HypertensionHypertension

Classification of hypertensionClassification of hypertension BP targetsBP targets Basic evaluationBasic evaluation When to evaluate for secondary When to evaluate for secondary

causescauses Which drug(s) you should useWhich drug(s) you should use Classes of antihypertensivesClasses of antihypertensives

Classification of blood pressure in adultsClassification of blood pressure in adults

BP classificationBP classification SBP (mmHg)SBP (mmHg) DBP (mmHg)DBP (mmHg)

NormalNormal < 120< 120 and < 80and < 80

PrehypertensionPrehypertension 120-139120-139 or 80-89or 80-89

Stage 1 Stage 1 hypertensionhypertension

140-159140-159 or 90-99or 90-99

Stage 2 Stage 2 hypertensionhypertension

>=160>=160 or >= 100or >= 100

Target BPTarget BP

Patients with diabetes and CKD – Patients with diabetes and CKD – 130/80130/80

Everybody else – 140/90Everybody else – 140/90

Basic evaluationBasic evaluation HistoryHistory

– HPI – onset of hypertension, antihypertensives (which ones HPI – onset of hypertension, antihypertensives (which ones used, side effects), severity of hypertensionused, side effects), severity of hypertension

– PMH – all drugs used including OTC meds, herbals; other PMH – all drugs used including OTC meds, herbals; other medical conditionsmedical conditions

– FH – specifically hypertension, renal diseaseFH – specifically hypertension, renal disease– SH – EtOH, salt intake, increase in weightSH – EtOH, salt intake, increase in weight– ROS – HA, palpitations, sweating, thyroid sxsROS – HA, palpitations, sweating, thyroid sxs

PhysicalPhysical– BP in both armsBP in both arms– fundoscopic examfundoscopic exam– thyroid examthyroid exam– heart, lungsheart, lungs– abd – specifically listen for bruitsabd – specifically listen for bruits– ext – pulses, edemaext – pulses, edema

Initial labsInitial labs

BUN, creat(eGFR), urinalysisBUN, creat(eGFR), urinalysis CalciumCalcium KK TSHTSH

When to eval for secondary causesWhen to eval for secondary causes When basic eval suggests a secondary cause –When basic eval suggests a secondary cause –

e.g. variable BP, HA, palpitations, sweating – e.g. variable BP, HA, palpitations, sweating – pheo; severe hypertension in a young female or pheo; severe hypertension in a young female or sudden worsening of hypertension in an older sudden worsening of hypertension in an older person – renovascular hypertensionperson – renovascular hypertension

When history is not consistent with essential When history is not consistent with essential hypertension (positive FH, onset in 20’s, initially hypertension (positive FH, onset in 20’s, initially mild) mild)

For resistant hypertension – elevated BP when For resistant hypertension – elevated BP when patient is reliably taking adequate doses of three patient is reliably taking adequate doses of three antihypertensives, one of which is a diureticantihypertensives, one of which is a diuretic

First drug with no other medical First drug with no other medical problemsproblems

Anything would work (the most important thing is Anything would work (the most important thing is to control the blood pressure)to control the blood pressure)

Diuretics have been the most thoroughly studied Diuretics have been the most thoroughly studied and are safe, effective and inexpensiveand are safe, effective and inexpensive

I recommend starting with chlorthlidone 12.5 qd; I recommend starting with chlorthlidone 12.5 qd; if the BP is not controlled I would add lisinoprilif the BP is not controlled I would add lisinopril

Compelling indicationsCompelling indications CHF – ACE, ARB, BB, Aldo ant; also diureticsCHF – ACE, ARB, BB, Aldo ant; also diuretics Post-MI – BB, ACEPost-MI – BB, ACE High CAD risk – BB, ACE; also diuretics, CCBHigh CAD risk – BB, ACE; also diuretics, CCB Diabetes – BB, ACE, ARB; also diuretics, CCBDiabetes – BB, ACE, ARB; also diuretics, CCB CKD – ACE, ARBCKD – ACE, ARB Recurrent stroke prevention – ACE; also diureticsRecurrent stroke prevention – ACE; also diuretics BPH (not in JNC VII) – BPH (not in JNC VII) – αα-blocker-blocker

Second and third drugsSecond and third drugs If first drug is not a diuretic second one should be If first drug is not a diuretic second one should be

(almost all non-diuretic antihypertensives result (almost all non-diuretic antihypertensives result in sodium retention which limits their efficacy)in sodium retention which limits their efficacy)

Best 3 drug combo is appropriate dose of a Best 3 drug combo is appropriate dose of a diuretic, an ACE inhibitor and a calcium channel diuretic, an ACE inhibitor and a calcium channel blockerblocker

DiureticsDiuretics

ThiazidesThiazides– qd for BP; chlorthalidone making a comebackqd for BP; chlorthalidone making a comeback

LoopLoop– GFR < 30 - 50GFR < 30 - 50– bid for BP (except for torsemide which is qd)bid for BP (except for torsemide which is qd)

Aldo antagonistsAldo antagonists– primary aldo and aldo mediated hypertension more primary aldo and aldo mediated hypertension more

common than previously thought so consider these common than previously thought so consider these drugs in resistant BPdrugs in resistant BP

– spironolactone – 25 qd is usually sufficientspironolactone – 25 qd is usually sufficient– eplerenone has few hormonal side effects but is very eplerenone has few hormonal side effects but is very

expensive (is half as potent as spironolactone)expensive (is half as potent as spironolactone)

Calcium channel blockersCalcium channel blockers Decrease tone of LES/dose-dependent edema/can Decrease tone of LES/dose-dependent edema/can

be used togetherbe used together DihydropyridinesDihydropyridines

glomerular pressure in CKD so don’t use as first BP glomerular pressure in CKD so don’t use as first BP drug; OK if patient already on ACE or ARBdrug; OK if patient already on ACE or ARB

– amlodipine is generic and has long half life without amlodipine is generic and has long half life without delivery systemdelivery system

DiltiazemDiltiazem glomerular pressure in CKDglomerular pressure in CKD– neg inotrope and chronotropeneg inotrope and chronotrope

VerapamilVerapamil glomerular pressure in CKDglomerular pressure in CKD– neg inotrope and chronotropeneg inotrope and chronotrope– all older patients get constipatedall older patients get constipated

ACE inhibitorsACE inhibitors

16% get dry cough, can start > 1 year after 16% get dry cough, can start > 1 year after starting ACEstarting ACE

AngioedemaAngioedema Captopril is short actingCaptopril is short acting Work great with diureticWork great with diuretic

Angiotensin receptor blockersAngiotensin receptor blockers

No coughNo cough 8% of patients who get angioedema with ACE get 8% of patients who get angioedema with ACE get

it with ARBit with ARB Probably like an ACE without the coughProbably like an ACE without the cough ONTARGET trial (25,000 patients with vascular ONTARGET trial (25,000 patients with vascular

disease or DM with end-organ damage) – disease or DM with end-organ damage) – proteinuria was decreased but CV outcomes and proteinuria was decreased but CV outcomes and renal function were worse in patient treated with renal function were worse in patient treated with combo ACE/ARB as opposed to either drug alonecombo ACE/ARB as opposed to either drug alone

Renin antagonists (aliskiren)Renin antagonists (aliskiren)

Very few clinical trialsVery few clinical trials Very expensiveVery expensive No coughNo cough Can cause angioedemaCan cause angioedema

ßß-blockers-blockers

Use metoprolol, not atenololUse metoprolol, not atenolol Metoprolol XL is now generic so is probably the Metoprolol XL is now generic so is probably the

preferred ß-blockerpreferred ß-blocker Lower BP by decreasing renin levels so add little Lower BP by decreasing renin levels so add little

BP lowering to ACEs or ARBsBP lowering to ACEs or ARBs

αα-blockers-blockers

Some risk of precipitating CHFSome risk of precipitating CHF Only indication is BPHOnly indication is BPH First dose syncope can occur after First dose syncope can occur after

stopping/restarting med or increasing dosestopping/restarting med or increasing dose Tamsulosin is much better than doxazosin or Tamsulosin is much better than doxazosin or

terazosin for BPH so often times I am switching terazosin for BPH so often times I am switching metoprolol to carvedilol instead of using metoprolol to carvedilol instead of using doxazosin or terazosindoxazosin or terazosin

Direct vasodilatorsDirect vasodilators

Hydralazine rarely indicatedHydralazine rarely indicated– frequent dosingfrequent dosing– drug induced lupusdrug induced lupus– possibly indicated in patient with CHF who gets possibly indicated in patient with CHF who gets

angioedema on ACE/ARBangioedema on ACE/ARB MinoxidilMinoxidil

– Extremely potent and effectiveExtremely potent and effective– Hirsutism is a problem in femalesHirsutism is a problem in females– Can cause severe fluid retention, tachycardia and Can cause severe fluid retention, tachycardia and

pericarditis so should probably only be used by pericarditis so should probably only be used by hypertension specialistshypertension specialists

Centrally acting agentsCentrally acting agents

ClonidineClonidine– short acting so good for EtOH withdrawal or short acting so good for EtOH withdrawal or

hypertensive urgencieshypertensive urgencies– bedtime dose can be used for patients with PTSDbedtime dose can be used for patients with PTSD– clonidine withdrawal can be severe – it is caused by clonidine withdrawal can be severe – it is caused by

rebound increase in centrally mediated rebound increase in centrally mediated αα and and ββ adrenergic stimulation; when patients are also on a adrenergic stimulation; when patients are also on a ββ--blocker unopposed blocker unopposed αα stimulation can increase the BP stimulation can increase the BP

– rash frequent with patchrash frequent with patch

Rules of thumbRules of thumb Never use ß-blocker and clonidine togetherNever use ß-blocker and clonidine together Never use ß-blocker and verapamil togetherNever use ß-blocker and verapamil together Be careful when using a ß-blocker and dilt Be careful when using a ß-blocker and dilt

togethertogether Never use 10 mg of furosemideNever use 10 mg of furosemide A 25% increase in creat after starting an ACE is A 25% increase in creat after starting an ACE is

good, not badgood, not bad Don’t increase doses of long acting BP meds dailyDon’t increase doses of long acting BP meds daily Never use tid antihypertensivesNever use tid antihypertensives