7/11/12 - P&P of HT Flashcards
Secondary Hypertension Causes
Goal:
Remove causative agent or treat underlying condition
Caused by:
- *Comorbid Conditions**
- *Renovascular / SLEEP APNEA / 1* Aldosteronism**
- cushings / pheochromocytoma / thyroid disease / HYPERparathyroidism*
Medications
Amphetamines / Steroids / Decongestants / NSAIDS
Estrogens / Calcineurin inhibitors / Ergot Alkaloids / Erythropoiesis-stimuating agents / Estrogens
- *Food:**
- *Alcohol / Licorice / Sodium**
What Determines BP?
(Arterial Blood Pressure)
- *ABP** = CO x PR
- *Cardiac Output x Peripheral Resistance**
CO = SV x HR
- *PR determined by:**
- *Vascular Structure/Function**
What determines CO = Cardiac Output?
BP = CO x PR
CO = SV x HR
Stroke Volume x Heart Rate
↑Preload = ↑Na+ Intake / renal retention
Venous Constriction
↑RAAS stimulation
↑SNS
What Determines HEART RATE?
BP = CO x PR
CO = HR x SV
ParaSympathetic
Rest / Digest
ACth on heart pacemaker cells –> ↓HR
Sympathetic
Fight/Flight
NE/Epi on pacemaker cells:
–> ↑HR & ↑SV –> vasoconstriction –> ↑PR
What Determines STROKE VOLUME?
BP = CO x PR
CO = HR x SV
- *Intrinsic Control**
- *HEART RATE** & Contractility
- *Extrinsic Control**
- *NE/Epi** on BETA-adrenergic receptors
- ↑*Force of Contraction–>↑SV
What determines PERIPHERAL RESISTANCE = PR?
BP = CO x PR
Vascular Constriction** +/- **Vascular HYPERtrophy
↑RAAS
↑SNS over-activity
genetic changes in cell membranes / endothelial factors
Normal BP
ACC/AHA Guidelines
SBP = <120 mmHg
AND
DBP = <80 mmHg
ELEVATED BP
ACC/AHA Guidelines
SBP = 120-129 mmHg
AND
DBP = <80 mmHg
Stage 1 HyperTension
ACC/AHA Guidelines
SBP = 130-139 mmHg
OR
DBP = 80-89 mmHg
Stage 2 HyperTension
ACC/AHA Guidelines
SBP = _>_140 mmHg
OR
DBP = >90 mmHg
SPRINT trial Population
Systolic BP Intevention Trial
>50 y/o w/ SBP 130-180
AND
> 1 additional RF for CV disease:
> 75 y/o // Clinical CVD (except stroke) // Subclinical CV disease
ASCVD > 15%
Exclusions:
DM / proteinuria / nursing home residents / symptomatic HF / history of CVA
- *SPRINT**
- *Prmary Study outcomes & results**
CVD composite - first occurence of:
MI / non-MI Acute Coronary Syndrome/Stroke / HF / Death
- *INTENSIVE TREATMENT** = 2-3 Meds
- *BETTER ALL**:
- *Reducing BP / Primary Outcomes / Mortality / Fraility / Gait**
ACCORD BP Results
Action to Control CV risk in DIABETES BP
NO BENEFIT in PRIMARY ENDPOINT
composite of non-fatal MI / stroke / CVD death
ACC/AHA BP Goals for:
Clinical CVD
or
10 yr ASCVD Risk > 10%
< 130/80
BP Threshold:
> 130/80
Same for those with these specific comorbidities:
DM / CKD / CHF / PAD / secondary stroke prevention
Stable ischemic Heart Disease
ACC/AHA BP Goals for:
No Clinical CVD
or
10 yr ASCVD Risk < 10%
< 130/80
BP Threshold:
> 140/90
ACC/AHA BP Goals for:
Older Person > 65y/o
Community Dwelling
< 130 SBP
BP Threshold:
> 130 SBP
Screening for Secondary HTN / Refractory HTN
Abrupt Onset
Onset < 30 yo
Exacerbation of previously controlled HTN
TOD disproportionate to degree of HTN
Malignant HTN
NEW Diastolic HTN > 65 yo
unprovoked / excessive HypoKalemia
Diagnosis of HT & New Recommendations
> 2-3 properly measured BP readings
@
> 2-3 of visits after initial screening
Home BP monitoring recommended
Daytime average > 130/80
ABPM= Ambulatory BP monitor //HBPM = Home
Diagnosis of MASKED HTN
when not on drug therapy
Office BP = 120-129 / < 80
after 3months of lifestyle mod & suspected MASKED HTN
Daytime ABPM or HBPM = <130/80mmhg?
- *YES = MASKED HTN**
- -> Lifestyle mods + START ANTI-HT DRUG THERAPY
- *NO = Normal Hypertension**
- -> Lifestyle mods + Annual ABPM or HBPM to detect progression
Diagnosis of WHITE COAT HT
when not on drug therapy
Office BP > 130/80 but <160/100
after 3months of lifestyle mod & suspected WCHT
Daytime ABPM or HBPM = <130/80mmhg?
- *YES = White Coat Hypertension**
- -> Lifestyle mods + Annual ABPM or HBPM to detect progression
- *NO = Normal Hypertension**
- -> Continue Lifestyle mods + START ANTI-HT DRUG THERAPY
When to treat HTN with Pharmacologic Therapy?
(ACC/AHA)
- *ABP > 140/90**
- *Primary prevention = no h/o CVD & ASCVD < 10%**
ABP > 130/80 with:
Secondary Prevention = CLINICAL CVD
Primary Prevention: 10yr ASCVD RISK > 10%
Age / Race / Cholesterol Panel / DM risk / BP meds / STATIN / ASA
Smoking
BP Thresholds & Recommendations
for Treatment + Follow up
ELEVATED BP = 120-129 / <80
Promote optimal lifestyle habits
Non-pharmacologic Therapy
Reassess in:
3-6 MONTHS
BP Thresholds & Recommendations
for Treatment + Follow up
Normal BP = <120/80
Promote optimal lifestyle habits
Reassess in:
1 YEAR
BP Thresholds & Recommendations
for Treatment + Follow up
Stage 1 HTN = 130-139 / 80-89
WITH:
Clinical ASCVDor10yr ASCVD >10%
Promote optimal lifestyle habits
+
BP-LOWERING MEDICATION
Reassess in:
1 MONTH
If BP goal is met –> reassess in 3-6 months
if not –> assess adherence / intensify therapy –> 1 month reassessment
BP Thresholds & Recommendations
for Treatment + Follow up
Stage 1 HTN = 130-139 / 80-89
WITHOUT:
Clinical ASCVD or 10yr ASCVD > 10%
Promote optimal lifestyle habits
Reassess in:
- *3-6 Months**
- same as Elevated BP*
BP Thresholds & Recommendations
for Treatment + Follow up
Stage 2 HTN** = **> 140/90
Promote optimal lifestyle habits
+
BP-LOWERING MEDS
Reassess in:
1 YEAR
If BP goal is met –> reassess in 3-6 months
if not –> assess adherence / intensify therapy –> 1 month reassessment
HTN in Older Adults > 65y/o
Linear increase in Systolic & Diastolic BP until ~50-60y/o
SBP –> continues to RISE
DBP –> gradually trends down
HYVET & SPRINT:
displayed BENEFIT in elderly, only includes COMMUNITY DWELLING
Monitor for:
- *Orthostatic Hypotension**
- *caution for Frequent falls / Cognitive imparment / comorbidities**
Best Proven Nonpharmacological Intervention
for the
Prevention/Treatment of Hypertension
Weight Loss
Heat-Healthy Diet
DASH / mediterranian
↓Na Intake & ↓Alcohol Intake
↑K+ Intake, as long as no CI’s
- ↑*Exercise
- *150 min/wk moderate exercise** // 30 min 5x/wk
Which HTN Drug?
Blockade of sodium reabsorption @distal tubule causing initial volume loss mostly in 1st week
long term CO & volume return closer to baselline while SVR decreases
2/2 Vasodilatory effects
ADR:
Electrolyte abnormalities: hypo-Na/Mg/K – HYPER-Calemia
frequent Urination / GOUT / dehydration / glucose intolerance
- *THIAZIDE_ _DIURETICS**
- *Hydrochlorothiazide, chlorthalidone, indapamide, metolazone**
1st Line Drug
Low dose chlorathalidone (12.5-25mg) preferred thiazide
longer t1/2 & proven CVD reduction
Limitations:
Reduced efficacy with comorbid renal disease
Which HTN Drug?
BLOCK conversion of AT1 –> AT2 = vasodilation / ↓aldosterone
↓Bradykinin metabolism –> ↑Bradykinin –> Vasodilation
ADR:
HYPERKalemia / COUGH
angioedema / nephrotoxicity / pancreatitis
- *ACE INHIBITORS**
- *-prils**
1st Line Drug
ACC/AHA:
CKD Stage 1 or 2 AND albumin:creatinine ratio > 300mg/g or 30-299mg/g creatinine
Or
CKD Stage 3 or 4 // HFrEF // CAD
Limitations:
COUGH –> ARB
Which HTN Drug?
Blockade of sodium reabsorption @distal tubule causing initial volume loss mostly in 1st week
long term CO & volume return closer to baselline while SVR decreases
2/2 Vasodilatory effects
ADR:
Electrolyte abnormalities: hypo-Na/Mg/K – HYPER-Calemia
frequent Urination / GOUT / dehydration / glucose intolerance
- *THIAZIDE_ _DIURETICS**
- *Hydrochlorothiazide, chlorthalidone, indapamide, metolazone**
1st Line Drug
Low dose chlorathalidone (12.5-25mg) preferred thiazide
longer t1/2 & proven CVD reduction
Limitations:
Reduced efficacy with comorbid renal disease
Which HTN Drug?
Blocks actions of AT2
Vasodilation, ↓aldosterone synthesis
ADR:
HYPERKalemia, Nephrotoxicity
angioedema (very rare)
- *ARBs**
- *-sartans**
1st Line Drug
typically for ACE intolerance
ACC/AHA:
CKD Stage 1 or 2 AND albumin:creatinine ratio > 300mg/g or 30-299mg/g creatinine
Or
CKD Stage 3 or 4 // HFrEF // CAD
Which HTN Drug?
Vasodilation of vascular smooth muscle via calcium antagonism
ADR:
Headache / lightheadedness / flushing
dose-dependent peripheral edema, gingival hyperplasia
–> decrease dose or switch agent and/or add RAAS-blocking (ACE/ARB)
- *Calcium Channel Blockers - DHP**
- *Amlodipine, Nifedipine, Felodipine, Nicardipine**
1st Line Drug
Biggest role is:
those w/o “compelling indications” & add-on therapy
Which HTN Drug?
↓CO via ↓HR & ↓Contractility
from inhibition of calcium ion from entering voltage sensitive areas of myocardium during depolarization
ADR:
- *Bradycardia / Heart block**
- *HF Exacerbation (↓CO)**, dose dependent CONSTIPATION
- *NON-DHP - Calcium Channel Blockers**
- *Diltiazem & Verapamil**
- *ADD-ON THERAPY**
- can be 1st line ACC/AHA*
Biggest role is
Patients w/ Comorbid AFIB
Patients w/ CAD who CANNOT tolerate Beta-Blocker Therapy
Limitations:
CI w/ Beta-blockers (additive) / HFrEF / 2nd-3rd Heart Block
PK drug interactions: CYP3a4 substrate/inhibitor
Which HTN Drug?
Blockade of B1-receptors –> ↓CO via ↓HR & ↓SV
Specifically:
NONselective B1 & B2 adrenergic blocker
ADR:
Bradycardia / heart block / Bronchoconstriction
lethargy / sex dysfunx / reynaud’s phenomenon
- *NON-Selective BETA BLOCKERs**
- *PROPRANOLOL**
2nd line / add-on Agent
Critical role in:
CAD (ischemic - MI) // HFrEF
rate control
Which HTN Drug?
- Blockade* of B1-receptors –> ↓CO via ↓HR & ↓SV
- *CARDIOSELECTIVE**
ADR:
Bradycardia / heart block / Bronchoconstriction
lethargy / sex dysfunx / reynaud’s phenomenon
- *Cardioselective BETA BLOCKERs**
- *Atenolol, Bisoprolol, Metoprolol, Nebivolol**
2nd line / add-on Agent
Critical role in:
CAD (ischemic - MI) // HFrEF
rate control
Which HTN Drug?
Blockade of B1-receptors –> ↓CO via ↓HR & ↓SV
Specifically:
MIXED - nonselective Alpha < Beta adrenergic blockade
ADR:
Bradycardia / heart block / Bronchoconstriction
lethargy / sex dysfunx / reynaud’s phenomenon
- *Mixed BETA BLOCKERs**
- *Carvedilol / Labetalol**
2nd line / add-on Agent
Critical role in:
CAD (ischemic - MI) // HFrEF
rate control
Which HTN Drug?
Inhibits Symphathetically mediated arterial vasoconstriction
via blockade of alpha-1 receptors on vascular smooth muscle
ADR:
First dose - orthosttic effect / dizziness / fatigue / HA
- *ALPHA-BLOCKERS**
- *Doxazosin, Terazosin, Prazosin**
- Rarely used, ADD-on only*
- ALLHAT trial –> inferiority to other drugs in CV endpoints*
BPH d/t Relaxation of Bladder neck
IF NOT HIGH CV RISK
Which HTN Drug?
Production of false SNS Neurotransmitters
ADR:
edema / dizziness / impotence / arrythmia
- *Centrally Acting Drugs**
- *METHYLDOPA**
RARELY USED
PREGNANCY
Which HTN Drug?
Binds to central pre-synaptic Alpha-2 adrenergic receptors
↓Sympathetic outflow from CNS
ADR:
Bradycardia / Drowsiness
Rebound HTN w/ abrupt DC –> Taper off
- *Centrally Acting Alpha-2 Agonist**
- *CLONIDINE**
Add-on Therapy
only later line 2/2 CNS SE
Once-Weekly transdermal dosage for non-adherent pts
Which HTN Drug?
Direct Vasodilation of Arterioles
ADR:
- *edema , drug-induced lupus/vasculitis**
- *reflex tachycardia**
- *Vasodilator**
- *HYDRALAZINE**
Add-on Therapy - 3rd/4th line
IV dosage –> QUICK onset & SHORT duration
Useful in combination with:
Nitrates for Pts w/ HFrEF - esp AA pts
Which HTN Drug?
Vasodilation via smooth muscle relaxation
possibly mediated by cAMP
ADR:
Hirsutism, edema, T-wave Changes
Reflex Tachycardia (always used w/ BB), pericadial effusions
- *Vasodilator**
- *MINOXIDIL**
limited Add-on Therapy - 3rd/4th line
Many ADR’s & limited efficacy (organ outcomes)
Significant BP reduction
When to use this HTN drug?
Loop Diuretics
bumetanide / furosemide / torsemide
Primarily used as:
- *DIURETIC**
when: CrCl <30 or CKD stage 4/5
Similar e- disturbances to thiazides, except:
- *Calcium Depleting**
- less likely to cause hypoNatremia*
When to use this HTN drug?
Potassium Sparing Diuretics
Amiloride / Triamterene
Primarily used as:
- *Thiazide + K-sparing combo_ if _hypoKalemic on thiazide** -
- BUT caution with GFR <45mL/min
When to use this HTN drug?
Anti-Aldosterone Antagonist
Eplerenone / Spironolactone
Primarily used for
Primary Aldosteronism
&
Resistant HYPERTension
- *Eplerenone = BID dosing**
- *Spironolactone = Gynecomastia**
HyperKalemia –> caution with K+ & CKD
Choosing a BETA BLOCKER:
HFrEF
Carvedilol
Mixed A/B
Metoprolol & Bisoprolol
cardioselective –> B1
Proven Mortality Benefit
Choosing a BETA BLOCKER:
Asthma / COPD
B-1 Selective Agent:
Atenolol / Metoprolol
Avoid Mixed / nonselective
Choosing a BETA BLOCKER:
BPH
Consider Alpha-Blockade
Carvedilol / Labetalol
Choosing a BETA BLOCKER:
Type 2 DM
CARVEDILOL > Metoprolol
Associated with lower A1c & microalbuminia
Choosing a BETA BLOCKER:
Migraines
Consider Lipid Solubility = Crosses BBB
Propanolol / Carvedilol
- *Exceptions to the rule:
- Avoid Drugs with SIMILAR TARGETS on BP control***
- *Ace + Arb + Renin Inhibitor**
- NOT RECOMMENDED*
Diuretics
Non-DHP + DHP CCB
Choosing Initial Antihypertensive Drug Therapy
Non-Black Population
&
W/ CKD
Thiazide / ACE / ARB / CCB
ACE/ARB preferred
for CKD
Choosing Initial Antihypertensive Drug Therapy
- *Black Population w/o HF/CKD**
- including those with DM*
- *THIAZIDES_ / _CCBs**
- preferred over ACE/ARB*
Choosing Initial Antihypertensive Drug Therapy
Black Population with
CKD+/-Proteinuria
- *CKD 1/2** + Proteinuria OR CKD 3/4:
- *ACE/ARB**
Choosing Initial Antihypertensive Drug Therapy
Black Population with
HFrEF&CHD s/p MI
Beta Blockers** & **ACEI/ARB
What antihypertensive for:
PREGNANT?
MethylDopa
Centrally Acting a2-agonist
Nifedipine
1,4-DHP CCB
Labetalol
Mixed a/b - blockers
What antihypertensive for:
HFrEF
Beta Blocker
ACE/ARB
Anti-Aldosterone
What antihypertensive for:
MI
Beta Blocker / ACE
What antihypertensive for:
CKD Stage 1 or 2
AND
urinary albumin:creatinine ratio > 300mg/g or 30-299mg/g creatinine
OR
CKD Stage 3 or 4
ACE/ARB
What AntiHypertensive for:
DIABETES
ACE / ARB
CCB - DIURETICS
if albuminuria –> ACE/ARB
What AntiHypertensive for:
AFIB / Flutter rate Control
NON-DHP CCB
Verapamil = PAA / Diltiazem = BTZ
Beta Blocker
lol’s
When to avoid this antihypertensive due to contraindications:
THIAZIDES
GOUT
When to avoid this antihypertensive due to contraindications:
CCBs / Vasodilators
- *Venous Insufficiency**
- avoid CCB & vasodilators*
Bradycardia / Heart Block
BB’s & Non-DHP CCB
- *HFrEF**
- caution with Non-DHP CCB*
When to avoid this antihypertensive due to contraindications:
Beta Blockers
ASTHMA / COPD
especialy NON-cardioselective like propranolol
Bradycardia / Heart Block
BB + Non-DHP CCB = negative chronotropes
When to avoid this antihypertensive due to contraindications:
ACE/ARB
HYPERKalemia
ACE/ARB + Spironolactone
Pregnancy
ACE/ARB + Renin Inhibitors -skirin
Results of ALLHAT trail
HTN + 1 Additional major CV risk factor
Primary Endpoint:
Fatal CHD or nonfatal MI
In comparison to Thiazide:
Amlodipine (CCB) / Lisinopril (ACE) = Very Similar
- except for:*
- *DOXAZOSIN = Beta Blocker**
- INFERIOR TO OTHER THERAPIES*
But is still recommeneded for initial therapy if patient has:
CAD/MI or CHF
1st line for secondary prevention of MI & ↓Mortality w/ HFrEF
When do patients require 2+ HTN Drugs?
Most patients require 2+ to reach goal BP
Especially when:
BP > 20/10 mmHG (>160)
over goal
Stage 2 HTN –> 2x 1st line drugs
Complementary Combination Therapies
ACE/ARB** + **Thiazide
for maintaining K+ Balance
Diuretics can trigger RAAS –> ACE can blunt this
- *ACE/ARB_ + _DHP-CCB**
- lessen peripheral edema* from CCB
Vasodilator + Beta-Blocker + Diuretic
BB blunting of reflex tachycardia
Diuretic for Na + H2O retention
Resistant HTN
Definition & Risk Factors
Not at goal on 3 BP Meds (including diuretic)
OR
Controlled on > 4 BP meds
Risk Factors:
Older Age >65
Obesity
Black
DM
Non-Pharmacologic Treatment
Resistant HTN
Assess/Improve ADHERENCE
Consider/Correct Secondary Causes:
1* Aldosteronism / OSA / Renal Artery Stenosis
Target other modifiable caracteristics:
Obesity / Inactivity / Salt / low Fiber
- *D/C Meds that can cause HTN:**
- *NSAIDS / DECONGESTANTS / AMPHETAMINES**
Medication Management
Resistant HTN Treatment
D/C or minimize: NSAIDS / Decongestants / Amphetamines
- *Maximize DIURETIC**
- *CHLORTHALIDONE** (preferred diuretic) > HCTZ
+ADD+ Anti-Aldosterone Diuretic
PATHWAY RCT, Spironolactone > a/b blockers
- *+ADD+ agents w/ different MoA**
- *Loop Diuretics** w/ CKD and/or those on potent vasodilators (minoxidil)
Major Causes of
SECONDARY HTN
&
Treatments
SLEEP APNEA
Spironolactone / CPAP / surgical correction
Aldosteronism
Spironolactone
RenoVascular Disease (Stenosis)
Vascular surgery, RAAS blockade w/ diuretic
HyperThyroid
Renal Parenchymal Disease
#1 Cause of Secondary Hypertension
&
TREATMENT
SLEEP APNEA
SPIRONOLACTONE
CPAP
Surgical Correction
Monitoring for BP therapy
MONTHLY follow-up until BP is controlled
Evaluate BP / Adherence / ADRs / Lifestyle Mods
- *Lab Assessment:**
- *dosing RAAS AGENT: BMP** within 2-4 weeks
- *dosing DIURETIC: BMP** within 1-2 weeks after changes –> q6-12m
HyperTensive Crisis
Definition & Target Organs
- *Acute** + Accelerated HTN that threatens or damages “end organs”
- *Brain** –> stroke/hemorrhage/EC(encephalopathy)
- *Heart**–> MI/aortic dissection / ventricular dysfxn
- *Kidneys** –> acute renal failure
- *Eyes** –> retinal hemorrhage
URGENCY vs EMERGENCY
HyperTensive Crisis
URGENCY vs EMERGENCY
URGENCY
Severe elevations in BP = >180/120 mmHg
Emergency
Severe Elevations in BP
+
SIGNS OF END ORGAN DMG
Treatment for
Hypertensive URGENCY
severe BP elevation:
>180/120 mmHg
- aggressive treatment does MORE HARM vs GOOD*
- *Abrupt “normalizing”** –> organ damage
- *Organs can be ACCLIMATED to highBP**
Management:
Investigate S/Sx of end-organ damage
&
reduce BP** **–> OVER DAYS- WEEKS
primarily with PO meds
Treatment for
Hypertensive EMERGENCY
severe BP elevation:
>180/120 mmHg
&
SIGNS OF END-ORGAN DMG
_WITHOUT compelling conditions_:
Aortic Dissection / Severe Preclamsia / Pheochromocytoma Crisis
Goal:
↓BP by 25% in 1st hour
then:
↓BP to 160/100-110 over the next 2-6 hours
then
Normalize over next 24-48 hours
Goal is to NOT normalize BP immediately!
exceptions = Aortic Dissection & Severe (pre)eclampsia or Pheochromocytoma criss
Treatment for
Hypertensive EMERGENCY** + **AORTIC DISSECTION
severe BP elevation:
>180/120 mmHg
&
SIGNS OF END-ORGAN DMG
Aortic Dissection = Exception
Reduce SBP < 120 during 1st hour
Treatment for
Hypertensive EMERGENCY + (Pre)eclamsia or Pheochromocytoma
severe BP elevation:
>180/120 mmHg
&
SIGNS OF END-ORGAN DMG
Exception
Reduce SBP < 140 during 1st hour
