Therapeutics of Hypertension Part 1

Question 1

HTN background

Answer 1

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

Question 2

Long-term consequences

Answer 2

Left ventricular hypertrophy
Angina or MI
Coronary revascularization
Heart failure
Stroke or TIA
Chronic kidney disease
Peripheral vascular disease
Retinopathy

Question 3

Essential HTN

Answer 3

elevated arterial blood pressure with an unknown etiology

Question 4

Secondary HTN

Answer 4

elevated arterial blood pressure due to concurrent medical conditions or medications (identifiable cause)

Question 5

Isolated systolic HTN

Answer 5

systolic BP values are elevated and diastolic BP values are not

Question 6

Resistant HTN

Answer 6

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

Question 7

Orthostatic HTN

Answer 7

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

Question 8

Essential HTN pathophysiology

Answer 8

Humoral abnormalities
Neuronal mechanisms
Vascular endothelial mechanisms
Peripheral autoregulation defects
Electrolyte disturbances

Question 9

Identify patients who would benefit from anti-hypertensive treatment.

Answer 9

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&raquo_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

Question 10

Substances that can increase BP

Answer 10

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)

Question 11

ACC/AHA BP strategies based on BP class and ASCVD risk

Answer 11

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

Question 12

BP thresholds for treatment initiation

Answer 12

clinical conditions: general and specific comorbidities

Question 13

Clinical CVD or 10 year ASCVD risk >/=10%

Answer 13

BP threshold: >/=130/80

Question 14

No clinical CVD and 10 years ASCVD risk <10%

Answer 14

BP threshold: >/= 140/90

Question 15

Older persons (>/= 65 yrs)

Answer 15

BP threshold: >/=130

Question 16

Diabetes mellitus

Answer 16

BP threshold: >/=130/80

Question 17

Chronic kidney disease

Answer 17

BP threshold: >/=130/80

Question 18

Heart failure

Answer 18

BP threshold: >/=130/80

Question 19

Stable ischemic heart disease

Answer 19

BP threshold: >/=130/80

Question 20

Secondary stroke prevention

Answer 20

BP threshold: >/= 140/90

Question 21

Peripheral arterial disease

Answer 21

BP threshold: >/=130/80

Question 22

HTN goals of treatment

Answer 22

decrease morbidity/mortality, reach BP targets, select agents with proven CV benefit

Question 23

BP goal

Answer 23

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

Question 24

Systolic BP intervention trial (SPRINT)

Answer 24

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

Question 25

Action to control cardiovascular risk in diabetes (ACCORD) BP arm

Answer 25

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

Question 26

Recommend non-pharmacological treatment options for hypertension

Answer 26

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)

Question 27

DASH diet

Answer 27

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

Question 28

Pharmacologic treatment options

Answer 28

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