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E. Brown-Myrie, Pharm. D. CLINICAL PHARMACY AND THERAPEUTICS  HYPERTENSION
E. Brown-Myrie, Pharm. D. Introduction  Definition An elevation of either the systolic blood pressure, the diastolic  blood pressure or both. BP = CO x PVR               Hypertension is a sign of many underlying disease processes,  the majority of which cause no symptoms.   It is a major risk factor for the development of stroke, renal  failure, myocardial infarction and coronary artery disease. It affects 10 – 15% of the world’s population and often coexists  with other disease conditions, diabetes being the most  prevalent.  
E. Brown-Myrie, Pharm. D. Blood Pressure Measurement and Clinical Evaluation   (JNC VII) Classification and Management of Blood Pressure for Adults  BP Classification Systolic (mm Hg) Diastolic (mm Hg) Normal  <120 and  <80 Prehypertension  120-139 or  80-89 Hypertension  ‡ Stage 1 140-159 or  90-99 Stage 2 >  160 or  >  100 JNC7 =  Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure Hypertension 2003;42:1206–1252
E. Brown-Myrie, Pharm. D. Recommendations for Follow-up Based on Initial Blood Pressure Measurements for Adults  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Components of Cardiovascular Risk Stratification in Patients with Hypertension ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Risk Stratification and Treatment Blood Pressure  Lifestyle Modification  Drug therapy  Normal (<120/80) Encourage     Without With compelling Compelling Indications Indications Pre-hypertension Yes No drug therapy Drugs to treat com- 120-139/80-89)  pelling indications Stage 1 Yes Thiazide-type Drugs for the com- (140-159/90-99) diuretics for most. pelling indications  ‡ May use ACEI, Other agents (diuretics. ARB, BB, CCB ACE, ARB, BB, CCB or combination as needed Stage 2  Yes Two drug As Above ( >  160/ > 100) combination for most † †   Initial combined therapy should be used cautiously in those at risk for orthostatic  hypotension. ‡   Treat patients with chronic renal disease or diabetes to BP goal of <130/80. Hypertension 2003;42:1206–1252
E. Brown-Myrie, Pharm. D. EVALUATION & DIAGNOSIS ,[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. BLOOD PRESSURE MEASUREMENTS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. COMPLETE MEDICAL HISTORY ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. PHYSICAL EXAMINATION Fundoscopic examination (arteriolar narrowing, focal arteriolar constrictions, AV nicking, hemorrhages, exudates and disc edema) Neck examination (carotid bruits, distended veins, enlarged thyroid) Heart (abnormal rates & rhythms, increased size, murmurs, third and fourth sounds) Lung (rales, evidence of bronchospasm) Abdomen (bruits, enlarged kidneys, masses, abnormal aortic pulses) Extremities (diminished or absent peripheral pulses,bruits and edema)
E. Brown-Myrie, Pharm. D. LABORATORY MEASUREMENTS ,[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. MANAGEMENT OF HYPERTENSION ,[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Goals of Therapy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
2007 – AHA Scientific Statement E. Brown-Myrie, Pharm. D. AREA BP Target (mm Hg) General CAD Prevention <140/90 High CAD risk <130/80 CAD LVD <130/80 <120/80 Circulation. 2007;115:2761-2788
2007 – AHA Scientific Statement AREA BP Target (mm Hg) Specific Drug Indications General CAD Prevention <140/90 Monotherapy or combination therapy: •  ACEI (or ARB), CCB, or thiazide diuretic first-line High CAD risk <130/80 Monotherapy or combination therapy: •  ACEI (or ARB), CCB, or thiazide diuretic first-line CAD LVD <130/80 <120/80 β-blocker and ACEI or ARB ACEI or ARB and β-blocker and aldosterone antagonist and diuretic Circulation. 2007;115:2761-2788
E. Brown-Myrie, Pharm. D. Lifestyle Modifications to Manage Hypertension ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. PHARMACOLOGIC TREATMENT ,[object Object],[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Treatment - Special Considerations ,[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Treatment Recommendations ,[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Treatment Recommendations cont. ,[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Clinical Trial & Guideline Basis for compelling Indications for Drug Therapy Compelling Indication Diuretic BB ACEI ARB CCB Aldo ANT Clinical Trials Basis Heart Failure • • • • • ACC/AHA Heart Failure Guidelines, MERIT-HF, COPERNICUS,CIBIS, SOLVD,AIRE, TRACE, ValHEFT,RALES Post MI • • • ACC/AHA Heart Failure Guidelines, BHAT, SAVE, Capricorn, EPHESUS High Coronary disease risk • • • • ALLHAT, HOPE, ANBP2, LIFE,CONVINCE Diabetes • • • • • NKF-ADA Guideline, UKPDS, ALLHAT,  Chronic Kidney disease • • NKF Guideline, Captopril Trial, RENAAL,IDNT,REIN, AASK Recurrent stroke prevention  • • PROGRESS
Study Abbreviations ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],E. Brown-Myrie, Pharm. D.
Study Abbreviations ,[object Object],[object Object],[object Object],[object Object],[object Object],E. Brown-Myrie, Pharm. D.
Study Abbreviations ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],E. Brown-Myrie, Pharm. D.
Study Abbreviations ,[object Object],[object Object],[object Object],[object Object],[object Object],E. Brown-Myrie, Pharm. D.
E. Brown-Myrie, Pharm. D. Special Considerations- Black Patients ,[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Special Considerations – Elderly Patients ,[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Special Considerations – Elderly Patients cont. ,[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Special Considerations- Young Patients ,[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Special Considerations – Pregnant Patients ,[object Object],[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Special Considerations – Cerebrovascular Disease ,[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Special Considerations – CAD Patients ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Special Considerations – CHF Patients ,[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Special Considerations – CHF Patients cont. ,[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Special Considerations – LV Hypertrophy ,[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Special Considerations – Peripheral Arterial Disease ,[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Special Considerations – DM Patients ,[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Special Considerations – COPD or Asthma Patients ,[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Special Considerations – Patients with Hyperlipidemia ,[object Object],[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Special Considerations - Gout ,[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Special Considerations – Patients with Renal Disease ,[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Hypertensive Urgencies & Emergencies ,[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Hypertensive Emergencies ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Resistant Hypertension ,[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Medications used in Hypertension ,[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Loop Diuretics ,[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Potassium-sparing Diuretics ,[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Alpha-1 receptor blockers ,[object Object],[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Alpha agonists ,[object Object],[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Beta Blockers ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. ACE Inhibitors ,[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Calcium Channel Blockers ,[object Object],[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Angiotensin II-Receptor Antagonists ,[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Vasodilators ,[object Object],[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Postganglionic Sympathetic Inhibitors  ,[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. RESERPINE ,[object Object],[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. Imidazoline receptor binding drugs ,[object Object],[object Object],[object Object],[object Object]
E. Brown-Myrie, Pharm. D. COMBINATION PRODUCTS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
New and Emerging Treatments for Hypertension ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],E. Brown-Myrie, Pharm. D.
Aliskiren ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],E. Brown-Myrie, Pharm. D.
What is Nebivolol ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],E. Brown-Myrie, Pharm. D.
E. Brown-Myrie, Pharm. D. Summary of JNC V11 Report ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

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Cpt htn march 2010

  • 1. E. Brown-Myrie, Pharm. D. CLINICAL PHARMACY AND THERAPEUTICS HYPERTENSION
  • 2. E. Brown-Myrie, Pharm. D. Introduction Definition An elevation of either the systolic blood pressure, the diastolic blood pressure or both. BP = CO x PVR              Hypertension is a sign of many underlying disease processes, the majority of which cause no symptoms.   It is a major risk factor for the development of stroke, renal failure, myocardial infarction and coronary artery disease. It affects 10 – 15% of the world’s population and often coexists with other disease conditions, diabetes being the most prevalent.  
  • 3. E. Brown-Myrie, Pharm. D. Blood Pressure Measurement and Clinical Evaluation (JNC VII) Classification and Management of Blood Pressure for Adults BP Classification Systolic (mm Hg) Diastolic (mm Hg) Normal <120 and <80 Prehypertension 120-139 or 80-89 Hypertension ‡ Stage 1 140-159 or 90-99 Stage 2 > 160 or > 100 JNC7 = Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure Hypertension 2003;42:1206–1252
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  • 6. E. Brown-Myrie, Pharm. D. Risk Stratification and Treatment Blood Pressure Lifestyle Modification Drug therapy Normal (<120/80) Encourage Without With compelling Compelling Indications Indications Pre-hypertension Yes No drug therapy Drugs to treat com- 120-139/80-89) pelling indications Stage 1 Yes Thiazide-type Drugs for the com- (140-159/90-99) diuretics for most. pelling indications ‡ May use ACEI, Other agents (diuretics. ARB, BB, CCB ACE, ARB, BB, CCB or combination as needed Stage 2 Yes Two drug As Above ( > 160/ > 100) combination for most † † Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension. ‡ Treat patients with chronic renal disease or diabetes to BP goal of <130/80. Hypertension 2003;42:1206–1252
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  • 10. E. Brown-Myrie, Pharm. D. PHYSICAL EXAMINATION Fundoscopic examination (arteriolar narrowing, focal arteriolar constrictions, AV nicking, hemorrhages, exudates and disc edema) Neck examination (carotid bruits, distended veins, enlarged thyroid) Heart (abnormal rates & rhythms, increased size, murmurs, third and fourth sounds) Lung (rales, evidence of bronchospasm) Abdomen (bruits, enlarged kidneys, masses, abnormal aortic pulses) Extremities (diminished or absent peripheral pulses,bruits and edema)
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  • 14. 2007 – AHA Scientific Statement E. Brown-Myrie, Pharm. D. AREA BP Target (mm Hg) General CAD Prevention <140/90 High CAD risk <130/80 CAD LVD <130/80 <120/80 Circulation. 2007;115:2761-2788
  • 15. 2007 – AHA Scientific Statement AREA BP Target (mm Hg) Specific Drug Indications General CAD Prevention <140/90 Monotherapy or combination therapy: • ACEI (or ARB), CCB, or thiazide diuretic first-line High CAD risk <130/80 Monotherapy or combination therapy: • ACEI (or ARB), CCB, or thiazide diuretic first-line CAD LVD <130/80 <120/80 β-blocker and ACEI or ARB ACEI or ARB and β-blocker and aldosterone antagonist and diuretic Circulation. 2007;115:2761-2788
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  • 21. E. Brown-Myrie, Pharm. D. Clinical Trial & Guideline Basis for compelling Indications for Drug Therapy Compelling Indication Diuretic BB ACEI ARB CCB Aldo ANT Clinical Trials Basis Heart Failure • • • • • ACC/AHA Heart Failure Guidelines, MERIT-HF, COPERNICUS,CIBIS, SOLVD,AIRE, TRACE, ValHEFT,RALES Post MI • • • ACC/AHA Heart Failure Guidelines, BHAT, SAVE, Capricorn, EPHESUS High Coronary disease risk • • • • ALLHAT, HOPE, ANBP2, LIFE,CONVINCE Diabetes • • • • • NKF-ADA Guideline, UKPDS, ALLHAT, Chronic Kidney disease • • NKF Guideline, Captopril Trial, RENAAL,IDNT,REIN, AASK Recurrent stroke prevention • • PROGRESS
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