HTN Definitions Flashcards
Definitions of HTN
2017 Guideline for High Blood Pressure in Adults
BP should be categorized as normal, elevated, or stages 1 or 2 hypertension to prevent and treat high BP.
Normal BP
Normal BP is defined as <120/<80 mm Hg
Elevated BP
Elevated BP 120-129/<80 mm Hg
Stage 1 HTN
Stage 1 Hypertension is 130-139 or 80-89 mm Hg
Stage 2 HTN
Stage 2 Hypertension is ≥140 or ≥90 mm Hg
Labeling someone HTNsive
Prior to labeling a person with hypertension, it is important to use an average based on ≥2 readings obtained on ≥2 occasions to estimate the individual’s level of BP.
Corresponding BPs based on site/methods are:
office/clinic 140/90, HBPM 135/85, daytime ABPM 135/85, night-time ABPM 120/70, and 24-hour ABPM 130/80 mm Hg. In adults with an untreated systolic BP (SBP) >130 but <160 mm Hg or diastolic BP (DBP) >80 but <100 mm Hg.
White Coat HTN
It is reasonable to screen for the presence of white coat hypertension using either daytime ABPM or HBPM prior to diagnosis of hypertension.
Masked HTN
In adults with elevated office BP (120-129/<80) but not meeting the criteria for hypertension, screening for masked hypertension with daytime ABPM or HBPM is reasonable.
HTN
A 20 mm Hg higher SBP and 10 mm Hg higher DBP are each associated with a doubling in the risk of death from stroke, heart disease, or other vascular disease.
HTN in persons > or = to 30 years of age
In persons ≥30 years of age, higher SBP and DBP are associated with increased risk for CVD, angina, myocardial infarction (MI), heart failure (HF), stroke, peripheral arterial disease, and abdominal aortic aneurysm.
HTN and CVD risk
For adults with confirmed hypertension and known CVD or 10-year ASCVD event risk of 10% or higher, a BP target of <130/80 mm Hg is recommended.
HTN and no CVD risk
For adults with confirmed hypertension, but without additional markers of increased CVD risk, a BP target of <130/80 mm Hg is recommended as reasonable.
Stage 1 HTN f/u
Adults with stage 1 hypertension and high ASCVD risk (≥10% 10-year ASCVD risk) should be managed with both nonpharmacologic and antihypertensive drug therapy with repeat BP in 1 month.
Stage 2 HTN f/u
Adults with stage 2 hypertension should be evaluated by a primary care provider within 1 month of initial diagnosis, and be treated with a combination of nonpharmacologic therapy and 2 antihypertensive drugs of different classes with repeat BP evaluation in 1 month.
High Average HTN f/u
For adults with a very high average BP (e.g., ≥160 mm Hg or DBP ≥100 mm Hg), prompt evaluation and drug treatment followed by careful monitoring and upward dose adjustment is recommended.
Principles of Drug Therapy and Special Populations
Chlorthalidone (12.5-25 mg) is the preferred diuretic because of long half-life and proven reduction of CVD risk.
Principles of Drug Therapy and Special Populations
Angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), and direct renin inhibitors should not be used in combination.
Principles of Drug Therapy and Special Populations
ACE inhibitors and ARBs should be discontinued during pregnancy.
Principles of Drug Therapy and Special Populations
Calcium channel blocker (CCB) dihydropyridines (Norvasc) cause edema. Non-dihydropyridine CCBs (verapamil & Diltiazem) are associated with bradycardia and heart block and should be avoided in HFrEF.
Principles of Drug Therapy and Special Populations
Loop diuretics are preferred in HF and when glomerular filtration rate (GFR) is <30 ml/min.
Principles of Drug Therapy and Special Populations
Amiloride and triamterene can be used with thiazides in adults with low serum K+, but should be avoided with GFR <45 ml/min.
Principles of Drug Therapy and Special Populations
Spironolactone or eplerenone is preferred for the treatment of primary aldosteronism and in resistant hypertension.
Principles of Drug Therapy and Special Populations
Beta-blockers are not first-line therapy except in CAD and HFrEF. Abrupt cessation of beta-blockers should be avoided.
Principles of Drug Therapy and Special Populations
Bisoprolol and metoprolol succinate are preferred in hypertension with HFrEF and bisoprolol when needed for hypertension in the setting of bronchospastic airway disease.
Principles of Drug Therapy and Special Populations
Beta-blockers with both alpha- and beta-receptor activity such as carvedilol are preferred in HFrEF.
Principles of Drug Therapy and Special Populations
Alpha-1 blockers are associated with orthostatic hypotension; this drug class may be considered in men with symptoms of benign prostatic hyperplasia.
Principles of Drug Therapy and Special Populations
Central acting alpha2-agonists should be avoided, and are reserved as last-line due to side effects and the need to avoid sudden discontinuation.
Principles of Drug Therapy and Special Populations
Direct-acting vasodilators are associated with sodium and water retention and must be used with a diuretic and beta-blocker.
Principles of Drug Therapy and Special Populations
Initial first-line therapy for stage 1 hypertension includes thiazide diuretics, CCBs, and ACE inhibitors or ARBs.
Principles of Drug Therapy and Special Populations
Two first-line drugs of different classes are recommended with stage 2 hypertension and average BP of 20/10 mm Hg above the BP target.
Principles of Drug Therapy and Special Populations
In HFpEF with symptoms of volume overload, diuretics should be used to control hypertension, following which ACE inhibitors or ARBs and beta-blockers should be titrated to SBP <130 mm Hg. Treatment of hypertension with an ARB can be useful for prevention of recurrence of atrial fibrillation.
Principles of Drug Therapy and Special Populations
CKD
CKD: BP goal should be <130/80 mm Hg. In those with stage 3 or higher CKD or stage 1 or 2 CKD with albuminuria (>300 mg/day), treatment with an ACE inhibitor is reasonable to slow progression of kidney disease. An ARB is reasonable if an ACE inhibitor is not tolerated.
Principles of Drug Therapy and Special Populations
ICH
In adults with acute intracranial hemorrhage and SBP >220 mm Hg, it may be reasonable to use continuous intravenous drug infusion with close BP monitoring to lower SBP. Immediate lowering of SBP to <140 mm Hg from 150-220 mm Hg is not of benefit to reduce death, and may cause harm.
Principles of Drug Therapy and Special Populations
Ischemic Stroke
In acute ischemic stroke, BP should be lowered slowly to <185/110 mm Hg prior to thrombolytic therapy and maintained to <180/105 mm Hg for at least the first 24 hours after initiating drug therapy. Starting or restarting antihypertensive therapy during the hospitalization when patients with ischemic stroke are stable with BP >140/90 mm Hg is reasonable.
Principles of Drug Therapy and Special Populations
In those who do not undergo reperfusion therapy with thrombolytics or endovascular treatment, if the BP is ≥220/120 mm Hg, the benefit of lowering BP is not clear, but it is reasonable to consider lowering BP by 15% during the first 24 hours post onset of stroke.
Principles of Drug Therapy and Special Populations
Secondary prevention following a stroke or transient ischemic attack (TIA) should begin by restarting treatment after the first few days of the index event to reduce recurrence. Treatment with ACE inhibitor or ARB with thiazide diuretic is useful.
Principles of Drug Therapy and Special Populations
DM & HTN
Diabetes mellitus (DM) and hypertension: Antihypertensive drug treatment should be initiated at a BP ≥130/80 mm Hg with a treatment goal of <130/80 mm Hg.
Principles of Drug Therapy and Special Populations
DM & HTN
In adults with DM and hypertension, all first-line classes of antihypertensive agents (i.e., diuretics, ACE inhibitors, ARBs, and CCBs) are useful and effective. ACE inhibitors or ARBs may be considered in the presence of albuminuria.
Principles of Drug Therapy and Special Populations
Metabolic Syndrome
Metabolic syndrome: Lifestyle modification with an emphasis on improving insulin sensitivity by means of dietary modification, weight reduction, and exercise is the foundation of treatment of the metabolic syndrome.
Principles of Drug Therapy and Special Populations
Metabolic Syndrome
Chlorthalidone was at least as effective for reducing CV events as the other antihypertensive agents in the ALLHAT study. Traditional beta-blockers should be avoided unless used for ischemic heart disease.
Principles of Drug Therapy and Special Populations
Aortic Disease
Aortic disease: Beta-blockers are recommended as the preferred antihypertensive drug class in patients with hypertension and thoracic aortic disease.
Principles of Drug Therapy and Special Populations
Race/ethnicity
Race/ethnicity: In African American adults with hypertension but without HF or CKD, including those with DM, initial antihypertensive treatment should include a thiazide-type diuretic or CCB. Two or more antihypertensive medications are recommended to achieve a BP target of <130/80 mm Hg in most adults, especially in African American adults, with hypertension.
Principles of Drug Therapy and Special Populations
Age Related Issues
Age-related issues: Treatment of hypertension is recommended for noninstitutionalized ambulatory community-dwelling adults (≥65 years of age), with an average SBP ≥130 mm Hg with SBP treatment goal of <130 mm Hg. For older adults (≥65 years of age) with hypertension and a high burden of comorbidity and/or limited life expectancy, clinical judgment, patient preference
Principles of Drug Therapy and Special Populations
Preoperative Surgical Procedures
Preoperative surgical procedures: Beta-blockers should be continued in persons with hypertension undergoing major surgery, as should other antihypertensive drug therapy until surgery. Discontinuation of ACE inhibitors and ARBs perioperatively may be considered.
Principles of Drug Therapy and Special Populations
Preoperative Surgical Procedures
For patients with planned elective major surgery and SBP ≥180 mm Hg or DBP ≥110 mm Hg, deferring surgery may be considered. Abrupt preoperative discontinuation of beta-blockers or clonidine may be harmful. Intraoperative hypertension should be managed with intravenous medication until oral medications can be resumed.
White coat hypertension (WCH)
Normal BP with usual activities, but higher in clinical setting (doctor’s office)
White coat hypertension (WCH)
Affected individuals may have impaired diastolic function and higher levels of catecholamines, renin/aldosterone, low-density lipoproteins.
May be at increased risk for eventual sustained HTN
White coat hypertension (WCH)
Start antihypertensive if:
Persistently elevated clinic BP and
Target organ damage or elevated 24-hour ambulatory BP
Masked HTN
BP measured in the clinical setting is lower than that measured in the ambulatory setting (opposite of WCH).
Masked HTN
Start antihypertensive if:
Persistently normal clinic BP,
Target organ damage, and
High 24-hour ambulatory BP
Sustained HTN
Sustained HTN: HTN both in and out of clinic setting, although BP tends to be higher in the former.
Pseudohypertension
Cuff BP is higher when compared with intra-arterial pressure because of excessive atheromatosis and/or medial hypertrophy in arterial tree.
Pseudohypertension
May be diagnosed by Osler maneuver:
Inflate BP cuff above SBP (detected by loss of pulse with auscultation).
Osler maneuver is positive when either brachial or radial artery remains palpable despite loss of pulse by auscultation.
Pseudohypertension
Pseudohypertension is defined as having cuff-measured DBP > 10 to 15 mm Hg compared with that of intra-arterial measurement.
Management of BP should be based on intra-arterial value
Isolated systolic hypertension (ISH)
Occurs with stiffening of large arteries, leading to reduced vessel capacitance and acceleration of pulse wave velocity, hence widening of pulse pressure.
Isolated systolic hypertension (ISH)
Increase in SPB continues throughout life, in contrast to DBP, which increases and peaks by age of 50 then decreases later in life.
After 50 years, SBP is more important than DBP.
Isolated diastolic hypertension
Isolated diastolic hypertension (IDH), DBP > 90 mm Hg with SBP < 140 mm Hg:
More common in young overweight/obese males.
Isolated diastolic hypertension
Management of IDH:
Focus on salt restriction and weight loss, the latter if overweight or obese.
Pharmacologic antihypertensive therapy if end-organ damage, (e.g. proteinuria or left ventricular HTN on ECG) or hypothyroidism. Hypothyroidism is associated with BP rise that is more pronounced with diastolic than systolic BP.
HTN in pregnancy
BP > 140/90 mm Hg
SBP > 30 mm Hg or DBP > 15 mm Hg increase compared with BP prior to pregnancy, but <140/90 should be managed as high-risk patients per US National High BP Education Program)
Accelerated HTN
Severe diastolic HTN, typically defined as having DBP > 120 mm Hg with grade III retinopathy (arteriolosclerotic changes of arteriolar narrowing and nicking plus hypertensive changes of flame-shaped hemorrhages and soft exudates).
Malignant HTN
Malignant HTN is similar to accelerated HTN but with grade IV retinopathy (i.e., grade III plus papilledema) ± hypertensive encephalopathy. Distinction between malignant and accelerated HTN is not clinically necessary in terms of treatment.
Hypertensive urgency
Hypertensive urgency: accelerated HTN requiring BP lowering within hours; also defined as having DBP > 120 mm Hg in asymptomatic patients.
Hypertensive emergency
Hypertensive emergency: accelerated HTN requiring BP lowering within minutes (i.e., acute aortic dissection, acute left ventricular failure, intracerebral hemorrhage [ICH], pheochromocytoma [PHEO] crises, drug abuse, eclampsia).
Blood pressure circadian pattern
BP during sleep is ~10% to 20% below daytime BP. Patients with nighttime BP fall are referred to as “dippers.”
Blood pressure circadian pattern
In CKD patients:
The proportion of dippers decreases with increasing CKD stage.
The proportion of “risers” (patients with increase nighttime BP) increases with increasing CKD stage.
Between-arm BP differences:
Between-arm BP differences of 4 to 5 mm Hg occur in healthy people.
Values > 10 mm Hg should be considered for vascular assessment.
Between-arm BP differences:
Values > 15 mm Hg is a predictor of prevalent vascular disease and death.
BP treatment should be based on higher BP arm.
