Hypertension Flashcards
1
Q
JNC 8
A
JNC 7 still final word
2
Q
Definition of hypertension
A
systolic blood pressure >140
Diastolic blood pressure > 90
3
Q
diagnosing htn
A
- at least 2 elevated measurements
- one in each arm
- 2 or more visits
- dx should not be made when pt is acutely ill (ex: pt in pain)
- take measurement in each arm to evaluate whether adult pt actually has “coarctation of the aorta” or another aortic anomaly (where pressure in right arm is high but left arm is low)
4
Q
screening healthy ppl for high bp
A
- begin at age 18 and older
- insufficient evidence to recommend an optimal interval for screening adults for htn
- Jnc7: every 2 yrs in ppl w bp < 120/80 and every year if bp 120-139/80-90
Jnc8: no comment on screening for htn
5
Q
one of most common causes of misdiagnosis or improper mgmt of htn
(+ proper office techniques)
A
blood pressure measurement errors: made by everyone
proper office techniques:
- pt seated quietly for 5 mins in a chair (not exam table), feet on floor, arm supported at heart level
- auscultory method w properly calibrated and validated instumrent (aneroid device, uses metal spring to measure bp); attached to cuff, accompanied by stethoscope
- use appropriate sized cuff to ensure accuracy: length of bladder should wrap around 80% of arm circumference; width of cuff must be at least 40% of arm circumference
6
Q
If bp cuff too small or large
A
if cuff too small: bp reading may be erroneously high
if cuff too large: bp reading may be slightly too low
w increasing prevalence of obesity, many adults no longer fit standard cuffs (may require extra large or thigh cuffs)
7
Q
Objectives of evaluation of pt w htn
A
- assess lifestyle and identify other cardiovascular risk factors or concomitant disorders that affects prognosis and guides treatment
- reveal identifiable causes of high blood pressure (secondary htn)
- assess presence or absence of target organ damage and cardiovascular dz
(how? proper h & p)
8
Q
Elements of proper initial history for pt w new essential htn: what to ask
A
Proper elements of initial hx of pt w new htn (jnc 7):
- does pt already have htn and if so for what duration?
- -> pts with >10yrs poorly controlled htn may be more likely to have end organ damage - does pt have congestive heart failure symptoms?
- chf considered end organ damage of htn - does pt have peripheral vascular dz?
- pvd conisdered end organ damage of htn - does pt have diabetes?
- pts w diabetes may also have htn as part of metabolic syndrome - does pt have hx or sx of cardiovascular dz?
- cvd is part of end organ damage of htn - does pt have renal dz?
- renal dz is part of end organ damage of htn - does pt have cholesterol issues?
- pts w cholesterol issues may also have htn as part of metabolic syndrome - does pt have fam hx premature heart attack or stroke death (s)?
- pt w fam hx of premature cvd or death (men < 55 yrs or women < 65 yrs) can mean pt has 8x higher risk of cvd or death than rest of pop - does pt have fam hx diabetes?
- fam hx diabetes may mean higher risk of diabetes for pt w htn - does pt have fam hx hypercholesterolemia?
- fam hx high cholesterol may mean higher risk of hyperlipidemia for pt w htn - review all meds including over the counter and complementary meds?
- review of all meds including otc and complementary is cruticial; some common rx meds like birth control pils, amphetamines, thyroid meds, steroids, certain antidepressants may elevate bp
some common otc meds can also elevate bp: pseudoephedrine, appetite suppressants, nsaids
some herbal remedies: ma huang, bitter orange, ginkgo, ginseng, licorice, st. johns wort
- review any weight change issues?
- wt changes esp wt gain are important - review smoking hx
- tobacco smoking elevates bp, contributes to increased morbidity and mortality, interferes w efficacy of bp meds - review alcohol and drug hx
- alcohol and drug hx imp; alcohol intake should be limited to no more than 1oz/30ml ethanol (=2drinks per day in most men) and no more than .5oz/15ml ethanol (one drink) per day in women and lighter weight persons
- cocaine and ketamine use and narcotic withdrawal can elevate bp - review diet hx
- assess diet hx to counsel pt appropriately - review psychosocial stressors
- review psychosocial stressors ; stress directly causes release of angiotensin II and norepinephrine in body (fight or flight) and also makes prioritizing adherence to bp meds hard
9
Q
Elements of proper initial history for pt w new essential htn: what doesnt need to be asked
A
- does pt have cancer hx?
- may be part of routine pt hx but doesnt play role in focused hx of pt w htn - does pt have glaucoma dz?
- routine but not focused hx; not directly associated w essential htn; however retinopathy may be considered target end organ damage from htn - does pt have fam hx colon cancer?
- may be routine but doesnt play role in focused hx of pt w htn
10
Q
Elements of proper initial physical exam for pt w new essential htn: what to do
A
- 2 bp measurements 2 minutes apart on each arm: look for coarctation of aorta or other anatomical anomalies (cause of secondary htn)
- calculate body mass index: bmi, usually overweight (>25) or obese (>30)
- fundoscopic exam: look for av nicking, papilledema (seen in hypertensive emergencies), cotton wool spots, hemorrhages
- examine thyroid: look for thyromegaly or polyps or other signs of hyperthyroidism (cause of 2ndary htn)
- check for neck bruits: cardiovascular dz
- auscultate heart for rate and murmurs: cardiovascular and valvular dz
- check the point of maximal impulse (PMI): look for signs of hypertrophy or cardiomegaly
- check for abdominal bruits: cardiovascular dz
- assess peripheral veins: cardiovascular or diabetic dz
- evaluate for lower extremity edema: cardiovascular dz
- neurological evaluation: getting good baseline neuro exam is imp even if exam is non focal
11
Q
Elements of proper initial physical exam for pt w new essential htn: what not to do
A
- assess tympanic membranes: though its part of general exam, not part of focused physical on pt w htn
- check for hepatosplenomegaly: though part of gen exam, not part of focused PE in pt w htn
- genital exam: not part of focused exam for pt w htn
- general skin exam: not part of focused PE w pt w htn
12
Q
diagnosing htn in adults >18 yrs: normal
A
systolic bp <80
13
Q
diagnosing htn in adults >18 yrs: prehypertension (normal)
A
systolic bp 120-139
or
diastolic bp 80-89
–> id ppl for whom early intervention by adoption of healthy lifestyles could reduce bp, decrease rate of progression of bp to hypertensive levels with age, or prevent htn entirely
14
Q
diagnosing htn in adults >18 yrs: stage 1 htn
A
systolic bp: 140-159
or
diastolic bp: 90-99
15
Q
diagnosing htn in adults >18 yrs:stage 2 htn
A
systolic bp: >160
or diastolic bp >100
16
Q
if systolic and diastolic measurements of bp are in diff htn categories…
A
classify the pt by the worst of the 2 measurements
17
Q
Dx of pre htn is confirmed with these values
A
s bp: 120-139
d bp: 80-89
(average values of 2 or more bp measurements on separate visits)
–> pre htn is not a disease category, so officially these readings are still “normal”
18
Q
true or false: pts with pre htn are at high risk of progression to htn
A
true:
- -> pre htn is designation chosen to identify ppl at high risk of developing htn
- -> 50% of prehypertensive patients will eventually develop htn
19
Q
Are pre hypertensive patients candidates for drug therapy?
A
It depends.
ppl w prehypertenion are not candidates for drug tehrapy based on their level of bp alone; should be strongly encouraged to practice lifestyle modifications to reduce risk of developing future htn
but if pt w diabetes or renal dz and prehypertension, should be treated (if sp=130 and dp=80)
20
Q
Initial laboratory testing for htn: what to do in a new dx (stage 1 essential htn, in this example)
A
- ekg:
- rate and rhythm issues (is pt bradycardic, tachycardic, or have an underlying heart block? are beta blockers or calcium channel blockers contraindicated? is there possibility of undiagnosed hyperthyroidism? are there rhythm disturbances such as atrial fibrillation
- ischemia: does patient have evidence of ischemic disease or previously undiagnosed myocardial infarctions? is there presence of end organ damage?
- hypertrophy: does the pt have ekg signs of cardiac hypertrophy? does pt have left ventricular hypertrophy (LVH)?
* LVH is second best prognosticator of death in all people; reversible w proper attn and medical mgmt; 1st and best prognosticator of death in all ppl is age * - Urinalysis
proteinuria: may be evidence of hypertensive nephropathy (target organ damage)
glucosuria: may be evidence of undiagnosed diabetes or poorly controlled diabetes (co-morbidity and sign of metabolic syndrome) - Blood glucose
- elevated blood glucose: elevated random or fasting blood glucose may be evidence of undiagnosed diabetes or poorly controlled diabetes (comorbidity and sign of metabolic syndrome)
- could possibly affect choice of 1st line agent to be used in managing htn - Blood hematocrit (can also use serum hemoglobin)
- low hematocrit: underlying anemic states in hypertensive pts make the likelihood of major cardiovascular event more likely (strokes, heart attacks)
- if hypertensive pt found to be anemic, underlying cause (ex: colon cancer, uterine fibroids) must be found and addressed + anemia corrected
- anemia may also be product of target organ damage in regards to severe end stage renal disease - Serum potassium
- several blood pressure meds can cause K+ derangements (ACE inhibitors, ARBs, potassium sparing diuretics causing or exacerbating hyperkalemia)
- baseline K level is necessary
- K disturbances can occur in Cushing’s syndrome or primary hyperaldosteronism - Serum Creatinine (or corresponding estimated GFR
- elevated serum creatinine may be indicative of end organ damage (hypertensive nephropathy) from long term uncontrolled htn
- some blood pressure meds also elevate cr (ace inhibitors, arbs, diuretics) - serum calcium (ca)
- 1/3 of patients w hyperparathyroidism and htn can be attributed to renal parenchymal damage due to nephrolithiasis
- increased ca levels can also have direct vasoconstrictive effect
- its unclear why increased serum calcium level in hyperparathyroidism raises bp, while epidemiologic studies suggest that high calcium intake lowers bp
- also not clear why calcium channel blocker agents are effective antihypertensive agents - Fasting serum cholesterol panel (total cholesterol, LDL, HDL, triglyceride)
- lipid profile, after 9-12 hour fast, that includes high density and low density lipoprotein cholesterol, and triglycerides
- hypertenisve pts require entire fasting cholesterol panel to properly assess lipid comorbidities as part of metabolic syndrome and risk of arteriosclerosis
- these pts have fasting lipid panels as surveillance of cholesterol problems, not as general screening tool - measurement of urinary albumin excretion or albumin/creatinine ratio
- measurement of urinary albumin excretion or albumin/creatinine ratio (ACR) considered to be optional except for those w diabetes or kidney dz where annual measurements should be made
- may become a recommended test for all hypertensive patients in future reports bc microalbuminuria does appear to have some prognostic implications
21
Q
1st and second best prognosticators of death in all ppl
A
- LVH
2. age (the older you are, the more likely you will die)
22
Q
Initial laboratory testing for HTN: what not to order in dx of new stage 1 essential htn
A
- Thyroid function tests
- not generally indicated in initial evaluation of essential htn pts unless you have clinical suspicion of hyperthyroidism or htn control cant be achieved
2 Echocardiogram
- not generally indicated in initial eval of essential htn pts unless have clinical suspicion of CHF, valvular dz, or cardiomyopathy
- Renal artery sonography
- not generally indicated in initial eval of essential htn pts unless have clinical suspicion of renal artery stenosis or htn control cant be achieved - Serum chloride
- not a proper element bc not generally indicated in initial eval of essential htn pts
- there are no derangements of serum chloride due to htn or hypertensive meds
- test may often be bundled w other electrolyte serology thats recommended (K, creatinine, glucose, calcium) - serum cortisol
- not generally indicated in initial eval of essential htn pts unless have some clinical suspicion of cushing’s dz or another metabolic disorder (cause of 2ndary htn) or htn control cant be achieved - random serum total cholesterol
- not cost effective in initial eval of essential htn
- full lipid profile, after 9-12 hr fast, that includes high density and low density lipoprotein cholesterol, and triglycerides is imp and cost effective
- hypertensive pts require entire fasting cholesterol panel to properly assess lipid comorbodities as part of metabolic syndrome and risk of arteriosclerosis
- pts have fasting lipid panels as surveillance of cholesterol problems, and not as general screening tool - MRI of abdomen
- not generally indicated in initial eval of essential htn pts unless have clinical suspicion of aortic aneurysm - complete blood count (CBC)
- although serum hemoglobin recommended in initial eval of essential htn, wbc and platelet counts not generally indicated
- blood hematocrit can also be used - complete liver enzyme panel (LFTs)
- not generally indicated in initial eval of essential htn - chest xray
- not generally indicated in initial eval of essential htn pts unless have clinical suspicion of congestive heart failure or cardiomegaly - serum sodium (Na)
- serum na not generally indicated in initial eval of essential htn pts
- surprising! bc some pts, esp the elderly, have been known to have serum Na derangements from bp meds (ex: hyponatremia fr diuretics and ACE inhibitors)
- this test may often be bundled w other electrolyte serology that is recommended (K, cr, glucose, ca)
23
Q
Essential htn
A
95-99% of htn in US
24
Q
Secondary htn
A
- far less prominent than essential htn
- should be suspected based on clinical judgment
- when bp fails to be controlled despite optimal medical mgmt
25
Metabolic syndrome
constellation of dyslipidemia (hypertriglyceridemia and low levels of HDL), elevated bp, impaired glucose tolerance, central obesity
"syndrome x"
will soon overtake cigarette smoking as #1risk factor for heart dz among US
effective interventions: diet, exercise, judicious use of pharmacologic agents to address specific risk factors
*wt loss significantly improves all aspects of metabolic syndrome*
26
Identifiable causes of secondary htn
1. pheochromocytoma
2. primary aldosteronism
3. renal artery stenosis
27
Hypertensive emergency
marked htn w evidence of end organ damage that requires immediate blood pressure control
(wiki: 180/120)
28
Malignant htn
marked htn w papilledema, retinal hemorrhages or exudates; considered a subset of hypertensive emergency
29
Hypertensive urgency
- marked htn that requires bp control within hours w out evidence of end organ damage
30
Age >=60
Initial mgmt of essential htn based on pts characteristics and comorbid indications
goal bp: < 150/90
strength of recommendation: A (strong)
*for pts > 60 years old who are tolerating blood pressure therapy that has resulted in pressure <140/90, it is acceptable to continue that treatment (based on expert treatment)
31
Age < 60 yrs
Initial mgmt of essential htn based on pts characteristics and comorbid indications
goal bp: diastolic bp < 90
strength of recommendation:
A (strong) for ages 30-59
E (expert opinion) for ages 18-29
32
Age < 60 years
Initial mgmt of essential htn based on pts characteristics and comorbid indications
systolic bp < 140
strength of recommendation: E (expert opinion)
33
Chronic kidney disease >= 18 years old
Initial mgmt of essential htn based on pts characteristics and comorbid indications
< 140/90
strength of recommendation: E (expert opinion)
34
Diabetes age >= 18 yrs old
Initial mgmt of essential htn based on pts characteristics and comorbid indications
goal bp: < 140/90
strength of recommendation (E)
35
JNC8 recommendations of bp levels that are strong recommendations (level A)
1. sbp and dbp target for the elderly
| 2. dbp target for ages 3-60
36
high quality
Evidence quality rating
JNC8
well designed, well executed *RCTs* that adequately represent populations to which results are applied and directly assess effects on health outcomes
well-conducted meta analyses of such studies
highly certain about the estimate of effect; further research is unlikely to change our confidence in estimate of effect
37
moderate quality
Evidence quality rating
JNC8
RCTs w minor limitations affecting confidence in, or applicability of, the results
- well designed, well executed, non randomized controlled studies and well designed, well executed observational studies
well conducted meta analyses of such studies
- moderately certain about estimate of effect; further research may have an impact on our confidence in estimate of effect and may change the estimate
38
Low quality
Evidence quality rating
JNC8
RCTs w major limitations
non randomized controlled studies and observational studies w major limitations affecting confidence in, or applicability of, the results
uncontrolled clinical observations w out an appropriate comparison group (eg case series, case reports)
- physiologic studies in humans
- low certainty about estimate of effect; further research likely to have an impact on our confidence in the estimate of effect and is likely to change the estimate
39
Grade A
| Strength of recommendations
strong recommendation
there is high certainty based on evidence that net benefit (benefits minus the risks/harms of the service/intervention) is substantial
40
Grade B
| Strength of recommendations
moderate recommendation
there is moderate certainty based on evidence that net benefit is moderate to substantial
OR
there is high certainty that the net benefit is moderate
41
Grade C
| Strength of recommendations
weak recommendation
there is at least moderate certainty based on evidence that there is a small net benefit
42
Grade D
| Strength of recommendations
recommendation against
there is at least moderate certainty based on evidence that it has no net benefit
OR
that risks/harms outweigh benefits
43
Grade E
| Strength of recommendations
expert opinion (there is insufficient evidence or evidence is unclear or conflicting, but this is what the committee recommends)
net benefit is unclear. balance of benefits and harms cant be determined bc of no evidence, insufficient evidence, unclear evidence, or conflicting evidence, but the committee thought it was important to provide clinical guidance and make a recommendation
further research is recommended in this area
44
Grade N
| Strength of recommendations
no recommendation for or against ("there is insuffiicent evidence or evidence is unclear or conflicting)
net benefit is unclear. balance of benefits and harms cant be determined bc of no evidence, insufficient evidence, or conflicting evidence, and committee thought no recommendation should be made. further research is recommended in this area.
45
LIfestyle modifications achieve the following objectives:
1. reduce blood pressure
2. enhance anti hypertensive drug efficacy
3. decreases cardiovascular risks
46
Weight reduction
| Lifestyle modifications directly contribute to bp reduction!
approximate systolic bp reduction range: 5-20 mm hg/10 kg weight loss
47
DASH eating plan
Lifestyle modifications directly contribute to bp reduction!
approximate systolic bp reduction range: 8-14 mm Hg
48
Dietary sodium reduction
Lifestyle modifications directly contribute to bp reduction!
approximate systolic bp reduction range: 2-8 mm Hg
49
Physical activity
| Lifestyle modifications directly contribute to bp reduction!
approixmate systolic bp reduction range: 4-9 mm Hg
50
Moderation of alcohol consumption
| Lifestyle modifications directly contribute to bp reduction!
approximate systolic bp reduction range: 2-4 mm Hg
51
weight reduction
| 2013 working group on lifestyle change
maintain normal body weight (bmi 18.5-24.9 kg/m^2)
52
adopt DASH, USDA food pattern, or AHA eating plan
| 2013 working group on lifestyle change
consume a diet rich in fruits, vegetables, whole grains, poultry, fish, legumes, non-tropical vegetable oils
limit sweets, sugar sweetened beverages, and red meats
*strength of recommendation: strong*
53
dietary sodium reduction
| 2013 working group on lifestyle change
lower sodium intake
*strength of recommendation: strong*
reduce dietary sodium intake to 2.4 g sodium (6 g sodium chloride)
*strength of recommendation: moderate*
54
Combined DASH diet and lower sodium
| 2013 working group on lifestyle change
*strength of recommendation: strong*
55
Physical activity
| 2013 working group on lifestyle change
engage in moderate-to-vigorous aerobic physical activity such as brisk walking (3-4 sessions a week, lasting on average 40 minutes/session)
*strenght of recommendation: moderate*
56
moderation of alcohol consumption
| 2013 working group on lifestyle change
limit consumption to more than 2 drinks (24 oz beer, 10 oz wine, or 3 oz 80 proof whiskey) per day in most men, and to no more than 1 drink per day in women and lighter weight persons
57
Drug therapies for non-black population, including those with diabetes
- thiazide type diuretic
- calcium channel blocker (CCB)
- angiotensin converting enzyme inhibitor (ACEi)
- angiotensin receptor blocker (ARB)
strength of recommendation: B (moderate)
58
Initial drug therapy options for general black population, including those with diabetes
- thiazide type diuretic
- calcium channel blockers
for general black population: B (modrate)
for black patients with diabetes: C (weak)
59
Initial drug therapy options in CKD (all races, with or without diabetes mellitus)
-ACEi
- ARB
(initial or added to existing regimen, to improve kidney outcomes)
strength of recommendation: B (moderate)
60
Initial drug therapy options in patients presenting with systolic blood pressure > 160 or diastolic bp > 100
use any 2 meds (from different classes) simultaneously
"some committee members"
61
Initial drug therapies in most
for most patients: first line agent of choice is thiazide type diuretics
- found to have best reduction in morbidity and mortality in regards to htn
- have known benefits and side effect profiles with > 70 yrs of data
- are extremely inexpensive
62
If thiazide diuretics (as 1st agent) dont work...
if thiazide diuretics dont optimize blood pressure, continue the thiazide but add another agent from the following classes of antihypertensives: ACE inhibitor, ARBs, beta blockers, or calcium channel blockers
*all have been found to work synergistically with thiazide diuretics to reduce blood pressure and all have data demonstrating equivalent reduction of morbidity and mortality
63
Beta blockers in JNC 8
in contrast to practice prior to JNC 8, beta blockers are not recommended for initial drug therapy in any hypertensive patient (although beta blockers may be used as add on therapy)
64
Stage 2 hypertension
- stage 2 hypertensive pts rarely controlled on one class of meds alone
- acc to evidence, most require 2 drug combo (usually thiazide type diuretic + ACEi or ARB or BB or CCB)
- combo pills (ex losartan-hydrochlorothiazide, lisinopril-hydrochlorozide, etc.) can reduce pill burden for patients
65
special caution in initial combined therapy in those at risk for orthostatic hypotension...
elderly, diabetic patients, and patients w autonomic dysfunction (ex paraplegic patients)
66
Combo meds in newly diagnosed htn pts
some providers reluctant ; if there is a negative side effect, there may be difficulty in pinpointing which is the offending agent in a combo med
67
Goals of treating htn
- reduction of cardiovascular and renal morbidity and mortality
- treat to bp < 140/90 mm Hg in patients younger than 60 years, or patients with diabetes or chronic kidney disease
- achieve a systolic bp goal < 150/90 in persons > 60 years of age
68
Algorithm for treatment of htn
adults age >= 18 yrs w htn, general population (no diabetes or CKD)
implement lifestyle interventions (continue throughout management)
--> set blood pressure goal and initiate blood pressure lowering meds based on age, diabetes, and chronic kidney dz (CKD)
if age >=60 yrs : 150/90 bp goal is <60 yrs: bp goal is 140/90
if black: initiate thiazide type diuretic or ccb alone or in combo
if nonblack: initiate thiazide type diruetic or ACEi or ARB or CCB, alone or in combo
*drug treatment titration strategy*:
A. maximize first medication before adding second
OR
B. add second medication before reaching maximum dose of first med
OR
C. start with 2 med classes separately or as fixed dose combo
69
Algorithm for all (CKD, diabetes, general pop without those 2 conditions)
Select a drug treatment titration strategy
A. maximize first medication before adding second
OR
B. add 2nd med before reaching max dose of first me
OR
C. start w 2 med classes separately or as a fixed-dose combo
```
at goal bp?
if Yes, continue current treatment and monitoring
if No, reinforce med and lifestyle adherence; for strategies A and B, add and titrate thiazide type diuretic or ACEi or ARB or CCB (use med class not previously selected and avoid combo use of ACEi and ARB); for strategy C, titrate doses of initial meds to maximum
```
if still not at goal bp, reinforce med and lifestyle adherence, add and titrate thiazidue diuretic or ACEi or ARB or CCB (use med class not previously selected and avoid combo ACEi and ARB)
if still not at goal bp, reinforce med and lifestyle adherence, add additional med class (beta blocker, aldosterone antagonsit, or others) and/or refer to physician w expertise in htn mgmt
70
Algorithm for treatment of htn
adults age >= 18 yrs w htn, diabetes or CKD
all ages: diabetes present, no ckd: blood pressure goal: <140/90
for all races: initiate ACEi or ARB, alone or in combo with other drug class
71
Strategy A
| Strategies to combine and titrate antihypertensive drugs (thiazide,CCB, ACEi, ARB) to achieve goal bp
start one drug, titrate to maximu, then add 2nd
--> after adding 2nd drug, titrate up to max recommended dose; add 3rd drug if needed but dont use ACEi and ARB together and titrate up to max recommended dose
72
Strategy B
| Strategies to combine and titrate antihypertensive drugs (thiazide,CCB, ACEi, ARB) to achieve goal bp
start one drug and then add a 2nd drug before achieving max dose of initial one
--> after reaching max dose of both drugs, add 3rd drug if necessary (but dont use ACEi and ARB together) and titrate up to max recommended dose
73
Strategy C
| Strategies to combine and titrate antihypertensive drugs (thiazide,CCB, ACEi, ARB) to achieve goal bp
begin with 2 drugs at same time, as 2 separate pills, or as a single pill combo
--> some JNC8 committee members recommend starting w 2 drugs when sbp >160 and/or dbp > 100 or if SBp is > 20 above goal and/or dbp is > 10 above goal
--> after reaching max dose of both drugs, add 3rd drug if necessary (but dont use ACEi and ARB together) and titrate up to max recommend dose
74
The main objective of htn trtmt
attain and maintain goal bp
if goal bp not reached within 1 month of treatment, increase the dose of initial drug or add 2nd drug from any one of classes in recommended list (thiazide diuretic, ccb, ACEi, arb)
continue to assess bp and adjust trtmt until goal bp reached
recognize evidence behind each med is based on specific (*high*) target dose!
75
If goal bp cant be reached w 2 drugs...
add and titrate 3rd drug from list
dont use ACEi and ARB together in same pt!
if goal bp cant be reached using only drugs in JNC8 list bc of contraindication or need to use more than 3 drugs to reach goal bp, antihypertensive drugs from other classes can be used
--> referral to htn specialist may be indicated for pts in whom goal bp cant be attained using above strategy or for mgmt of otherwise complicated pts
76
What defines max dose for pts?
1. may be max dose allowed of a drug as set by pharma company or federal drug enforcement agency
ex: metoprolol whose initital starting dose is 25-50 mg/day and max allowed dose is 400 mg/day
2. max dose may be determined by drug's side effect profile
ex: metoprolol may have max allowed dose of 400 mg/day, however if pt pulse is 58 at a metoprolol dose of 50, then that is the max dose for pt due to bradycardia
3. max dose may also be determined by pt preference: pt may refuse to take sustained release nifedipine at 90 mg/day bc these pills are too large (but may be willing to take the smaller 60)
4. imp to cite in your clinical notes *why* a pt has achieved a max dose of an anti-hypertensive drug
77
Generic drugs
reduce costs to pts, institutions, and society!
use 24 hr formulations of meds whenever possible! allow 50% of med to still be in system 24 hrs later, and keep drug levels and bp levels that are constant all day
--> pts also prefer taking 1/day drug over those taken several times a day
- -> consider combo meds when pt achieved bp control w separate meds
ex: pt w excellent bp control on losartan 100 mg/day and hydrochlorothiazide 25 mg/day will have a reduced pill burden with 1 combo pill/day ofo both together
78
Tobacco
- nicotine increases blood pressure and reduces efficacy of blood pressure medications
- hypertensive patients should be vigorously encouraged towards smoking reduction and cessation at every visit by their physicians
79
Follow up and monitoring
- patients should return for monthly follow up and adjustment of meds until bp goal reached
- more frequent visits for stage 2 htn or complicating comorbid conditions
- serum K and cr should be monitored 1-2 times per year
- after bp is at goal an stalbe follow up visits 1-2x /yr
- though not mentioned, consider periodic rechecking fasting cholesterol panels and glucose, possibly urine microalbumin if initial surveillance was negative
80
Special considerations and diseases in selecting specific anti hypertensive med classes
```
CHF
post MI
high coronary artery dz risk
diabetes
chronic renal dz
recurrent stroke prevention
```
81
CHF (Heart failure)
Most providers may continue to use these compelling indications...
initial therapy options: thiaz, bb, acei, arb, aldo ant
clinical trials basis...
not ccb!
--> diuretics reduce heart failure, beta blockers reduce cardiac work demand, ACEi and ARBs reduce afterload
low dose aldo antagonists reduce morbidity and mortality in CHF but these agents should not be titrated to higher levels (as other bp meds) as they may be associated w neg outcomes
82
Post MI
| special considerations in choosing treatments
bb, acei, aldo ant
not thiaz or arb or ccb!
83
High CAD risk
| special considerations in choosing therapy
- thiaz, ace, ccb
not arb or aldo ant!
84
Diabetes
| special considerations
ace, arb (initial);
thiaz, bb, ccb (add on)
not aldo ant!
--> ACEi and ARBs are renal protective in addition to lowering bp (ideal 1st line choices for diabetes and ckd)
beta blockers in diabetics (contrary to common belief/teaching, do NOT mask hypoglycemia and are actually excellent reducers of morbidity and mortality)
85
Chronic kidney dz
| special considerations
acei, arb
not ccb, bb, thiaz, aldo ant!
--> ACEi and ARBs are renal protective in addition to lowering bp (ideal 1st line choices for diabetes and ckd)
86
Recurrent stroke prevention/stroke prevention
| special considerations for treatment
thiaz, acei
not arb, ccb, bb, aldo ant!
87
Thiazide diuretics (video transcript)
- may be a problem in urine incontinent patients or elderly who become urine incontinent
- studies show doses above 25 mg/day of hctz does not decrease bp or morbidity and mortality
- watch chemistry levels (hyponatremia or hypokalemia)
- avoid in gout pts
- start at lower dose in elderly who may be v sensitive
- may slow demineralization in osteoporosis
- may be associated w erectile dysfunction
88
Loop diuretics
- monitor electrolytes and creatinine
- start at lower doses in elderly
- not included in jnc8 trmt algorithm
89
Beta blockers
- check initial ekg and pulse
- dont have to avoid in diabetic pts
- excellent for use in tachyarrythmias /fibrillation, migraines, essential tremor, and perioperative hypertension
- usually avoid in pts w asthma and 3rd degree heart block
90
ACE inhibitors
- watch potassium (hyperkalemia), sodium (hyponatremia), and elevated Cr levels
- great for renal protection
- reduces microalbuminuria
- 1st line in renal dz
- shown to have direct heart remodeling effects
- a rise of up to 35% above baseline in creatinine is acceptable
- ACEi cough common in 15-20% of pts due to bradykinin production
- angioedema is serious side effect to monitor in patients
- avoid in pregnant women as they are category C drugs
91
ARBs
- reduces microalbuminuria and macroabluminuria
- shown to have heart remodeling effects
- avoid in pregnant pts as they are category C drugs
- less bradykinin production
92
Ca2+ channel blockers
- may be useful in Raynaud's syndrome
- may be useful in certain arrhythmias
- often causes leg edema (15-30% depending on diff studies)
- short acting ca channel blockers contraindicated for use in essential htn and hypertensive urgencies or emergencies!!!
93
Aldosterone antagonists and potassium sparing diuretics
- may cause hyperkalemia
- avoid in pts w K >= 5 prior to starting meds
- low dose aldo antagonists reduce morbidity and mortality in CHF pts but increase sudden death in higher doses!
94
Alpha blockers
- no proven decrease in morbidity and mortality demonstrated in research studies
- not mentioned in jnc7 or 8 algorithms for treatment of essential htn
- only useful as adjunct in hard to control blood pressure
- may be useful in prostatism but should not be used as 1st line anti-hypertensive in pts with BPH
95
Resistant hypertension (definition)
failure to reach goal bp in pts adhering to full dose of an approximate 3-drug regimen that includes a diuretic
96
Causes of resistant htn
- improper bp measurement
- excess sodium intake
- inadequate diuretic therapy
- medication: inadequate doses, drug actions and interactions (eg NSAIDs, illicit drugs, sympathomimetics, oral contraceptives), over the counter drugs and herbal supplements
- excess alcohol intake
- underlying identifiable causes of hypertension (secondary hypertension)
97
Women
| special populations
- not represented appropriately in cardiovascular research studies so they are a "special population"
- more likely than men to be aware that they have htn, to have medical treatment, and to have their bp under control
--> oral contraceptive pills can cause elevated bp
women w high bp should consider discontinuing ocps and using alternative form of contraception (to see if ocps are the cause)
- women on ocps should have their bp assessed every 6 months
- data on effect of menopause on bp is controversial (info mixed, nothing conclusive)
* while women respond to antihypertensives similarly to men, some special considerations may dictate treatment choices for women
- -> ACEi and ARBs may not be a good choice in women of reproductive age and/or may be trying to get pregnant
98
Minority populations
- treamtnet similar for all demographics in general but socioeconomic factors and lifestyle issues may be important barriers to bp control
- bp control rates lowest in mexican americans and native americans
- prevalence, severity, impact on htn is increased in african americans
- -> african americans demonstrate somewhat reduced bp response to monotherapy with bb's, ace i, or arbs compared to diuretics or ccb's
- differences usually eliminated by adding adequate doses of a diuretic!
bb, acei, and arbs still reduce morbidity and mortality from htn in african americans (renal protection, cardioprotection) separate from the bp levels
*african americans 2-4 x more likely to develop angioedema from ACEi than other groups*
99
Elderly
| special populations
- > 2/3 ppl over age 65 have htn
this pop has lowest rates of bp control!
treatment of elderly (including those w isolated systolic htn) should follow same principles outlined for general care of htn
lower initial drug doses may be indicated to avoid sx
standard doses and multiple drugs will be needed to reach bp targets!
elderly person starts at lower doses but ends up on as much bp med as younger person to control htn
100
Other special populations
- obesity and metabolic syndrome
- left ventricular hypertrophy
- peripheral arterial dz
- postural htn
- dementia
- hypertension in children and adolescents
- htn in urgencies and emergencies
