Treatment of HTN

Question 1

What is the goal BP for HTN patients?

Answer 1

140/90 or less if >65

130/80 or less if <125 / 75

Question 2

Why treat HTN? What are the benefits?

Answer 2

Reduces:
CVD-associated mortality
Risk of stroke
Risk of other coronary events

Thus improves QOL

Question 3

Who should be instructed on non-pharmacological methods to lower BP?

Answer 3

All patients

Some high-risk patients will need to be started on pharmacological treatment immediately, but all patients should modify lifestyle factors to further decrease CVD risk

Question 4

Drug therapy should be given to which patients?

Answer 4

Patients with sustained high initial readings
Patients with target organ damage (heart, retina, kidneys, brain)
Patients in whom non-pharmacological management has failed

Question 5

First, 2nd, then 3rd line drugs for HTN treatment

Answer 5

1. ACEI / ARB
OR 
CCB
OR
Low-dose thiazide (if 65 years or older)

2. If target not reached:
   ACEI + CCB
   OR
   ACEI + Thiazide (>65)
3. If target still not reached
   ACEI + CCB + Thiazide

Question 6

Guidelines for undergoing drug therapy

Answer 6

Start with single drug at low dose
Wait 4-6 weeks for full effect to become apparent
If ineffective:
Consider either raising dose, or adding another low-dose drug, or changing to another drug class
Use only 1 drug from a single class at a time

Question 7

What if HTN is refractory to treatment?

Answer 7

Re-consider that an underlying kidney or adrenal lesion may have been missed

Question 8

When to refer the HTN patient?

Answer 8

1. In refractory HTN
2. Suspected white coat HTN, for ambulatory monitoring
3. Severe HTN diastolic >115
4. Hypertensive emergency
5. If evidence of ongoing target organ damage
6. If there is significant kidney impairment
7. If a treatable cause of secondary HTN is found