Ziegler

Control of hypertensives: 

Control of hypertensives

Common Causes of Hypertension: 

Common Causes of Hypertension Obesity Lack of Exercise Dietary Fat and Sodium Sleep Apnea Ethanol Aldosteronism Kidney Disease

Slide6: 

Metaanalysis of the effects of diet on BP

Exercise &SBP: 

Exercise & SBP

Slide9: 

Effect of Sodium Restriction on Blood Pressure

EtOH Reduction and BP: 

EtOH Reduction and BP

Effect size for treatment of hypertension relative to SD of BP (metaanalysis of 103 studies): 

Effect size for treatment of hypertension relative to SD of BP (metaanalysis of 103 studies) Drugs* Weight loss* Yoga* Muscle relaxation* Meditation Biofeedback Placebo 2.9 1.6 1.4 1.3 0.7 0.7 0.6

Slide12: 

BP Effects of Low Calorie, Sodium or Fat Diet

Slide13: 

It Could Happen

Sleep Apnea Affects 10% to 50% of Hypertensives: 

Sleep Apnea Affects 10% to 50% of Hypertensives

Slide15: 

Prominence of Psych symptoms in OSA Depression Fatigue Cognitive impairment

Urinary Norepinephrine Increased in Apneics Dimsdale et al, Sleep 1995: 

Urinary Norepinephrine Increased in Apneics Dimsdale et al, Sleep 1995

Decreased Beta Receptor Sensitivity in Apneics (p<0.01) Mills & Dimsdale, Sleep 1995: 

Decreased Beta Receptor Sensitivity in Apneics (p<0.01) Mills & Dimsdale, Sleep 1995

CPAP: 

CPAP

CPAP improves contractility: 

CPAP improves contractility

CPAP Lowers Ambulatory BP, : 

CPAP Lowers Ambulatory BP,

Treating the Causes of Hypertension: 

Treating the Causes of Hypertension Modest BP Lowering Effects Weight loss Exercise Sodium and ethanol restriction Fish oil CPAP Moderate BP Lowering Effects Aldosterone antagonists

Slide23: 

The Big Gun for Blood Pressure?

The JNC 7 ReportThe Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JAMA 2534-2573, 2003): 

The JNC 7 Report The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JAMA 2534-2573, 2003) JNC recommends beginning doses at least 50% lower than the PDR, Package Insert, textbooks and handheld guides for more than half of BP drugs

THIAZIDES: 

Thiazides dose-response (mmHg) Thiazides % side effects THIAZIDES

ACE INHIBITORS: 

ACE inhibitors dose-response (mmHg) ACE inhibitors % side effects ACE INHIBITORS

AII rec. ANTAGONISTS: 

Angiotensin II receptor antagonists dose-response (mmHg) Angiotensin II receptor antagonists % side effects AII rec. ANTAGONISTS

Ca CHANNEL BLOCKERS: 

Calcium channel blockers dose-response (mmHg) Calcium channel blockers % side effects Ca CHANNEL BLOCKERS

Beta - BLOCKERS: 

b-blockers dose-response (mmHg) b-blockers % side effects Beta - BLOCKERS

Superdrug forBlood PressureDoes Not Exist: 

Superdrug for Blood Pressure Does Not Exist

Actual Response to 2 BP Drugs = the Sum of Individual Responses: 

Actual Response to 2 BP Drugs = the Sum of Individual Responses

Aliskiren Valsartan Combination: 

Aliskiren Valsartan Combination

Slide37: 

Aliskiren, HCTZ effects on BP Placebo 0 -8.2 -6.8 -13.7 Corrected BP

BP Drug Combinations: 

BP Drug Combinations RAISE SNS & RENIN Diuretics Calcium Channel Blocks Vasodilators LOWER SNS & RENIN ACEI ARB Beta Blockers Clonidine

Slide39: 

Combination Therapy is the Big Gun for Blood Pressure

Control of Blood Pressure: 

Control of Blood Pressure Treat the common causes of hypertension. Diet, exercise, alcohol, aldosterone, sleep apnea Treat with low doses of synergistic drugs Assume poor compliance and monitor drug use

Drug Compliance: 

Drug Compliance Product persistency curves after 1 year as much as a 50 percent decline after 5 years, compliance as low as 29% to 33% greatest declines in first six months

Compliance in medical practice: 

Compliance in medical practice Less than 1/3 of U.S. hypertensives have BP controlled 15% of hypertensives take all meds 35% of hypertensives taking meds take too little to do any good 50% stop Rx in one year 75% stop Rx in 5 years

WHO TAKES BP PILLS?: 

WHO TAKES BP PILLS? 95% of those at <60% of clinic appointments are non-compliant Psychiatric patients comply less Disabled patients comply more Emphasizing adverse outcomes worsens compliance

DETECTING NON-COMPLIERS: 

DETECTING NON-COMPLIERS Physicians detect 10% of non-compliers Do you take your meds? 50% sensitivity 87% specificity Patient has high BP or admits 83% sensitivity to not taking meds 66% specificity

Using The NexDose ® Digital Assistant: 

Using The NexDose ® Digital Assistant NexDose® manages up to ten individual medications. When it is time to take a medication, NexDose® sounds an alarm and the screen flashes TAKE with the name of the medication. Pushing the TAKE button (or SKIP) twice enters your selection, and NexDose® displays what’s next. That’s all you have to do to use the NexDose® digital assistant effectively. 30

Effect of a Computerized Pill Bottle Cap for 3 Months: 

Effect of a Computerized Pill Bottle Cap for 3 Months Computerized cap---BP fell 8/8 mmHg Regular bottle---BP fell 3/0 mmHg

Impact of CPAP on Quality of Life, : 

Impact of CPAP on Quality of Life,

Change in Mood (POMS) on CPAP: Non-specific, : 

Change in Mood (POMS) on CPAP: Non-specific,

Effect of CPAP on SNS : 

Effect of CPAP on SNS

BP Dose-Response toExercise from30 to >120 minper weekTakata et al. Am J Hyper 2003: 

BP Dose- Response to Exercise from 30 to >120 min per week Takata et al. Am J Hyper 2003

Slide52: 

Effect of Fish Oil on Blood Pressure

Aldosteronoma: Surgical Cure: 

Aldosteronoma: Surgical Cure

PRA/Aldo ratio: 

PRA/Aldo ratio

Slide55: 

Spironolactone Lowers BP in Patients with Untreated Hyperaldosteronism

Slide56: 

Spironolactone lowers BP more in Resistant Hypertensives on Multiple Drugs

Weight Loss from Orlistat: 

Weight Loss from Orlistat

BP Response toNumber of Exercise Sessionsper WeekTakata et al. Am. J Hyper 2003: 

BP Response to Number of Exercise Sessions per Week Takata et al. Am. J Hyper 2003

Aldosteronism and Hypokalemia: 

Aldosteronism and Hypokalemia MRC series---100% of 62 patients with aldosteronism had hypokalemia Gordon Series---20% of 400 patients diagnosed by aldosterone:renin ratio had hypokalemia Potassium above 3.9 makes aldosteronism unlikely

MRI T-1 T-2 OF BENIGN ADENOMA: 

MRI T-1 T-2 OF BENIGN ADENOMA

Adrenal Adenoma CT: 

Adrenal Adenoma CT

INDICATIONS for BP Rx: 

INDICATIONS for BP Rx SYSTOLIC BP ABOVE 160 DIASTOLIC BP ABOVE 95 RISK FACTOR and DIASTOLIC BP ABOVE 90

Risk Score vs. Mortality. A 10 mm Hg Higher SBP Adds 1 Point : 

Risk Score vs. Mortality. A 10 mm Hg Higher SBP Adds 1 Point

Diuretics Lower SBP More: 

Diuretics Lower SBP More

Effect of Angioplasty on BP in RAS: 

Effect of Angioplasty on BP in RAS