PHM HTN

HTN

90

persons who are normotensive at age 55 have a ____% lifetime risk for developing HTN

natural course of hypertension

* stroke
* hemorrhagic, ischemic
* coronary heart disease
* angina, myocardial infarction, CHF
* retinopathy
* retinal infarcts, hemorrhages
* nephropathy
* chronic kidney disease

normal

BP classification

* systolic

elevated

BP classification

* systolic 120-129
* diastolic

hypertension stage 1

BP classification

* systolic 130-139
* diastolic 80-89

hypertension stage 2

BP classification

* systolic ≥140
* diastolic ≥90

weight reduction

lifestyle modification

* 70.2% of american adults are overweight/obese
* reduces BP
* decreases total CHD risk
* should be pursued in combination with drug therapy

alcohol intake

lifestyle modification

* excessive chronic intake can cause resistance to drug therapy
* limit intake to
* 1 oz ethanol/day (2 drinks) in men
* 0.5 oz ethanol/day (1 drink) in women

physical activity

lifestyle modification

* regular aerobic exercise effective in lowering BP
* enhances weight loss and overall health

limit dietary sodium

lifestyle modification

* largest benefit in black/elderly pts
* optimal goal in

first line agents

antihypertensives all shown to decrease CV morbidity/mortality w/ chronic use; relatively well tolerated

thiazide diuretics

first line agent

* initially lower BP through diuresis
* chronically decrease peripheral vascular resistance
* often used in combination w/ other antihypertensive drugs
* adds second MOA
* offsets sodium retention caused by other agents

thiazide ADRs

* nausea/diarrhea
* erectile dysfunction
* **sun sensitivity**
* metabolic
* hypokalemia
* hyperglycemia
* hyperlipidemia
* __won’t see at small dosages__
* __most ADRs are dose related__
* limit dose to 25 mg/day

pregnant women, diabetes, gout, renal failure

caution thiazide diuretics in:

anuria (no urine)

thiazides contraindications

renin-angiotensin-aldosterone system (RAAS)

major cause of increased BP in pts

ACE inhibitors

first line agent

* -pril drugs


* blocks the conversion of ANG I to ANG II
* ANG II is potent vasoconstrictor
* causes decreased aldosterone secretion
* blocks degradation of bradykinin (natural vasodilators)
* broken down by ACE, but blocked
* specific advantages
* HF
* chronic kidney disease

ACE inhibitor ADRs

* hyperkalemia (arrythmias)
* acute kidney failure
*

angiotensin II receptor blockers (ARBs)

first line agent

* -sartan drugs


* angiotensin II receptor antagonist
* do not affect bradykinin levels (no cough)
* cheaper, more used than ACE inhibitors
* pregnancy warning

ARBs ADRs

* orthostasis
* much less angioedema than ACEi (maybe none)

calcium channel blockers

first line agent

* dihydropyridine & non-dihydropyridine
* both equally effective for HTN


* blocks influx of calcium across cell membrane
* causes coronary/peripheral vasodilation
* negative inotropic effects
* decreased contractile strength of heart
* only affects pts who alr have CV problems

dihydropyridine CCB ADRs

* dizziness
* flushing
* headache
* peripheral edema

non-dihydropyridine CCB ADRs

* anorexia & nausea
* peripheral edema (less than DHP CCBs)
* **constipation (verapamil)**

alternative agents

* may have worse side effects than first line agents
* still used but don’t have long term data

direct renin inhibitors

* aliskiren (Tekturna)
* blocks renin’s activity to convert angiotensinogen to angiotensin I
* otherwise similar to ACE inhibitors
* pregnancy warning

direct renin inhibitors ADRs

* orthostasis
* angioedema
* alternative agent

beta-blockers

alternative agent

* cardioselective, non-selective, intrinsic sympathomimetic activity


* does not have general better evidence of reducing morbidity/mortality; ARBs have better evidence
* many physiologic effects documented, but uncertain what causes decreased BP effect

cardioselective

* type of beta-blocker
* greater affinity for B1 receptors (in heart/kidney) than B2 receptors (in lungs, liver, pancreas, arteriolar smooth muscle)
* in general, more preferred for HTN

non-cardioselective

* type of beta-blocker
* block beta 1 and beta 2 receptors about the same

intrinsic sympathomimetic activity

* type of beta blocker
* partial beta-receptor agonists (kind of stimulates receptors)
* do not reduce CV events as well as other beta-blockers
* basically never used for most people

beta-blocker ADRs

* bradycardia
* dizziness/drowsiness
* bronchoconstriction in COPD/asthma pts
* abrupt discontinuation can result in rebound HTN or increased HR (taper dose 1-2 weeks)

alpha blockers

alternative agent

* selective alpha-1 receptor antagonists in the peripheral vasculature
* results in vasodilation and lowered BP
* reserved for pts with treatment resistant HTN

alpha blocker ADRs

* first dose effect
* dizziness, faintness, syncope within 1-2 hours of first dose
* take first dew doses before bedtime
* can also occur with changes in dose/non-adherence
* sustained orthostatic hypotension
* esp elderly
* CNS effects
* lassitude (mental/physical fatigue)
* vivid dreams
* depression
* priapism (erection >4 hours)

central alpha agonists

* alternative agent
* reduces sympathetic outflow from vasomotor center in the brain
* decreases HR, CO, and BP
* reserved for pts with treatment resistant hypertension

clonidine (Catapres)

most common central alpha agonist

central alpha agonist ADRs

* sodium/water retention, often used with diuretic
* depression
* high incidence of orthostatic hypotension (elderly)
* anticholinergic effects (sedation, dry mouth, urinary retention)
* abrupt cessation results in rebound hypertension

black pts

* tend to have HTN at younger age and absolute pressures often higher
* greater risk for HTN complications
* most effective treatment are thiazides & calcium channel blockers
* less effective as monotherapy (one drug) and less positive CVD outcomes
* beta-blockers, ACEi, ARBs

pregnant women

* chronic hypertension (already hypertensive before pregnancy)
* preeclampsia/eclampsia
* gestational hypertension (hypertensive from pregnancy)

chronic/gestational HTN drugs

preferred:

* labetalol, long-acting nifedipine, methyldopa
* good safety history

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alternatives:

* other beta-blockers and calcium channel blockers

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contraindicated:

* ACEi, ARB, direct renin inhibitors

elderly pts

* often present with isolated systolic hypertension
* no agents more effective, follow general drug selection guidelines
* due to risk of orthostatis, generally avoid
* central alpha agonists
* peripheral alpha-blockers
* start other drugs at lower doses

children and adolescents

* HTN more common in obese children
* lifestyle modifications important
* secondary hypertension more common
* evidence supports use of
* ACEi
* ARB
* beta-blocker
* calcium channel blockers
* thiazides
* tend to not use ACEis, ARBs in adolescent girls due to pregnancy risk