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

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

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)

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

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