ACCERLERATED HYPERTENSION

Dr. Sachin Verma MD, FICM, FCCS, ICFCFellowship in Intensive Care Medicine

Infection Control Fellows Course Consultant Internal Medicine and Critical Care

Ivy Hospital Sector 71 MohaliWeb:- http://www.medicinedoctorinchandigarh.com

Mob:- +91-7508677495 1

Hypertension is defined as a usual BP of 140/90 mm Hg or more.

In children and adolescents Hypertension ▬ average SBP and/or DBP is

≥95th percentile for sex, age, and height on 3 or more occasions.

Prehypertension ▬Children with average SBP or DBP levels are

≥90th percentile, but <95th percentile.Adolescents with BP levels ≥120/80 mmHg.

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Blood Pressure Classification

Blood Pressure Classification

SBP mmHgDBP mmHg LifestyleModification

Initial drug therapy

Without CompellingIndication

With CompellingIndications

Normal <120 and <80  EncourageNo antihypertensivedrug indicated.

Drug(s) for compellingindications.‡Prehypertension 120–139 or 80–89  Yes

Stage 1 hypertension

140–159 or 90–99  Yes Thiazide-type diureticsfor most. May considerACEI, ARB, BB, CCB,or combination.

Drug(s) for the compellingindications.‡Other antihypertensivedrugs (diuretics, ACEI,ARB, BB, CCB)as needed.

Stage 2 hypertension

≥160 or ≥100  Yes Two-drug combinationfor most† (usuallythiazide-type diureticand ACEI or ARB or BBor CCB).

Isolated systolic hypertension

≥140 and <90 

* Treatment determined by highest BP category.

† Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.

‡ Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.

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Classification of blood pressure

This classification of BP is for adults ages 18 and older.

The classification is based on the average of two or more properly measured, seated BP readings on each of two or more office visits.

Patients with prehypertension are at increased risk for progression to hypertension; those in the 130–139/80–89 mmHg BP range are at twice the risk to develop hypertension as those with lower values.

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Hypertensive crises encompass a spectrum of clinical presentations where uncontrolled BPs lead to progressive or impending target organ dysfunction (TOD).

Hypertensive emergency represent severe HTN with acute impairment of an organ system (eg, central nervous system, cardiovascular, renal). In these conditions, the BP should be lowered aggressively within 1 hours.

Hypertensive urgency is defined as a severe elevation of BP, without evidence of progressive TOD. These patients require BP control over several days to weeks.

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Accelerated-Malignant Hypertension

A syndrome associated with an abrupt increase of blood pressure in a patient with underlying hypertension or related to the sudden onset of hypertension in a previously normotensive individual.

When the rise in pressure causes retinal hemorrhages, exudates, or papilledema, the term accelerated-malignant hypertension is used

The absolute level of blood pressure is not as important as its rate of rise.

Pathologically, the syndrome is associated with diffuse necrotizing vasculitis, arteriolar thrombi, and fibrin deposition in arteriolar walls (arterioles of kidney, brain, retina, and other organs).

Clinically, the syndrome is recognized by progressive retinopathy (arteriolar spasm, hemorrhages, exudates, and papilledema), deteriorating renal function with proteinuria, microangiopathic hemolytic anemia, and encephalopathy.

In these patients, historic inquiry should include questions about the use of monamine oxidase inhibitors and recreational drugs (e.g., cocaine, amphetamines). 7

Why is it Important to control Blood Pressure ?

Reduce stroke incidence by 35-40%

Reduce MI by 20-25 %

Reduce Heart Failure by 50 %

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What is the proper way of taking Blood Pressure ?

1. Instruments should be properly calibrated.

2. Patients should be seated quietly for at least 5 minutes.

3. Seated on a chair with arms supported at heart level and feet planted on the floor.

4. Appropriate cuff size. (encircling at least 80% of area)

5. At least two measurements should be made.

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Ambulatory blood pressure monitoring(ABPM)

It provides information about BP during daily activities and sleep and ambulatory BP values are usually lower than clinic readings.

Warranted for evaluation of “white-coat” hypertension in the absence of target organ injury.

To assess patients with apparent drug resistance, hypotensive symptoms with antihypertensive medications, episodic hypertension, and autonomic dysfunction.

Correlates better than office measurements with target organ injury.

Awake, individuals with hypertension have an average BP of more than 135/85 mmHg and during sleep, more than 120/75 mmHg.

In most individuals, BP decreases by 10 to 20 percent during the night; those in whom such reductions are not present are at increased risk for cardiovascular events.

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Three Objectives in Evaluating Patients with Documented Hypertension

1. To assess the lifestyle & identify other cardiovascular risk factors or concomitant disorders that may affect prognosis & guide treatment.

2. To reveal identifiable causes of high BP.

3. To asses the presence or absence of target organ damage & CVD.

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Cardiovascular Risk Factors

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Major Risk Factors

•Hypertension*•Cigarette smoking•Obesity* (body mass index ≥30 kg/m2)•Physical inactivity•Dyslipidemia*•Diabetes mellitus*•Microalbuminuria or estimated GFR <60 mL/min•Age (older than 55 for men, 65 for women)•Family history of premature cardiovascular disease (men under age 55 or women under age 65)

Target Organ Damage

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Heart

• Left ventricular hypertrophy• Angina or prior myocardial infarction• Prior coronary revascularization• Heart failure

Brain

• Stroke or transient ischemic attack

Peripheral arterial disease

Chronic kidney disease

Retinopathy

Blood Pressure Variability and Its Determinants

Nicotine in cigarette smoke (10 to 20 mm Hg rise in BP with every single cigarette)

Alcohol consumptionCaffeine consumption (only a small

transient rise in BP).

Habitual physical inactivity (in part because of weight gain).

Excessive consumption of calories and salt.14

Types of Hypertension In ~80–95% of hypertensive patients are diagnosed as

having "essential" hypertension (also referred to as primary or idiopathic hypertension).

In the remaining 5–20% of hypertensive patients, a specific underlying disorder causing the elevation of blood pressure can be identified.

In individuals with "secondary" hypertension, a specific mechanism for the blood pressure elevation is often more apparent. Renal disease is the most common cause of secondary hypertension.

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Identifiable causes of hypertension

•Sleep apnea•Drug-induced or related causes (see table 9)•Chronic kidney disease•Primary aldosteronism•Renovascular disease•Chronic steroid therapy and Cushing’s syndrome•Pheochromocytoma•Coarctation of the aorta•Thyroid or parathyroid disease

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Systolic Hypertension with Wide Pulse Pressure

1. Decreased vascular compliance (arteriosclerosis)

2. Increased cardiac output

  a. Aortic regurgitation

  b. Thyrotoxicosis

  c. Hyperkinetic heart syndrome

  d. Fever

  e. Arteriovenous fistula

  f. Patent ductus arteriosus

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Secondary Causes of Systolic and Diastolic Hypertension

Renal Parenchymal diseases, renal cysts (including polycystic kidney disease), renal tumors (including renin-secreting tumors), obstructive uropathy

Renovascular Arteriosclerotic, fibromuscular dysplasia

Adrenal Primary aldosteronism, Cushing's syndrome, 17-hydroxylase deficiency, 11-hydroxylase deficiency, 11-hydroxysteroid dehydrogenase deficiency (licorice), pheochromocytoma

Aortic coarctation  

Obstructive sleep apnea  

Preeclampsia/eclampsia  

Neurogenic Psychogenic, diencephalic syndrome, familial dysautonomia, polyneuritis (acute porphyria, lead poisoning), acute increased intracranial pressure, acute spinal cord section

Miscellaneous endocrine Hypothyroidism, hyperthyroidism, hypercalcemia, acromegaly

Medications High-dose estrogens, adrenal steroids, decongestants, appetite suppressants, cyclosporine, tricyclic antidepressants, monamine oxidase inhibitors, erythropoietin, nonsteroidal anti-inflammatory agents, cocaine

Mendelian forms of hypertension 18

Diagnosis

Diagnostic Procedure

Initial Additional

Chronic renal disease Urinalysis, serum creatinine, renal sonography

Isotopic renography, renal biopsy

Renovascular disease Renal sonography Magnetic resonance or computed tomography (CT) angiography, aortographyDuplex Doppler sonography

Endocrine Serum sodium, potassium, calcium, TSH

Metabolic Fasting blood glucose, total cholesterol, HDL and LDL (often computed) cholesterol, triglycerides

Coarctation Blood pressure in legs Echocardiography, magnetic resonance imaging or contrast aortography

Primary aldosteronism Plasma and urinary potassium, plasma renin and aldosterone

Urinary aldosterone after oral salt load, adrenal CT, adrenal venous sampling

Cushing syndrome Morning plasma cortisol after 1 mg dexamethasone at bedtime

Urinary cortisol after variable doses of dexamethasone, adrenal CT, and scintiscans

Pheochromocytoma Plasma-free metanephrineUrine metanephrines and catechols

Plasma normetanephrine (basal and after 0.3 mg clonidine)

Other Hematocrit, electrocardiogram19

Other laboratory tests may include cardiac enzymesFor cushing's syndrome- 24-h excretion rates of

urine free cortisol or an overnight dexamethasone-suppression test and late night salivary cortisol (sensitive and convenient screening test)

For pheochromocytoma- 24-hour urine collection for vanillylmandelic acid and catecholamines.

Chest radiograph - cardiac enlargement, pulmonary edema, or involvement of other thoracic structures, such as rib notching with aortic coarctation or a widened mediastinum with aortic dissection.

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As a screening test, Renal blood flow may be evaluated with a radionuclide [131I]-ortho iodo hippurate (OIH) scan. or Glomerular filtration rate may be evaluated with [99mTc]-diethylene triamine pentaacetic acid (DTPA) scan, before and after a single dose of captopril .

Doppler ultrasound of the renal arteries produces reliable estimates of renal blood flow velocity and .

To track a renal artery lesion Gadolinium-contrast magnetic resonance angiography, Contrast arteriography remains the "gold standard" for evaluation and identification of renal artery lesions.

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Physical Examination Recommended

1. BP measurement / includes contralateral arm

2. Examination of optic disc

3. Calculation of BMI (Wt (Kg)/sq (Ht(m))

4. Auscultation ( carotid, renal & femoral bruits)

5. Palpation of thyroid gland

6. Examination of Heart & Lungs

7. Examination of Abdomen

8. Lower extremities

9. Neurological assessment

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ABSTRACT The “Seventh Report of the Joint National Committee on

Prevention, Detection, Evaluation, and Treatment of High Blood Pressure” a new guideline for hypertension prevention and management. The following are the report’s key messages:

In persons older than 50 years, systolic blood pressure greater than 140 mmHg is a much more important cardiovascular disease (CVD) riskfactor than diastolic blood pressure.

The risk of CVD beginning at 115/75 mmHg doubles with each increment of 20/10 mmHg; individuals who are normotensive at age 55 have a 90 percent lifetime risk for developing hypertension.

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Individuals with a systolic blood pressure of 120–139 mmHg or a diastolic blood pressure of 80–89 mmHg should be considered as prehypertensive and require health-promoting lifestyle modifications to prevent CVD.

Thiazide-type diuretics should be used in drug treatment for most patients with uncomplicated hypertension, either alone or combined with drugs from other classes.

Certain high-risk conditions are compelling indications for the initial use of other antihypertensive drug classes (angiotensin converting enzyme inhibitors, angiotensin receptor blockers,beta-blockers, calcium channel blockers).24

Most patients with hypertension will require two or more antihypertensive medications to achieve goal blood pressure (<140/90 mmHg, or <130/80 mmHg for patients with diabetes or chronic kidney disease).

If blood pressure is >20/10 mmHg above goal blood pressure, consideration should be given to initiating therapy with two agents, one of which usually should be a thiazide-type diuretic.

The most effective therapy will control hypertension only if patients are motivated.

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Goals in Therapy

1. Reduction of Cardiovascular & Renal Morbidity & Mortality.

2. For >50 year old, the focus is SBP control.

3. <140/90 mmHg

4. <130/80 mmHg for patients with hypertension, DM & renal disease.

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Algorithm for Treatment of Hypertension

Not at Goal Blood Pressure (<140/90 mmHg) (<130/80 mmHg for those with diabetes or chronic kidney disease)

Initial Drug Choices

Drug(s) for the compelling indications

Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB)

as needed.

With Compelling Indications

Lifestyle Modifications

Stage 2 Hypertension (SBP >160 or DBP >100 mmHg)

2-drug combination for most (usually thiazide-type diuretic and

ACEI, or ARB, or BB, or CCB)

Stage 1 Hypertension(SBP 140–159 or DBP 90–99

mmHg) Thiazide-type diuretics for most.

May consider ACEI, ARB, BB, CCB,

or combination.

Without Compelling Indications

Not at Goal Blood Pressure

Optimize dosages or add additional drugs until goal blood pressure is achieved.

Consider consultation with hypertension specialist.

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Hypertension: Treatment

Lifestyle InterventionsLifestyle modifications are the first line of treatment in

hypertension. Implications for both the prevention and treatment of

hypertension. Recommended for individuals with pre-hypertension and

as an adjunct to drug therapy in hypertensive individuals.According to the JNC, lifestyle modifications can reduce

systolic blood pressure from a low of 2-8 mm Hg for dietary sodium restriction, to a high of 5-20 mm Hg for weight reduction.

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Life Style Modifications

Dietary Approaches to Stop Hypertension (DASH Diet)

Promotes fruits, vegetables, whole grains and low fat dairy products. Low in saturated fat, cholesterol, and total fat.

Rich in Calcium, Potassium, Magnesium, protein, and fiber.

Low in red meat, sweets and sugar beverages.Lowering homocysteine with DASH may reduce CVD risk

an additional 7%-9%.Fully compatible with dietary recommendations for

reducing risk of CVD, osteoporosis and cancer.Lowers systolic BP in normotensive patients by an

average of 3.5 mm Hg and in hypertensive patients by 11.4 mm Hg.

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Pharmacologic Therapy

Drug therapy is recommended for individuals with blood pressures ≥140/90 mmHg. The degree of benefit derived from antihypertensive agents is related to the magnitude of the blood pressure reduction.

Lowering systolic blood pressure by 10–12 mmHg and diastolic blood pressure by 5–6 mmHg confers relative risk reductions of 35–40% for stroke and 12–16% for CHD within 5 years of initiating treatment. Risk of heart failure is reduced by >50%.

Low-dose aspirin therapy should be considered only when BP is controlled, because the risk of hemorrhagic stroke is increased in patients with uncontrolled hypertension.

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Thiazide-type diuretics have been the basis of antihypertensive therapy in most outcome trials. In these trials, including the recently published Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), diuretics have been virtually unsurpassed in preventing the cardiovascular complications of hypertension.

Diuretics enhance the antihypertensive efficacy of multidrug regimens, can be useful in achieving BP control, and are more affordable than other antihypertensive agents.

Thiazide-type diuretics should be used as initial therapy for most patients with hypertension, either alone or in combination with one of the other classes (ACEIs, ARBs, BBs, CCBs) demonstrated to be beneficial in randomized controlled outcome trials.

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Blood Pressure Goals of Antihypertensive Therapy

The maximum protection against combined cardiovascular endpoints is achieved with pressures <135–140 mmHg for systolic blood pressure and <80–85 mmHg for diastolic blood pressure.

More aggressive blood pressure targets for blood pressure control (< 130/80 mmHg) may be appropriate for patients with diabetes, CHD, chronic kidney disease, or with additional cardiovascular disease risk factors.

In diabetic patients, effective blood pressure control reduces the risk of cardiovascular events and death as well as the risk for microvascular disease (nephropathy, retinopathy). Risk reduction is greater in diabetic than in nondiabetic individuals.

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Clinical Trial & Guideline basis for compelling Indications for individual Drug Classes

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Heart failureHeart failure(HF), in the form of systolic or diastolic

ventricular dysfunction, results primarily from systolic hypertension and IHD. Fastidious BP and cholesterol control are the primary preventive measures for those at high risk for HF.

In asymptomatic individuals with demonstrable ventricular dysfunction, ACEIs and BBs are recommended.

For those with symptomatic ventricular dysfunction or end-stage heart disease, ACEIs, BBs, ARBs and aldosterone blockers are recommended along with loop diuretics.

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Diabetic Hypertension

Combinations of two or more drugs are usually needed to achieve the target goal of <130/80 mmHg.

Thiazide diuretics, BBs, ACEIs, ARBs, and CCBs are beneficial in reducing CVD and stroke incidence in patients with diabetes.

ACEI- or ARB-based treatments favourably affect the progression of diabetic nephropathy and reduce albuminuria, and ARBs have been shown to reduce progression to macroalbuminuria.

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Chronic Kidney DiseaseIn people with chronic kidney disease (CKD), as

defined by either

(1) reduced excretory function with an estimated GFR below 60 ml/min per 1.73 m2 (corresponding approximately to a creatinine of >1.5 mg/dL in men or >1.3 mg/dL in women), or

(2) the presence of albuminuria (>300 mg/day or 200 mg albumin/g creatinine).

Therapeutic goals are to slow deterioration of renal function and prevent CVD. Hypertension appears in the majority of these patients, and they should receive aggressive BP management, often with ≥3 drugs to reach target BP values <130/80 mmHg. 37

ACEIs and ARBs have demonstrated favorable effects on the progression of diabetic and nondiabetic renal disease. A limited rise in serum creatinine of as much as 35 percent above baseline with ACEIs or ARBs is acceptable and is not a reason to withhold treatment unless hyperkalemia develops.

With advanced renal disease (estimated GFR <30 ml/min 1.73 m2, corresponding to a serum creatinine of 2.5–3 mg/dL), increasing doses of loop diuretics are usually needed in combination with other drug classes.

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Cerebrovascular Disease

Control of BP at intermediate levels (approximately 160/100 mmHg) is appropriate until the condition has stabilized or improved.

Recurrent stroke rates are lowered by the combination of an ACEI and thiazide-type diuretic.

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Obesity and the metabolic syndromeObesity (BMI >30 kg/m2) is an increasingly prevalent risk

factor for the development of hypertension and CVD. Metabolic syndrome as the presence of three or more of

the following conditions: abdominal obesity (waist circumference >40 inches in men or >35 inches in women), glucose intolerance (fasting glucose >110 mg/dL), BP >130/85 mmHg, high triglycerides (>150 mg/dL), or low HDL (<40 mg/dL in men or <50 mg/dL in women).

Intensive lifestyle modification should be pursued in all individuals with the metabolic syndrome, and appropriate drug therapy should be instituted for each of its components as indicated.

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Left ventricular hypertrophy

Left ventricular hypertrophy (LVH) is an independent risk factor that increases the risk of subsequent CVD.

Regression of LVH occurs with aggressive BP management, including weight loss, sodium restriction, and treatment with all classes of antihypertensive agents except the direct vasodilators hydralazine, and minoxidil.

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Peripheral arterial disease

Peripheral arterial disease (PAD) is equivalent in risk to IHD. Any class of antihypertensive drugs can be used in most PAD patients.

Other risk factors should be managed aggressively, and aspirin should be used.

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Hypertension in older personsHypertension occurs in more than two-thirds of

individuals after age 65. This is also the population with the lowest rates of BP control.

Treatment recommendations for older people with hypertension, including those who have isolated systolic hypertension, should follow the same principles outlined for the general care of hypertension.

In many individuals, lower initial drug doses may be indicated to avoid symptoms; however, standard doses and multiple drugs are needed in the majority of older people to reach appropriate BP targets.

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Postural hypotensionA decrease in standing SBP >10 mmHg, when

associated with dizziness or fainting, is more frequent in older patients with systolic hypertension, diabetes, and those taking diuretics, venodilators (e.g., nitrates, alpha-blockers, and sildenafil like drugs), and some psychotropic drugs.

BP in these individuals should also be monitored in the upright position. Caution should be used to avoid volume depletion and excessively rapid dose titration of antihypertensive drugs.

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Dementia

Dementia and cognitive impairment occur more commonly in people with hypertension.

Reduced progression of cognitive impairment may occur with effective antihypertensive therapy.

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Hypertension in womenOral contraceptives may increase BP, and the

risk of hypertension increases with duration of use. Women taking oral contraceptives should have their BP checked regularly.

Development of hypertension is a reason to consider other forms of contraception. In contrast, menopausal hormone therapy does not raise BP.

Women with hypertension who become pregnant should be followed carefully because of increased risks to mother and fetus.

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Methyldopa, BBs, and vasodilators are preferred medications for the safety of the fetus ACEI and ARBs should not be used during pregnancy because of the potential for fetal defects and should be avoided in women who are likely to become pregnant.

Preeclampsia, which occurs after the 20th week of pregnancy, is characterized by new-onset or worsening hypertension, albuminuria, and hyperuricemia, sometimes with coagulation abnormalities.

In some patients, preeclampsia may develop into a hypertensive urgency or emergency and may require hospitalization, intensive monitoring, early fetal delivery, and parenteral antihypertensive and anticonvulsant therapy

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Hypertension in children and adolescents

Lifestyle interventions are strongly recommended, with pharmacologic therapy instituted for higher levels of BP or if there is insufficient response to lifestyle modifications.

Choices of antihypertensive drugs are similar in children and adults, but effective doses for children are often smaller and should be adjusted carefully.

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Hypertensive emergencyAlthough blood pressure should be lowered rapidly

in patients with hypertensive encephalopathy, there are inherent risks of overly aggressive therapy.

In hypertensive individuals, the upper and lower limits of autoregulation of cerebral blood flow are shifted to higher levels of arterial pressure, and rapid lowering of blood pressure to below the lower limit of autoregulation may precipitate cerebral ischemia or infarction. Renal and coronary blood flows may also decrease with overly aggressive acute therapy. 49

The initial goal of therapy is to reduce mean arterial blood pressure by no more than 25% within minutes to 2 h or to a blood pressure in the range of 160/100–110 mmHg.

In patients with malignant hypertension without encephalopathy or some other catastrophic event, it is preferable to reduce blood pressure over hours or longer rather than minutes.

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Acute, transient blood pressure elevations, lasting days to weeks, frequently occur following thrombotic and hemorrhagic strokes. Autoregulation of cerebral blood flow is impaired in ischemic cerebral tissue, and higher arterial pressures may be required to maintain cerebral blood flow. Aggressive reductions of blood pressure are to be avoided.

In the absence of other indications for acute therapy, for patients with cerebral infarction who are not candidates for thrombolytic therapy, one recommended guideline is to institute antihypertensive therapy only when a systolic blood pressure > 220 mmHg or a diastolic blood pressure > 130 mmHg.

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If thrombolytic therapy is to be used, the recommended goal blood pressure is <185 mmHg systolic pressure and <110 mmHg diastolic pressure.

In patients with hemorrhagic stroke, suggested guidelines for initiating antihypertensive therapy are systolic > 180 mmHg or diastolic pressure > 130 mmHg.

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The management of hypertension after subarachnoid hemorrhage is controversial. Cautious reduction of blood pressure is indicated if mean arterial pressure is >130 mmHg.

In addition to pheochromocytoma, an adrenergic crisis due to catecholamine excess may be related to cocaine or amphetamine overdose, clonidine withdrawal, acute spinal cord injuries, and an interaction of tyramine-containing compounds with monamine oxidase inhibitors. These patients may be treated with phentolamine or nitroprusside. 53

Preferred Parenteral Drugs for Selected Hypertensive Emergencies

Hypertensive encephalopathy Nitroprusside, nicardipine, labetalol

Malignant hypertension (when IV therapy is indicated)

Labetalol, nicardipine, nitroprusside, enalaprilat

Stroke Nicardipine, labetalol, nitroprusside

Myocardial infarction/unstable angina Nitroglycerin, nicardipine, labetalol, esmolol

Acute left ventricular failure Nitroglycerin, enalaprilat, loop diuretics

Aortic dissection Nitroprusside, esmolol, labetalol

Adrenergic crisis Phentolamine, nitroprusside

Postoperative hypertension Nitroglycerin, nitroprusside, labetalol, nicardipine

Preeclampsia/eclampsia of pregnancy Hydralazine, labetalol, nicardipine54

Intravenous Doses of Antihypertensive Agents Used in Hypertensive

EmergenciesAntihypertensive Agent Intravenous Dose

Nitroprusside Initial 0.3 (g/kg)/min; usual 2–4 (g/kg)/min; maximum 10 (g/kg)/min for 10 min

Nicardipine Initial 5 mg/h; titrate by 2.5 mg/h at 5–15 min intervals; max 15 mg/h

Labetalol 2 mg/min up to 300 mg or 20 mg over 2 min, then 40–80 mg at 10-min intervals up to 300 mg total 

Enalaprilat Usual 0.625–1.25 mg over 5 min every 6–8 h; maximum 5 mg/dose

Esmolol Initial 80–500 g/kg over 1 min, then 50–300 (g/kg)/min

Phentolamine 5–15 mg bolus

Nitroglycerin Initial 5 g/min, then titrate by 5 g/min at 3–5 min intervals; if no response is seen at 20 g/min, incremental increases of 10–20 g/min may be used

Hydralazine 10–50 mg at 30-min intervals 55

Drug class

Examples Usual Total Daily Dose (Dosing Frequency/Day)

Other Indications

Contraindications/Cautions

Diuretics         

Thiazides Hydrochlorothiazide 6.25–50 mg (1–2)   Diabetes, dyslipidemia, hyperuricemia, gout, hypokalemia

Chlorthalidone 25–50 mg (1)  

Loop diuretics

Furosemide 40–80 mg (2–3) CHF, renal failure

Diabetes, dyslipidemia, hyperuricemia, gout, hypokalemia

Ethacrynic acid 50–100 mg (2–3)  

Aldosterone antagonists

Spironolactone 25–100 mg (1–2) CHF, primary aldosteronism

Renal failure, hyperkalemia

Eplerenone 50–100 mg (1–2)  

K+ retaining 

Amiloride 5–10 mg (1–2)   Renal failure, hyperkalemia

  Triamterene 50–100 mg (1–2)    56

Drug Class Examples Usual Total Daily Dose (Dosing Frequency/Day)

Other Indications

Contraindications/Cautions

Beta blockers 

      Asthma, COPD, 2nd or 3rd degree heart block, sick-sinus syndrome

Cardioselective

Atenolol 25–100 mg (1) Angina, CHF, post-MI, sinus tachycardia, ventricular tachyarrhythmias

Metoprolol 25–100 mg (1–2)

Nonselective Propranolol 40–160 mg (2)

    Propranolol LA 60–180 (1)

Combined alpha/beta

Labetalol 200–800 mg (2) ? Post-MI, CHF

Carvedilol 12.5–50 mg (2)  

Alpha antagonists 

       

Selective Prazosin 2–20 mg (2–3) Prostatism  

Doxazosin 1–16 mg (1)    

Terazosin 1–10 mg (1–2)    

Nonselective Phenoxybenzamine

20–120 mg (2–3) Pheochromocytoma

  57

Drug Class Examples Usual Total Daily Dose

(Dosing Frequency/Day)

Other Indications

Contraindications/Cautions

Sympatholytics 

       

  Central Clonidine 0.1–0.6 mg (2)    

Clonidine patch 0.1–0.3 mg (1/week)

   

Methyldopa 250–1000 mg (2)    

Reserpine 0.05–0.25 mg (1)    

Guanfacine 0.5–2 mg (1)    

ACE inhibitors  Captopril 25–200 mg (2) Post-MI, CHF, nephropathy

Renal failure, bilateral renal artery stenosis, pregnancy, hyperkalemia

Lisinopril 10–40 mg (1)

Ramipril 2.5–20 mg (1–2)

Angiotensin II antagonists 

Losartan 25–100 mg (1–2) CHF, diabetic nephropathy, ACE inhibitor cough

Renal failure, bilateral renal artery stenosis, pregnancy, hyperkalemia

Valsartan 80–320 mg (1)

Candesartan 2–32 mg (1–2)58

Drug Class Examples Usual Total Daily Dose

(Dosing Frequency/Day)

Other Indications

Contraindications/Cautions

Calcium antagonists        Heart failure, 2d or 3d degree heart block

Dihydropyridines Nifedipine (long acting)

30–60 mg (1) Angina

Nondihydropyridines Verapamil (long acting)

120–360 mg (1–2)

Post-MI, supraventricular tachycardias, angina

Diltiazem(long-acting)

180-420 mg (1)

Direct vasodilators  Hydralazine 25–100 mg (2)   Severe coronary artery disease

Minoxidil 2.5–80 mg (1–2)   59

Resistant Hypertension

Blood pressure persistently >140/90 mmHg despite taking three or more antihypertensive agents, including a diuretic, in reasonable combination and at full doses.

Exclusion of identifiable cause of HTN

More common in patients >60 years

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Causes of Resistant Hypertension

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Followup and MonitoringOnce antihypertensive drug therapy is initiated, most patients

should return for followup and adjustment of medications at approximately monthly intervals until the BP goal is reached.

More frequent visits will be necessary for patients with stage 2 hypertension or with complicating comorbid conditions.

Serum potassium and creatinine should be monitored at least 1–2 times/year.

After BP is at goal and stable, followup visits can usually be at 3- to 6-month intervals.

Comorbidities, such as heart failure, associated diseases such as diabetes, and the need for laboratory tests influence the frequency of visits. Other cardiovascular risk factors should be treated to their respective goals, and tobacco avoidance should be promoted vigorously.

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THANKS

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