Hypertension Flashcards
Pathophysiology of HTN
- Regulation of BP- Baroreceptors, endothelial factors, kidneys, genetic influences
- BP= CO x pulmonary vascular resistance (PVR)
- Most essential: patients with HTN have increased peripheral resistance & normal CO
- Primary or “essential” (95%): atherosclerosis
- Secondary (5%): adrenal, renal
- BP relies on balance between CO & PVR
HTN: Labs and Diagnostic Workup
- ECG
- UA
- BG
- Serum potassium, creatinine, calcium
- Lipid profile
- C-reactive protein
- Homocysteine
Classifications of HTN
Normal: SBP less than 120, DBP less than 80
Early HTN: SBP 120-139, DBP 80-89
Stage 1 HTN: SBP 140-159, DBP 90-99
Stage 2 HTN: SBP greater than or equal to 160, DBP greater than or equal to 100
HTN: Goals of Treatment
Prevent the rise of BP with age
Improve control of HTN to below 140/90
- In patients with concurrent HTN & diabetes or renal disease, the BP goal is less than 130/80
- Others start medications closer to 150 level
The primary focus should be on obtaining SBP goal
Improve recognition of importance of risk factors on development of HTN
Reduce ethnic, socioeconomic, and regional variations in HTN care
HTN: Rational Drug Selection
Lifestyle modifications first- weight loss, dietary approaches to stop HTN (DASH) diet, dietary sodium reduction (most consume too much; not a restriction, but conscious effort), limit alcohol consumption, physical activity
HTN: Stepped Therapy
- Set an appropriate minimum therapeutic BP goal: no longer less than 120/80
- Be patient, and work on attaining the BP goal over many weeks to months
- Titrate BP medications no more often than every 4-6 weeks
- Do not automatically assign to the drug symptoms reported by patients
- Plan at beginning of therapy for use of more than one drug
- Treat to achieve goal SBP in older adults even if DBP is normal, but go more slowly, allowing SBP of 150-160 if asymptomatic
- Extracellular fluid volume must be controlled to achieve BP goals
Initial Drug Therapy for HTN
ACEs or CCBs if:
- BP is more than 20 above the systolic goal or 10 above diastolic goal
- Can start with mild diuretic or add on quickly to achieve goals
Indications for Individual Drugs: HF
Diuretics, BBs, ACEIs, ARBs, aldosterone antagonists
Indications for Individual Drugs: Post MI
BBs, ACEIs, aldosterone antagonists
Indications for Individual Drugs: High coronary disease risk
Diuretics, BBs, ACEIs, CCBs
Indications for Individual Drugs: Diabetes
Diuretics, ACEIs, ARBs, CCBs
Indications for Individual Drugs: Chronic Kidney Disease
ACEIs, ARBs until stage 3 chronic kidney disease
Indications for Individual Drugs: Recurrent Stroke Prevention
Diuretics, ACEIs
HTN: Stepping Up to Multiple Drugs
Do NOT wait until full dose of first drug
If BP is not controlled:
- Add second drug, or
- Substitute a drug in a different class
Choose the second drug based on its being different from the ADR profile & action of first drug
HTN: Patient Variables in Children & Adolescent, & Older Adults
Children & Adolescents:
- Definition of HTN is based on age, height, and BP
- Lifestyle modification is initial therapy
- Drugs are similar to those for adults
Older Adults:
- HTN occurs in two out of three adults older than age 65
- Begin with lifestyle modifications
- Target BP goals less stringent than young adults
HTN: Patient Variables in Women
Oral contraceptives and HRT may increase BP due to weight gain
During pregnancy, there may be increased risk to mother and fetus
- Methyldopa, BBs, vasodilators are drugs of choice
- Avoid ACEIs, ARBs, & direct renin inhibitors
- Preeclampsia occurs after the 20th week of gestation and requires intensive monitoring; preexisting HTN is NOT the same
HTN: Patient Variables in Racial and Ethnic Minorities
Native Americans have the same or slightly higher prevalence rates compared with caucasian populations
Hispanics have the same to slightly lower prevalence rates
Asians have about the same prevalence rate as caucasians
African Americans have a higher and earlier HTN incidence
- Reduced response to monotherapy, beta blockers, ACEIs, ARBs
- Equal response if mixed with diuretic
- BiDil was the first drug suggested for African American patients specifically
- CCB is first line for most African Americans
HTN Monitoring
BP measurement - Caffeine, exercise, and smoking to be avoided for at least 30 minutes prior to measurement - Home or clinic measurement Lab values monitored if any ADRs - Electrolytes, renal function, CBC ECG
HTN: Self care monitoring
May unmask true white coat syndrome
May increase adherence to regimen
Fosters implementation of Chronic Care Model
Patient activation may “spill over” into other self-care activities
HTN: Aderence Issues
ADRs:
- Sexual dysfunction, fatigue, depression
Complexity of drug regimen
- Use of combined drugs when possible
More flexibility with goals to keep patient on medications
