End Organs - Health Alliance Blog

End Organs •  The blood vessels •  The heart •  The kidneys •  The brain •  The eyes Effects on the Cardiovascular System •  Ventricular hypertrophy (thickened heart muscle) •  Heart failure •  Heart rhythm disorders (esp., atrial fibrilla6on) •  Coronary artery disease / heart aOack •  Arterial aneurysm, dissec6on, and rupture •  Peripheral arterial disease Effects on Other End-­‐Organs •  Impaired kidney func6on / kidney failure •  Stroke –  Hemorrhagic (bleeding into the brain) –  Thrombo6c (disrup6on of blood supply to the brain) •  Encephalopathy (a form of acute brain dysfunc6on) •  Cerebral atrophy and demen6a •  Eye damage: re6nal hemorrhages / re6nal detachment Hypertensive Crises •  Hypertensive Urgency (Accelerated Hypertension): –  Severely elevated BP without acute end-­‐organ dysfunc6on –  Examples: BP >180/100 mm Hg without severe headache, shortness of breath or chest pain •  Hypertensive Emergency (Malignant Hypertension): –  Severely elevated BP with acute end-­‐organ dysfunc6on –  Require emergent lowering of BP. –  Examples: BP > 180/100 mm Hg with confusion, acute heart failure, shortness of breath, chest pain, or dissec6ng aor6c aneurysm J
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JNC-8 Report. JAMA. 2014;311(5):507-520.
Comparison of Recent Guidelines JNC 8 ESH/ESC AHA/ACC ASH/ISH >140/90 Threshold for Drug Rx >140/90 < 60 yr >150/90 >60 yr Eldery SBP >160 Consider SBP 140-­‐150 if <80 yr >140/90 >140/90 <80 yr >150/90 >80 yr B-­‐blocker First line Rx No Yes No No Ini6ate Therapy w/ 2 drugs >160/100 "Markedly elevated BP" >160/100 >160/100 JNC-8 Report. JAMA. 2014;311(5):507-520.
JNC-8 Report. JAMA. 2014;311(5):507-520.
Effect of Lifestyle Modifica6ons www.nhlbi.nih.gov
HYVET* Trial Study Design •  Prospec(ve, randomized, double-­‐blind, placebo-­‐controlled trial •  Mean follow-­‐up, 1.8 years •  3845 pa(ents ≥80 years with sustained hypertension and systolic blood pressure ≥160 mm Hg before randomiza(on Ac(ve treatment: 1.5 mg sustained-­‐
release indapamide (n = 1933) Matching placebo dose (n = 1912) 2 years of follow-­‐up •  Primary end point: fatal and nonfatal strokes •  Secondary end points: death from stroke, cardiovascular causes, cardiac causes, and any cause = Hypertension in the Very Elderly Trial *HYVET BeckeV NS, et al. N Engl J Med. 2008;358(18):1887-­‐1898. Blood Pressure Changes with Therapy in 15 mmHg
Median follow-up 1.8 years
6 mmHg
Fatal Stroke (39% Risk ReducOon) Heart Failure (64% Risk ReducOon) How I Manage HTN in 2015? ü  In pa6ents <80 y/o, I use ≥140/90 mmHg as the cut-­‐off for both diagnosis AND ini6a6on of Rx for HTN, with a goal BP of <140/90, [<130/80 in the presence of diabetes, kidney disease (CKD), high risk or h/o of coronary disease, atrial fibrilla6on or heart failure] ü  In pa6ents ≥80 y/o, I use ≥150/90 mmHg as the cut-­‐off for ini6a6on of Rx for HTN, with a goal BP of <150/90, but if on-­‐treatment BP is <140/90, and well-­‐tolerated, do not modify therapy ü  In pa6ents with BP >160/100 mmHg, I start with 2 drugs ü  I rarely use beta-­‐blockers as a first line or sole agent ü  In Blacks, I use diure6cs & CCB preferen6ally to ACE-­‐I/ARB, unless the pa6ent has CKD ü  In CKD, I use ACE-­‐I or ARB first, irrespec6ve of age or race ü  I never combine an ACE-­‐I and an ARB ü  I do not use hydrochlorothiazide (use chlorthalidone or indapamide) Ques6ons?