Choosing the Best Antihypertensive

Introduction

• Presenter: David Rebedu

  • Board certified in family medicine, fellow of the AFP, and certified medical director.

  • No relevant financial disclosures.

Objectives

• Overview of different antihypertensive classes.

  • Discuss main indications and contraindications.

  • Explore niche areas to enhance practice.

Measurement of Blood Pressure

• Importance of correct blood pressure measurement.

  • Recommended resource: validatebp.org for validated blood pressure cuffs.

  • Importance of cost-effective options for patients.

• Recommendations for blood pressure measurements:

  • Obtain two measurements in the morning and two in the afternoon.

  • Morning measurements pre-medication for immediate baseline.

  • Afternoon measurements for peak effect evaluation.

Antihypertensive Dosing Timing

• Discussion on the HYGEA trial leaning towards patient adherence:

  • Dosing can be done at night or day based on patient preference and routine.

Factors Affecting Blood Pressure Readings

• Importance of patient comfort and relaxation during measurements:

  • Urination prior to measurements recommended.

  • Encourage deep breathing and positivity to minimize anxiety-induced hypertension.

• Mention of common scenarios leading to elevated blood pressure readings:

  • Acute urinary retention, stressful situations, and expectation bias.

Hypertension Management

• The impact of lowering blood pressure by 10 mmHg on health outcomes:

  • Significant reduction in stroke incidence associated with smaller blood pressure reductions.

  • Importance of patient education on hypertension thresholds.

• Recommendations for patients reluctant to use medications:

  • Suggest potassium supplements (3.5 grams) or increased fruit and vegetable intake.

• Explanation of dosage increase impact:

  • Only a 4 mmHg difference by maximizing medication dosage emphasizes dual therapy approach.

Optimal Medication Strategies

• Guidelines trend towards dual therapy instead of single agents:

  • 50% of patients may be controlled on one medication; this can increase to 70-75% with two medications.

  • Acknowledgment of controlled patients on a single medication in low-risk scenarios.

  • Key patients to consider single vs. dual therapy include:

  • Low ASCVD risk individuals vs. those with repeated cardiac events.

Antihypertensive Medication Costs

• Comparison of medication costs via GoodRx and Cost Plus Drugs:

  • Cost-effectiveness and types of antihypertensive used:

  • Mention of cost ceilings; e.g., amlodipine valsartan hydrochlorothiazide's high cost at $277.

  • Common low-cost options such as lisinopril and hydrochlorothiazide at $4 lists at retailers.

Side Effects and Considerations in Blood Pressure Management

• Discussion of hypotension:

  • Symptoms and signs such as dizziness and neck/shoulder tightness discussed as indicators of poor perfusion.

Antihypertensive Classes and Their Use

• Engagement question about first-line antihypertensive classes:

  • Options included calcium channel blockers, ACE inhibitors, ARBs, thiazides -- answered all above.

  • Suggested charting for reviewing indications and contraindications for medication classes:

  • Calcium channel blockers, ACE inhibitors, ARBs, thiazide diuretics listed for key attributes.

• Specific cases discussed:

  • Thiazides used for nephrolithiasis (kidney stone prevention).

  • ARBs (specifically losartan) used to prevent gout.

  • Beta blockers Labetalol as treatment for pregnancy hypertension.

  • Usage of antihypertensive in end-stage renal disease.

Resistant Hypertension Solutions

• Recommendation for resistant hypertension management:

  • Consideration for dual therapy; mention of spironolactone among third-line agents.

• Special populations for treatment therapy:

  • Discussed diabetes, kidney stones, and psychiatric conditions (PTSD).

Management of Special Populations

• Overview of breastfeeding and antihypertensive therapy:

  • Recommendations for ARBs, calcium channel blockers, and considerations regarding ACE inhibitors like lisinopril.

• Discussion on managing blood pressure in patients with chronic kidney disease:

  • Potential use of chlorthalidone based on CLICK trial findings to lower pressures even in stage three-four disease.

Best Practices in Antihypertensive Management

• Recommendations for outpatient prescriptions based on anticipated outcomes and patient adherence to medications:

  • Emphasis on the importance of future health considerations.

  • Utilizing cost-effective drug options and assessing insurance parameters with medications.

Q&A and Concluding Remarks

• Discussion on the integration of guidelines and individual patient considerations while prescribing antihypertensives.

• Final takeaway: Choose medications tailored to individual patient's needs, circumstances and likely future health profiles.

• Use of validatebp.org for blood pressure management. Emphasis on cost-effective therapies through GoodRx and direct to patient delivery models.