Hypertension Pharmacotherapy

Dr. Eddy

What does systolic blood pressure (SBP) represent?

Heart contracting

What does diastolic blood pressure (DBP) represent?

Heart chambers filling up

What is the most common hypertension?

Primary hypertension

What is the cause of primary hypertension?

Unknown cause but could be caused by multiple factors and genetics can play an important role

What does primary hypertension cause?

Increase in cardiac output (CO), increase total peripheral resistance (TPR), or a combination

Can primary hypertension be cured?

No - can be controlled

What causes secondary hypertension?

Comorbid disease or product (drug) induced

What are some of the diseases that causes secondary hypertension?

Chronic kidney disease and obstructive sleep apnea

What are some of the drugs that causes secondary hypertension?

Decongestants and NSAIDS

Can secondary hypertension be cured?

Yes - if the cause if identified

What is a hypertension diagnosis based on?

On an average of 2 or more properly measured BP values from 2 or more clinical encounters.

What is the Stage 1 hypertension classification?

SBP: 130-139 or DBP: ≥ 90

What is the Stage 2 hypertension classification?

SBP: ≥ 140 or DBP: ≥ 90

Do patients show signs/symptoms of hypertension?

No → asymptomatic

BP and CV morbidity and mortality have a STRONG correlation. What is an example that shows this?

Starting at a BP of 115 mmHg risk of CV disease doubles with every 20/10 mmHg increase.

What are some “non-modifiable or relatively fixed” risk factors?

Family history, age, gender, race, stress, CKD, sleep apnea, & socioeconomic status

What are some “modifiable” risk factors?

Low exercise, poor diet, overweight, alcohol use, dyslipidemia, diabetes mellitus, current smoker, & secondhand smoke

What can hypertension lead to in the brain?

Stroke, transient ischemic attack, dementia

What can hypertension lead to in the eye?

Retinopathy

What can hypertension lead to in the heart?

Left ventricular hypertrophy, angina, myocardial infarction, heart failure

What can hypertension lead to in the kidney?

Chronic kidney disease

What can hypertension lead to in the arteries?

Peripheral arterial disease

What is the BP threshold for a patient with clinical CVD or 10-year ASCVD risk ≥ 10%?

≥ 130/80

What is the BP goal for a patient with clinical CVD or 10-year ASCVD risk ≥ 10%?

< 130/80

What are some non-pharmacologic therapies?

Weight loss, DASH diet, reduced salt intake, physical activity, moderation of alcohol intake, and tobacco cessation

What are the primary (first-line) pharmacologic agents?

ACE-i, ARBs, CCBs, and Thiazide Diuretics

What are the thiazides that are first line antihypertensive agents?

Chlorthalidone & Hydrochlorothiazide (used the most)

What kind of patients does thiazides help the most?

Patients that have a GFR ≥ 30 mL/min

What is the MOA for thiazide diuretics?

Mobilize sodium and water from arteriolar walls and reduces peripheral vascular resistance.

What is the adverse effect of thiazide diuretics?

Hypokalemia

What are some counseling points for thiazide diuretics?

Take in the morning (to prevent nocturnal diuresis), may increase blood glucose in patients with diabetes, may precipitate gout flares, and increased sun sensitivity → use sunscreen

What are the ACE-i that are first line antihypertensive agents?

Lisinopril, Benazepril, Enalapril

What is the MOA of ACE-i?

Blocks conversion of angiotensin I to angiotensin II

What are some adverse effects of ACE-i?

Dry cough, angioedema, hyperkalemia, acute liver failure

What is the BBW of ACE-i?

Do not use when pregnant

What are the counseling points of ACE-i?

May cause skin rash or impaired taste perception, do not use potassium supplements or salt substitutes, call your provider if you have a persistent cough or you notice a sore throat, fever, difficulty breathing, and swelling of the lips/tongue

What ARBs are first line antihypertensive agents?

Losartan, Olmesartan, Valsartan

What is the MOA of ARBs?

Blocks angiotensin II from all pathways, not just RAS

What are some side effects of ARBs?

Hyperkalemia, contraindicated in pregnancy

What are some counseling points of ARBs?

May cause kidney insufficiency, hyperkalemia, and hypotension, do not use with ACE-i

What dihydropyridine CCBs are first line antihypertensive agents?

Amlodipine, Nifedipine

What is the MOA of DHP-CCBs?

Through vasodilation

What is an AE for DNP-CCBs?

Peripheral edema

What non-dihydropyridine CCBs are not first line antihypertensive agents?

Diltiazem, Verapamil

What is the MOA for Non-DHP CCBs?

Through decreased heart rate and slowing of AV nodal conduction

What are some counseling points for CCBs?

Notify provider if you experience irregular HR, SOB, dizziness, constipation, & extreme hypotension

When is combination drug therapy recommended?

In adults with stage 2 hypertension and an average BP more than 20/10 mmHg above their BP target.

What cardio-selective beta blockers are second-line antihypertension therapy?

Atenolol, Bisoprolol, Metoprolol

What are the mixed alpha and beta blockers that are second line antihypertension therapy?

Carvedilol, Labetalol

When are beta blocker agents more preferred?

In patients that are post MI.

What are some AE of beta blockers?

Bradycardia, AV conduction abnormalities (heart block), bronchospasm, Raynaud’s phenomenon, sexual dysfunction, increased TG, depressed HDL, and depression

What are some counseling points for beta-blockers?

Abrupt discontinuation can cause unstable angina, MI, rebound hypertension, and death

What are the loop diuretics that are second-line antihypertension agents?

Furosemide, Bumetanide, Torsemide

When are loop diuretics recommended?

When a patient needs edema relief, symptomatic HF and moderate-to-severe CKD (GFR < 30 mL/min)

What are some AE of loop diuretics?

Hypocalcemia or hypokalemia, ototoxicity in high doses

What are the potassium sparing diuretics that are second line antihypertension agents?

Triamterene and HCTZ (Maxzide), Amiloride

What are some AE of potassium sparing diuretics?

May cause hyperkalemia in patients with CKD, diabetes, and being treated with an ACE-I, ARB, direct renin inhibitor, or potassium supplement

What are the aldosterone antagonists that are second-line antihypertension agents?

Spironolactone, eplerenone

What is an AE of aldosterone antagonists?

Hyperkalemia

What are some counseling points for aldosterone antagonists?

Avoid use with K+ supplements, other K+ sparing diuretics or significant renal dysfunction.

What are the alpha-1 blockers that are second-line antihypertension agents?

Doxazosin, Prazosin, Terazosin

When is alpha-1 blockers recommended?

In patients with concomitant BPH.

What are some AE of alpha-1 blockers?

Associated with orthostatic hypotension in geriatric patients

What direct renin inhibitors are second line antihypertension agents?

Aliskiren

What are some AE of Aliskiren?

Hyperkalemia in CKD or in patients taking K+ supplements, acute renal failure

What are some counseling points for Aliskiren?

Do not use when pregnant, do not use in combination with ACE-I or ARBs

What are the central alpha-2 agonists that are second line antihypertension agents?

clonidine, methyldopa, guanfacine

What are some AE of alpha-2 agonists?

Sedation, dry mouth, orthostatic hypotension, and dizziness

What are some counseling points for clonidine?

Do not give to elderly patients or for patient that is non-adherent, do not stop abruptly, and must be tapered

What are the direct vasodilators that are second-line antihypertension agents?

hydralazine, minoxidil

What are some AE of direct vasodilators?

Have Na+ and water retention and reflex tachycardia when used with a diuretic and beta blocker

What is an AE of hydralazine?

Causes drug-induced lupus-like syndrome at higher doses

What is an AE of minoxidil?

Hirsutism and requires a loop diuretic, and can induce pericardial effusion

When should BP be evaluated after starting therapy?

4 weeks

How often should a patient be monitored when they are at their goal?

Every 3 to 6 months

What common labs and vitals should we monitor for ACE-I and ARBs?

BP, SCr, K

What common labs and vitals should we monitor for thiazides?

BP, SCr, K

What common labs and vitals should we monitor for CCBs?

DHP: BP, edema

Non-DHP: BP, pulse

What common labs and vitals should we monitor for BB?

BP, pulse

What medications are recommended for HF (reduced)?

Metoprolol, Bisoprolol, & Carvedilol

What medications are recommended for HF (preserved)?

Metoprolol, Bisoprolol, & Carvedilol + ACE-i or ARB

What medications are recommended for CKD?

ACE-i or ARB

What medications are recommended for comorbid diabetes?

ACE-i or ARB

What medications are recommended for atrial fibrillation (AF)?

ARB

What medications are recommended for African-American adults without CKD or HF?

Thiazide or CCB

What medications are recommended for pregnant patient?

Methyldopa, nifedipine, labetalol

What should you do when escalating therapy?

Assess adherence, home monitoring, split dosing (AM and PM), add another first line agent

What is resistant hypertension (RHTN)?

Blood pressure that remains above guideline-specified targets despite the use of three or more antihypertensive agents.

What is the treatment for RHTN?

ACD (ACE-I/ARB, CCB, thiazide diuretic)

- spironolactone: 4th agent

- then try hydralazine or clonidine