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Dyslipidemia Management

Deborah David-Ona, MD, FPCP


Clinical Associate Professor, Section of Hypertension,
Department of Medicine
University of the Philippines-Philippine General Hospital
St. Lukes Medical Center, Global City

Meet Amor
47 year old, teacher, consulted for headaches and nape pains.
She is a non smoker, non alcoholic drinker.
Family History: Father and Mother (+) HPN, (+) DM
G2P2 with regular menstruation.
On PE, her BMI was 24 kg/m2. BP of 140/100. Other systems unremarkable.
Laboratory:
FBS 120 mg/dl,
Crea 0.73 mg/dl,
TC = 258mg/dl, TG=181.73 mg/dl, LDL=165.76 mg/dl, HDL=55.83 mg/dl,
ALT 35 u/l
HBA1C= 6.3%
12 lead ECG Normal, CXR No Significant Chest Findings.
She was given Losartan 100 mg OD

How will you manage Amors cholesterol levels?

A. Start patient with statin therapy


B. Focus on lifestyle modification first before starting any
lipid lowering medication
C. Lifestyle modification and start on low dose statin
therapy
D. No intervention, repeat lipid profile after 1 month

PRIMARY PREVENTION
Statement 2
For non-diabetic individuals aged 45 years with LDL-C 130
mg/dL and 2 risk factors*, without ASCVD, statins are
RECOMMENDED for the prevention of cardiovascular events.
*Risk factors are:
Male, postmenopausal women, smoker, hypertension, BMI > 25 kg/m2, family
history of premature CHD, familial hypercholesterolemia, microalbuminuria,
proteinuria, and left ventricular hypertrophy

*Patients who fulfill the criteria for Familial Hypercholesterolemia should be


initiated therapy for aggressive LDL-C lowering

Applicability to our Filipino Patient


ASCVD RISK ESTIMATOR

Estimates of 10-year risk for ASCVD are based on data from multiple
community-based populations and are applicable to African-American and
non-Hispanic white men and women 40 through 79 years of age.
For other ethnic groups, ATP 4 recommends using the equations for nonHispanic whites as well. These estimates may underestimate the risk for
persons from some race/ethnic groups.

Risk Factor Counting vs


ASCVD Risk Estimator
Unfortunately, there is no local risk scoring that has been
developed for Filipinos to determine the risk for development
of ASCVD, and studies on the applicability of other risk scoring
systems on Filipinos have not been done.
There are no POOLED COHORT POPULATIONS of similar
proportion in the Philippines for us to make a similar Risk
Estimator
More practical to use even in the rural setting
RISK FACTOR COUNTING IS ADVOCATED FOR ESTIMATION OF LEVEL OF
RISK FOR CV EVENTS IN FILIPINO DYSLIPIDEMIC PATIENTS

Meet Amor

47 year old, teacher, consulted for headaches and nape pains.


She is a non smoker, non alcoholic drinker.
G2P2 with regular menstruation. On PE, her BMI was 24 kg/m2.
BP of 140/100. Other systems unremarkable.
FMHx = Father and Mother (+) HPN, (+) DM
Laboratory: FBS 120 mg/dl, creat 0.73 mg/dl, TC = 258mg/dl,
TG=181.73 mg/dl, LDL=165.76 mg/dl, HDL=55.83 mg/dl, ALT 35 u/l,
HBA1C= 6.3%
12 lead ECG Normal, CXR: No Significant Chest Findings
Assessment: Hypertension, Stage 2, Pre Diabetes, Dyslipidemia
Recommendation:
She was given Losartan 100 mg OD
Advised to lose weight through diet and exercise with close follow up
PRIMARY PREVENTION OF CARDIOVASCULAR EVENTS IN THE GENERAL POPULATION

PRIMARY PREVENTION
Statement 2
For non-diabetic individuals aged 45 years with LDL-C 130
mg/dL and 2 risk factors*, without ASCVD, statins are
RECOMMENDED for the prevention of cardiovascular events.
*Risk factors are:
Male, postmenopausal women, smoker, hypertension, BMI > 25 kg/m2, family
history of premature CHD, familial hypercholesterolemia, microalbuminuria,
proteinuria, and left ventricular hypertrophy

*Patients who fulfill the criteria for Familial


Hypercholesterolemia should be initiated therapy for aggressive
LDL-C lowering

Criteria For Heterozygous


Familial Hypercholesterolemia

Amor was lost to follow-up


She came back at age 58 and she consulted for chest pain on
effort.
BP 130/80 on Losartan 100 mg OD, Metformin 500 mg OD.
BMI 30 kg/m2

Labs:
HBA1C = 11%
TC 246 mg/dl, TG 312.15 mg/dl, LDL 138.13 mg/dl, HDL 44.66 mg/dl
Creatinine 1.04 mg%, ALT 20 u/l (nv < 85)

How should you address Amors high cholesterol levels?


A.
B.
C.
D.

Start her on Low Intensity statin therapy


Start patient with Moderate Intensity statin therapy
Start patient with High Intensity statin therapy
Focus on lifestyle modification first before starting any
lipid lowering medication

PRIMARY PREVENTION
Statement 3
For diabetic individuals without evidence of ASCVD,
statins are RECOMMENDED for primary prevention of
cardiovascular events.

ALL DIABETICS, regardless of age or


duration (new-onset or long standing)

Applicability to our Filipino Patient


(Primary Prevention of ASCVD in DM)

Applicability to our Filipino Patient


(Primary Prevention of ASCVD in DM)

CANDI MANILA 2009

PRIMARY PREVENTION of ASCVD in


DM
RECOMMEND:
DIABETIC FILIPINO PATIENTS, REGARDLESS OF AGE, SHOULD
BE GIVEN STATIN THERAPY FOR PRIMARY PREVENTION OF
ASCVD
Appropriate Statin Treatment Goal:
30% or greater reduction of LDL-C from baseline or less than 70 mg/dL
for very high risk patients

(trials on moderate- vs high-intensity statin therapy have shown a


dose-dependent response in terms of benefit in the reduction of
adverse outcomes)

You started Amor on Atorvastatin 10 mg once a


day.
On follow up, the following were Amors lab
results:

HBA1c: 9.0
Total chol: 220mg/dl
LDL: 102 mg/dl
HDL: 48 mg/dl
Trig: 250 mg/dl
AST: 112 ( normal <85)

You noted that the AST was elevated from


baseline, but Amor remains asymptomatic.
What will you do?
A. Continue with statin treatment
B. Continue with statin treatment and recheck LFTs
C. Stop statin treatment
D. Lower the dose of the statin

Further investigation showed the following


regarding Amors condition:
2DECHO = Concentric LVH with good systolic
function
Treadmill Exercise Test = (+) for ischemia at 6
mets

She was advised to undergo coronary


angiography but she refused

How will you manage the cholesterol levels of Amor at this


point?
A. Start patient with High Intensity Statin Therapy
B. Continue on previous statin dose (moderate intensity
statin therapy)
C. Give Fenofibrate as medication for the lipid level
D. Add Fenofibrate on top of statin therapy

SECONDARY PREVENTION
Statement 5
For individuals with ASCVD, statin therapy is
RECOMMENDED

ASCVD are patients with prior Coronary Heart Disease, transient


ischemic attack, stroke, carotid artery disease and clinical Peripheral
Artery Disease

STATIN TREATMENT GOAL

Intensity of Statin Therapy

Amor was given the following meds:


Atorvastatin 40 mg OD
Losartan was shifted to Irbesartan 150 mg +
Amlodipine 5 mg OD
Metformin 1000 mg BID and Glimepiride 2 mg OD
ASA 80 mg OD and Metoprolol 50 mg BID

After 3 months, Amor followed up with muscle aches over the


shoulders and hips, upper arms and thighs of 1 week duration.
(-) tea colored urine

Her laboratory results showed:


Creatinine 1.37 mg% (NV <1.3mg%)
Total Cholesterol 153.62 mg%, TG 132.16 mg%, LDL 79.43 mg%, HDL
47.36, ALT 79.10 (NV < 85). HBA1C = 8.3%

Result

Normal Value

Total CPK

6,018.33 u/l

30 135 u/l

CPK - MM

5,966.23 u/l

< 115 u/l

CPK - MB

52.0 u/l

0.0 16.0 u/l

Amor was admitted and given IV hydration.


Atorvastatin was withheld.
Repeat Creatinine after 3 days was 1.0 mg%.
She was discharged on ASA, Amlodipine 5 mg
OD, Glimepiride 2 mg OD, and Metoprolol 50
mg BID.
Irbesartan and statins were withheld.

What would be your next step after discontinuing


statins?
A. Repeat lipid profile after 1 month
B. Restart combination therapy with low dose statin
and ezetemibe after 6 weeks
C. Restart low dose rosuvastatin as alternate dosing or
weekly dosing
D. Use non statin therapies such as ezetemibe or
fibrates

Statin +
Ezetimibe
Fibrates

Lipid Effect

Outcome Information

LDL

IMPROVE-IT showed significant


reduction in the composite CV endpoint

TG HDL Negative outcome trials in diabetic


LDL()
patient; subgroup with elevated Tg and
low HDL-C may benefit

Omega-3 FAs

Tg HDL

Negative outcome trials in patients with


IFG, IGT or early T2DM; limitation: low
dose of omega-3 FAs was used

Bile acid sequestrants

LDL Tg

No outcome trial with concomitant


statin therapy; older trials suggest
benefit in patients not on statins

Niacin

Tg HDL
LDL
Lp(a)

Wu L et al. Metabolism clinical and Experimental 2014;63:1469-1479.

Negative outcome trials in diabetic and


non-diabetic patients; limitation: very
low baseline levels (on statin therapy)

Should addressing high triglyceride value or low HDL level be


a primary concern in managing dyslipidemia?
A. YES
B. NO

Treatment goals for LDL-C and non-HDL-C are no longer recommended

High- and moderate-intensity statin treatment emphasized; lowintensity statin treatment eliminated.
ASCVD now includes stroke in addition to ischemic heart disease and
peripheral arterial disease.
Four groups are targeted for treatment.
Non-statin treatments de-emphasized.

No guidelines provided for treating high triglycerides.


Stone NJ et al. Circulation 2013; 00: 000-000.

Hypertension
Management:
Deborah David-Ona, MD, FPCP
Clinical Associate Profession
Section of Hypertension , Department of Medicine
University of the Philippines-Philippine General Hospital

45-yo , Executive
Chief complaint: intermittent headache and nape pain (6/10
in pain scale) 3 days PTC

PMHX: unremarkable
10 pack-years smoking history
Occasional alcohol drinker
No blurring of vision, vomiting, chest pain, shortness of breath,
numbness or weakness

BP 190/110 HR 110 RR 22
PE findings unremarkable

Daniel reported increased work load over the past 6 months. He


had a few similar episodes of headache partially relieved by pain
medication and/or rest. What is your clinical impression?
A.
B.
C.
D.

Hypertensive emergency
Hypertensive urgency
Malignant Hypertension
Resistant Hypertension

Daniels repeat BP after 5 minutes was 185/95, both arms. Which


of the following will be your immediate course of action?
A. Send to ER for rapid BP reduction.
B. Treat with oral antihypertensive and closely follow-up as
out patient.
C. Offer ambulatory BP monitoring or home BP monitoring.
D. Request for laboratory and other relevant tests and make
a formal assessment of CV risk.

SBP 180 mm Hg
and/or
DBP 120 mm Hg

Progressive end
organ damage

Hypertensive
Crisis

YES

NO

Hypertensive
Emergency

Hypertensive
Urgency

(24%)

(76%)

1. Ramos AP et al. Curr Hypertens Rep 2014;16:450. 2. Papadopoulos DP et al. Blood Pressure 2010;19:328. 3. Chobianan
AV et al. Hypertension 2003;41:1178.

Symptoms: chest pain (myocardial ischemia), dyspnea (pulmonary edema),


back pain (aortic dissection), headache (encephalopathy, subarachnoid
hemorrhage), visual disturbances (retinopathy)

Past medical hx: HTN, CAD, renal disease, peripheral vascular disease, cerebral
vascular disease

Prescribed meds: assess compliance especially if known hypertensive

Meds that can raise BP: liquorice, nasal drops, oral contraceptives, steroids,
non-steroidal anti-inflammatory drugs, erythropoietin, cyclosporine)

Illicit drugs: amphetamines, cocaine


1. Ramos AP et al. Curr Hypertens Rep 2014;16:450. 2. Papadopoulos DP et al. Blood Pressure 2010;19:328. 3. Vidt DG.
Journal of Clinical Hypertension 2001;3:158. 4.

Papilledema (ICP),
retinal hemorrhages,
exudates (retinopathy)
Inspiratory crackles
(pulmonary edema)

Altered mental status


(HTN encephalopathy)
S3 (heart failure), mitral
regurgitation (papillary
muscle rupture)

Bruit (partial occlusion


of renal artery)

Peripheral edema
(LV failure)

Absent arterial pulse


(aortic dissection)

1. Ramos AP et al. Curr Hypertens Rep 2014;16:450. 2. Papadopoulos DP et al. Blood Pressure 2010;19:328. 3. Vidt DG.
Journal of Clinical Hypertension 2001;3:158. 4.

Group 1 High BP

Group 2 Urgency

Group 3 Emergency

BP

>180/110

>180/110

Usually >220/140

Symptoms

Headache
Anxiety
Asymptomatic

Severe headache
Shortness of breath
Edema

Shortness of breath
Chest pain
Nocturia
Dysarthria
Weakness
Altered mental status

Exam

No end organ
damage
No clinical CVD

End organ damage


Clinical CVD
present/Stable CVD

Encephalopathy
Pulmonary edema
Renal insufficiency
Stroke
ACS

1. Ramos AP et al. Curr Hypertens Rep 2014;16:450. 2. Papadopoulos DP et al. Blood Pressure 2010;19:328. 3. Vidt DG.
Journal of Clinical Hypertension 2001;3:158. 4.

Group 1 Urgency
Goal

Group 2 Urgency

Group 3 Emergency

Reduce BP over 24 to 48 hours

Reduce BP by 10 to
15% over 3060 min*

Therapy

Initiate /resume
medication
Increase dosage of
inadequate agent
Observe 1-3 hrs

Lower BP with
short-acting oral
agents
Adjust current
therapy
Observe 3-6 hrs

Plan

Arrange follow-up
evaluation in <72
hrs

Arrange follow-up
evaluation within
24 hours

Admission to ICU
Treat to initial goal
BP
Additional dx
studies

Baseline labs
IV line
Monitor BP
Parenteral therapy
in ER

*except aortic dissection and acute intracranial bleed, BP must be reduced in 5 to 10 mins or to a target SBP
<140 mm Hg and MAP <80 mm Hg.
1. Ramos AP et al. Curr Hypertens Rep 2014;16:450. 2. Papadopoulos DP et al. Blood Pressure 2010;19:328. 3. Vidt DG.
Journal of Clinical Hypertension 2001;3:158. 4.

Overall Approach for Hypertensive Urgency


(Severe Asymptomatic Hypertension)
How quickly should the BP be reduced?
Over a period of hours to days
Slower reductions may be needed in older adult patients at
high risk for cerebral and myocardial ischemia

What is the BP target?


BP <160/100 mmHg
MAP should not be lowered by more than 25-30% over a
relatively short time

How should this goal be achieved?

Depends upon whether BP should be lowered more


quickly (period of hours) or less quickly (period of days)
Moving patients to a quiet room will reduce BP by 10-20
mmHg

Agent

Dose

Onset/
Duration of
Action

Precautions

Catopril

25 mg p.o., repeat as
needed

1530 min/
26 hr

Hypotension, renal failure in


bilateral renal artery stenosis

Clonidine

0.10.2 mg p.o., repeat


hourly as required to
total dose of 0.6 mg

3060 min/
816 hr

Hypotension, drowsiness,
dry mouth

Labetalol

200400 mg p.o.,
repeat every 23 hr

30 min2hr/
212 hr

Bronchoconstriction, heart
block, orthostatic
hypotension

Prazosin

12 mg p.o., repeat
hourly as needed

12 hr/
812 hr

Syncope (first dose),


palpitations, tachycardia,
orthostatic hypotension

1. Ramos AP et al. Curr Hypertens Rep 2014;16:450. 2. Papadopoulos DP et al. Blood Pressure 2010;19:328. 3. Handler J. .
Journal of Clinical Hypertension 2006;8:61. 4. Vidt DG. Journal of Clinical Hypertension 2001;3:158.

Hypertensive urgency
In general, treatment is:
Resumption of antihypertensive therapy (in nonadherent patients)
Initiation of antihypertensive therapy (in
treatment nave patients)
Addition of another antihypertensive drug (in
currently treated patients)

After oral antihypertensive and 30-minute rest, Daniels BP


decreased to 170/95 and his headache improved. After
another hour of rest, BP reading was 165/90. If you are to
start him on antihypertensive regimen, what BP goal will you
set?
A.
B.
C.
D.

<150/90
<140/90
<130/80
<120/80

JNC 7

JNC 8

ASH/ISH

ESH/ESC

CHEP

ADA

2004

2014

2013

2013

2013

2016

BP goals in general population without diabetes or CKD


<60 yo

<140/90

<140/90

<140/90

<140/90

<140/90

60-79 yo

<140/90

<150/90

<140/90

<140/90

<140/90

80 yo

<140/90

<150/90

<150/90

<150/90

<150/90

BP goals in population with diabetes mellitus but without CKD

Adults

<130/80

<140/90

<140/90

<140/85

<130/80

<140/90

BP goals in population with CKD


+ protein

<130/80

<140/90

<140/90

<130/90

<140/90

- protein

<130/80

<140/90

<140/90

<140/90

<140/90

1. Salvo M et al. Annals of Pharmacotherapy 2014;48:1242. 2. Cefalu Wt et al. Diabetes Care 2016;39:Suppl 1.

Population: 9,361 patients with SBP 130 mm Hg and an increased CV


risk but without diabetes or prior stroke
Intervention: SBP target of <120 mm Hg (intensive treatment) or <140
mm Hg (standard treatment)
Outcome: composite of MI, other ACS, stroke, heart failure, or CV
death

Methodology: randomized, controlled, open-label trial


SPRINT Research Group. N Engl J Med 2015; DOI:10.1056/NEJMoa1511939.

Systolic BP (mm Hg)

150
Standard Treatment
Average # of meds: 1.9

140

130

120
Intensive Treatment
Average # of meds: 3.0

110
0

Years
SPRINT Research Group. N Engl J Med 2015; DOI:10.1056/NEJMoa1511939.

25%
NNT 62

SPRINT Research Group. N Engl J Med 2015; DOI:10.1056/NEJMoa1511939.

Outcome

Intensive Tx

Standard Tx

Hazard Ratio

p-value

# of patients
(%)

# of patients
(%)

n = 4678

n = 4683

MI

97 (2.1)

116 (2.5)

0.83 (0.64 - 1.09)

0.19

ACS

40 (0.9)

40 (0.9)

1.00 (0.64 1.55)

0.99

Stroke

62 (1.3)

70 (1.5)

0.89 (0.63 1.25)

0.50

Heart Failure

62 (1.3)

100 (2.1)

0.62 (0.45 0.84)

0.002

38%

CV Death

37 (0.8)

65 (1.4)

0.57 (0.38 0.85)

0.005

43%

All-Cause
Death

155 (3.3)

210 (4.5)

0.73 (0.60 0.90)

0.003

1o Outcome
or Death

332 (7.1)

423 (9.0)

0.78 (0.67 0.90)

<0.001

SPRINT Research Group. N Engl J Med 2015; DOI:10.1056/NEJMoa1511939.

27%
22%

Adverse Events

Significantly higher rate of some treatment-related AEs in the


intensive treatment group: syncope, hypotension, acute kidney
injury or failure.
These need to be weighed against the benefits with respect to CV
events and death.
Limitations
Generalizability to population not included in the study: persons
with diabetes, those with prior stroke, those younger than 50 years
of age, those at lower CV risk
Daniel
SPRINT Research Group. N Engl J Med 2015; DOI:10.1056/NEJMoa1511939.

His BP reading before discharge from the clinic was 165/90. His
headache was almost completely relieved. He was given a request
for laboratory tests, advised to monitor BP at home (HMBP) and
follow-up in 1 week. Which of the following medications will you
send him home with?

A.
B.
C.
D.

Clonidine as needed for BP >180/120


Combination antihypertensive regimen daily
Both
Neither. You will wait for the HMBP results before
prescribing maintenance medications.

HBPM

ABPM

For each BP recording, 2 consecutive


measurements are taken, at least 1
minute apart and with the person
seated &

Ensure that at least two measurements


per hour are taken during the patients
usual waking hours.

BP is recorded 2x daily, ideally in the


morning and evening &

Use the average value of at least 14


measurements taken during the
patients usual waking hours.

BP recording continues for at least 4


days, ideally for 7 days

Discard the measurements taken on the


first day and use the average value of all
the remaining measurements.

NICE Hypertension Guidelines 2011

If the clinic blood pressure is 140/90 mmHg or higher, offer


ambulatory blood pressure monitoring (ABPM) to confirm
the diagnosis of hypertension.
If a person is unable to tolerate ABPM, home blood pressure
monitoring (HBPM) is a suitable alternative to confirm the
diagnosis of hypertension.
If the person has severe hypertension, consider starting
antihypertensive drug treatment immediately, without
waiting for the results of ABPM or HBPM.
NICE Hypertension Guidelines 2011

Daniel

Which of the following treatment will you start Daniel


with?
a.
b.
c.
d.

Monotherapy with CCB


Monotherapy with ACE or ARB
Monotherapy with Diuretics
Combination Therapy

Percent of Adult Population 18 yo

30

28

22

21

20

11
10

0
1992

1997

Sison J et al. PRESYON 3. 2013 PHA Annual Convention.

2007

2013

80

75

70

65 66
57

Percentage (%)

60
51
50

Prevalence

40

Treated
28

30

22 22

20
11

13 11

10

21
10 10

Compliant
20

13

Natl Registry
1992-1993

PRESYON 1
1997-1998

PRESYON 2
2007

PRESYON 3
2012-2013

Controlled

Trial
Hypertension

Diabetes

Kidney
disease

SBP achieved
(mm Hg)

ALLHAT

138

HOT

138

MDRD

132

ACCORD (intensive)*

119

ACCORD (standard)*

133

INVEST

133

IDNT

138

RENAAL

141

ABCD

132

UKPDS

144

AASK

128
1

Copley JB, Rosario R. Dis Mon. 2005;51:548-614.


The ACCORD Study Group. N Engl J Med. 2010 Mar 14.

2
3
No. of BP medications

Daniel

James PA et al. JAMA. doi: 10.1001/jama.2013.284427

Description
A

Start 1drug, titrate to


max dose, then add a
2nd drug

Details
If goal BP not achieved initial drug, titrate to max
recommended dose.

If goal BP achieved with 1 drug despite titration to max


dose, add a 2nd drug from list (TZD-type, CCB, ACEI, ARB)
and titrate to max recommended dose.
If goal BP not achieved with 2 drugs, add a3rd drug from list
and titrate to max dose. Avoid combined use of ACEI and
ARB
B

Start 1 drug and add a Start with 1 drug then add a 2nd drug from list, titrate both
2nd drug before
drugs up to max recommended dose to achieve goal BP.
achieving max dose of
the initial drug
If goal BP not achieved, add a 3rd drug from list and titrate to
max dose.
James PA et al. JAMA. doi: 10.1001/jama.2013.284427

Description
C

Details

Begin with 2 drugs at Initiate therapy with 2 drugs simultaneously, either as 2


the same time, either separate drugs or single pill combination.
as 2 separate pills or a
single pill combination Start therapy with 2 drugs when SBP >160 mm Hg and/or
DBP >100 mm Hg, or if SBP is >20 mm Hg above goal and/or
DBP is >10 mm Hg above goal.

Daniel

If goal BP is not achieved with 2 drugs, select a third drug


from list and titrate to max recommended dose.

James PA et al. JAMA. doi: 10.1001/jama.2013.284427

Daniel
Mild BP elevation
Low/moderate CV risk

Choose between

Single agent

Marked BP elevation
High/very high CV risk

Two-drug combination

Switch to
different agent

Previous agent
at full dose

Previous combination
at full dose

Add a
third drug

Full-dose
monotherapy

Two-drug
combination
at full doses

Switch to different
two-drug
combination

Three-drug
combination
at full doses

Mancia G et al. Journal of Hypertension 2013; 31: 1281-1357.

Thiazide diuretics

BBs

ARBs

Other
Anti-HTN

Calcium
antagonists

Initiate 2-drug
combination for
patients with markedly
elevated BP or high CV
risk.
Fixed-dose
combination may be
favored to improve
adherence, which is low
in hypertensive
patients.
Preferred

ACEIs

Useful (w/ some limitations)


Possible (less well-tested)

Mancia G et al. Journal of Hypertension 2013; 31: 1281-1357.

Not recommended

Daniel was started on ARB-CCB combination. He followed-up 1 week later


with his laboratory results which were within acceptable limits. Average
HMBP over the last 3 days was ~150/90. He was advised to continue his
medication with lifestyle modification. He followed up 1 month later with a
BP of 155/90 despite adherence and lifestyle changes. A TZD diuretic was
added in his regimen. 2 weeks later, he followed-up as advised with a BP of
150/90. What will be your next step?
A.
B.
C.
D.

Add a low-dose aldosterone receptor antagonist or maximize TZD


diuretic dose
Conduct ABPM or HBPM
Work up to identify possible secondary causes of HTN
Refer to a hypertension specialist

Blood pressure that remains above goal in spite of concurrent


use of 3 antihypertensive agents of different classes at
optimal doses, ideally one of which is a diuretic.
Includes patients whose blood pressure is controlled with use
of more than 3 medications.
Prevalence of 10% to 30% of hypertensive patients.

Not synonymous to uncontrolled hypertension.


1. Mancia G et al. Journal of Hypertension 2013; 31: 1281-1357 2. Fagard RH et al. Heart 2012;98:254 3. NICE
Hypertension Guidelines 2011 4. Calhoun DA et al. Hypertension 2008;51:1403.

Confirm Treatment Resistance


Office BP above goal despite treatment with 3 agents from
different classes, ideally including a diuretic
or
Office BP at goal but patient requiring 4 or more medications

Exclude Pseudoresistance
Is patient adherent with the prescribed regimen?
Obtain home or ambulatory blood pressure readings to exclude
white coat effect.

1. Mancia G et al. Journal of Hypertension 2013; 31: 1281-1357 2. Fagard RH et al. Heart 2012;98:254 3. NICE
Hypertension Guidelines 2011 4. Calhoun DA et al. Hypertension 2008;51:1403.

Identify and Reverse Contributing Lifestyle Factors


Obesity
Physical inactivity
Excessive alcohol ingestion
High salt, low fiber diet

Discontinue or Minimize Interfering Agents


Non-steroidal anti-inflammatory agents
Sympathomimetics (diet pills, decongestants)
Stimulants
Oral contraceptives
Licorice
Ephedra

1. Mancia G et al. Journal of Hypertension 2013; 31: 1281-1357 2. Fagard RH et al. Heart 2012;98:254 3. NICE
Hypertension Guidelines 2011 4. Calhoun DA et al. Hypertension 2008;51:1403.

Pharmacologic Treatment
Maximize TZD diuretic if serum potassium is 4.5 mmol

Further diuretic therapy with low-dose spirinolactone if serum


potassium is 4.5 mmol
Consider alpha- or beta-blocker

Refer to Specialist
For suspected secondary causes of hypertension
or
If blood pressure remains uncontrolled after 6 months of
treatment
1. Mancia G et al. Journal of Hypertension 2013; 31: 1281-1357 2. Fagard RH et al. Heart 2012;98:254 3. NICE
Hypertension Guidelines 2011 4. Calhoun DA et al. Hypertension 2008;51:1403.

Screen for Secondary Causes of Hypertension


Obstructive sleep apnea (snoring, witnessed apnea, excessive daytime sleepiness)
Primary aldosteronism (elevated aldosterone/renin ratio)
Chronic kidney disease (creatinine clearance <30 ml/min)
Renal artery stenosis (young female, known atherosclerotic disease, worsening renal
function)
Pheochromocytoma (episodic hypertension, palpitations, diaphoresis, head ache)
Cushings syndrome (moon facies, central obesity, abdominal striae, inter-scapular
fat deposition)
Aortic coarctation (differential in brachial or femoral pulses, systolic bruit)

1. Mancia G et al. Journal of Hypertension 2013; 31: 1281-1357 2. Fagard RH et al. Heart 2012;98:254 3. NICE
Hypertension Guidelines 2011 4. Calhoun DA et al. Hypertension 2008;51:1403.

Almost 6 months and 4 drugs later (ARB, CCB, TZD diuretic,


spironolactone), BP was 150-160/90-100
Referred to a hypertension specialist.

Currently being evaluated for secondary hypertension.

3F Feliza Building,108 VA Rufino St., Legaspi Village, 1229 Makati City, Philippines Tel: +63 2 8595555 Fax: +63 2 8131676

PH.PRC.16.04.06

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