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The Pharmacists’ Role in Treating Hypertension

The Pharmacists’ Role in Treating Hypertension. Thomas Owens, MD Saint Francis University CERMUSA. Objectives. Enhance your understanding of hypertension to include cardiovascular risks, management, and goals for individual patients

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The Pharmacists’ Role in Treating Hypertension

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  1. The Pharmacists’ Role in Treating Hypertension Thomas Owens, MD Saint Francis University CERMUSA

  2. Objectives • Enhance your understanding of hypertension to include cardiovascular risks, management, and goals for individual patients • Review and discuss the current pharmacotherapy standards of care for hypertension • Describe the pharmacist’s role in counseling patients on hypertensive medications

  3. Hypertension >140/90 mm Hg • United States: 65 million adults • Risk factors include: • Stroke, myocardial infarction, heart failure, peripheral vascular disease, aortic dissection, chronic renal failure • Hypertension price tag: $59.7 billion Wexler & Feldman, 2005

  4. Hypertension • Typical onset • second decade of life • Primary Hypertension • identifiable behaviors • Secondary Hypertension • more discrete Cecil, 2004

  5. African Americans 43% female & 39% male Ratio 1:3 Increase in sodium sensitivity? Caucasians 28% female 29% male Mexican Americans Ratio 1:4 or 1:5 Ethnic Groups DASH Diet Cecil, 2004

  6. Dietary Sodium Intake • Salt Hypothesis? • Strong genetic underpinning ADA, 2005

  7. Metabolic Syndrome • Risk of Hypertension increases with BMI • Obesity accounts for 50% to 60% of new cases of hypertension Cecil, 2004

  8. Sleep Apnea Potential Causes of Hypertension • Expanded plasma volume plus sympathetic over activity • Peripheral vasoconstriction • Renal salt retention • Renal water retention www.sleepconsultants.com, 2007 Cecil, 2004

  9. Blood Pressure Equation Blood Pressure = Cardiac Output x Peripheral Vascular Resistance Most pharmacologic agents lower Some pharmacologic agents lower Some pharmacologic agents lower both Cecil, 2004

  10. Genetics of High BP • Sympathetic up-regulation leads to a cascade of events • Peripheral vascular resistance • Genetic factors • 30% of cases • 2x as likely if parents have hypertension Discoveryedge.mayo.com, 2007; ADA, 2003

  11. Systolic & Diastolic ?? • What is more important? • Depends on age • Live long enough almost all develop systolic hypertension systolic 120 80 diastolic Cecil, 2004

  12. Age Dependant Rise in BP (Whelton & Rocella, 1995)

  13. Framingham Study (age: 50-79) (Khan, Wong, Larson, & Levy, 1999)

  14. Systolic Hypertension • Decreased distensibility of large arteries • Majority of uncontrolled hypertension • Due to focus on diastolic BP Cecil, 2004

  15. Risk of cardiovascular mortality by systolic BP (National High Blood Pressure Education Program Working Group, 1993)

  16. Hypertension Study Results • Hypertension is excess of 140/90 mm Hg • Studies found • Increase risk when above 115 mm Hg systolic or 75 mm Hg diastolic • High normal BP had twice increased risk for cardio disease • More studies are needed to fully understand Cecil, 2004

  17. The Silent Killer • 1/3 of adults do not know they have hypertension • Hypertension: 60% are treated • 45% of treated remain uncontrolled Despite over 75 different antihypertensive agents in 9 different classes! Cecil, 2004

  18. Reclassification of BP Stages • Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) • New category “pre-hypertension” • Pharmacotherapy not recommended • Lifestyle modification recommended! Cecil, 2004; JNC, 2007

  19. JNC Drug Therapy Recommendations ≥130/80 (w/ heart and kidney disease or diabetes mellitus) recommendation (healthy) JNC, 2007

  20. Modest reduction in BP = big benefits !! • Decrease 5 mm Hg decreases risks • Small changes can have a big difference • Results of studies • Systolic surge 34 mm Hg = 3x increase of stroke • Systolic ≥135 mm Hg = 74% increase of cardio event Cecil, 2004; JNC, 2007

  21. Clinical Presentation • No specific signs or symptoms • Possible symptoms • Occipital headache, dizziness, tinnitus, dimmed vision, palpitations, fatigue • Physical Exam • May reveal evidence Cecil, 2004

  22. Hypertensive Retinopathy Grades of hypertensive retinopathy shown (Forbes, Jackson, 2003)

  23. Electrocardiogram (ECG or EKG) BAD (Antero-Septal MI) GOOD (Normal) physiol.umin.jp/cardiovasc, 2007

  24. Counseling Patients:Proper BP Readings • At least 30 minutes before NO • Caffeine, decongestants, oral contraceptives, alcohol, tobacco • Sit down for at least 5 minutes Cecil, 2004; ADA, 2005

  25. Counseling Patients:Proper Fit of BP Cuff Length of bladder of the cuff at least 80% 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

  26. Help Patients Understand:White Coat Hypertension • Anxiety of going to doctor office raises BP • Recommend self-monitoring • Daytime: >135/85 mm Hg • Nighttime: >120/70 mm Hg • 24 hr: >130/80 mm Hg • Follow patients every 6 months for possible progression to persistent hypertension Cecil, 2004

  27. Closely Monitor Medications with High-Risk Patients Cecil, 2004

  28. Counseling Patients:Causes of Organ Damage

  29. Counseling Patients:Treatment JNC, 2005

  30. Counseling Patients:Lifelong Treatment • Objective: reduce BP and metabolic abnormalities • Pharmacotherapy & lifestyle modification • Reduce sodium intake • Weight loss • Exercise • Moderating alcohol • Reduce systolic BP by 21 to 55 mm Hg Cecil, 2004

  31. Counseling Patients:Dietary Changes • Losing only 10 to 12 lbs lowers BP by 10/5 mm Hg • Reduce daily salt • 10 to 6 grams • Teach patients to read food labels • DASH Diet • www.nhlbi.nih.gov/health/public/heart/dash Cecil, 2004

  32. Counseling Patients:Health Behaviors JNC, 2005

  33. Counseling Patients:Helpful Resources www.lotrel.com

  34. Barriers to Successful Health Behavior Modifications • Lack of education • Lack of access to safe places to exercise • Added salt in prepared foods and restaurant meals • Higher cost of foods low in salt Patient self-management is realistic and feasible! Cecil, 2004

  35. Pharmacologic Therapy • Scientific proof lowering BP reduces organ damage • Certain classes of antihypertensive agents exert organoprotective effects • Not all medications equal Cecil, 2004; JNC, 2005

  36. Major Challenges for Science • Identify the key gene-environment interactions • Eliminate the patient and medical provider barriers ADA, 2003

  37. Counseling Patients:Target Blood Pressure • Most patients below 140/90 mm Hg • Patients w/ diabetes or chronic disease 130/80 mm Hg • Help patients self-monitor BP • 1/3 do not know they are hypertensive • Research studies on targeting BP Cecil, 2004

  38. Improve Hypertension Control Rates • Titrating blood pressure medications to achieve target goals • Most patients require 2 or 3 antihypertensive medications • Patient compliance with multi-drug regimens ADA, 2005

  39. Patient Compliance and Quality of Life • Hypertension requires lifelong treatment • Medications can produce side effects • Men often concerned with sexual dysfunction • Patients with controlled BP, rate a significantly higher quality of life Cecil, 2004

  40. Patient Compliance Principles • Titrating medical therapy based on home readings • Long-acting preparations w/ once daily dosing • Low dose combinations of medications from different drug classes • Fixed-dose combinations to reduce overall number of pills JNC, 2005

  41. Drug Therapy • Old method: high-dose monotherapy • Recent studies (ex. ALLHAT) • At least 2 medications of different classes to treat mild hypertension • 3 or 4 different medications to treat more difficult cases • Thiazide-type antihypertensive medications cost-effective • Initial treatment: • Beta blockers, Angiotensin-converting enzyme (ACE) inhibitors, Angiotensin receptor blockers, Calcium antagonists Cecil, 2004

  42. Stage 2 Drug Therapy • JNC recommends: • 2 drug combination • Additional medications needed for each 10 mm Hg of systolic BP above goal • Great majority should include low-dose diuretic • High-risk conditions (heart failure/diabetes) • Angiotensin-converting enzyme inhibitors (ACE-Is) • Angiotensin receptor blockers (ARBs) Cecil, 2004

  43. Cardio Events in Hypertensive Patients Verdecchia, Carin, Circo,2001

  44. Left Ventricular Hypertrophy www.medem.com, 2007

  45. Counseling Patients: Contradictions & Side Effects Considerations For Individualizing Antihypertensive Drug Therapy

  46. Hypertensive Sub-Populations • Hypertensive patients with nephrosclerosis • Diabetic hypertensive patients • Hypertensive patients with coronary artery disease • Isolated systolic hypertension in older persons • Hypertensive disorders of women • Oral contraceptives • Pregnancy Cecil, 2004

  47. Hypertension Case Study How would we modify his treatment since he did not change his health behaviors (and he is diabetic)?

  48. Thank you for attending

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