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1、The Pharmacists Role in Treating Hypertension,Thomas Owens,MDSaint Francis UniversityCERMUSA,Objectives,Enhance your understanding of hypertension to include cardiovascular risks,management,and goals for individual patientsReview and discuss the current pharmacotherapy standards of care for hyperten
2、sionDescribe the pharmacists role in counseling patients on hypertensive medications,Hypertension 140/90 mm Hg,United States:65 million adultsRisk factors include:Stroke,myocardial infarction,heart failure,peripheral vascular disease,aortic dissection,chronic renal failureHypertension price tag:$59.
3、7 billion,Wexler&Feldman,2005,Hypertension,Typical onsetsecond decade of lifePrimary Hypertensionidentifiable behaviorsSecondary Hypertensionmore discrete,Cecil,2004,Ethnic Groups,African Americans43%female&39%maleRatio 1:3 Increase in sodium sensitivity?Caucasians28%female 29%maleMexican AmericansR
4、atio 1:4 or 1:5,DASH Diet,Cecil,2004,Dietary Sodium Intake,Salt Hypothesis?Strong genetic underpinning,ADA,2005,Metabolic Syndrome,Risk of Hypertension increases with BMIObesity accounts for 50%to 60%of new cases of hypertension,Cecil,2004,Potential Causes of Hypertension,Expanded plasma volume plus
5、 sympathetic over activityPeripheral vasoconstrictionRenal salt retentionRenal water retention,Sleep Apnea,2007,Cecil,2004,Blood Pressure Equation,Blood Pressure=Cardiac Output x Peripheral Vascular Resistance,Most pharmacologic agents lower,Some pharmacologic agents lower,Some pharmacologic agents
6、lower both,Cecil,2004,Genetics of High BP,Sympathetic up-regulation leads to a cascade of eventsPeripheral vascular resistanceGenetic factors30%of cases2x as likely if parents have hypertension,2007;ADA,2003,Systolic&Diastolic?,What is more important?Depends on ageLive long enough almost all develop
7、 systolic hypertension,12080,systolic,diastolic,Cecil,2004,Age Dependant Rise in BP,(Whelton&Rocella,1995),Framingham Study(age:50-79),(Khan,Wong,Larson,&Levy,1999),Systolic Hypertension,Decreased distensibility of large arteriesMajority of uncontrolled hypertensionDue to focus on diastolic BP,Cecil
8、,2004,Risk of cardiovascular mortality by systolic BP,(National High Blood Pressure Education Program Working Group,1993),Hypertension Study Results,Hypertension is excess of 140/90 mm HgStudies foundIncrease risk when above 115 mm Hg systolic or 75 mm Hg diastolicHigh normal BP had twice increased
9、risk for cardio diseaseMore studies are needed to fully understand,Cecil,2004,The Silent Killer,1/3 of adults do not know they have hypertensionHypertension:60%are treated45%of treated remain uncontrolledDespite over 75 different antihypertensive agents in 9 different classes!,Cecil,2004,Reclassific
10、ation of BP Stages,Joint National Committee on Prevention,Detection,Evaluation,and Treatment of High Blood Pressure(JNC)New category“pre-hypertension”Pharmacotherapy not recommendedLifestyle modification recommended!,Cecil,2004;JNC,2007,JNC Drug Therapy Recommendations,recommendation(healthy),130/80
11、(w/heart and kidney disease or diabetes mellitus),JNC,2007,Modest reduction in BP=big benefits!,Decrease 5 mm Hg decreases risksSmall changes can have a big differenceResults of studiesSystolic surge 34 mm Hg=3x increase of strokeSystolic 135 mm Hg=74%increase of cardio event,Cecil,2004;JNC,2007,Cli
12、nical Presentation,No specific signs or symptomsPossible symptomsOccipital headache,dizziness,tinnitus,dimmed vision,palpitations,fatiguePhysical ExamMay reveal evidence,Cecil,2004,Hypertensive Retinopathy,Grades of hypertensive retinopathy shown(Forbes,Jackson,2003),Electrocardiogram(ECG or EKG),GO
13、OD(Normal),BAD(Antero-Septal MI),2007,Counseling Patients:Proper BP Readings,At least 30 minutes before NOCaffeine,decongestants,oral contraceptives,alcohol,tobaccoSit down for at least 5 minutes,Cecil,2004;ADA,2005,Counseling Patients:Proper Fit of BP Cuff,Length of bladder of the cuff at least 80%
14、circumference of arm,Bladder of cuff at least 40%circumference of arm,Place the center of the bladder over the brachial artery,Pump until radial pulse disappears,then continue for additional 30 mm Hg,Help Patients Understand:White Coat Hypertension,Anxiety of going to doctor office raises BPRecommen
15、d self-monitoringDaytime:135/85 mm HgNighttime:120/70 mm Hg24 hr:130/80 mm HgFollow patients every 6 months for possible progression to persistent hypertension,Cecil,2004,Closely Monitor Medications with High-Risk Patients,Cecil,2004,Counseling Patients:Causes of Organ Damage,Counseling Patients:Tre
16、atment,JNC,2005,Counseling Patients:Lifelong Treatment,Objective:reduce BP and metabolic abnormalitiesPharmacotherapy&lifestyle modificationReduce sodium intakeWeight lossExerciseModerating alcoholReduce systolic BP by 21 to 55 mm Hg,Cecil,2004,Counseling Patients:Dietary Changes,Losing only 10 to 1
17、2 lbs lowers BP by 10/5 mm HgReduce daily salt10 to 6 gramsTeach patients to read food labelsDASH Diet/health/public/heart/dash,Cecil,2004,Counseling Patients:Health Behaviors,JNC,2005,Counseling Patients:Helpful Resources,Barriers to Successful Health Behavior Modifications,Lack of educationLack of
18、 access to safe places to exerciseAdded salt in prepared foods and restaurant mealsHigher cost of foods low in saltPatient self-management is realistic and feasible!,Cecil,2004,Pharmacologic Therapy,Scientific proof lowering BP reduces organ damageCertain classes of antihypertensive agents exert org
19、anoprotective effectsNot all medications equal,Cecil,2004;JNC,2005,Major Challenges for Science,Identify the key gene-environment interactionsEliminate the patient and medical provider barriers,ADA,2003,Counseling Patients:Target Blood Pressure,Most patients below 140/90 mm HgPatients w/diabetes or
20、chronic disease 130/80 mm HgHelp patients self-monitor BP1/3 do not know they are hypertensiveResearch studies on targeting BP,Cecil,2004,Improve Hypertension Control Rates,Titrating blood pressure medications to achieve target goalsMost patients require 2 or 3 antihypertensive medicationsPatient co
21、mpliance with multi-drug regimens,ADA,2005,Patient Compliance and Quality of Life,Hypertension requires lifelong treatmentMedications can produce side effectsMen often concerned with sexual dysfunctionPatients with controlled BP,rate a significantly higher quality of life,Cecil,2004,Patient Complian
22、ce Principles,Titrating medical therapy based on home readingsLong-acting preparations w/once daily dosingLow dose combinations of medications from different drug classesFixed-dose combinations to reduce overall number of pills,JNC,2005,Drug Therapy,Old method:high-dose monotherapyRecent studies(ex.
23、ALLHAT)At least 2 medications of different classes to treat mild hypertension3 or 4 different medications to treat more difficult casesThiazide-type antihypertensive medications cost-effectiveInitial treatment:Beta blockers,Angiotensin-converting enzyme(ACE)inhibitors,Angiotensin receptor blockers,C
24、alcium antagonists,Cecil,2004,Stage 2 Drug Therapy,JNC recommends:2 drug combinationAdditional medications needed for each 10 mm Hg of systolic BP above goalGreat majority should include low-dose diureticHigh-risk conditions(heart failure/diabetes)Angiotensin-converting enzyme inhibitors(ACE-Is)Angi
25、otensin receptor blockers(ARBs),Cecil,2004,Cardio Events in Hypertensive Patients,Verdecchia,Carin,Circo,2001,Left Ventricular Hypertrophy,2007,Counseling Patients:Contradictions&Side Effects,Considerations For Individualizing Antihypertensive Drug Therapy,Hypertensive Sub-Populations,Hypertensive p
26、atients with nephrosclerosisDiabetic hypertensive patientsHypertensive patients with coronary artery diseaseIsolated systolic hypertension in older personsHypertensive disorders of womenOral contraceptivesPregnancy,Cecil,2004,Hypertension Case Study,How would we modify his treatment since he did not change his health behaviors(and he is diabetic)?,Thank you for attending,
