Hypertension

Question 1

Pathophysiology of HTN

Answer 1

• 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

Question 2

HTN: Labs and Diagnostic Workup

Answer 2

• ECG
• UA
• BG
• Serum potassium, creatinine, calcium
• Lipid profile
• C-reactive protein
• Homocysteine

Question 3

Classifications of HTN

Answer 3

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

Question 4

HTN: Goals of Treatment

Answer 4

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

Question 5

HTN: Rational Drug Selection

Answer 5

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

Question 6

HTN: Stepped Therapy

Answer 6

1. Set an appropriate minimum therapeutic BP goal: no longer less than 120/80
2. Be patient, and work on attaining the BP goal over many weeks to months
3. Titrate BP medications no more often than every 4-6 weeks
4. Do not automatically assign to the drug symptoms reported by patients
5. Plan at beginning of therapy for use of more than one drug
6. Treat to achieve goal SBP in older adults even if DBP is normal, but go more slowly, allowing SBP of 150-160 if asymptomatic
7. Extracellular fluid volume must be controlled to achieve BP goals

Question 7

Initial Drug Therapy for HTN

Answer 7

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

Question 8

Indications for Individual Drugs: HF

Answer 8

Diuretics, BBs, ACEIs, ARBs, aldosterone antagonists

Question 9

Indications for Individual Drugs: Post MI

Answer 9

BBs, ACEIs, aldosterone antagonists

Question 10

Indications for Individual Drugs: High coronary disease risk

Answer 10

Diuretics, BBs, ACEIs, CCBs

Question 11

Indications for Individual Drugs: Diabetes

Answer 11

Diuretics, ACEIs, ARBs, CCBs

Question 12

Indications for Individual Drugs: Chronic Kidney Disease

Answer 12

ACEIs, ARBs until stage 3 chronic kidney disease

Question 13

Indications for Individual Drugs: Recurrent Stroke Prevention

Answer 13

Diuretics, ACEIs

Question 14

HTN: Stepping Up to Multiple Drugs

Answer 14

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

Question 15

HTN: Patient Variables in Children & Adolescent, & Older Adults

Answer 15

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

Question 16

HTN: Patient Variables in Women

Answer 16

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

Question 17

HTN: Patient Variables in Racial and Ethnic Minorities

Answer 17

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

Question 18

HTN Monitoring

Answer 18

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

Question 19

HTN: Self care monitoring

Answer 19

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

Question 20

HTN: Aderence Issues

Answer 20

ADRs:
- Sexual dysfunction, fatigue, depression

Complexity of drug regimen
- Use of combined drugs when possible

More flexibility with goals to keep patient on medications