if overweightLimit alcohol intake to no more than 1 oz(30 mL)of ethanol(ie,24 oz 720 mL of beer,10 oz 300 mL of wine,2 oz 60 mL of 100-proof whiskey)per day or 0.5(15 mL)ethanol per day for women and people of lighter weight Increase aerobic activity(30-45 min most da
17、ys of the week)Reduce sodium intake to no more than 100 mmol/d(2.4 g sodium)Maintain adequate intake of dietary potassium(approximately 90 mmol/d)Maintain adequate intake of dietary calcium and magnesium for general health Stop smoking and reduce intake of dietary saturated fat and cholesterol for o
18、verall cardiovascular health,JNC VII recommendations.Chobanian AV,et al.JAMA.2003;289:2560-2572.,Lifestyle Modification,Lifestyle Modification,Hypertension Increases With Obesity in WomenEspecially After Age 45,Huang Z et al.Ann Intern Med.1998;128:8188.,Multivariate RR*for HypertensionAccording to
19、Weight Change,*Adjusted for age,BMI at age 18 years,height,family history of myocardial infarction,parity,oral contraceptive use,menopausal status,postmenopausal use of hormones,and smoking.140/90 mmHg.,Age 45Age 4554Age 55,Loss 10,Loss 5.09.9,Loss 2.14.9,Change 2.1,Gain 2.14.9,Gain 5.09.9,Gain 1.01
20、9.9,Gain 20.024.9,Gain 25,Multivariate Relative Risk,7,6,5,4,3,2,1,0,Weight Change After 18 Years,kg,Reasons for Inadequate BP Control,Poor compliance to lifestyle modificationsAcceptance of inadequate control by physicianDifficulty achieving BP control with one agent/suboptimal regimensBP goals are
21、 more aggressive than in previous yearsLack of compliance due to:perceived side effects of antihypertensive medication(s)frequency of dosing/multiple agents to attain control,(Adapted from JNC VI.Arch Intern Med.1997),Prevalence of Nonbiomedical Expectationsin African-Americans(N=93),Yes,No,Cure of
22、hypertensionTake medications for lifeTake medications only with symptomsHaving at least one non-biomedical expectationHaving all three nonbiomedical expectations,Nonbiomedical Expectations,38%48%23%65%15%,51%38%67%35%85%,11%14%10%0%0%,Dont Know,Ogedegbe G.J Natl Med Assoc.2004;96:442449.,*Computed b
23、y M.Wolz(unpublished data cited by Chobanian et al.)Adapted from Chobanian AV,et al.JAMA.2003;289:2560-2572.,NHANES III19911994,NHANES III19881991,Adults,%,PatientAwareness,NHANES II19761980,Treatment,Control,19992000*,51,73,68,31,55,54,10,29,27,70,59,34,0,10,20,30,40,50,60,70,80,The Gap Between Rat
24、es of Hypertension Awareness and Control,Age-Adjusted Blood Pressure Control Rates in Different Groups,Group HBP control 2003-04Mexican-American men31.1%Mexican-American women 24.6%Non-hispanic white men34.8%Non-hispanic white women41.8%Non-hispanic black men26.8%Non-hispanic black women30.3%,Monoth
25、erapy for Hypertension Is Inadequate in 4050%of Patients,Adapted from Materson BJ et al.Am J Hypertens.1995;8:189192.,0,20,40,60,80,CCB(diltiazem),BetaBlocker(atenolol),Diuretic(HCTZ),Alpha1Antagonist(prazosin),ACEI(captopril),Alpha2Agonist(clonidine),50%response,*Response=diastolic blood pressure(D
26、BP)90 mmHg at the end of titration period and having maintained a DBP of 95 mmHg for 1 year without drug tolerance.Mean baseline blood pressure=152/99 mmHg.,Patients With Response*,%,Placebo,Blood Pressure Control Usually Requires Combination Therapy,Vicious Cycle of Therapeutic Failure,Inadequate M
27、anagement of Blood Pressure in VA Hypertensive Population,Retrospective chart review of 800 hypertensive men followed over 2 years at 5 VA hospitals Mean age=65,Ave duration of HTN=12 yrsApprox 40%had BP 160/90 mm HgMean no of visits/year=6.4Antihypertensive meds were increased at 6.7%of the HTN vis
28、itsMore intensive therapy was associated with better BP control,Berlowitz DR NEJM 1998;339:1957,In Clinical Practice,Most Patients Undertreated,Lloyd-Jones DM et al.JAMA.2005;294:466-72.,*Framingham Heart Study,N=4919 treated patients,Suboptimal number of antihypertensive medications*,60,30,10,0,20,
29、40,60,1,2,3,Patients(%),Antihypertensive medications(n),Cushman WC et al.Arch Intern Med.2000;160:825831.,Treatment Success,*%,Outside the Stroke BeltInside the Stroke Belt,100,80,60,40,20,0,Hydrochloro-thiazide,Atenolol,Captopril,Diltiazem Hydrochloride,Clonidine,Prazosin Hydrochloride,Antihyperten
30、sive Medications for African American Patients,65,47,58,39,57,21,81,77,66,41,42,49,100,80,60,40,20,0,Hydrochloro-thiazide,Atenolol,Captopril,Diltiazem Hydrochloride,Clonidine,Prazosin Hydrochloride,Antihypertensive Medications for White Patients,62,30,70,68,64,55,66,65,76,55,63,67,Treatment Success,
31、*%,*One-year treatment success rates in controlling diastolic blood pressure.,Efficacy of Various Antihypertensive Medications in and Out of the Stroke Belt,ALLHAT:SBP Changes in African-Americans and Non-Black*Participants,Adapted from Wright JT Jr.et al.JAMA.2005;293:15951608.,Black,Non-Black,Stud
32、y Year:,2,4,Chlorthalidone,2,4,Amlodipine,2,4,Lisinopril,8.6,10.2,10.5,12.3,7.1,9.8,8.8,12.3,3.4,9.5,6.8,12.0,14,12,10,8,6,4,2,0,*White,Asian,Native American,and other(92%White).,Blood Pressure Response,mmHg,Relative Risk Reduction With Ramipril vs.Amlodipine Besylate:AASK,RamiprilAmlodipine besylat
33、e,Eventsperperson-yr,GFR,ESRD,GFR,ESRD,or death,GFR,glomerular filtration rate;ESRD,end-stage renal disease.Agodoa LY et al.JAMA.2001;285:2719-2728.,RRR=41%P=0.03,RRR=44%P=0.01,RRR=38%P=0.005,RAAS Activity in African-Americans an Apparent Paradox,African-American hypertensive patients have Plasma re
34、nin activity Salt-sensitivity Pressure natriuresis responseBut also have Activation of intrarenal RAAS Renovasoconstriction Impaired renal vascular response to Ang II and RAS blockage,Price DA,Fisher ND,Curr Hypertens Rep.2003;5:225-230,Pulse Pressure and the Incidence of Cardiovascular Disease,A cr
35、oss-sectional prospective study by Benetos et.al of 19,083 patients 40-69 yo,pulse pressure alone was shown to be an independent predictor of cardiac risks judged by degree of cardiac hypertrophy,Hypertension,vol.30,p.1410,1997,VALUE:Outcome and SBP Differences at Specific Time Periods:Primary Endpo
36、int,Time Interval,(months),Overall study,3648,2436,1224,612,03,Study end,Favors amlodipine,1.0,2.0,0.5,PRIMARY ENDPOINT Odds Ratios and 95%CIs,D,SBP,mmHg,1.4,1.6,1.8,2.0,3.8,1.7,2.2,36,2.3,Favors valsartan,4.0,Julius S et al.Lancet.June 2004;363.,Mortality From High Blood Pressure Higher in African-
37、Americans,Overall Mortality Rates From Causes Related to Hypertension,2003*,*High blood pressure listed as a primary or contributing cause of death.High blood pressure=systolic 140 mmHg or diastolic 90 mmHg,taking antihypertensive medicine,being told 2 times by a physician that you have high blood p
38、ressure.,Mortality Rate,%,African American,Female,Male,Female,20,10,30,40,50,49.7,14.9,40.8,14.5,0,60,Male,White,In hypertensive African-Americans,30%and 20%of all deaths inmen and women,respectively,may be due to high blood pressure.,Adapted from Thom T et al.Circulation.2006;113:e85e151.,Complicat
39、ions Related to Hypertensionin African-American Patients,Compared with the general population,African-Americans have a higher rate of:hypertension40%heart disease mortality50%obesity70%stroke mortality80%diabetes mellitus100%ESRD320%,ESRD,end-stage renal disease.American Heart Association.2001 Heart
40、 and Stroke Statistical Update.Burt JL et al.Hypertension.1995;25:305-313.JNC VI.Arch Intern Med.1997;157:2413-2446.,Complications of Hypertension:Target-Organ Damage,CHD,coronary heart disease;CHF,congestive heart failure;LVH,left ventricular hypertrophy.JNC VI.Arch Intern Med.1997;157:2413-2446.,C
41、heck fundi EKG or echocardiographyAtherosclerotic plaque(x-ray or ultrasound evidence in carotid,iliac,or femoral arteries or aorta)Fasting blood sugar or 2-hr Post-prandial Hgb A1c Microalbumin:creatinine ratioserum creatinine,Hypertensive Target-Organ Disease:Assessment,Hypertensive Retinopathy,Ca
42、uses of Resistant Hypertension,PseudoresistancePoor complianceDrug InteractionsUnderdosingImproper combinations,ObesityExcess Alcohol Volume OverloadSleep ApneaSecondary Hypertension,Coarctation of aorta,Renal Artery StenosisRenin tumorGlomerulonephritisDM nephrosclerosisPolycystic diseaseCollagen d
43、iseaseChronic Pyelonephritis,Conns syndromePheochromacytomaCushing syndromeThyroid DiseaseAcromegalyHyperparathyroidism,Drug Induced,Causes of Secondary Hypertension,Clues to Suggest Secondary Hypertension,Historical CluesResistance to 4 drug therapyYoung age of onset of HTN(teens,20s)Sudden increas
44、e in BPEpisodes of extreme BPsLow potassium&muscle crampsWomen age 35-55 new onsetDaytime sleepiness,snoring,poor sleep habits,Physical Exam CluesAbdominal bruit,reduced LE pulsesFemoral bruit/Renal bruitUnequal BP in extremitiesReduced pulse in extremitiesSevere LE edemaWide pulse pressure&cardiac
45、murmurBuffalo hump,striae,central obesityEnlarged thyroid,Managing Hypertension in African-Americans,Most will require combination therapy when initial therapy failsAll antihypertensive classes,including RAAS agents,are associated with BP-lowering effects in African-AmericansBe vigilant in pursuit o
46、f BP goals as stated in ISHIB Guidelines,RAAS=renin-angiotensin-aldosterone systemDouglas JG et al.Arch Intern Med.2003;163:525-541,If BP 145/90 mm Hg,monotherapy or combination therapy including a RAS blocker,If BP 155/100 mm Hg,monotherapy,If BP 155/100 mm Hg,combination therapy,Add a 2nd agent fr
47、om a different class orincrease dose,Increase doseor add a 3rd agentfrom a different class,Uncomplicated hypertensionGoal BP:140/90 mm Hg,Not at BP goal?Intensify lifestyle changes AND,Consensus Statement:Management of High Blood Pressure in African-Americans,*Preferable BP goal for patients with re
48、nal disease with proteinuria 1 gm/24 h is 125/75 mm Hg.Initiate monotherapy at recommended starting dose with an agent from any of the following classes:diuretics,beta blockers,CCBs,ACE inhibitors,ARBsTo achieve BP goals more expeditiously,initiate low-dose combination therapy with any of the follow
49、ing combinations:beta blocker/diuretic,ACE inhibitor/diuretic,ACE inhibitor/CCB,or ARB/diuretic.Consider specific clinical indications when selecting agents.,If BP 145/90 mm Hg,combination therapy including a RAS blocker,Add a 2nd agent from a different class orincrease dose,Increase doseor add a 3r
50、d agentfrom a different class,Diabetes/nondiabetic renal disease with proteinuria 1 g/24 h*Goal BP:130/80 mm Hg,Not at BP goal?Intensify lifestyle changes AND,Patient with elevated BP,The majority of patients will require combination therapy to achieve target BP.Effective combinations are:beta block
