cpha guidelines hypertension

7/29/2019 CPhA Guidelines Hypertension

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Caring or Patients with Hypertension

Application o the 2005 Canadian GuidelinesCynthia A. Jackevicius, BScPhm, MSc, PharmD, BCPS, FCSHP

CPhA ProessionalAdvancement

2005Learning Series


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Hypertensioncpha.learning.medi resource.com All material 2005 MediResource Inc.

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Lesson description

Hypertension is a commoncondition affecting many

Canadians. More deaths world-

wide are attributable to hyper-tension than to other commonrisk factors such as smoking andhigh cholesterol. Hypertensionis a signicant risk factor forcoronary artery disease, stroke,congestive heart failure, renalfailure, peripheral vascular dis-ease, dementia, and atrial bril-lation. Optimal treatment ofhypertension reduces the risk ofdeveloping target organ damageand adverse clinical outcomes.

However, research suggests thatmany Canadians are unawarethat they have hypertension, andof those aware, many are under-treated, leaving their blood pres-sure uncontrolled. The CanadianHypertension Education Pro-gram (CHEP) has embarked ona process to revise and imple-ment evidence-based recommen-dations for the management ofhypertension on an annual basis

in an attempt to improve themanagement of hypertension inCanada. The latest 2005 guide-lines are summarized in the fol-lowing lesson. Pharmacists canplay a vital role in assistingpatients with hypertension.Opportunities for pharmacistparticipation in the care ofpatients with hypertension arereviewed. Cases will be used tohelp apply the information con-tained in the lesson.

Learning objectives

Upon successful completionof this lesson, the partici-

pant should be able to:

1. dene and classify hyperten-sion

2. discuss the complications ofhypertension

3. describe effective non-phar-macological therapies forhypertension

4. summarize the recommenda-tions of the 2005 canadianhypertension guidelines

5. discuss the efcacy, adverseeffects and monitoring of

antihypertensive agents6. explain the reasons for poor

response to antihypertensivetherapy

7. educate patients receivingantihypertensive therapy


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Cynthia Jackevicius, BScPhm,MSc, PharmD, FCSHPCynthia Jackevicius has provided

pharmaceutical care to patientswith cardiovascular disease inboth the inpatient and outpatientsetting of the Heart and Circu-lation Program at the UniversityHealth Network - Toronto Gen-eral Hospital for many years. Inaddition to her clinical experi-ence, she has also been involvedwith numerous teaching activi-ties at the hospital with studentsand residents, as well as in theFaculty of Pharmacy and the Fac-

ulty of Medicine at the Univer-sity of Toronto. She has lecturedwidely and written numerousarticles on many aspects of treat-ment of patients with cardio-vascular disease. Cynthia alsoconducts research at the Insti-tute for Clinical Evaluative Sci-ences in Toronto where she isan Adjunct Scientist. Currentongoing research focuses on thequality of care of patients with

cardiovascular disease andadherence to medications.

John Hawboldt, BScPhm, PharmDDr. Hawboldt is currently anAssistant Professor at the School

of Pharmacy at Memorial Uni-versity and is cross-appointed tothe Health Care Corporation ofSt. Johns, Department of Phar-macy. He provides care to bothinpatients on the Infectious Dis-eases Consult Service and Gen-eral Medicine. Dr. Hawboldt isalso afliated with the Drug Uti-lization Committee and the Anti-biotic Utilization Committee ofthe Health Care Corporation andis responsible for drug utiliza-

tion evaluations (DUEs), formu-lary reviews, and more. As apart of his teaching responsibil-ities, Dr. Hawboldt teaches tothe pharmacotherapy of hyper-tension to the nal year phar-macy students. Dr. Hawboldt isalso on the School of PharmacyCurriculum Committee, which islooking at new and innovativeways to improve the pharmacycurriculum.

Dr. Hawboldts interestsinclude effective drug utilization,quality initiatives, and curricu-lum development. Current ini-tiatives include a study on theeffectiveness of surgical prophy-laxis guidelines as well as thedevelopment of a clinical skillscourse in the school of phar-macy.

Chantal Pharand, PharmD, BCPSDr. Chantal Pharand is associateprofessor at the Faculty of

Pharmacy at the Universit deMontral. After completing aPharmD degree, she pursued aresearch career by completingtwo research fellowships in car-diovascular pharmacology andin cardiovascular therapeutics.For the past ten years, she hasbeen teaching classes on thepathophysiology and pharmaco-therapy of cardiovascular dis-eases, including hypertension,to pharmacy students and resi-

dents. In addition, she has beeninvolved in clinical research,being the principal investigatorfor a number of cardiovascularresearch projects, as well as beinga clinical pharmacist practicingat the Coronary Care Unit ofthe Hpital du Sacr-Coeur deMontral. She has published sev-eral articles, book chapters, andbooks in the eld of cardiologyand has given several presenta-

tions to local and national meet-ings on cardiovascular topics,including hypertension.

Author Expert reviewers


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Contents

page1 1. Epidemiology and pathophysiology

1 2. Identifable causes o hypertension 1 Table1.Identifablecausesosecondaryhypertension

1 3. Consequences o hypertension 1 4. Underdiagnosis and treatment 2 5. Diagnosis and defnition o hypertension 2 Table2.Recommendedtechniqueormeasuringbloodpressure 2 Table3.Targetorgandamage 3 Table4.Causesopoorresponsetohypertensiontherapy 3 6. Therapy 3 6.1 Initiation o therapy and goals o therapy 3 6.2 Benets o treating hypertension 3 Table5.Thresholdorinitiationotreatmentandtargetvalues 4 6.3 Combination therapy 4 6.4 Canadian Hypertension Guidelines 2005 recommendations 4 Table6.Liestylemodifcationstomanagehypertension

5 6.5 Non-pharmacological therapy 5 6.6 Drug therapy 5 Table7.Majorcardiovascularriskactors 5 Table8.Useuldualcombinations 6 Table9.Considerationsintheindividualizationo

antihypertensivetherapy

7 Table10.Adverseeectsandcontraindicationsoantihypertensiveagents

8 6.7 Drug therapy or individualized antihypertensive therapy 8 6.8 Non-antihypertensive therapy 8 7. Key dierences between Canadian, American, and European

guidelines9 8. Monitoring

9 Table11.Monitoringoantihypertensiveagentsbyclass10 9. Medication adherence10 10. Patient education10 Table12.Strategiestoimproveadherencetotherapy10 11. Opportunities or pharmacists11 Table13.Herbalproductsandhypertension12 12. Web resources12 Table14.Hypertensionandheartdiseasewebsites12 13. Summary13 Reerences15 Questions


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Case Study

PWis a 57-year-old artist who presents to your

pharmacy to obtain some sublingual nitroglyc-erin for her angina. She just moved to your small com-munity last month. You nd out from the patient that shewas just diagnosed with stable angina 3 months ago. Shealso uses nitroglycerin ointment for her angina. After

further discussion with the patient, you nd out that

she has had mild diabetes for 5 years, well controlledon diet. She has had hypertension for 12 years, initiallytreated with a water pill for a couple of years butrecently controlled by lifestyle measures. While waitingto speak with you, she takes her blood pressure on thestore machine and is concerned that the reading was143/92, much higher than her usual reading on herhome machine. She also mentions to you that she takesibuprofen for her osteoarthritis a few times a week, acet-aminophen for headaches since she started the nitroglyc-erin ointment, and Tums for stomach upset usually oncea week for the last couple of years. She states that she isa non-smoker, but her husband smokes like a chimney

and she has 12 glasses of wine each week. She takes hermedications regularly, but prefers to manage with non-drug or natural therapy if possible.

1. Epidemiology and pathophysiology

Hypertension, or high blood pressure, is acommon medical condition, affecting a large

proportion of Canadians. It is estimated to be theleading risk factor associated with death world-wide.1 Based on a large population-based surveyacross Canada, 22% of Canadians between 18 and 70

years, or just over one in ve, and 50% of Canadians65 years and older have hypertension.2 Risk factorsfor the development of hypertension include age,family history, obesity, sedentary lifestyle, sodiumintake, and high dietary fat intake. Ethnic originalso plays a role, in that African-Americans have thehighest prevalence of hypertension worldwide. Themost common type of hypertension is called pri-mary (or essential) hypertension, which is denedas arterial hypertension without a denable cause.Primary hypertension is a multifactorial disorderinuenced by both genetic predisposition and envi-ronmental factors.3

2. Identifable causes o hypertensionSecondary hypertension occurs when elevated bloodpressure is due to a specic cause, such as drugs orcertain conditions, including pregnancy. It accountsfor approximately 10% of all hypertensive patients.4Identiable causes of hypertension are listed inTable 1. This lesson will focus on the managementof essential hypertension.

3. Consequences o hypertension

Hypertension damages the lining of arteries andaccelerates atherosclerosis. Complications of hyper-tension include damage to the end organs, includ-ing the heart, eyes, kidneys, brain, and large vessels.Hypertension is a major risk factor for cerebrovas-cular disease (stroke, transient ischemic attacks),coronary artery disease (myocardial infarction [MI],angina), renal failure, congestive heart failure,peripheral vascular disease, dementia, and atrial

brillation. When hypertension is combined withother cardiovascular risk factors, the chance for sub-sequent cardiovascular morbidity and mortality isincreased.3,4 According to the Framingham study,patients with hypertension are at a signicantlyincreased risk of coronary disease, stroke, periph-eral artery disease, and cardiac failure.6

In reviewing PWs medical history, you note thatshe has developed one of the potential complicationsof hypertension in that she was just recently diag-nosed with angina. Therefore, she has known cor-onary artery disease and atherosclerosis. No other

complications are apparent.

4. Underdiagnosis and treatmentThe Canadian Heart Health Survey found that toomany Canadians are not aware of their hyperten-sion or, if they are aware, it is not under control.Over 40% of patients were unaware that they hadhypertension. Only 16% of those with hypertensionin the survey were treated and had their blood pres-sure under control. The remainder were aware oftheir hypertension but either were treated withoutcontrol (21%) or were untreated and uncontrolled

(22%). Undiagnosed, untreated, and uncontrolledhypertension clearly places a signicant strain onthe healthcare system and reduces population healthin Canada.2

Recent data suggest that there have been signi-cant increases in the prescription of major classesof antihypertensive drugs in Canada, including thi-azide diuretics, in the three years after the Cana-dian Hypertension Education Program began.7 Thisincreased utilization coincides with the release of the

Table 1. Identifable causes o secondaryhypertension35

chronic kidney disease primary hyperaldosteronism

renovascular disease cushing syndrome pheochromocytoma

coarctation o the aorta thyroid or parathyroid disease


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annual recommendations of the Canadian Hyper-tension Society, possibly representing an improve-ment in treatment rates of hypertension in Canada.It is vital for all healthcare professionals, includingpharmacists, to understand the current limitationswith the diagnosis and treatment of hypertension inCanada and to become involved in improving thecurrent situation. A follow-up survey will be con-ducted in 2006 to assess the prevalence, treatment,

and control rates for hypertension in Canada.

5. Diagnosis and defnition

o hypertension

The Canadian Hypertension Society (CHS) Guide-lines suggest a standardized technique for measuringblood pressure, as listed in Table 2.8 Hypertensionis dened as a persistent ofce blood pressure read-ing of 140 mmHg or more systolic, or 90 mmHg ormore diastolic. Isolated systolic hypertension, whichoccurs more frequently in the elderly, is diagnosed

when the systolic blood pressure (SBP) is greaterthan 140 mmHg but the diastolic blood pressure(DBP) is less than 90 mmHg. A key message fromthe 2005 CHS guidelines is that the diagnosis ofhypertension can be expedited. It is recommendedthat hypertension may be diagnosed in the clinicvisit as follows according to visit number:

Visit Diagnose hypertension i fndings indicate:1 Hypertensive urgency/emergency2 BP 180/110 or target organ damage,

diabetes, chronic kidney disease with

BP

140/903 SBP 160 or DBP 1004 SBP 140 or DBP 905 SBP 140 or DBP 90

New to the 2005 CHS guidelines is that hyper-tension may also be diagnosed by ambulatory andself/home blood pressure monitoring with valuesas indicated in Table 5. Note that different algo-rithms are noted in the 2005 guidelines for 24-hourambulatory blood pressure monitoring and self/home blood pressure monitoring.

Hypertensive emergency is dened by very ele-

vated blood pressure readings with DBP usuallyhigher than 120130 mmHg and the presence ofacute or imminent complications for target organs,such as papilledema, cardiac ischemia, or enceph-alopathy. Hypertensive urgency is dened by thesame blood pressure parameters as hypertensiveemergency, but without any evidence of acute targetorgan damage. See Table 3 for a list of acute andchronic target organ damage. A search should bemade for potentially modiable factors that can

induce or aggravate hypertension (Table 4). If thepossibility of white coat hypertension exists, 24-hourambulatory blood pressure monitoring should beconducted.8

If, at the last diagnostic visit, the blood pressureis less than 140/90 mmHg, and the patient has noevidence of risk factors or target organ damage, thepatient should be assessed yearly if the blood pres-

sure is in the high normal range of 130/85 to139/89 mmHg and at two-year intervals if the lastblood pressure is 120/80 to 129/84. These patientsfrequently go on to develop hypertension.8

While you know that hypertension cannot be diag-nosed with one measurement by the machine in yourstore, PW already has an established diagnosis of hyper-tension. You know there are many reasons for impropertechnique related to various blood pressure monitors. You

Table 2. Recommended technique ormeasuring blood pressure8

1. Seat the patient with his/her back supported, armbare and supported at heart level.

2. Make sure that the patient has not smoked within1530 minutes or consumed caeine within onehour beore the measurement.

3. Ensure that the bowel and bladder are comort-able.

4. Have the patient rest or 5 minutes beore takingthe measurement.

5. Use an appropriate-size cu.6. Use a mercury manometer or recently calibrated

aneroid or a validated electronic device.

7. Measure blood pressure on both arms at the initialvisit to determine i there is a dierence.

8. Take two measurements separated by one minuteon the side where the blood pressure is the high-

est. Average the results.

Table 3. Target organ damage3,4,8

heart let ventricular hypertrophy

angina acute coronary syndromes

need or coronary revascularization heart ailure

brain stroke or transient ischemic attack

chronic kidney disease/renal insuciency

peripheral arterial disease intermittentclaudication

retinopathy


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calm down PW through your discussion and have herrepeat her blood pressure after sitting calmly for 5 min-utes. The second measurement is 139/92, giving her anaverage of 141/92.

In reviewing PWs history, you notice that she mayhave potential drug-related causes that may aggravate

her hypertension. She is taking ibuprofen for her arthri-tis, which may contribute to sodium and water retention.You know that acetaminophen is the rst-line therapy fortreatment of pain due to osteoarthritis and consider thisas you continue to assess her case.

6. Therapy

6.1 Initiation o therapy and goals o therapyInitiation of pharmacological therapy and treatmenttargets are dependent on specic patient character-istics. Threshold values for initiation of drug ther-apy and treatment targets are listed in Table 5.For the majority of patients, the goal is to achievea blood pressure less than 140/90 mmHg. How-ever, the table lists other important target levelsdependent on patient factors. Other goals of treat-ing hypertension include preventing morbidity andmortality associated with hypertension.9

PW is using nitroglycerin for her angina, which may

also have antihypertensive effects. You want to determinewhether she meets criteria for drug therapy and is achiev-ing the goal of therapy. Upon reviewing the handy tableyou have in your Palm, you note that she also has dia-betes in addition to mixed diastolic/systolic hypertension.Given this, she should initiate therapy at a blood pressure>130/80 and achieve a target value


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risk or pretreatment blood pressure, is consistentlyaround 2530% reduction in clinical outcomes.5 Arecent meta-analysis suggests that for a chronicreduction in diastolic blood pressure of 56 mmHg,there is a 3540% reduction in stroke and a 814%reduction in coronary heart disease.11 From anothermeta-analysis in elderly patients, a reduction of89 mmHg in systolic blood pressure was found toreduce stroke-related events by 50% and cardiovas-

cular events by 3040%.12

6.3 Combination therapyMany patients will need combination drug therapyto control their blood pressure to the target range. Inthe HOT study, 68% of patients required at least two

agents to achieve their blood pressure target and asignicant proportion required three agents.13 At theend of the ve-year follow-up of the ALLHAT study,63% of patients required at least two antihyper-tensive agents to achieve blood pressure control.14In several studies (AASK, HOT, MDRD, ABCD,UKPDS), patients with diabetes or renal impairmentrequired an average of 3.2 medications to reachtarget diastolic blood pressure goals.15

6.4 Canadian Hypertension Guidelines 2005recommendationsThe Canadian Hypertension Society creates revisedguidelines each year and publishes the guidelinesin the Canadian Journal of Cardiology as well as on

Table 6. Liestyle modifcations to manage hypertension3,9

Weight reduction Maintain normal body weight (BMI 18.524.9 kg/m2).Weight loss (5 kg) in those who are overweight

(BMI>25). Target waist circumerence o 80 mmol/day o dietary

potassium

For those salt-sensitive indi-

viduals. Requirements maybe less in patients with renal

disease.

Stress management For those in whom stress appears to be an importantissue: behaviour modication

incorporation o relaxation techniques

BMI: body mass index, DASH: Dietary Approaches to Stop Hypertension, SBP: systolic blood pressure

Modifcation Recommendation Comments


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their website, www.hypertension.ca. The followingtreatment recommendations are summarized fromthe 2005 CHS guidelines, and include importantupdates related to recently published clinical trials,such as the ALLHAT study.

6.5 Non-pharmacological therapyNon-drug therapy is an important cornerstone inthe management of hypertension. Non-pharmaco-

logical therapy, in the form of lifestyle modica-tion, is important as an initial step in some patientsto control their blood pressure, and as an adjunctto all patients receiving pharmacological therapy.Current recommendations are summarized in Table6, including estimated reductions in SBP for someinterventions.9

PW notes that she is very good about maintaininglifestyle modications to control her blood pressure. Youreview the various aspects with her and discover that she isonly physically active 12 times per week since her move toyour community. You discuss ways of incorporating more

activity into her routine. She also is concerned about theeffects of her husbands smoking on her health, and youboth decide to ask him to schedule an appointment at the

pharmacy to discuss his cardiac risk factors and potentialfor smoking cessation at a future date.

6.6 Drug therapyMost antihypertensive drugs lower blood pressureby about 1015%. Monotherapy is effective in about3050% of patients, particularly those in the lowerrange of hypertensive pressures.5 Initiation of drugtherapy should be strongly considered for DBP at

or above 90 mmHg and either target organ damage,including cardiovascular disease, or presence ofindependent cardiovascular risk factors. (See Table7 for list of risk factors.) Drug therapy should alsobe strongly considered for DBP at or above 80mmHg in patients with diabetes. Choice of treat-ment depends on associated risk factors, presenceof target organ damage or complications, and con-comitant diseases or conditions.9

6.6.1 Drug therapy for those without compelling

indicationsLifestyle modication should be used in concert with

drug therapy.9

The Canadian Hypertension Societyguidelines now suggest that any of the following vedrug classes may be used as rst-line therapy: thia-zide diuretics, angiotensin converting enzyme inhib-itors (ACEIs), angiotensin receptor blockers (ARBs),long-acting calcium channel blockers (CCB), or beta-blockers (BB). Each of these classes has demonstrateda reduction in morbidity and mortality. Recent evi-dence with reductions in morbidity and mortalitywith blood pressure reduction with ARBs, ACEIs,

and long-acting CCBs has added them to the list ofpossible rst-line agents with these new guidelines.9Specic caveats about these therapies are listed in

Table 9. If there is only a partial response to stan-dard dose monotherapy, it is suggested that nonad-herence, secondary hypertension, interfering drugsor lifestyle, and the white coat effect be considered.If none of these are present or cannot be eliminated,then dual combination therapy is recommended.Useful dual combinations include one drug fromcolumn 1 with any drug from column 2 in Table 8.If dual therapy is not effective, then triple or quadru-ple therapy must be considered.9

Table 7. Major cardiovascular risk actors5,9

Related to initiation o antihypertensive drug therapy elevated systolic blood pressure cigarette smoking

obesity (BMI 30) physical inactivity dyslipidemia

amily history o premature heart disease (men


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Table 9. Considerations in the individualization o antihypertensive therapy9

Hypertension without

compelling indications

or other medications

Thiazide diuretics,

BBs, ACEIs, ARBs, or

LA DHP CCBs (amlo-

dipine, elodipine, LA

niedipine)

Alpha-blockers are not recom-

mended as initial therapy. BB are

not recommended as initial therapy

in those >60 years. Hypokalemia

should be avoided through use o

potassium sparing agents in thoseprescribed diuretics. Use low-dose

thiazides (12.525 mg/day). ACEIs

are not recommended as initial

monotherapy in Arican-Americans.

BBs are not recommended as initial

therapy in smokers.

Combinations o rst-line drugs

Isolated systolic hyper-

tension without other

compelling indications

Thiazide diuretics; also

ARBs or LA DHP CCBs

Hypokalemia should be avoided in

those prescribed diuretics through

use o potassium-sparing diuretics.

Combinations o rst-line drugs

Diabetes mellitus with

nephropathy

ACEIs or ARBs 34 drug combination may be

needed or control.

Addition o one or more o thi-

azide diuretics, cardioselective

BBs, or LA CCBs, or use o ARB/ACEI combination

Diabetes mellitus with-

out nephropathy

ACEIs, ARBs or thia-

zide diuretics

I SCr>150 mol/L, a loop diuretic

should be used instead o a thiazide

i volume control is needed.

Combination o rst line drugs or

addition o cardioselective BBs

(acebutolol, atenolol, bisoprolol,

metoprolol) and/or LA CCBs

Angina BBs (strongly consider

adding ACEIs)

Avoid short-acting niedipine. Cau-

tion with combined use o BB and

non-DHP-CCB.

LA CCBs

Prior myocardial

inarction

BBs and ACEIs I BB cannot be used and HF

present: use LA DHP CCB; i no

HF, use LA CCB. Combination o

additional agents.

Heart ailure ACEIs, BBs and

spironolactone (class

III-IV) (ARBs i ACEI

intolerant)

Avoid non-DHP CCBs (diltiazem,

verapamil). ARB may be added to an

ACEI or other drugs.

Hydralazine/ISDN, thiazide or

loop diuretics as additive therapy

Past stroke or TIA ACEIs/diuretic combi-

nation

Blood pressure reduction reduces

recurrent events ater the acute phase.

Atrial brillation BB, non-DHP CCB Both classes control heart rate.

Renal disease ACEIs (diuretics as

additive therapy)

Avoid ACEIs and ARBs i bilateral

renal artery stenosis. Loop diuretics

more eective than thiazides inpresence o renal disease.

Combinations o additional

agents (ARBs i ACEIs intolerant)

Let ventricular

hypertrophy

ACEIs, ARBs, LA CCBs,

thiazide diuretics (BBs

or patients under 60

years o age)

Avoid hydralazine and minoxidil.

Initial therapy Notes/cautionsSecond-line therapy

ACEIs: angiotensin converting enzyme inhibitors, ARBs: angiotensin II receptor blocker, BBs: beta-blockers, CCBs: calcium channel blockers,

DHP: dihydropyridine, HF: heart ailure, ISDN: isosorbide dinitrate, LA: long acting, SCr: serum creatinine, TIA: transient ischemic attack


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While the choice of treatment may depend onthe patients concomitant diseases or conditions, theimpact on mortality reduction should also be con-sidered. The most recent large comparative trial, theALLHAT study, conrmed the central role of thia-

zide diuretics in the rst-line therapy of hyperten-sion without compelling indications.14,16 This studyfound no difference in the primary outcome of fatalcoronary disease or nonfatal MI between the drugsstudied (chlorthalidone, amlodipine, lisinopril, ordoxazosin-based regimens). None of the newer drugclasses was found to be any more effective thandiuretics in this large, well-conducted study. In fact,the chlorthalidone group also had lower rates ofstroke and heart failure as compared to the othertherapies.14 In addition, the alpha-blocker arm hadbeen stopped early due to an increased incidenceof heart failure with this therapy, despite the fact

that doxazosin lowered blood pressure to about thesame degree as chlorthalidone.17 As a result, alpha-blockers are currently not accepted as rst-line anti-hypertensive therapy.3,9

Despite the fact that diuretics and beta-blockersare the oldest of the drugs suggested for rst-linetherapy, with evidence demonstrating a signicantreduction in morbidity and mortality, and are theleast expensive, they are not prescribed as fre-quently as expected. This is likely due to some mis-

conceptions about unacceptably high rates of sideeffects with diuretics and beta-blockers. Two largestudies (SHEP, TOMHS) have found that the effectsof diuretics and beta-blockers on serum lipids weretransient and small. For most patients, glucose and

cholesterol increases are usually clinically insigni-cant. Despite these metabolic changes, studies havestill found a signicant morbidity and mortalitybenet.18,19 In addition, in terms of tolerability ofvarious drug classes, a large US study found thatrates of patient withdrawal from several studies dueto adverse effects were 1% for hydrochlorothiazide,2% for atenolol, 5% for captopril, 6% for placebo,and 7% for diltiazem, demonstrating good tolerancefor diuretics and beta-blockers.20 Common adverseeffects and contraindications to each antihyperten-sive drug class are summarized in Table 10.

For isolated systolic hypertension, lifestyle mod-

ication should be used along with drug therapywith a thiazide diuretic. Other appropriate agentsinclude an ARB or a long-acting dihydropyridineCCB. If there is only a partial response to standarddose monotherapy, it is suggested that nonadher-ence, secondary hypertension, interfering drugs orlifestyle and the white coat effect be considered. Ifnone of these are present or cannot be eliminated,then dual combination therapy is recommendedwith one of the other two drug classes not used.9

Table 10. Adverse eects and contraindications o antihypertensive agents3,4

ACE inhibitors Cough, angioedema, hyperkalemia, loss o taste, rash,renal dysunction

Pregnancy, bilateral renal arterystenosis, hyperkalemia

ARBs Angioedema (rare), hyperkalemia, renal dysunctionPregnancy, bilateral renal arterystenosis, hyperkalemia

Alpha blockers Headache, drowsiness, atigue, postural hypotension, rst

dose hypotension, nasal stuness, erectile dysunction

Orthostatic hypotension, heart

ailure, diabetes

Beta-blockers Bronchospasm, heart ailure, impaired peripheral circu-lation, insomnia, atigue, bradycardia, elevated triglycer-

ides, impotence, exercise intolerance, hyperglycemia

Asthma, COPD with reactive air-ways component, heart block,

severe Raynauds syndrome

Calcium channelblockers

Headache, fushing, peripheral edema, gingival hyper-plasia (verapamil), constipation (verapamil), erectile dys-unction

Heart block, systolic dysunctionheart ailure (verapamil, diltiazem)

Centrally acting

agents (methyl-

dopa, clonidine)

Rebound hypertension with discontinuation, sedation,

dry mouth, bradycardia, erectile dysunction, sodium and

fuid retention, hepatitis (rare)

Depression, liver disease (methyl-

dopa), diabetes

Diuretics Hypokalemia, hyperuricemia, glucose intolerance

(except indapamide), hypercalcemia (thiazides), hyper-lipidemia, hyponatremia, impotence (thiazides)

Gout

Drug class Adverse eectsContraindications

ACE: angiotensin converting enzyme, ARB: angiotensin receptor blocker, COPD: chronic obstructive pulmonary disease


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6.7 Drug therapy or individualizedantihypertensive therapyTable 9 lists the rst-line and second-line therapysuggestions for medications in patients with specicconditions that affect drug choice. It is importantto recognize that patients may have multiple con-comitant conditions that must be taken into accountwhen choosing antihypertensive drug therapy. Inaddition, the benets of treating smokers with beta-

blockers remain uncertain in the absence of specicindications like angina or post-MI. Therefore, beta-blockers are not routinely recommended in smok-ers without these indications. For patients withRaynauds syndrome or severe peripheral arterialdisease, vasodilator drugs (CCBs, ACEIs, ARBs,alpha-blockers) are rst-line therapy, while beta-blockers should not be used.9

In assessing PWs need for individualized therapy,you need to take into account her diabetes and anginadiagnoses. You ask whether her doctor has checked herkidney function recently. She tells you that he did, and

said her kidneys were ne now but would need to bechecked each year. In determining potential drug therapy

for her, you note that rst-line therapy for hypertensivepatients with diabetes without nephropathy is a thiazidediuretic, an ACEI, or an ARB. You also know that most

patients with diabetes will require at least 2 medicationsto control their blood pressure. Also, rst-line therapy for

patients with angina is beta-blockers, with a strong con-sideration for adding an ACEI. Upon checking her pulse,you nd her heart rate to be 82 bpm, and determine thatshe may benet from the heart-rate-lowering effects of thebeta-blocker (target heart rate ~70 bpm for angina) in

addition to the ACEI effects for protecting her kidneysfrom diabetic nephropathy. These agents can be usedinstead of her topical nitroglycerin.

6.8 Non-antihypertensive therapyAn important new message from the 2004 updateof the guidelines is the headline selected for2004: Blood pressure control is only one compo-nent (albeit a very important component) of theoverall vascular protection strategy of the hyper-tensive patient. The guidelines recommend deter-mining the patients global cardiovascular risk inorder to assess the need for other preventive ther-

apies. Based on this mandate, the following addi-tional recommendations have been added to thisyears guidelines:

a) Statins should be considered for all hyperten-sives at higher risk (3 or more cardiovascularrisk factors) for atherosclerotic complications orwith existing atherosclerotic disease (see Table 7column 2).

b) Low-dose ASA should be strongly considered

for all hypertensive patients above 50 years oldwhose blood pressure is controlled.

c) ACEI should be used for all patients with estab-lished atherosclerotic disease.5

These recommendations are based on data fromrecent studies. The ASCOT-LLA study with atorvas-tatin found a signicant reduction in fatal and non-fatal MI with atorvastatin 10 mg/day.21 The Heart

Protection Study (HPS) found a signicant reduc-tion in all-cause mortality associated with the useof simvastatin 40 mg/day, with the results similarin patients with hypertension. This was over andabove other therapies known to be cardioprotective,such as, ASA, ACEI, and beta-blockers.22 In the HOTtrial, which included a low-dose ASA (75 mg/day)arm, patients given ASA had a signicant reductionin major cardiovascular events, particularly fewerMIs.13 The benets were primarily seen in patientswith lower blood pressures; therefore, the bloodpressure should be controlled prior to initiation ofASA. In the HOPE trial with ramipril, in patients

at high risk for cardiovascular disease, ramipril-treated patients had less MI, stroke and cardiovas-cular death. This effect appeared to be independentof blood-pressure-lowering effects and was seenover and above the benets of other cardioprotec-tive agents given, such as ASA, statins, and beta-blockers.23

In reviewing the recommendations for non-antihy-pertensive therapy, you nd that since she has existingatherosclerosis (angina), she qualies for statin therapy.She also qualies for low-dose aspirin therapy based on

1) being above 50 years and having hypertension and2) primary cardiovascular prevention for chronic stableangina. She also meets the criteria for ACEI therapybased on the HOPE trial. You plan to discuss your nd-ings with her and her doctor to create a plan for her andschedule an appointment for her with her doctor.

7. Key dierences between Canadian,

American, and European guidelines

Two key differences exist between the Canadianand the American (JNC 7) guidelines for hyperten-

sion. The JNC 7 has introduced the new classica-tion of prehypertension for those with SBP 120139mmHg or DBP 8089 mmHg in order to identifyindividuals at high risk for developing hypertensionso that lifestyle modications may be implemented.Based on the ALLHAT study, complimenting priorevidence, JNC 7 places a stronger emphasis on thia-zide diuretics as the rst-line agent for treatment ofhypertension, either alone or in combination withother therapies.3,24,25 Differences also exist in the


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European guidelines, which include a complex clas-sication system for stages of hypertension, as wellas a detailed determination of risk assessment basedon the Framingham criteria. This system providesfor a somewhat less aggressive approach comparedto the Canadian and American guidelines. Like theCanadian guidelines, the European guidelines deferdrug choice for rst-line agents to the healthcareproviders judgment of the patients specic charac-

teristics.26

8. MonitoringMost antihypertensive drugs lower blood pressureby about 1015%.5 The time to respond to therapyranges from 2 to 8 weeks. If a patients bloodpressure is not at target, monthly visits should bescheduled until control is achieved for 2 consecu-tive months. If the patient has symptoms, severehypertension, intolerance to therapy, or target organdamage, then more frequent visits may be neededin order to meet the goals of therapy more quickly.

For patients whose blood pressure readings havebeen below target for 2 consecutive monthly visits,follow-up is appropriate at 36 month intervals.If hypertension has been controlled for over oneyear in uncomplicated patients, it may be possible

to gradually step-down therapy in certain patients,especially if lifestyle modications are maintained.9

Specic adverse effects and laboratory param-eters that are recommended to be monitored aredrug-specic and are summarized in Table 11. Inorder to measure the effectiveness of therapy, thefollowing should be monitored:

blood pressure measurements

target organ damage heart, kidney, eye, brain adherence drug interactions

In order to measure toxicity to therapy, adverseeffects and drug interactions should be assessed ona regular basis.

For those patients who will be conducting homemeasurement of blood pressure, several issues needto be addressed. Patients need to have a devicethat has the appropriate cuff size for their armand has met the standards of the Association forthe Advancement of Medication Instrumentation

(AAMI) and/or the British Hypertension Society(BHS) and/or International Protocol (IP). Althoughapproved devices may be difcult to nd, the CHSnow has a logo to indicate ones approved to meettheir standards in Canada. Pharmacists may wish to

Table 11. Monitoring o antihypertensive agents by class3,4

ACE inhibitors Renal unction, electrolytesFirst-dose hypotension, lightheadedness, dizziness, cough,

blood pressure, adherence

ARBs Renal unction, electrolytesFirst-dose hypotension, lightheadedness, dizziness, bloodpressure, adherence

Alpha-blockers Postural hypotension (especially with rst dose), dizziness,


Beta-blockers Signs o heart ailure, bloodglucose

Heart rate, blood pressure, energy level, exercise tolerance,dizziness, lightheadedness, sexual dysunction, symptomso heart ailure, adherence

Calcium channel

blockers

Signs o heart ailureHeart rate (verapamil, diltiazem), peripheral edema, head-

ache (especially with DHPs), symptoms o heart ailure,


Centrally acting

agents (methyl-dopa, clonidine)

Liver enzymes (methyldopa),

signs o fuid retention

Sedation, dry mouth, heart rate, symptoms o fuid retention,


Diuretics Renal unction, electrolytes,blood glucose

Lightheadedness, dizziness, fuid status, urine output,weight, blood pressure, adherence

Drug classAdditional physicianmonitoring parametersPharmacist/patientmonitoring parameters

ACE: angiotensin converting enzyme; ARB: angiotensin receptor blocker; DHP: dihydropyridine


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review the devices they carry to attempt to supplydevices of the highest quality. Patients need to betrained in measuring their blood pressure and inter-preting their readings. Any blood pressure over136/83 should be considered elevated (analogousto an ofce measurement above 140/90).8 Thereshould be regular verications of the accuracy ofthe device and the patients measuring techniqueswith their physician. Self-measurement has been

shown to improve patient adherence, especiallyin patients with known nonadherence and inpatients with diabetes, and is an important tool inthis regard.27,28 Self-measurement is also useful inpatients who are thought to have white coat hyper-tension.

Since PW measures her blood pressure at home, youreview her technique with her and suggest she verify theaccuracy of her device. You encourage her to continuemeasuring her blood pressure, but with the lower targetof


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refer patients to physicians for management deci-sions.36 Talking to the patient about the benets ofhypertensive therapy is at least as important as dis-cussing adverse effects. When patients understandthe potential benets of drug treatment for hyper-tension, they may be more inclined to adhere totherapy. In the discussion of adverse effects, phar-macists should discuss with patients how to avoidor manage these effects as they arise in order to help

patients continue their therapy if possible.37Several studies in the United States have demon-

strated that pharmacists working in hypertensionclinics or in collaboration with physicians in familypractice are able to improve the care of hyperten-sion patients. When pharmacists are involved, bloodpressure control and the quality of prescribing areimproved compared to control groups receivingusual care. As well, several studies have shownthat community-based pharmacists can improveblood pressure control when they focus on patientmanagement.3840 A recent pilot study of 100 hyper-tensive patients from Quebec has shown that phar-

macists in the community setting in Canada can alsoaffect antihypertensive therapy.41 The major inter-vention in this study was education and counselingby the pharmacist, rather than comprehensive phar-maceutical care. Perhaps even greater impact wouldbe seen in a setting where more detailed and thor-ough interventions were possible.

Nonpharmacological measures require a greatdeal of attention by health professionals if they areto be successful. They require behavioural changeand continuous reinforcement. Assisting patientswith how they can incorporate these modications

into their lifestyle can help them achieve these goals.For example, suggestions about how to incorporatephysical activity into daily activities are somethingthe pharmacist can discuss with the patient. Phys-ical activity will also help with weight reduction.Weight loss does not need to be dramatic to helpwith hypertension control. Even a 4.57 kg (~1015lb) weight loss can have a measurable effect onblood pressure. Pharmacists can also discuss smok-ing cessation with patients, exploring the use ofprescription and non-prescription cessation aids aswell as smoking cessation support groups. Veryimportant to the success of modifying antihyper-

tensive drug regimens is to develop a rapport withlocal physicians and act as a resource to help theirpatients meet their blood pressure targets.

Other roles pharmacists can have include:

individual consultation meetings with patients blood pressure monitoring monitoring overall response to therapy encouraging patient self-monitoring/adherence

to therapy hypertension clinic days medication review sessions identication of drug-related causes of hyperten-

sion simplifying dosing regimens

creating patient medication schedules assessment of herbal products in relation tohypertension (see Table 13)

home visits rentals of 24-hour blood pressure ambulatory

monitors.

Upon questioning, PW states that she takes echinaceafor colds as needed in the winter months and ginsengfor a general pick-me-up remedy. You discuss with herthat ginseng may be contributing to worsening of herblood pressure control and ask her to develop other waysto increase her energy. Increasing her exercise schedule

as previously discussed may help her in this regard. Youexplain to her that even natural remedies and herbalmedications can have both benecial and adverse sideeffects.

Table 13. Herbal products andhypertension4244

May worsen hypertension or lessen eect o therapy bayberry

blue cohosh capsicum coltoot

country mallow ephedra (ma huang)

European mandrake gentian

ginseng goldenseal licorice

mistletoe Scotchbroom fower

yohimbine

Claims o some antihypertensive eects(some supporting clinical data) garlic

hawthorn


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12. Web resources

Listed in Table 14 is a sample of some websitesrelated to hypertension that may be useful for fur-ther information for patients or health profession-als.

13. Summary

Hypertension is a common condition affecting onein every ve Canadians. Hypertension is a signi-cant risk factor for coronary artery disease, stroke,congestive heart failure, renal failure, peripheral vas-cular disease, dementia, and atrial brillation. ManyCanadians are unaware that they have hypertensionand, of those aware, many are undertreated, leav-ing their blood pressure uncontrolled. The Cana-dian Hypertension Education Program (CHEP) isattempting to improve the management of hyper-tension in Canada by annually revising and imple-menting evidence-based recommendations for themanagement of hypertension. The 2005 guidelines

include recommendations for individualization oftherapy for specic patients. Pharmacists can becomefamiliar with the current recommendations and playa vital role in assisting patients with many aspectsof hypertension management.

Table 14. Hypertension and heart diseasewebsites

www.hypertension.ca www.canadianbpcoalition.org

www.heartandstroke.ca www.bloodpressure.com

www.ccs.ca

www.hypertension.qc.ca www.americanheart.org

www.ash-us.org www.heartcenteronline.com

www.nhlbi.nih.gov/health/public/heart www.mayohealth.org

www.mco.edu/org/whl www.phac-aspc.gc.ca/ccdpc-cpcmc/hhk-tcs/

english/03_highpressure/03_high_reduce.htm


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2. Joffres MR, Ghadirian P, Fodor JG, Petrasovits A,

Chockalingam A, Hamet P. Awareness, treatment and

control of hypertension in Canada. Amer J Hypertens

1997;10:10971102.3. Chobanian AV, Bakris GL, Black HR, et al. Seventh

report of the Joint National Committee on Preven-

tion, Detection, Evaluation, and Treatment of High

Blood Pressure: JNC 7 Complete Report. Hyperten-

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4. DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG,

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5. Khan NA, McAlister FA, Campbell NRC, Feldman

RD, Rabkin S, Mahon J, et al for the Canadian Hyper-

tension Education Program. The 2004 Canadian rec-

ommendations for the management of hypertension:

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6. Kannel WB. Blood pressure as a cardiovascular risk

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7. Campbell NRC, McAlister R, Brant R, et al, for the

Canadian Hypertension Education Process and Eval-

uation Committee. Temporal trends in antihyperten-

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introduction of the Canadian Hypertension Education

Program. J Hypertens 2003;21:15917.

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CHEP_2005_Diagnosis.ppt. Accessed February 18,

2005.9. www.hypertension.ca/recommendations_2005/

CHEP_2005_Treatment.ppt. Accessed February 18,

2005.

10. Neaton JD, Wentworth D. Serum cholesterol, blood

pressure, cigarette smoking, and death from coro-

nary heart disease. Overall ndings and differences

by age for 316,099 white men. Multiple Risk Factor

Intervention Trial Research Group. Arch Intern Med

1992;152:5664.

11. MacMahon S, Peto R, Cutler J, Collins R, Sorlie

P, Neaton J, et al. Blood pressure, stroke and cor-

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in blood pressure: Prospective observational studiescorrected for the regression dilution bias. Lancet

1990;335:76574.

12. Psaty BM, Smith NL, Siscovick DS, Koepsell TD,

Weiss NS, Heckbert SR, et al. Health outcomes associ-

ated with antihypertensive therapies used as rst-line

agents: a systematic review and meta-analysis. J Amer

Med Assoc 1997;277:73945.

13. Hansson L, Zanchetti A, Carruthers SG, Dahlof B,

Elmfeldt D, Julius S, et al, for the HOT Study Group.

Effects of intensive blood-pressure lowering and low-

dose aspirin in patients with hypertension: principal

results of the Hypertension Optimal Treatment (HOT)

randomized trial. Lancet 1998;351:175562.

14. The ALLHAT Ofcers and Coordinators for the

ALLHAT Collaborative Research Group. Major out-

comes in high-risk hypertensive patients randomized

to angiotensin-converting enzyme inhibitor or cal-

cium channel blocker or diuretic. The Antihyper-

tensive and Lipid-Lowering Treatment to PreventHeart Attack Trial (ALLHAT). J Amer Med Assoc

2002;288:298197.

15. Bakris GL, Williams M, Dworkin L, Elliot WJ, Epstein

M, Toto R, et al. Preserving renal function in adults

with hypertension and diabetes: a consensus approach.

National Kidney Foundation Hypertension and Dia-

betes Executive Committees Working Group. Am J

Kidney Dis 2000;36:64661.

16. Appel LJ. The verdict from ALLHAT thiazide diuret-

ics are the preferred initial therapy for hypertension. J

Amer Med Assoc 2002;288:303941.

17. The ALLHAT Ofcers and Coordinators for the

ALLHAT Collaborative Research Group. Major cardio-

vascular events in hypertensive patients randomized

to doxazosin vs chlorthalidone. The Antihyper-

tensive and Lipid-Lowering Treatment to Prevent

Heart Attack Trial (ALLHAT). J Amer Med Assoc

2000;283:196775.

18. Neaton JD, Grimm RH, Prineas RJ, et al for the Treat-

ment of Mild Hypertension Study Research Group.

Treatment of Mild Hypertension Study: nal results. J

Amer Med Assoc 1993;270:71324.

19. Frost PH, Davis BR, Burlando AJ, et al for the Sys-

tolic Hypertension in the Elderly Program Cooper-

ative Research Group. Serum lipids and incidenceof coronary heart disease ndings from the Systolic

Hypertension in the Elderly Program (SHEP). Circu-

lation 1996;94:23818.

20. Materson BJ, Reda DJ, Cushman WC, et al. Single-

drug therapy for hypertension in men: a comparison

of six antihypertensive agents with placebo. N Engl J

Med 1993;328:91421.

21. Sever PS, Dahlof B, Poulter NR, et al, for the ASCOT

Investigators. Prevention of coronary and stroke events

with atorvastatin in hypertensive patients who have

average or lower-than-average cholesterol concentra-

tions, in the Angelo-Scandinavian Cardiac outcomes

Trial Lipid Lowering Arm (ASCOT-LLA): multicen-tre randomized trial. Lancet 2003;361:114958.

22. Heart Protection Study Collaborative Group. MRC/

BHF Heart Protection Study of cholesterol lowering

with simvastatin in 20,536 high-risk individuals:

a randomized placebo-controlled trial. Lancet

2002;360:722.

23. The Heart Outcomes Prevention Evaluation Study

Investigators. Effects of an angiotensin-converting-

enzyme inhibitor, ramipril, on cardiovascular events


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in high-risk patients. N Engl J Med 2000;342:14553.

24. Franco V, Oparil S, Carretero OA. Hypertensive Ther-

apy: Part I. Circulation 2004;109:29538.

25. Franco V, Oparil S, Carretero OA. Hypertensive Ther-

apy: Part II. Circulation 2004;109:30818.

26. Mancia G, Rosei A, DeBaker G, et al. 2003 European

Society of Hypertension European Society of Car-

diology guidelines for the management of arterial

hypertension. J Hypertens 2003;21:101153.

27. OBrien E, Pickering T, Asmar R, et al. Working Groupon Blood Pressure Monitoring of the European Soci-

ety of Hypertension International Protocol for valida-

tion of blood pressure measuring devices in adults.

Blood Press Monit 2002;7:317.

28. Lopez LM, Taylor JR. Home blood pressure mon-

itoring: point-of-care testing. Ann Pharmacother

2004;38:86873.

29. Houston Miller N, Hill M, Kottke T, et al. The mul-

tilevel compliance challenge: recommendations for a

call to action. Circulation 1997;95:108590.

30. Caro JJ, Speckman J. Existing treatment strategies:

Does noncompliance make a difference? J Hypertens

1998 (Suppl);16:S314.

31. Marentette M, Gerth W, Billings D, Zarnke K. Antihy-

pertensive persistence and drug class. Can J Cardiol

2002;18:64956.

32. Thrift AG, McNeill JJ, Forbes A, et al. Three impor-

tant subgroups of hypertensive persons at greater

risk of intracerebral hemorrhage. Hypertension

1998;31:12239.

33. Willey C. Behavior-changing methods for improving

adherence to medication. Curr Hypertens Rep

1999;1:47781.

34. McDonnell HP, Garg A, Haynes RB. Interventions to

enhance patients adherence to medication prescrip-tions. J Amer Med Assoc 2002;288:286879.

35. Petrella R. Survey on awareness of hypertension. Per-

spectives in Cardiology 2002 March.

36. ASHP therapeutic position statement on optimizing

treatment of hypertension. Amer J Health-Syst Pharm

2000;57:16273.

37. Myers M. Compliance in hypertension: why dont

patients take their pills? Can Med Assoc J

1999;160:645.

38. Carter BL, Barnette DJ, Chrischilles E, Mazzotti GJ,

Asali ZJ. Evaluation of hypertensive patients after care

provided by community pharmacists in a rural set-

ting. Pharmacotherapy 1997;17:127485.39. Carter BL, Zillich AJ. Pharmaceutical care services

for patients with hypertension. Pharmacotherapy

2003;37:13357.

40. Carter BL, Zillich AJ, Elliott WJ. How pharmacists can

assist physicians with controlling blood pressure. J

Clin Hypertens 2003;5:317.

41. Chabot I, Moisan J, Gregoire JP, Milot A. Pharmacist

intervention program for control of hypertension. Ann

Pharmacother 2003;37:118693.

42. Mansoor GA. Herbs and alternative therapies in the

hypertension clinic. Amer J Hypertens 2001;14:9715.

43. Ruck B, Shih RD, Marcus SM. Hypertensive crisis

from herbal treatment of impotence. Amer J Emerg

Med 1999;17:3178.

44. Fetrow CW, Avila JR. Professionals Handbook of

Complementary and Alternative Medicines. Spring-

house: Springhouse Corp., 1999.


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QuestionsAccording to CCCEP guidelines, participants have two attempts to achieve

a score o 70% on the post-test questions. Successul participants will

receive a certicate documenting their completion o the course. While

not required to do so, participants are encouraged to use the eedback

orm to provide comments and suggestions about the course.

The following scenario applies to questions 15:JR is a 57-year-old male with hypertension, osteoarthri-tis, and asthma. He was diagnosed with hypertension

approximately 5 years ago. JR takes hydrochlorothiazide25 mg daily for his high blood pressure and acetamin-ophen prn for his osteoarthritis. His most recent blood

pressure reading was 156/94. JR is a heavy smoker.

1. What is JRs maximum target blood pressure?a. 120/80b. 130/85c. 139/89d. 125/85

2. When combined with hypertension, which of thefollowing increases JRs risk of subsequent cardio-

vascular disease?a. asthmab. smokingc. osteoarthritisd. duration of JRs hypertension

3. What changes to JRs lifestyle should be recom-mended in order to decrease his blood pressure?

a. smoking cessationb. drinking 3 alcoholic beverages per dayc. taking a magnesium supplementd. none of the above

4. The consequences of long-term uncontrolledhypertension include:

a. stroke or transient ischemic attacksb. kidney diseasec. retinopathyd. all of the above

5. Which of the following agents should JR avoid?a. ramiprilb. valsartanc. nadolold. amlodipine

The following scenario applies to questions 616:AT is a 62-year-old woman. She has been on metoprolol50 mg twice daily for over 10 years to treat her hyper-tension. Her current blood pressure is 145/90. AT is alsotaking metformin 500 mg three times daily for diabetes.Her diabetes is not well-controlled, and as a result, shehas developed nephropathy (albuminuria 500 mg/day).

6. What changes should be made to ATs hyperten-

sion therapy?a. No changes need to be made.b. Discontinue metoprolol and start an ACE

inhibitor.c. Increase the dose of metoprolol.d. Discontinue metoprolol and start a low-dose

thiazide diuretic.

7. What is the goal blood pressure for AT?a.


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11. Which medications have been shown throughclinical trials to reduce the risk of mortality inpatients with hypertension?

a. ACE inhibitors, ARBs, beta-blockers, calciumchannel blockers, and diuretics

b. alpha blockers, beta-blockers, diureticsc. angiotensin receptor blockers, ACE inhibitors,

alpha blockersd. angiotensin receptor blockers, ACE inhibitors,

central acting agents

12. For elderly hypertensive patients (with isolatedsystolic hypertension), which statement is true?

a. Beta-blockers should be used rst line.b. Low-dose thiazide diuretics should be used as

rst-line therapy.c. Alpha-blockers, as initial monotherapy, are

the drugs of choice in this patient group.d. Loop diuretics such as furosemide should be

used rst line.

13. Which statement about hypertension is false?

a. Many hypertensive patients do not adhere totheir blood pressure medication.

b. Patients with uncontrolled hypertension areurged to continue a sedentary lifestyle untiltheir blood pressure is brought under control.

c. In overweight patients, a 5 kg weight lossmay reduce blood pressure.

d. There is an association between sodiumintake and blood pressure levels.

14. ACE inhibitors are indicated as rst-line agentsfor hypertension in all the following situations

except:a. systolic dysfunction congestive heart failureb. diabetes mellitus with proteinuriac. atrial brillationd. recent myocardial infarction

15. Which agent is least likely to cause exacerbationsof high blood pressure?

a. pseudoephedrineb. niacinc. venlafaxined. ginseng

16. Which statement is false?a. Indapamide may cause glucose intolerance.b. High doses of diuretics should be avoided in

patients with gout.c. Thiazide diuretics can be used in patients

with osteoporosis because they cause calciumretention.

d. Patients with hyperlipidemia can be treatedwith diuretics.

The following scenario applies to questions 1724:AB, a 38-year-old female, comes to the pharmacy to geta rell of her simvastatin, which she uses for hyperlip-idemia. While waiting for her prescription, she decidesto take her blood pressure using the in-store electronicblood pressure machine. She is shocked when she discov-ers that her blood pressure is 157/94. She states that shehas never had high blood pressure before.

17. Which statement(s) is/are true?a. Only a mercury sphygmomanometer with a

stethoscope should be used to measure bloodpressure.

b. Hypertension is diagnosed after at least veassessments over a six-month period.

c. BT should take another blood pressure read-ing after one minute and average the 2 read-ings.

d. B and C

18. AB returns to your pharmacy 4 months laterwith a prescription for enalapril 2.5 mg daily

to treat hypertension. What nonpharmacologicaltreatment(s) can be recommended?

a. weight reduction if AB is overweightb. moderate exercise 4 or more times a weekc. limiting alcohol intake to a maximum of 9

drinks per weekd. all of the above

19. Which of the following hypertension medica-tions should not be used as rst-line therapy in AB?

a. beta-blockersb. long-acting calcium channel blocker

c. angiotensin receptor blockersd. alpha-blockers

20. Which of following counseling tips for AB isincorrect?

a. AB will reach target blood pressure in 2 to 3days after starting drug therapy.

b. Most medications for hypertension willdecrease systolic blood pressure by a maxi-mum of approximately 15 mmHg.

c. Lifestyle modication, in conjunction withdrug therapy, will help AB reach her targetblood pressure.

d. AB should have her blood pressure measuredregularly.


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Hypertension

21. After 6 months of therapy, AB has still notreached her target blood pressure. The enalapril iswell tolerated. Which of the following could be rec-ommended to improve ABs blood pressure con-trol?

a. increasing the dose of enalaprilb. adding a diureticc. substituting enalapril with methyldopad. A or B

22. Beta-blockers are rst-line agents in the treat-ment of hypertension except in the following con-comitant condition(s):

a. Raynauds phenomenonb. 2nd or 3rd degree heart blockc. isolated systolic hypertensiond. all of the above

23. Which of the following should be monitored inpatients taking beta-blockers?

a. blood pressureb. heart rate

c. energy leveld. all of the above

24. Which of the following statements is true?a. In the early stage of the disease, hypertension

is associated with many symptoms.b. The majority of patients with hypertension

have well-controlled blood pressure.c. If a patient has two different blood pressures

in each arm, the higher blood pressure isused.

d. Electronic blood pressure devices do not

require periodic calibration and validation.

25. A patient comes into the pharmacy with a listof herbal medications that she is taking. She wasrecently diagnosed with hypertension. Which of thefollowing herbal preparations have some clinicaldata supporting an antihypertensive effect?

a. garlicb. ma huangc. licoriced. blue cohosh

26. Verapamil and diltiazem are indicated as rst-line therapy in hypertensive patients with concomi-tant:

a. atrial brillationb. stable anginac. myocardial infarctiond. systolic dysfunction (CHF)

27. The goal(s) of hypertension therapy is/are:

a. to eliminate symptomsb. to reduce blood pressure to below 120/80 in

all patientsc. to reduce mortality and morbidityd. all of the above

28. Which of the following may cause an inadequateresponse to hypertension therapy?

a. nonadherenceb. drug interactionsc. renal diseased. all of the above

29. Strategies for improving adherence include all ofthe following except:

a. home blood pressure monitoringb. reminder systems (e.g., dosettes, calendars)c. simplifying regimensd. using self-will alone without other tools

30. Potential roles for pharmacists in improving out-comes in patients with hypertension include:

a. working with the patient and the physician tooptimize the treatment plan

b. working with the patient to optimize adher-

encec. conducting medication review consultationsessions with patients

d. all of the above.

To earn CEUs associated with this CE program,you must complete the online post-test availablethrough the CPhA 2005 Home Study ProgramCD-ROM.

cpha guidelines hypertension

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