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 patientsReview and discuss the current pharmacotherapy standards of care for hypertensionDescribe 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: $59.7 billion,Wexler & Feldman, 2005,Hypertension,Typical onset second decade of lifePrimary Hypertension identifiable behaviorsSecondary Hypertension more discrete,Cecil, 2004,Ethnic Groups,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,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 sympathetic over activity Peripheral vasoconstriction Renal salt retention Renal water retention,Sleep Apnea,www.sleepconsultants.com, 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 lower both,Cecil, 2004,Genetics of High BP,Sympathetic up-regulation leads to a cascade of events Peripheral vascular resistanceGenetic factors 30% of cases 2x as likely if parents have hypertension,Discoveryedge.mayo.com, 2007; ADA, 2003,Systolic & Diastolic ?,What is more important? Depends on ageLive long enough almost all develop systolic hypertension,120 80,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 hypertension Due to focus on diastolic BP,Cecil, 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 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,The Silent Killer,1/3 of adults do not know they have hypertension Hypertension: 60% are treated 45% of treated remain uncontrolledDespite over 75 different antihypertensive agents in 9 different classes!,Cecil, 2004,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,JNC Drug Therapy Recommendations,recommendation (healthy),130/80 (w/ heart and kidney disease or diabetes mellitus),JNC, 2007,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,Clinical Presentation,No specific signs or symptoms Possible symptoms Occipital headache, dizziness, tinnitus, dimmed vision, palpitations, fatigue Physical Exam May reveal evidence,Cecil, 2004,Hypertensive Retinopathy,Grades of hypertensive retinopathy shown(Forbes, Jackson, 2003),Electrocardiogram (ECG or EKG),GOOD (Normal),BAD (Antero-Septal MI),physiol.umin.jp/cardiovasc, 2007,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,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,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 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: Treatment,JNC, 2005,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,