PHM HTN

HTN

90

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 <120

• diastolic <80

elevated

BP classification

• systolic 120-129

• diastolic <80

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 <1500 mg/day

  • at least 1000 mg/day reduction

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

  • <1% of users

  • stop/decrease dose if serum creatinine >35% above baseline

• angioedema (face swelling from fluid accumulation)

  • rare, more likely in black pts/smokers

• persistent, dry dough in 20% (bradykinin accumulation)

• orthostatic hypotension

• contraindicated in pregnancy

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

alternatives:

• other beta-blockers and calcium channel blockers

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