Hypertension and HTN Emergencies

Ch. 28 2025 Naplex book

What is hypertension and why is it called a silent disease?

High blood pressure bc it is usually asymptomatic which can delay diagnosis

What factors contribute to poor hypertension control?

Medication non-adherence due to asymptomatic disease, side effects, cost, and pill burden

Pts with uncontrolled hypertension are at an increased risk to develop which conditions?

Heart disease, stroke, and kidney disease

What type of hypertension do ~90% of patients have and what causes it?

Primary (essential) hypertension with an unknown cause but multiple contributing risk factors

What are the major risk factors for primary hypertension?

Obesity, sedentary lifestyle, excessive salt intake, smoking, family history, diabetes, and dyslipidemia

What is secondary hypertension and what are common causes?

Hypertension with an identifiable cause such as renal disease, adrenal disease, obstructive sleep apnea, or drugs

Which two neurohormonal systems are primarily responsible for hypertension?

Sympathetic nervous system (SNS) and renin-angiotensin-aldosterone system (RAAS)

How do SNS and RAAS increase blood pressure?

By increasing norepinephrine, angiotensin II, and aldosterone which increase vascular resistance, heart rate, and fluid retention

Describe the RAAS pathway

Angiotensinogen → Renin → Angiotensin I → ACE → Angiotensin II → Vasoconstriction and aldosterone secretion

Where do renin inhibitors, ACE inhibitors, and ARBs work?

Renin inhibitors block angiotensinogen to angiotensin I, ACE inhibitors block angiotensin I to II conversion, and ARBs block angiotensin II receptors

What effect does aldosterone have and which drugs target it?

Aldosterone increases sodium and water reabsorption; aldosterone antagonists and thiazide diuretics oppose this effect

Describe the SNS pathway

SNS activation → Norepinephrine → Vasoconstriction and increased heart rate/contractility

Where do alpha-2 agonists, beta-blockers, non-DHP CCBs, and DHP CCBs work?

Alpha-2 agonists reduce SNS activity; beta-blockers reduce norepinephrine cardiac effects; non-DHP CCBs reduce heart rate/contractility; DHP CCBs reduce vasoconstriction

What are the two major determinants of blood pressure?

Systemic vascular resistance and cardiac output

What is the formula for blood pressure?

BP = SVR × Cardiac Output

What is the formula for cardiac output?

Cardiac Output = Stroke Volume × Heart Rate

What drug classes can increase blood pressure through increased sympathomimetic activity?

ADHD drugs, decongestants, recreational stimulants, and antidepressants such as TCAs, SNRIs, and MAO inhibitors

What drug classes can increase blood pressure through sodium and water retention?

NSAIDs, immunosuppressants such as cyclosporine, and systemic steroids

What drugs can increase blood pressure by increasing blood viscosity or through other mechanisms?

Erythropoiesis-stimulating agents, oral contraceptives with higher estrogen content, and VEGF inhibitors

Why are multiple blood pressure readings needed to diagnose hypertension?

Blood pressure varies throughout the day due to stress, exercise, medications, eating, and daily activities

How should hypertension be diagnosed?

Average of at least two readings obtained on at least two separate occasions

Why is out-of-office blood pressure monitoring preferred?

It helps avoid falsely elevated readings such as white coat hypertension and improves clinical decision-making

What are the ACC/AHA blood pressure categories?

Normal: <120/<80 mmHg;

Elevated: 120-129 and <80 mmHg;

Stage 1 HTN: 130-139 or 80-89 mmHg;

Stage 2 HTN: ≥140 or ≥90 mmHg

What are the proper steps for measuring blood pressure at home?

Empty bladder, sit with both feet on the floor and back supported for at least 5 minutes, use the correct cuff size, support the arm at heart level, and wait 1-2 minutes between measurements

What should patients avoid when measuring blood pressure?

Talking, lying down or sitting without back support, drinking caffeine, exercising or smoking within 30 minutes, and using finger or wrist monitors when possible

How is ambulatory blood pressure monitoring performed?

A device is worn continuously for about 24 hours during daily activities and sleep and obtains readings every 15-60 minutes

How is home blood pressure monitoring BEST performed?

Record the average of at least 2 readings in the morning and evening before eating or taking medications

What lifestyle interventions are proven to lower blood pressure?

Weight loss, DASH diet, adequate potassium intake, sodium restriction, routine physical activity, and limited alcohol consumption

How do weight loss help manage hypertension?

each 1 kg of weight loss lowers BP by about 1 mmHg

What natural products may be used for hypertension and what counseling point is important?

Garlic and fish oil are not guideline-recommended and may increase bleeding risk

What nonpharmacologic intervention should be emphasized throughout hypertension treatment?

Lifestyle modifications

What factors determine when antihypertensive drug therapy should be started?

Hypertension stage and ASCVD risk

What strategies improve medication adherence in hypertension?

Use once-daily regimens and combination products when possible

What are important medication selection principles for hypertension?

Use agents from the preferred drug classes first and do not combine ACE inhibitors with ARBs

What are the preferred initial drug classes for hypertension?

Thiazide diuretics, dihydropyridine CCBs, ACEis, and ARBs

When should drug therapy be started for Stage 1 hypertension?

If the patient has clinical CVD, a 10-year ASCVD risk ≥10%, or does not reach BP goal after 6 months of lifestyle modifications

When should drug therapy be started for Stage 2 hypertension?

Start treatment for all Stage 2 hypertension patients (upon diagnosis/ no criteria)

When should 2 drugs be initiated for HTN tx?

f BP is >20/10 mmHg above goal (e.g., >150/90 mmHg)

What are the blood pressure goals and monitoring recommendations for hypertension?

Goal BP is <130/80 mmHg;

CKD patients may have a goal SBP <120 mmHg if tolerated;

check BP monthly and titrate therapy if not at goal

Which antihypertensives are contraindicated in pregnancy due to a BBW for fetal toxicity?

ACE inhibitors, ARBs, and the direct renin inhibitor aliskiren

When should chronic hypertension be treated during pregnancy and what is the BP goal?

Initiate treatment if SBP ≥140 mmHg or DBP ≥90 mmHg;

maintain SBP 120-139 mmHg and DBP 80-89 mmHg

What are the preferred first-line antihypertensives during pregnancy?

Labetalol, extended-release nifedipine, and methyldopa

What is preeclampsia and how is it managed?

New-onset hypertension after 20 weeks gestation with proteinuria or significant end-organ dysfunction;

severe cases may require IV labetalol or hydralazine, and high-risk patients should receive daily low-dose aspirin after the first trimester

What are the major hypertension combination product categories?

ACE inhibitor or ARB + diuretic,

ACE inhibitor or ARB + CCB,

beta blocker + diuretic,

potassium-sparing diuretic + thiazide-type diuretic,

triple combinations

What are common examples of ACE inhibitor or ARB + diuretic combinations?

Lisinopril/HCTZ (Zestoretic)

Losartan/HCTZ (Hyzaar)

Olmesartan/HCTZ (Benicar HCT)

Valsartan/HCTZ (Diovan HCT)

Benazepril/ HCTZ (Loensin HCT)

(all have HCTZ)

What are common examples of ACE inhibitor or ARB + CCB combinations?

Benazepril/Amlodipine (Lotrel)

Valsartan/Amlodipine, (Exforge)

What are common examples of beta blocker + diuretic combinations?

Atenolol/Chlorthalidone (Tenoretic)

Bisoprolol/HCTZ (Ziac)

What are common examples of potassium-sparing + thiazide-type diuretic combinations?

Triamterene/HCTZ (Maxzide, Maxzide-25)

Amiloride/HCTZ

What are the common triple-combination antihypertensive products?

Olmesartan/Amlodipine/HCTZ and Valsartan/Amlodipine/HCTZ

What is a hypertensive crisis?

Acute severe blood pressure elevation, generally ≥180/120 mmHg

What is a hypertensive emergency?

Severe hypertension with acute target organ damage such as encephalopathy, stroke, acute kidney injury, acute coronary syndrome, aortic dissection, or acute pulmonary edema

How is a hypertensive emergency treated?

Use IV antihypertensive medications

How quickly should blood pressure be lowered in a hypertensive emergency?

Decrease BP by no more than 25% in the first hour, then if stable decrease to about 160/100 mmHg over the next 2-6 hours

Which IV medications are commonly used for hypertensive emergencies?

Clevidipine, enalaprilat, esmolol, hydralazine, labetalol, nicardipine, nitroglycerin, and nitroprusside

What is a hypertensive urgency?

Severe asymptomatic hypertension without evidence of acute target organ damage

How is a hypertensive urgency treated?

Short-acting oral medications such as captopril or clonidine, or restart chronic antihypertensive therapy

How quickly should blood pressure be lowered in a hypertensive urgency?

Gradually over 24-48 hours

What counseling points apply to all antihypertensive medications?

May cause orthostasis; check blood pressure regularly; take as directed even if you feel well because treatment lowers the risk of heart disease, kidney disease, and stroke

What are important counseling points for thiazide diuretics?

Take early in the day (no later than 4 PM) to avoid nighttime urination

What adverse effects should patients know about with thiazide diuretics?

Hyperglycemia, photosensitivity, and sexual dysfunction

What adverse effects and counseling points are important for calcium channel blockers?

May cause peripheral edema and gingival hyperplasia; ghost tablet may appear in stool with Procardia XL

What counseling points are important for ACE inhibitors, ARBs, and aliskiren?

Avoid in pregnancy; may cause angioedema and dry hacking cough

What counseling points are important for beta-blockers?

Do not discontinue abruptly; may mask hypoglycemia symptoms except sweating and hunger; may cause sexual dysfunction

What administration pearls should patients know for carvedilol and metoprolol products?

Take Coreg/Coreg CR with food; take Lopressor and Toprol XL with or immediately after meals

What counseling points are important for clonidine?

Do not discontinue abruptly; clonidine patch is applied weekly to the upper outer arm or chest; do not cut the patch; remove before MRI; may cause sexual dysfunction

What symptoms of hypoglycemia may still be present despite beta-blocker use?

Sweating and hunger

Where should the clonidine patch be applied?

Upper outer arm or chest

What should patients do before an MRI if wearing a clonidine patch?

Remove the patch before the MRI

Why is it important to continue taking antihypertensive medications even when feeling well?

Lowering blood pressure reduces the risk of heart disease, kidney disease, and stroke