hypertension 1 pre-class

95% of patients have what kind of hypertension

primary/essential

the cause of primary hypertension is unclear. what are the three likely contributors?

lifestyle/environment, age, genetics

secondary hypertension is hypertension with what?

an identifiable cause

what are the 7 major causes of secondary hypertension listed in the slides?

CKD, renal artery stenosis (renovascular hypertension), primary aldosteronism, obstrucive sleep apnea, pheochromocytoma, drug-induced, thyroid disease

what is the equation for BP?

cardiac output x total peripheral resistance

list the classes of hypertensive medications in the RAAS

ACE inhibitors, Beta Blockers, Calcium Channel Blockers, Thiazide Diuretics, Alpha Blockers

RAAS stands for

Renin-Angiotensin-Aldosterone System

what target organs are often damaged by hypertension?

cardiac, neurologic, renal, and ocular organs

what are the key points of a BP assessment?

two measurements per visit, use readings from more than 2 visits, ensure proper technique, get out of office readings from patient to confirm diagnosis and consider variations due to time of day or activity level.

normal BP is

<120 systolic AND <80 diastolicthe range for optimal cardiovascular health.

elevated BP is

120-129 systolic AND <80 diastolic

stage 1 hypertension is

130-139 systolic OR 80-89 diastolic

stage 2 hypertension is

greater than or equal to 140 systolic OR greater than or equal to 90 diastolic

what are the 5 kinds of hypertension

primary, secondary, white-coat, masked, pregnancy-associated

what is white coat hypertension

elevated BP in clinic, normal BP outside of clinic

what is masked hypertension

normal BP in clinic, elevated BP outside of clinic

what are the indicators for secondary hypertension

stage 2 hypertension, treatment resistant hypertension, sudden onset of hypertension, increased BP in patients with previously controlled hypertension, early onset hypertension (<30yrs old)

what are the three EXTREMELY important factors in treatment of secondary hypertension

detection, diagnosis, and specific targeted therapy

which hypertension threshold should you promote lifestyle therapy modification in?

all thresholds

when should you reassess a patient with normal BP?

1 year

when should you reasess a patient with elevated BP?

3-6 months

a patient presents with stage 1 hypertension. what questions should you ask/what should you do next?

does the patient have diabetes or chronic kidney disease? what is their 10yr CVD score and is it equal to or over 7.5%?

a diabetic patient presents with stage 1 hypertension. what should you do next? treatment goal?

start on blood pressure medication and reassess in 1 month. treatment goal is less than 130/80, with a preferred goal of less than 120/80.

a diabetic patient presents with stage 1 hypertension. you start them on BP meds, but at their 1 month reassessment, they have not met their BP goal. what do you do next? treatment goal?

intensify therapy and optimize adherence. treatment goal is less than 130/80, with a preferred goal of less than 120/80.

a diabetic patient presents with stage 1 hypertension. you start them on BP meds, and they have met their goal at their 1 month assessment! what do you do from here? treatment goal?

reassess in 3-6 months, treatment goal is the same- less than 130/80, with a preferred goal of less than 120/80.

a patient presents with stage 2 hypertension, what do you do? treatment goal?

begin BP lowering medication and reassess in 1 month. treatment goal is less than 130/80, with a preferred goal of less than 120/80.

patient presents with a bp of 145/70 with CKD and a CVD risk score of 10%. what is your diagnosis and what do you do? treatment goal?

stage 2 hypertension. start BP lowering therapy and reassess in 1 month. treatment goal is less than 130/80, with a preferred goal of less than 120/80.

patient presents with a bp of 120/90 no other medical history. what is your diagnosis and what do you do? treatment goal?

stage 2 hypertension. start on BP lowering medication and reassess in 1 month. treatment goal is less than 130/80, with a preferred goal of less than 120/80.

patient presents with a bp of 128/71 with CKD and diabetes. what is your diagnosis and what do you do? treatment goal?

elevated BP. lifestyle counsel and reassess in 3-6 months. treatment goal is less than 130/80, with a preferred goal of less than 120/80.

patient presents with a bp of 132/94 with no medical history otherwise. what is your diagnosis and what do you do? treatment goal?

stage 2 hypertension. start on BP lowering therapy and reassess in 1 month. treatment goal is less than 130/80, with a preferred goal of less than 120/80.

patient presents with a bp of 121/86. what is your diagnosis and what do you do? treatment goal?

stage 1 hypertension. does the patient have CKD, diabetes, or a 10yr CVD risk of >10%? if yes, start on BP lowering therapy and reassess in 1 month. if no, lifestyle counsel and reassess in 3-6 months. treatment goal is less than 130/80, with a preferred goal of less than 120/80.

patient presents with a bp of 97/90. what is your diagnosis and what do you do? treatment goal?

stage 2 hypertension. start on BP lowering therapy and reassess in 1 month. treatment goal is less than 130/80, with a preferred goal of less than 120/80.

patient presents with a bp of 98/60. what is your diagnosis and what do you do?

normal BP. reassess in 1 year.

the treatment goal for hypertensive patients with diabetes, CKD, dementia, cognitive impairment, heart failure, and/or AFIB is what?

less than 130/80, with a preferred goal of less than 120/80.

the treatment goal for hypertensive CKD patients, according to the KDIGO guidelines, is what? this is different from the standard goal for hypertensive patients with CKD, which is what?

less than 120/80, less than 130/80

what are the two ways to confirm treatment resistant hypertension?

office BP over 130/80 while on >3 antihypertensives

office BP less than 130/80 but requires >4 hypertensives

what is the usual maximum hypertensive medication combination?

ACEi/ARB + CCB + thiazide like diuretic

what are the things you should assess before adjusting pharmacological therapy for treatment resistant hypertension

exclude pseudoresistance by making sure office readings are accurate, confirming adherence, and obtaining outside-of-office BP readings

identify and reverse potential contributing factors

discontinue or minimize interfering substances (prescription or otherwise)

screen for secondary causes of hypertension

what is the pharmacological recommendation for treatment resistant hypertension

maximize diuretic therapy by replacing thiazides with chlorthalidone 12.5-25mg qd or indapamide 1.25-2.5mg qd

add spironolactone 25-50mg qd (or equivalent doseage of eplerenone 25-50mg BID if eGFR >45)

use chlorthalidone or loop diuretics in patients with CKD stage 4 or greater

add agents with a different MOA like BB, central sympatholytic drugs, or nondihydropyridine CCB for elevated heart rate

add potent vasodilators like aprocitentan, hydralazine, or minoxidil if already on a beta blocker (or bradycardic) and a loop diuretic

when should you refer a patient to a hypertension specialist?

known or suspected secondary hypertension, uncontrolled BP after more than 6 months of treatment

what drugs should be used to treat resistant hypertension in patients with CKD stage 4 or greater?

chlorthalidone or loop diuretics

there are 16 major external inducers of hypertension. what are they?

1. alcohol

2. caffeine

3. decongestants

4. supplements: st. johns wart/ephedra/ma huang

5. black licorice

6. NSAIDs

7. recreational drugs: bath salts, meth, cocaine

8. central acting cympatholytic (clonidine, tizanidine) withdrawal

9. amphetamines

10. antidepressants

11. atypical antipsychotics

12. immunosuppressants

13. oral contraceptives

14. systemic corticosteroids

15. angiogenesis and tyrosine kinase inhibitors

16. androgen deprivation therapy

what lifestyle modifications can be made to treat hypertension?

weight loss, better diet/nutrient intake, reduced alcohol intake, physical activity, stress reduction

what is the BP goal for institutionalized older patients?

<150 SBP or <140 SPB if tolerated

what is the BP goal for patients with high disease burden/comorbidities?

<150 SBP or <140 SPB if tolerated

what is the BP goal for patients with limited life expectancy?

<150 SBP or <140 SPB if tolerated

what is clinical inertia?

an office visit where no indicated blood pressure therapy (pharmacologic or otherwise) is given to a patient with uncontrolled hypertension

what are the main medications given to a patient with stage 1 hypertension & diabetes, CKD, and/or a ASCVD risk >10%/CVD risk > 7.5%?

monotherapy of an ACEi, ARB, CCB, or thiazide

what are the main medications given to a patient with stage 2 hypertension?

ACEi/ARB + CCB or ACEi/ARB + thiazide

primary antihypertensive medications for chronic coronary disease patients?

start with ACEi, ARB, or BB

add on additional BB or DHP calcium channel blocker if angina is present

start thiazide or mineralocorticoid receptor antagonist for additional add on therapy

primary antihypertensive medications for diabetes mellitus patients?

ACEi, ARB, CCB, or thiazide

primary antihypertensive medications for chronic kidney disease patients?

ACEi/ARB

primary antihypertensive medications for peripheral artery disease patients?

ACEi/ARB

primary antihypertensive medications for secondary stroke prevention patients?

thiazide, ACEi, or ARB monotherapy OR thiazide + ACEi

what are the electrolyte goals for the DASH diet?

sodium intake <1.5g/day or start with a reduction of 1g/day

potassium intake should be ideally 3500-5000g/day

non-pharmacological methods to treat hypertension

dietary adjustment (DASH diet)

reduced alcohol intake

weight loss

at least 90-150 minutes of aerobic exercise per week

true or false? smoking cessation lowers blood pressure

false, but it does lower risk of cardiovascular disease so it should still be discussed with patient

when can a beta blocker be used for hypertensive treatment

when there is a “compelling indication”/patient cannot take first line therapies OR in combination with a first line therapy