Hypertension Flashcards
1
Q
Hypertension definition
A
Defined as two elevated blood pressures on two or more visits
Systolic >140 mmHg
Diastolic >90 mmHg
2
Q
HTN screening - how, when
A
Patients should be seated, comfortable with back and feet supported, arm supported at heart level
Adults should be screened at each visit
No recommendations for screening asymptomatic children
3
Q
HTN Exam includes:
A
Exam should include
Heart and lung sounds
Orthostatics (especially if on medication, elderly)
Neuro exam
Fundoscopic exam
Peripheral vascular exam (check for bruits, peripheral pulses)
4
Q
HTN Labs:
A
Diagnostics
ECG
Labs: CBC, BMP, LFTs, Lipids, TSH, UA
5
Q
How is BP usually mediated via meds?
A
Must understand how blood pressure is mediated to prescribe medications
Most patients require 2 medications for blood pressure control, need to understand how medications can work together
6
Q
Name 5 mechanisms/ etiologies of HTN
A
Mechanisms of hypertension Hypervolemia Na retention Increased cardiac output Tachycardia Increased vascular tone
7
Q
Major changes from JNC VIII?
A
Major changes in JNC VIII
More evidenced based as opposed to expert opinion
Less stringent guidelines for BP in patients 65-79 y/o
Thresholds for initiating pharmacologic treatment
Can start with multiple classes of medicatons
8
Q
Stages of HTN
A
Normal:
PREHTN:
HTN, STAGES:
I
II
9
Q
Types of HTN and etiologies
A
Primary
Most common
No identifiable cause or cure
Secondary
Caused by drug, disease, or other identifiable cause
Oral contraceptives, cocaine or other stimulant abuse, pheochromocytoma, sleep apnea, thyroid disease
Curable once cause is identified
10
Q
Common side effects of HTN
A
Some common side effects:
All can cause headache, dizziness, syncope, hypotension
11
Q
Monitoring parameters
A
Common monitoring parameters:
Blood pressure, most need BMP
12
Q
Name the 7 general (broad) categories of HTN RX choices:
A
- Diuretics
- Beta-Blockers (“Sympatholytics”)
a) alpha 2 agonists
b) alpha 1 ANTAGONISTS
c) beta 1 ANTAGONISTS
d) mixed alpha/beta ANTAGONISTS - Vasodilators
- Calcium Channel Blockers
- Angiotensin Converting Enzyme Inhibitors
- Angiotensin Receptor Blockers
- Renin Inhibitors
13
Q
Name the 3 types of Diuretics
A
- Thiazide
- K+ sparing
- Loop
14
Q
Thiazide Diuretics: Names, MOA
A
Hydrochlorothiazide, chlorthalidone Developed in the late 1950’s, one of the oldest class of antihypertensives Mechanism of action: inhibits Na reabsorption in distal renal tubule causing increased H2O, as well as Na, K, and H Decreased circulating volume = lower bp
15
Q
Thiazide Diuretics: Pharmacokinetics
A
Pharmacokinetics Good PO absorption Causes diuresis in approximately 2 hours, antihypertensive effects seen in 3-4 days Up to 68% protein bound Not metabolized Excreted in urine as unchanged drug
16
Q
**Important! THINK when someone is on a THIAZIDE… what are you concerned about (monitoring)?
A
Electrolyte imbalances/ monitor BMP!
Get a BMP at initiation of RX and periodically
17
Q
Side effects of Thiazides:
A
Side effects: hypokalemia, hypomagnesmia, pancreatitis, hyperglycemia, phototoxicity
18
Q
**Emphasis of MOA for Thiazides
A
Decreased circulating volume = lower bp
19
Q
**Emphasis of timing to take meds
A
Take in AM because…
Causes diuresis in approximately 2 hours, antihypertensive effects seen in 3-4 days
20
Q
Contraindications for Thiazides:
A
anuria, sulfa allergy
21
Q
Pregnancy category for Thiazides, indications for BFEED and PEDS?
A
Safe in pregnancy (category B), excreted in breast milk but safe in breastfeeding (might decrease milk production though), safe in pediatrics
22
Q
K+ Sparing Diuretics: names and MOA
A
Spironolactone (Aldactone), Triamterene (Dyrenium)
Mechanism of action: competitively binds to aldosterone-dependent Na/K exchange site in distal convoluted tubule, causing increased H2O excretion (S); directly blocks Na reabsorption in distal renal tubule (T)
23
Q
**K+ Sparings: emphasis on monitoring K+
A
while K+ sparing diuretics have no impact on lowering the K+, there can be an INCREASED K+ so watch out!
24
Q
K+ Sparing: pharmacokinetics
A
Pharmacokinetics Well absorbed PO (~70% bioavailibility) VERY protein bound (90%, spironolactone; 67% triamterene) Metabolized in liver and kidneys Excreted in both urine and stool
25
K+ Sparing: monitoring parameters
BMP
26
K+ Sparing: adverse effects
Adverse effects: rash, photosensitivity, thrombocytopenia, Stevens-Johnson Syndrome
27
K+ Sparing: because they are highly PROTEIN BOUND.... WHO are you most worried about taking this type of diuretic?
VERY protein bound (90%, spironolactone; 67% triamterene)
SO in liver disease, when they are not producing enough circulating proteins for the drug to bind....
worry about TOO MUCH FREE DRUG ie TOXICITY!
28
K+ Sparing: Contraindications:
Contraindications: anything that can cause hyperkalemia (Addison’s disease), anuria, liver disease
29
K+ Sparing Pregnancy category/ BFEED/ PEDS?
Safe in pregnancy (category B), excreted in breast milk but safe in breastfeeding (might decrease milk production though), safe in pediatrics
30
K+ Sparing Pregnancy category/ BFEED/ PEDS?
Category C in pregnancy, not for use in breastfeeding, off label in pediatrics
31
Diuretics: Loop- name, MOA
Furosemide (Lasix), torsemide (Demedex)
Not great antihypertensives, NOT first line
Mechanism of action: inhibits Na and Cl reabsorption in proximal and distal tubules and loop of henle
32
**Emphasis: Loops are NOT first line for HTN but usually seen with...
CHF
33
**Emphasis: Loop diuretics are selective: YES OR NO and why is this important?
Loop diuretics are NOT selective, so....
| WATCH THE K+! MONITOR BMP!
34
Loop Diuretics: Pharmacokinetics
Pharmacokinetics
Good PO absorption (64% bioavailability)
VERY protein bound (99%)
Metabolized in liver, excreted in urine
35
Loop Diuretics: monitoring parameters
Monitoring parameters: BMP (especially K) but also Ca, Mg
36
Loop Diuretics: Adverse Effects
Adverse effects: muscle cramps, glucose intolerance, rash, gout
37
** Emphasis- Loop Diuretics: pregnancy categories/ BFEED/ PEDS?
Furosemide is C in pregnancy, torsemide B; do not use either in lactation, torsemide not approved in pediatrics
38
Sympatholytics- Beta Blockers- name 2 centrally-acting alpha-2 agonists
1. Clonidine (Catapres)
| 2. Methyldopa (Aldomet)
39
Clonidine (Catapres) - MOA and PK
Mechanism of action: alpha-2 agonist in CNS, decreasing sympathetic outflow ( HR, vascular tone = BP)
Pharmacokinetics
Well absorbed PO (85% bioavailibility)
Metabolized in liver, excreted in urine
40
Clonidine (Catapres)- side effects and contraindications
Side effects: dry mouth, anxiety, constipation, rash, abnormal LFTs
Contraindications: rash
41
Clonidine (Catapres) - monitoring parameters
Monitoring Parameters: LFTs
42
**Emphasis: Clonidine (Catapres) - pregnancy category, BFEED/ PEDS?
Safe in pregnancy, not recommended in breastfeeding, approved for use in pediatrics >12 y/o
43
Methyldopa (Aldomet)- MOA and PK
BASIC WAY TO SAY IT: AFFECTS CASCADE OF EVENTS
Mechanism of action: Alpha 2 agonist in CNS, which decreases sympathetic outflow ( HR, vascular tone = BP); also a competitive inhibitor of DOPA decarboxylase, which converts L-DOPA to dopamine, a precursor to norepi and epi, so less norepi/epi, less adrenergic effects.
Pharmacokinetics
Well absorbed PO (50% bioavailability)
Minimal protein binding
Mretabolized in liver, excreted in urine (small amount in stool)
44
Methyldopa (Aldomet)- side effects and contraindications
Side Effects: depression, anxiety, parkinsonism (because of antidopaminergic effects); hyperprolactinemia, gynecomastia, rash, hemolytic anemia
Contraindications: liver disease, concomitant use of MAOIs, pheochromocytoma
45
**Emphasis- Methyldopa (Aldomet) - because of these side effects, what other diseases in a pt can be affected?
Be careful with Psych and Parkinson's pts because of the antidopaminergic affects/ parkinsonism side effects
46
Methyldopa (Aldomet)- monitoring parameters
Monitoring parameters: CBC, LFTs
47
Methyldopa (Aldomet) - pregnancy and BFEED/ PEDS?
Very safe in pregnancy and breastfeeding, approved for use in pediatrics
48
Alpha 1 ANTAGONISTS: name, MOA, PK
Doxazosin (Cardura), terazosin (Hytrin)
Mechanism of Action: blocks postsynaptic alpha-1 receptors causing arterial, arteriolar, and venous dilation, decreasing peripheral resistance
Pharmacokinetics
Good PO absorption, up to 90% bioavailability
VERY protein bound, up to 99%
Metabolized extensively in liver
Excreted in urine
49
Doxazosin (Cardura), Terazosin (Hytrin)- side effects and contraindications
Side effects: dizziness, fatigue, dose-related orthostasis (first dose effect)
Contraindications: severe liver disease,
50
Doxazosin (Cardura), Terazosin (Hytrin)- monitoring parameters
Monitoring parameters: LFTs, urinary symptoms in BPH
51
Doxazosin (Cardura), Terazosin (Hytrin)- pregnancy category, BFEED/ PEDS?
Category C in pregnancy, unknown if excreted in breast milk, so avoid, off-label in pediatrics
52
** Emphasis: Doxazosin (Cardura), Terazosin (Hytrin)- side effect to remember
"First Dose Effect;" dose-related orthostasis
53
Doxazosin (Cardura), Terazosin (Hytrin)- pregnancy category, BFEED/ PEDS?
Category C in pregnancy, unknown if excreted in breast milk, so avoid, off-label in pediatrics
54
Doxazosin (Cardura), Terazosin (Hytrin)- great option in what pt population?
Men with BPH
55
BETA-1 ANTAGONISTS: names, MOA, PK:
| Are they selective or not?
Propranolol (Inderal), nadolol (Corgard)
Mechanism of action: block stimulation of beta-1 and beta-2 adrenergic receptors Pharmacokinetics:
Fair PO absorption (Maximum 40% bioavailability)
Minimally protein bound (nadolol), propranolol 90% protein bound in adults, 68% newborns
Not metabolized (nadolol), metabolized in liver via CYP2D6 (propranolol)
Excreted in urine (both)
**they are NONSELECTIVE
56
**Emphasis: Propranolol (Inderal), Nadolol (Corgard): Because they are NONSELECTIVE, in what pt populations should you avoid use?
```
AVOID in pts with:
ASTHMA
COPD
BRADYARRYTHMIAS
**can cause bronchoconstriction, and compete with Albuterol/ rescue inhalers
```
57
Propranolol (Inderal), Nadolol (Corgard): side effects and contraindications
Side Effects: fatigue, depression, constipation, Raynaud phenomenon, ED
Contraindications: asthma, COPD, bradyarrhythmias
58
Propranolol (Inderal), Nadolol (Corgard): Monitoring parameters
Monitoring parameters: BP, HR
59
**Emphasis: Propranolol (Inderal), Nadolol (Corgard): Special notes-
Must taper dose, abrupt withdrawal can exacerbate cardiac ischemia and precipitate an MI
60
Propranolol (Inderal), Nadolol (Corgard): Pregnancy category, BFEED/ PEDS?
Category C in pregnancy, drug excreted in breast milk but safe per AAP (both propranolol and nadolol). Propranolol off label in pediatrics, Nadolol not approved for use in pediatrics
61
SELECTIVE BETA-1 ANTAGONISTS- names, MOA, PK
Atenolol (tenormin), metoprolol (Toprol XL, Lopressor)
Mechanism of action: block stimulation of beta-1 adrenergic receptors with little to no effect on beta-1 receptors
Pharmacokinetics:
Good PO absorption ( up to 70% bioavailability)
Minimally protein bound (maximum 16%)
Metabolized in liver, metoprolol via CYP2D6
Excreted in urine
62
Atenolol (Tenormin), Metoprolol (Toprol XL, Lopressor)- side effects, contraindications
Side Effects: fatigue, depression, constipation, Raynaud phenomenon
Monitoring parameters: BP, HR
Contraindications: asthma, COPD, bradyarrhythmias
**(these are safer b/c they are selective, but consider options other than B-Blockers in these pts...)
63
Atenolol (Tenormin), Metoprolol (Toprol XL, Lopressor)- monitoring parameters
Monitoring parameters: BP, HR
64
Atenolol (Tenormin), Metoprolol (Toprol XL, Lopressor)- Pregnancy category/ BFEED/ PEDS?
Category C in pregnancy, drug excreted in breast milk but safe per AAP (metoprolol), do not breastfeed with atenolol. Metoprolol safe in pediatrics, Atenolol off-label
65
**Emphasis: Atenolol (Tenormin), Metoprolol (Toprol XL, Lopressor)- Special Notes
Must taper dose, abrupt withdrawl can exacerbate cardiac ischemia and precipitate an MI
66
ALPHA/BETA MIXED ANTAGONIST: name, MOA, PK
Mechanism of Action: nonselective beta antagonist with additional alpha antagonism
Pharmacokinetics
Poor PO absorption (25% bioavailability)
50% protein bound
Metabolized via conjugation to glucuronide metabolites
Excreted in urine
67
Labetolol (Trandate): side effects, contraindications, monitoring parameters
Side effects: tingling sensation on scalp (decreases with use), fatigue, depression, elevated LFTs
Monitoring parameters: LFTs
Contraindications: asthma, COPD, bradyarrhythmias
68
Labetolol (Trandate) Pregnancy category/ BFEED/ PEDS
Category C in pregnancy, safe in breastfeeding, off-label in pediatrics
69
Vasodilators: 2 names
Hydralazine and Nipride (Nitroprusside Sodium)
70
Hydralazine: MOA, PK
Hydralazine
Mechanism of action: directly vasodilates arterioles with little effect on veins, decreasing systemic vascular resistance
Pharmacokinetics
Good PO absorption, up to 50% bioavailability
VERY protein bound (up to 90%)
Metabolized in liver, excreted in urine
71
Hydralazine: SE's, C/I
Side effects: palpitations, headache, psychotic reaction, N/V/D, thrombocytopenia, leukopenia, hepatotoxicity
Monitoring Parameters: CBC, LFTs
Contraindications: dissecting aortic aneurysm, mitral valve rheumatic heart disease
72
Hyrdalazine: Pregnancy category/ BFEED / PEDS
Category C in pregnancy, not for use in breastfeeding, safe in pediatrics
73
**Emphasis: most common SE's for Hydralazine
palpitations and HA
74
**EMphasis: Hydralazine/ vasodilators C/I in pts with known....
dissecting aortic aneurysm
75
Nitroprusside Sodium (Nipride): MOA, PK
Mechanism of action: relaxes vascular smooth muscle to reduce preload and afterload by producing NO, also dilates coronary arteries
Pharmacokinetics:
IV only, rapid onset (within 2 min), short duration (max 10 min)
Metabolized in the blood; ferrous ion in nitroprusside reacts with sulfhydryl compounds in RBCs causing cynaide release, metabolized in liver and kidney into thiocyanate
Excreted in urine
76
Nitroprusside Sodium (Nipride): SE's, C/I
Side effects: cardiac arrythmias, rash, thyroid suppression, cyanide poisoning
77
Nitroprusside Sodium (Nipride): Monitoring parameters
Monitoring parameters: blood pressure, SpO2 (for cyanide toxicity monitoring, thiocyanate levels
78
Nitroprusside Sodium (Nipride): Pregnancy category / BFEED/ PEDS
Category C in pregnancy, not for use in breastfeeding. Safe in pediatrics, max dose of 10 mcg/kg/min (6 mcg/kg/min in neonates)
79
**Emphasis: Nitroprusside Sodium (Nipride) used in ...
severe hypertensive crises only, not used in outpatient!
80
Calcium Channel Blockers: Dihydropyridines-
| Names, MOA, PK
Amlodipine (Norvasc), nifedipine (Procardia)
Mechanism of action: inhibits transmembrane influx of extracellular calcium ions across myocardial and vascular smooth muscle, thereby inhibiting cardiac and vascular smooth muscle contraction and causes vasodilation
Pharmacokinetics
Good PO absorption (up to 89%)
VERY protein bound (98%)
Metabolized in liver via CYP3A4
Excreted in urine and stool
81
Amlodipine (Norvasc), Nifedipine (Procardia): SE's and C/I, monitoring parameters
Side effects: peripheral edema (can be severe, especially in women), flushing, Stevens-Johnson Syndrome, photosensitvity
Monitoring Parameters: LFTs
Contraindications: concominant use with strong CYP3A4 inducers (reduces drug effect)
82
Amlodipine (Norvasc), Nifedipine (Procardia): Pregnancy category, BFEED, PEDS
Category C in pregnancy, manufacturer states drug excreted in breast milk and to stop breastfeeding, but per AAP it is safe in breastfeeding (nifedipine), amlodipine not recommended in breastfeeding. Not FDA approved in children
83
**EMphasis- Amlodipine (Norvasc), Nifedipine (Procardia):
| most common SE
flushing
84
**Emphasis: Amlodipine (Norvasc), Nifedipine (Procardia):
| re-phrase MOA in simpler terms....
basically inhibits heart's ability to contract leading to vasodilation
85
**Emphasis: Amlodipine (Norvasc), Nifedipine (Procardia):
| how would you handle a child?
Call a pediatrician; not FDA approved in peds
86
Calcium Channel Blockers: Nondihydropyridines:
| Names, MOA, PK
Verapamil (Calan), diltiazem (Cardizem)
Also have antiarrythmic properties
Mechanism of action: same as dihydropyridines, also blocks slow Ca current for sinus and AV node repolarization (good for tachyarrythmias)
Pharmacokinetics
Fair PO availability (40% diltiazem, 20-35% verapamil)
VERY protein bound (80% diltiazem, 98% verapamil)
Metabolized in liver via CYP3A4 (both)
Excreted in urine
87
**Emphasis- Verapamil (Calan), Diltiazem (Cardizem): also great for....
Great for tachyarrhythmias/ has antiarrhythmic properties
88
Verapamil (Calan), Diltiazem (Cardizem): SE's, C/I
Side effects: peripheral edema, gingival hyperplasia, headaches, flushing, constipation
Contraindications: history of bradyarrythmias, CHF, avoid IV diltiazem in newborns (contains benzyl alcohol)
89
Verapamil (Calan), Diltiazem (Cardizem): Monitoring parameters
Monitoring Parameters: BP, EKG
90
Verapamil (Calan), Diltiazem (Cardizem): Pregnancy, BFEED, PEDS
Category C in pregnancy, excreted in breast milk, but AAP states it is compatible with nursing, Diltiazem off-label in pediatrics, verapamil only approved for SVT in pediatrics
91
ACE-INHIBITORS: Names, MOA, PK
Lisinopril (Zestril), trandolopril (Mavik)
Mechanism of action: prevents conversion of angiotensin I to angiotensin II; angiotensin II is powerful vasoconstrictor and increases aldosterone activity
Angiotensin II will increase systemic vascular resistance, thereby increasing preload/afterload
Pharmacokinetics
Poor PO absorption (25% bioavailability)
Minimally protein bound (lisinopril), 80% (trandolapril)
Not metabolized, excreted in urine (lisinopril)
Metabolized by liver, excreted in urine and stool (trandolapril)
92
Lisinopril (Zestril), Trandolopril (Mavik): SE's, C/I
Side effects: COUGH, hyperkalemia, angioedema
| Contraindications: bilateral renal artery stenosis
93
**Emphasis: Lisinopril (Zestril), Trandolopril (Mavik): rephrase MOA in simpler terms...
stops conversion from angiotensin I> angiotensin II, essentially decreasing peripheral resistance and causing vasodilation
94
**Emphasis: Lisinopril (Zestril), Trandolopril (Mavik): most COMMON SE
COUGH!!! "ACE-I cough"
95
**Emphasis: Lisinopril (Zestril), Trandolopril (Mavik):
| monitoring parameters
BMP (r/t SE of hyperkalemia)
96
Lisinopril (Zestril), Trandolopril (Mavik): Pregnancy, BFEED, PEDS
Not safe in pregnancy or breastfeeding, lisinopril off label for use in pediatrics >6 y/o, trandolapril not safe in pediatrics
97
ANGIOTENSIN RECEPTOR BLOCKERS (ARB's)-
| Names, MOA, PK
Losartan (Cozaar), olmesartan (Benicar)
Mechanism of action: blocks binding of angiotensin II to receptors, which blocks the vasconstricing and aldosterone-secreting effects of angiotensin II
Pharmacokinetics
Poor PO absorption (25% bioavailibility)
VERY protein bound (98%)
Metabolized in liver via CYP2C9 (Losartan), olmesartan de-esterfied in intestinal wall only, no liver metabolism
Excreted in urine (losartan), urine and stool (olmesartan)
98
Losartan (Cozaar), Olmesartan (Benicar): SE's, C/I and monitoring parameters
Side effects: hypoglycemia, anemia, cough, angioedema
Monitoring Parameters: BMP, CBC
Contraindications: allergy
99
Losartan (Cozaar), Olmesartan (Benicar): Pregnancy, BFEED, PEDS
Do not use in pregnancy, breastfeeding, avoid use in patients >6 y/o
100
**Emphasis: Losartan (Cozaar), Olmesartan (Benicar)-
| re-phrase MOA...
works in a slightly different area than ACE-I's; actually blocks the receptors for angiotensin II
101
RENIN INHIBITORS: name, MOA, PK
Aliskiren (Tekturna)
New, only drug in its class
Mechanism of action: inhibits conversion of angiotensinogen to angiotensin I, which causes decrease in angiotensin II
Pharmacokinetics
Poor PO absorption ( 3% bioavailibilty), reduced when taken with high fat meal
Metabolized in liver via CYP3A4
Excreted in urine
Needs 2 weeks for antihypertensive effect
102
Aliskiren (Tekturna): SE's, C/I, monitoring parameters
Side effects: Diarrhea, cough, rash, hyperkalemia, increased serum creatinine, angioedema
Monitoring Parameters: BMP
Contraindications: do not use in patients already taking an ACEI or an ARB in patients with DM (increased risk of stroke, renal complications, hyperkalemia, hypotension)
**ALL OF THESE working on same cascade of events**
103
Choosing an Antihypertensive
BP goal depends on age, presence of diabetes/CKD
Age 60 or older, no diabetes or CKD
BP goal
104
**Emphasis: in choosing an antihypertensive in African Am population, what are you considering?
Protect the kidneys! Possibly consider TX sooner in Afr Am pop... they are more prone to renal disease at younger ages.
105
Best choice for Afr Am pt with NO DM or CKD
Thiazide diuretic and/ or CCB
106
Best choice for someone with renal disease, with or without DM- all ages- all races-
ACE-I or ARB
107
Choosing an anti-HTN RX for:
| pt with HX MI
Needs a beta blocker to reduce sympathetic stimulation and ACEI to reduce cardiac remodeling
108
Choosing an anti-HTN RX for:
| pt with DM
ACEI are renal-protective, so these are often the best choice for these patients
Beta blocker not a great option, can mask early symptoms of hypoglycemia
109
Choosing an anti-HTN RX for:
| pt with HX migraines, anxiety, palpitations/ tachyarryhthmias
Often do well with a beta blocker that reduces sympathetic stimulation
110
Choosing an anti-HTN RX for:
| pregnancy
Methyldopa, labetalol first choices
| Beta blockers and diuretics probably safe
111
Choosing an anti-HTN RX for:
| BFEEDING MOM
Diuretics and beta blockers
| Often on methyldopa or labetalol for pregnancy, fine to continue
112
Choosing an anti-HTN RX for:
| PEDS
ACEI, metoprolol, amlodipine, ARB if >6 y/o, otherwise propranolol, hydralazine best choices
Keep in mind most classes have at least one option, so there are many choices for treating hypertension in your pediatric patients!
113
Pt's BP not at goal? Pros/Cons of single agent-
Maximize dose on single agent
Pros: staying with one drug, might increase compliance, cheaper
Cons: may have to add another medication even on increased dose
114
Pt's BP not at goal? Pros/Cons of additional agent-
Add additional agent
Pros: combination therapy allows patients to be on lower doses of medications
Cons: patients often feel like a failure, may reduce compliance as pill count increases, cost increases
115
If pt BP very high to begin with....
If BP very high initially start with two agents and choose one to modify
116
**Emphasis from JNC VIII:
| If pt BP very high to begin with....
If BP very high initially start with two agents and choose one to modify
