HTN Special Pops Flashcards
Primary hypertension
– no identifiable cause
Secondary hypertension
– an underlying cause is identified
Goals: 1.
Determine if its primary or secondary.
Goal 2
If secondary, identify underlying cause
Goal 3
. Identify other co-morbid factors for CVD, or diseases associated with an increased risk for CVD
Normal BP under 13
<90th precentile
Elevated BP under 13
<90th precentitile to <95th precenitle, or 120/80 whichever is lower
Stage 1 under 13
Systolic BP >95th precentile to <95th precntile + 12 mm Hg, or 130/80 to 139/89 mmHg, (whichever is lower)
Stage 2 under 13
Systolic and diastolic BP >95th precentile +12 mmHg or >140/90 mmHg (whichever is lower)
Normal BP over 13
<120 and <80
Elevated BP over 13
120 to 129
<80
Stage 1 over 13
130/80 to 139/89
Stage 2 Over 13
> 140/90
Peds Initiate treatment in following examples
Symptomatic HTN Stage 2 HTN Stage 1 HTN without evidence of end-organ damage, that persists despite 6 months of non-pharm therapy Hypertensive end-organ damage Any stage of HTN or high BP with CKD Any stage of HTN with DM
Drugs in children’s and adolecents
Ace inhibitors Angiotensin-receptor blockers (ARBs) Thiazide diuretics Calcium channel blockers Beta blockers
Choice of drug for peds
data comparing antihypertensive drugs in children are lacking and hence it is not possible to make an evidence-based choice
Recommendations based upon the underlying cause of HTN, concurrent disorders, and the preference and experience of the responsible provider
Four major hypertensive disorders that occur in pregnant women:
preeclampsia-eclampsia
chronic hypertension
preeclampsia-eclampsia superimposed upon chronic hypertension
gestational hypertension
Preeclampsia-eclampsi
syndrome of new onset of hypertension and proteinuria or new onset of hypertension and end-organ dysfunction with or without proteinuria, most often after 20 weeks of gestation in a previously normotensive woman.
Chronic (preexisting) hypertension
hypertension that antedates pregnancy, is present before the 20thweek of pregnancy, or persists longer than 12 weeks postpartum
Preeclampsia-eclampsia superimposed upon chronic hypertension
diagnosed when a woman with chronic hypertension develops worsening hypertension with new onset proteinuria or other featur
Gestational hypertension
elevated blood pressure first detected after 20 weeks of gestation in the absence of proteinuria or other diagnostic features of preeclampsia.
Treatment of severe hypertension (defined as systolic BP ≥160 mmHgand/ordiastolic BP ≥110 mmHg) persisting for
Treatment of severe hypertension (defined as systolic BP ≥160 mmHgand/ordiastolic BP ≥110 mmHg) persisting for
Mild (systolic 140 to 150mmHg, diastolic 80 to 100mmHg) – consider
symptoms and co-morbidities
All anti-HTN cross the
placenta
Methyldopa – wildly used in
in pregnancy women/long-term safety for fetus has been demonstrated
Other options for HTN in pregnancy
Beta-blockers, calcium channel blockers, hydralazine, thiazide diuretics, clonidine.
Drugs to avoid in pregnancy
ACE inhibitors, ARBs, direct renin inhibitors
Mineralocorticoid receptor antagonists
Nitroprusside
Breastfeeding what beta blockers can be used
Propranolol, metoprolol, labetalol
Breastfeedign what CCB can be used
Diltiazem, nifedipine, nicardipine, and verapamil
Appear to be safe during lactation
Breast feeding what ACE can be used
Transferred into milk at very low levels.
Newborns may be more susceptible to the hemodynamic effects of these drugs (hypotension, oliguria and seizures)
Captopril, enalapril
Breastfeeding what Diruetics can be used
HCT < 50mg/day
Breastfeeding diuretics may reduce
may reduce milk volume.
HCT <150 mg/day
Methyldop and hydralazine apear to be ___ in breastfeding
safe
Geriatrics general principles
Lower dose to minimize SE
Lower BP over a period of weeks to up to 6 months as long as no HTN emergency or urgency
Systolic Pressure Intervention Trial (SPRINT)
Consider orthostatic hypotension
Lower dose to minimize SE
Lower BP over a period of weeks to up to 6 months as long as no HTN emergency or urgency
Systolic Pressure Intervention Trial (SPRINT)
Consider orthostatic hypotension
Low-to-moderate-dose thiazide diuretics (e.g., 12.5 to 25mg/dayofchlorthalidone)
Long-acting calcium channel blockers (most often dihydropyridines)
ACE inhibitors or ARBs.
A long-acting dihydropyridine or a thiazide diuretic is generally preferred in older adult patients because of increased efficacy in blood pressure lowering
JNC-8 – initial therapy – older adults
Co-morbid conditions with compelling indications (e.g., HF, MI, CKD: ACE-1 or ARB)
Co-morbid conditions for older adults
Co-morbid conditions with compelling indications (e.g., HF, MI, CKD: ACE-1 or ARB)
Addition for a second line drug for older adults
Addition of a second-drug
ACCOMPLISH trial - significant improvement in outcomes at the same attained blood pressure withbenazeprilplusamlodipinecompared with benazepril plushydrochlorothiazide.
Long-acting ACEinhibitor/ARB
Resistant HTN
BP remains above goal despite concurrent use of three anti-hypertensive agents of three different classes.
Resistant HTN one agent should be a
should be a diuretic, and all agents should be prescribed at maximum recommend dose (or maximally tolerated)
Resistant HTN if BP controlled with
If BP controlled with 4 or more medications
