Montepara Hypertension

Primary Hypertension

AKA essential hypertension

Most common → ~90% of HTN patients

No identifiable cause

Cannot be cured but can be controlled

Modifiable Risk Factors for Primary Hypertension

Current cigarette smoking

Secondhand smoke

Diabetes

Dyslipidemia

Obesity

Physical inactivity

Unhealthy diet

Excessive alcohol intake

Relatively Fixed Risk Factors for Primary Hypertension

Family history

Elderly age

Low socioeconomic/educational status

Male sex

Psychosocial stress

Diseases that can cause secondary hypertension

Chronic kidney disease

Cushing’s disease

Obstructive sleep apnea

Pheochromocytoma

• Tumor in adrenal gland → Increases catecholamines → increased BP

Primary aldosteronism

Thyroid disease

• Typically hyperthyroidism

Drugs that can cause secondary hypertension

Amphetamines

Decongestants

Corticosteroids

Immunosuppressants

Estrogens

NSAIDs

Nicotine

Cocaine

Anabolic steroids

Food that can cause secondary hypertension

Sodium

Caffeine

Alcohol

Licorice

• Glycyrrhizic Acid → Low K⁺, High Na⁺

White Coat Hypertension

BP values rise in a clinical setting but return to normal in nonclinical environments

• May lead to overtreatment for hypertension

Masked Hypertension

Home BP is hypertensive, while the in-office BP is normal or substantially lower than at home

• May lead to undertreatment or no treatment for hypertension

Hypertension Related Complications

Brain → Stroke, transient ischemic attack (TIA), dementia

Eyes → Retinopathy

Heart → Left ventricular hypertrophy (LVH), heart failure, angina, MI

Kidney → CKD

Peripheral vasculature → Peripheral arterial disease (PAD)

Blood Pressure Goal for Patient with Hypertension

< 130/80 mmHg

Normal Blood Pressure

Less than 120 systolic AND less than 80 diastolic

Elevated Blood Pressure

120-129 systolic AND less than 80 diastolic

Hypertension Stage 1

130-139 systolic OR 80-89 diastolic

Hypertension Stage 2

140 or higher systolic OR 90 or higher diastolic

Hypertensive Crisis

Higher than 180 systolic OR higher than 120 diastolic

Nonpharmacologic Therapy for Hypertension

Reduce weight

DASH diet

Lower sodium intake

Increase physical activity

Restrict alcohol consumption

Weight goal for Hypertension

Maintain normal body weight → BMI 18.5-24.9 kg/m²

Sodium intake goal for hypertension

Reduce intake to < 2300 mg/day

Optimal goal is < 1500 mg/day

Even if goal is not achieved, reduce sodium intake by at least 1000 mg/day

Physical activity goal for hypertension

90-150 minutes per week of aerobic exercise and resistance training

Alcohol consumption goal for hypertension

Reduce alcohol to 2 drinks or less daily for men and 1 drink or less daily for women

Treatment recommendation for normal blood pressure

Healthy lifestyle changes and reassess in 1 year

Treatment recommendation for elevated blood pressure

Healthy lifestyle changes and reassess in 3-6 months

Treatment recommendations for Hypertension Stage 1

10 year PREVENT-CVD risk < 7.5%

• Healthy lifestyle changes and reassess in 3-6 months

10 year PREVENT-CVD risk ≥ 7.5%, known CVD, diabetes, or CKD

• Healthy lifestyle changes, start ONE medication, and reassess in 1 month

Treatment recommendation for Hypertension Stage 2

Healthy lifestyle changes, start TWO medications (from different classes), especially when BP is > 20/10 mmHg above goal, and reassess in 1 month

First-line medications for treatment of hypertension

Thizide diuretic, CCB, and ACEI OR ARB

Initial treatment for black patients with hypertension who do NOT have HF or CVD should include _____

Thiazide diuretic or CCB (ACEI or ARB recommended if the do have HF or CVD)

• Black patients have less endogenous bradykinin → may be more sensitive to high bradykinin → higher incidence of angioedema with ACEIs

• They also have less endogenous renin

First-line hypertension agents recommended for patients with diabetes

Any first line (thiazide diuretic, CCB, ACEI, or ARB)

First-line hypertension agents recommended for patients with diabetes with albuminuria

ACEI or ARB

First-line hypertension agents recommended for patients with CKD

ACEI or ARB

First-line hypertension agents recommended for patients with Heart Failure with reduced Ejection Fraction (HFrEF)

Beta blocker, ACEI or ARB, aldosterone antagonist

• Beta blocker should be metoprolol succinate, bisoprolol, and carvedilol

First-line hypertension agents recommended for patients with Heart Failure with preserved Ejection Fraction (HFpEF)

ACEI or ARB, aldosterone antagonist

First-line hypertension agents recommended for patients with Stable Ischemic Heart Disease

Beta blocker (any), ACEI or ARB

• CCB if angina

First-line hypertension agents recommended for patients that need Secondary Stroke Prevention

Thiazide diuretic, ACEI or ARB

Thiazide Diuretics (and thiazide-like) Generic Names

Chlorothiazide

Chlorthalidone

Hydrochlorothiazide

Indapamide

Metolazone

Adverse Effects of Thiazide Diuretics

Hypokalemia, Hypomagnesemia, Hyponatremia

Hypercalcemia, Hyperglycemia, Hyperuricemia

Elevated LDL and TGs

Renal dysfunction

Dizziness

Photosensitivity

Rash

Contraindications for Thiazide Diuretics

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

Anuria (kidneys don’t produce urine)

Monitoring for Thiazide Diuretics

Blood pressure

Electrolytes

Renal function (SCr)

Fluid status (input and output, weight)

Glucose (diabetes)

Uric acid (gout)

Drug Interactions with Thiazide Diuretics

NSAIDs

Increased lithium concentration

Increased dofetilide concentration

DHP CCBs Generic Names

Amlodipine

Clevidipine (IV)

Felodipine

Isradipine

Nicardipine (IV)

Nifedipine ER

Nisoldipine

Why is nifedipine IR not used?

Lowers blood pressure too fast → stroke

Adverse Effects of DHP CCBs

Reflex tachycardia

Hypotension

Peripheral edema

Dizziness

Fatigue

Flushing

Headache

Gingival hyperplasia

Hypertriglyceridemia (clevidipine)

• Clevidipine is an IV fatty emulsion

Contraindications for DHP CCBs

Hypersensitivity to drug

Allergy to soybeans, soy products, eggs, or egg products (clevidipine)

Monitoring for DHP CCBs

Blood pressure

Heart rate

Peripheral edema

Drug Interactions with DHP CCBs

Strong CYP3A4 inducers and inhibitors

Non-DHP CCBs Generic Names

Diltiazem SR

Diltiazem ER

Verapamil IR

Verapamil SR

Verapamil Delayed Onset ER

Adverse Effects of Non-DHP CCBs

Bradycardia (HR < 60 bpm)

AV block

Hypotension

Edema

Headache

Dizziness

Gingival hyperplasia

Constipation

Increased LFTs

Contraindications for non-DHP CCBs

Hypotension (SBP < 90 mmHg) ot cardiogenic shock

2nd or 3rd degree AV block or sick sinus syndrome (unless pacemaker)

Monitoring for non-DHP CCBs

Blood pressure

Heart rate

ECG

LFTs

Drug interactions with non-DHP CCBs

Strong CYP3A4 inducers and inhibitors

ACEIs Generic Names

Benazepril

Captopril

Enalapril

Fosinopril

Lisinopril

Moexipril

Perindopril

Quinapril

Ramipril

Trandolapril

Adverse Effects of ACEIs

Dry, hacking cough

Angioedema

Hyperkalemia

Hypotension

Renal dysfunction

Dizziness

Headache

Rash

Contraindications for ACEIs

History of angioedema

Use with aliskiren in patients with diabetes

Use within 36 hours of a neprilysin inhibitor (sacubitril)

Bilateral renal artery stenosis

Pregnancy

Monitoring for ACEIs

Blood pressure

Potassium

Renal function

Drug interactions with ACEIs

RAAS inhibitors

Increased lithium concentration

ARBs Generic Names

Azilsartan

Candesartan

Eprosartan

Irbesartan

Losartan

Olmesartan

Telmisartan

Valsartan

Adverse Effects of ARBs

Hyperkalemia

Hypotension

Renal dysfunction

Dizziness

Headache

Rash

Angioedema

• Very low risk, not contraindication

Contraindications for ARBs

Use with aliskiren in patients with diabetes

Bilateral renal artery stenosis

Pregnancy

Monitoring for ARBs

Blood pressure

Potassium

Renal function

Drug Interactions with ARBs

RAAS inhibitors

Increased lithium concentration

A non-first line agent for hypertension should ONLY be added if _____

Patient is already on all first line agents or cannot add them

Loop Diuretics Generic Names

Bumetanide

Furosemide

Torsemide

Adverse Effects of Loop Diuretics

Decreased Na⁺, K⁺, Ca²⁺, Mg²⁺, Cl^-

Increased glucose, uric acid, LDL, TGs

Renal dysfunction

Photosensitivity

Ototoxicity

Contraindications for Loop Diuretics

Anuria

Caution with sulfa allergy (Not likely to react)

• Does not apply to ethacrynic acid

Monitoring for Loop Diuretics

Blood pressure

Electrolytes

Renal function

Fluid status

Glucose

Uric acid

Drug Interactions with Loop Diuretics

NSAIDs

Increased lithium concentration

Increased dofetilide concentration

Potassium-Sparing Diuretics Generic Names

Amiloride

Triamterene

Eplerenone

Spironolactone

Adverse Effects of Potassium-Sparing Diuretics

Dehydration

Hyperkalemia

Hyponatremia

Dizziness

Spironolactone:

• Gynecomastia

• Breast tenderness

• Irregular menses

Contraindications for Potassium-Sparing Diuretics

Hyperkalemia

Anuria

Renal impairment

Concurrent use of potassium-sparing diuretics or potassium supplementation

Monitoring for Potassium-Sparing Diuretics

Blood pressure

Electrolytes

Renal function

Fluid status

Drug Interactions with Potassium-Sparing Diuretics

Strong CYP3A4 inhibitors (eplerenone)

Adverse Effects of Beta Blockers

Bradycardia

Hypotension

Fatigue

Dizziness

Depression

Impotence/decreased libido

Mask symptoms of hypoglycemia

Rebound hypertension if abrupt discontinuation

Contraindications for Beta Blockers

Severe bradycardia

2nd or 3rd degree AV block or sick sinus syndrome (unless pacemaker)

Cardiogenic shock

Monitoring for Beta Blockers

Heart rate

Blood pressure

ECG

Drug Interactions with Beta Blockers

Caution with other drugs that decrease heart rate

Direct Renin Inhibitor Generic Name

Aliskiren

Adverse Effects of Direct Renin Inhibitors

Angioedema

Hyperkalemia

Hypotension

Renal dysfunction

Diarrhea

Contraindications for Direct Renin Inhibitors

Use with ACEIs or ARBs in patients with diabetes

Bilateral renal artery stenosis

Pregnancy

Monitoring for Direct Renin Inhibitors

Blood pressure

Potassium

Renal function

Drug Interactions with Direct Renin Inhibitors

RAAS inhibitors

Alpha-1 Blockers Generic Names

Doxazosin

Prazosin

Terazosin

Adverse Effects of Alpha-1 Blockers

Orthostatic hypotension (BP drops when getting up)

Syncope

Fatigue

Dizziness

Headache

Edema

Contraindications for Alpha-1 Blockers

Hypersensitivity to drug

Monitoring for Alpha-1 Blockers

Blood pressure

Drug Interactions with Alpha-1 Blockers

Caution with other drugs that decrease blood pressure

PDE-5 inhibitors (Sildenafil, Tadalafil, Vardenafil, etc.)

• May cause profound hypotension

Centrally Acting Alpha-2 Agonists Generic Names

Clonidine

Guanfacine IR

Methyldopa

Adverse Effects of Centrally Acting Alpha-2 Agonists

Bradycardia

Hypotension

Dry mouth

Headache

Fatigue

Dizziness

Depression

Constipation

Rebound hypertension if abrupt discontinuation

Drug-induced lupus (methyldopa)

Contraindications for Centrally Acting Alpha-2 Agonists

For Methyldopa

• Active liver disease

• Concurrent use with MAOIs

Monitoring for Centrally Acting Alpha-2 Agonists

Blood pressure

Heart rate

Mental status

Drug Interactions with Centrally Acting Alpha-2 Agonists

Beta blockers

Direct Vasodilators Generic Names

Hydralazine

Minoxidil

Adverse Effects of Direct Vasodilators

For Hydralazine

• Headache

• Hypotension

• Reflex tachycardia

• Palpitations

• Drug-induced lupus

For Minoxidil

• Fluid retention

• Tachycardia

• Hair growth

Contraindications for Direct Vasodilators

For Hydralazine

• Mitral valve rheumatic heart disease

• Coronary artery disease

For Minoxidil

• Pheochromocytoma

Monitoring for Direct Vasodilators

Blood pressure

Heart rate

Antinuclear antibody (ANA) titer (hydralazine) → monitoring for lupus

Drug Interactions with Direct Vasodilators

Caution with other drugs that lower blood pressure

Preferred Hypertension Medications in Pregnancy

Labetalol

Nifedipine ER

Methyldopa

• More side effects than the other two

Hypertensive Emergency

Severe elevations in blood pressure (>180/120 mmHg) associated with evidence of new or worsening target organ damage

Signs of target organ damage may include:

• Brain → Stroke, vision loss

• Heart → Angina

• Aorta → Dissection

• Liver/kidney dysfunction

Treatment recommendation for hypertensive emergency

Decrease blood pressure by no more than 25% within the first hour

Then if stable, decrease to 160/100 mmHg within the next 2-6 hours

Then decrease to normal over the next 24-48 hours

Treatment: Initiate IV antihypertensive drug therapy (esmolol, labetalol, hydralazine, nicardipine, nitroglycerin, nitroprusside)

Hypertensive Urgency

Severe elevations in blood pressure (>180/120 mmHg) without acute target organ damage

Treatment recommendation for hypertensive urgency

Decrease blood pressure gradually over 24-48 hours

Treatment: Reinstate/intensify oral antihypertensive drug therapy

What antihypertensive medications can cause drug-induced lupus?

Methyldopa and Hydralazine