HTN Monte 1

What is the epidemiology of HTN?

• Nearly half (48%) of adults in US have HTN= 120 mil ppl

• About 1 in 4 adults w/ HTN have BP under control

• High BP was primary/contributing cause of death for over 680,000 Americans in 2024

What is primary HTN?

• AKA essential HTN

• Most common: ~90% of HTN pts

• Cannot be cured but can be controlled

• No identifiable cause

What are the modifiable risk factors for primary HTN?

• Current cigarette smoking, second hand

• Diabetes

• Dyslipidemia

• Overweight/obesity

• Physical inactivity

• Unhealthy diet

• Excessive alcohol intake

What are the relatively fixed risk factors of primary HTN?

• Family history

• Elderly age

• Low SE/educational status

• Male sex

• Psychosocial stress

What is secondary HTN?

• Less common: ~10% of HTN pts

• Treat underlying cause &/or remove agents if possible

What diseases cause secondary HTN?

• CKD

• Cushing’s syndrome

• Obstructive sleep apnea

• Pheochromocytoma

• Primary aldosteronism

• Thyroid disease

What drugs cause secondary HTN?

• Amphetamines

• Decongestants

• Corticosteroids

• Immunosuppressants

• Estrogens

• NSAIDs

• Nicotine

• Cocaine

• Anabolic steroids

What foods cause secondary HTN?

• Sodium

• Caffeine

• Alcohol

• Licorice

What is white coat HTN?

• BP values rise in clinical setting but return to normal in non clinical environments (home, grocery store)

• May lead to overtreatment for HTN

What is masked HTN?

• Home HTN is hypertensive, while in-office BP is normotensive/substantially lower than at home

• May lead to undertreatment/no treatment for HTN

What are HTN-related complications?

• Brain: stroke, transient ischemic attack (TIA), dementia

• Eyes: retinopathy

• Heart: left ventricular hypertrophy (LVH), HF, angina, MI

• Kidney: CKD

• Peripheral vasculature: PAD

What is the BP goal?

<130/80 mmHg

What is the normal BP category?**

• Systolic: <120

And

• Diastolic: <80

What is the elevated category?**

• Systolic: 120-129

And

• Diastolic: <80

What is the high BP (HTN) stage 1 BP category?**

• Systolic: 130-139

Or

• Diastolic: 80-89

What is the high BP (HTN) stage 2 BP category?**

• Systolic: >140

Or

• Diastolic: >90

What is the hypertensive crisis (consult doctor immediately) BP category?**

• Systolic: >180

And/Or

• Diastolic: >120

What if pt has average BP >140/90?

Start medications to lower BP & reduce CVD risk

What if pt has existing clinical CVD (CHD, stoke, HF)?

Start medications to lower BP & reduce CV risk if >130/80 mmHg

What if pt has diabetes/CKD or at increased risk for CVD (10 year risk >7.5)?

Start medications to lower BP & reduce CVD risk if >130/80 mmHg

When to start medications to lower BP w/ average >130/80 mmHg after?

3-6 months of lifestyle intervention

What are the nonpharm therapies for HTN?

• Reduce weight

• DASH diet

• Lower sodium intake

• Increase physical activity

• Restrict alcohol consumption

What weight loss is recommend for HTN?

• Maintain normal body weight (BMI 18.5-24.9 kg/m²)

• Through combo of reduced calorie intake & increased physical activity

• 1-kg loss of body weight is associated w/ ~1 mmHg drop in BP

What nutrition is recommended for HTN?

• DASH (Dietary Approaches to Stop HTN) diet

• Eat more: fruits & vegs, whole grains, lean protein, low-fat dairy, nuts, seeds, legumes

• Eat less: saturated & trans fat, sweets, & salty foods

What sodium intake is recommended for HTN?

• Reduced intake to <2,300 mg/day

• Optimal goal is <1,500 mg/day

• Even if desired daily sodium intake is not achieved, sodium intake should be reduced by at least 1,000 mg/day

What alcohol consumption is recommended for HTN?

Reduce alcohol to </= 2 drinks daily for men & </= 1 drink daily for women

What alcohol consumption is recommended for HTN?

Reduce alcohol to </= 2 drinks daily for men & </= 1 drink daily for women

What is the treatment/follow-up for normal BP?

Healthy lifestyle changes & reassess in 1 year

What is the treatment/follow-up for elevated BP?

Healthy lifestyle changes & reassess in 3-6 months

What is the treatment/follow-up for HTN stage 1 BP?

• 10-yr PREVENT-CVD risk <7.5%

  • Healthy lifestyle changes & reassess in 3-6 months

• 10-yr PREVENT-CVD risk >/= 7.5%, known CVD, diabetes, or CKD

  • Healthy lifestyle changes, start 1 medication, & reassess in 1 month

What is the treatment/follow-up for HTN stage 2 BP?

Healthy lifestyle changes, start 2 medications (from different classes), esp when BP >20/10 mmHg above goal & reassess in 1 month

What are the 1st-line agents for initial medication?

• Thiazide diuretics

• CCBs

• Ace-Is/ARBs

What is the choice for combination therapy?

2 first-line agents of different classes in stage 2 HTN when BP is >20/10 mmHg above goal

What is initial treatment for black pts?**

Thiazide diuretics or CCB if they do NOT have HF or CKD (ACE-I or ARB if they do)**

What is the 1st-line agent if pt has diabetes?

• Thiazide diuretic

• CCBs

• ACE-I/ARB

What is the 1st-line agent if pt has diabetes w/ albuminuria?

ACE-I/ARB

What is the 1st-line agent if pt has CKD?

ACE-I/ARB

What is the 1st-line agent if pt has HF w reduced EF?

• Beta blocker

• ACE-I/ARB

• Aldosterone antagonist

What is the 1st-line agent if pt has HF w preserved EF?

• ACE-I/ARB

• Aldosterone antagonist

What is the 1st-line agent if pt has stable ischemic heart disease?

• Beta blocker

• ACE-I/ARB

• (CCB if angina)

What is the 1st-line agent if pt has secondary stroke prevention?

• Thiazide diuretic

• ACE-I/ARB

What are the thiazide diuretics?

• Chlorthiazide (Diuril)

• Chlorthalidone (Hygroton)

• Hydrochlorothiazide (Microzide)

• Indapamide (Lozol)

• Matolazone (Zaroxolyn)

What is the brand name for chlorothiazide?

Diuril

What is the brand name for chlorthalidone?

Hydroton

What is the brand name for Hydrochlorothiazide?

Microzide

What is the brand name for Indapamide?

Lozol

What is the brand name for metolazone?

Zaroxolyn

What are the AEs of thiazide diuretics?

• Hypokalemia, hypomagnesemia, hyponatremia

• Hypercalcemia, hyperglycemia, hyperuricemia

• Elevated LDL & TGs

• Renal dysfunction

• Dizziness

• Photosensitivity

• Rash

What are contraindications w/ thiazide diuretics?

• Hypersensitivity to sulfonamide-derived drugs (not likely to cross-react)

• Anuria

What is monitoring for thiazide diuretics?

• BP

• Electrolytes

• Renal function (SCr)

• Fluid status (input & output, weight)

• Glucose (diabetes)

• Uric acid (gout)

What are drug interactions w/ thiazide diuretics?

• Increased lithium concentration

• Increased dofetilide concentration

• NSAIDs