Therapeutics of Hypertension Part 1 Flashcards
HTN background
Hypertension = persistently elevated arterial blood pressure (BP)
Majority of patients are asymptomatic
Most significant risk factor for cardiovascular disease (CVD)
By 2030 over 40% of Americans are projected to have hypertension
Long-term consequences
Left ventricular hypertrophy
Angina or MI
Coronary revascularization
Heart failure
Stroke or TIA
Chronic kidney disease
Peripheral vascular disease
Retinopathy
Essential HTN
elevated arterial blood pressure with an unknown etiology
Secondary HTN
elevated arterial blood pressure due to concurrent medical conditions or medications (identifiable cause)
Isolated systolic HTN
systolic BP values are elevated and diastolic BP values are not
Resistant HTN
fail to attain goal BP while adherent to a regimen that includes at least 3 agents at maximum dose (including a diuretic) or when 4 or more agents are needed
Orthostatic HTN
a systolic blood pressure decrease of > 20 mmHg, a diastolic blood pressure decrease of > 10 mmHg within three minutes of positional change, and/or increase in heart rate > 20 bpm
Essential HTN pathophysiology
Humoral abnormalities
Neuronal mechanisms
Vascular endothelial mechanisms
Peripheral autoregulation defects
Electrolyte disturbances
Identify patients who would benefit from anti-hypertensive treatment.
risk factors: modifiable - High sodium intake; Obesity; Low potassium intake; Excess alcohol intake; non-modifiable - Age, Ethnicity, Genetic predisposition, Gender: Age < 55: Male > Female; Age 55 – 64: Female > Male; Age > 64: Female»_space; Male
secondary HTN: Food/substances (sodium, ethanol); Pheochromocytoma; Cushing’s syndrome/chronic steroid use; Thyroid or parathyroid disease; Aortic coarctation; Chronic kidney disease; Renovascular disease; Primary aldosteronism; Obstructive sleep apnea; Drug-induced
Substances that can increase BP
Illicit drugs (cocaine, ecstasy)
Caffeine
Nicotine
Decongestants (pseudoephedrine, phenylephrine)
Amphetamines (methylphenidate, dextroamphetamine, amphetamine)
Antidepressants (MAOIs, SNRIs, TCAs)
Atypical antipsychotics (clozapine, olanzapine)
Immunosuppressants (cyclosporine)
Oral contraceptives (estrogens, androgens, progesterone)
NSAIDs (ibuprofen, naproxen, etc.)
Systemic steroids (methylprednisolone, prednisone, prednisolone, dexamethasone)
Oncology agents (angiogenesis inhibitors, tyrosine kinase inhibitors)
ACC/AHA BP strategies based on BP class and ASCVD risk
normal BP <120/80 –> promote healthy lifestyle –> reassess in 1 year
elevated BP 120-129/<80 –> non-pharmacological treatment –> reassess in 3-6 months
stage 1 130-139/80-90 –> ASCVD risk >/= 10% or a specific comorbidity –> yes: non-pharmacological and medication, reassess in 1 month; no: non-pharmacological treatment, reassess in 3-6 months
stage 2 >/=140/90 –> non-pharmacological + 2 meds –> reassess in 1 month
HTN pts at goal should have follow-up every 3-6 months
BP thresholds for treatment initiation
clinical conditions: general and specific comorbidities
Clinical CVD or 10 year ASCVD risk >/=10%
BP threshold: >/=130/80
No clinical CVD and 10 years ASCVD risk <10%
BP threshold: >/= 140/90
Older persons (>/= 65 yrs)
BP threshold: >/=130
Diabetes mellitus
BP threshold: >/=130/80
Chronic kidney disease
BP threshold: >/=130/80
Heart failure
BP threshold: >/=130/80
Stable ischemic heart disease
BP threshold: >/=130/80
Secondary stroke prevention
BP threshold: >/= 140/90
Peripheral arterial disease
BP threshold: >/=130/80
HTN goals of treatment
decrease morbidity/mortality, reach BP targets, select agents with proven CV benefit
BP goal
ACC/AHA: <130/80 - may consider <140/90 in elderly frail pts with high comorbidity burden and limites life expectancy based on clinical judegement
ADA: <130/80
KDIGO: SBP <120 for adults with elevated BP and CKD, if tolerated
Systolic BP intervention trial (SPRINT)
9,361 participants WITHOUT diabetes or prior stroke
BP goals
Intensive Group: <120 mmHg
Standard Group: <140 mmHg
Average achieved BP
Intensive Group: 121.4 mmHg
Standard Group: 136.2 mmHg
Primary composite outcome (MI, ACS, stroke, heart failure, and CV death)
25% lower risk in intensive group
Reduced risk of death by 27%
2.8 medications needed on average in intensive group
Increased risk of electrolyte abnormalities, hypotension, and acute kidney injury
Action to control cardiovascular risk in diabetes (ACCORD) BP arm
4,733 participants WITH type 2 diabetes age 40-79 years with CVD or multiple CVD risk factors
BP goals
Intensive Group: <120 mmHg
Standard Group: 130-140 mmHg
Average achieved BP
Intensive Group: 119.3 mmHg
Standard Group: 133.5 mmHg
Primary composite outcome (MI, stroke, and CV death)
No benefit
Reduced risk of stroke by 41%
Increased risk of adverse events
Recommend non-pharmacological treatment options for hypertension
weight loss, DASH diet, decrease sodium intake (<1500 mg/day or 1000 mg reduction per day), enhance dietary potassium intake (3500-5000 mg/day), physical activity (aerobic, resistance), moderation in alcohol intake (men </= 2 drinks daily, women </= 1 drink daily)
DASH diet
Recommend:
Vegetables and fruits
Whole grains
Fat-free or low-fat dairy products
Fish, poultry, beans
Nuts and vegetable oils
Foods rich in potassium, calcium, magnesium, fiber, protein, and lower in sodium(1500 mg/day)
Limiting foods that are:
High in saturated fat (fatty meats, full-fat dairy products, tropical oils)
Sugar-sweetened beverages and sweets
Pharmacologic treatment options
Angiotensin-converting enzyme inhibitors (ACEi)
Angiotensin receptor blockers (ARBs)
Calcium channel blockers (CCB)
Direct renin inhibitors
Beta blockers
Diuretics (thiazide, loop, K+ sparing, aldosterone antagonists)
Alpha 1 blockers
Central alpha 2 agonists
Vasodilators
