Hypertension u Classification u BP of hypertension targets

Hypertension u Classification u BP of hypertension targets u Basic evaluation u When to evaluate for secondary causes u Which drug(s) you should use u Classes of antihypertensives

Classification of blood pressure in adults BP classification SBP (mm. Hg) DBP (mm. Hg) < 120 and < 80 Prehypertension 120 -139 or 80 -89 Stage 1 hypertension 140 -159 or 90 -99 Stage 2 hypertension >=160 or >= 100 Normal

Target BP u Patients with diabetes and CKD – 130/80 u Everybody else – 140/90

Basic evaluation u History – HPI – onset of hypertension, antihypertensives (which ones used, side effects), severity of hypertension – PMH – all drugs used including OTC meds, herbals; other medical conditions – FH – specifically hypertension, renal disease – SH – Et. OH, salt intake, increase in weight – ROS – HA, palpitations, sweating, thyroid sxs u Physical – – – BP in both arms fundoscopic exam thyroid exam heart, lungs abd – specifically listen for bruits ext – pulses, edema

Initial labs u u BUN, creat(e. GFR), urinalysis Calcium K TSH

When to eval for secondary causes u u u When basic eval suggests a secondary cause –e. g. variable BP, HA, palpitations, sweating – pheo; severe hypertension in a young female or sudden worsening of hypertension in an older person – renovascular hypertension When history is not consistent with essential hypertension (positive FH, onset in 20’s, initially mild) For resistant hypertension – elevated BP when patient is reliably taking adequate doses of three antihypertensives, one of which is a diuretic

First drug with no other medical problems u u u Anything would work (the most important thing is to control the blood pressure) Diuretics have been the most thoroughly studied and are safe, effective and inexpensive I recommend starting with chlorthlidone 12. 5 qd; if the BP is not controlled I would add lisinopril

Compelling indications u u u u CHF – ACE, ARB, BB, Aldo ant; also diuretics Post-MI – BB, ACE High CAD risk – BB, ACE; also diuretics, CCB Diabetes – BB, ACE, ARB; also diuretics, CCB CKD – ACE, ARB Recurrent stroke prevention – ACE; also diuretics BPH (not in JNC VII) – α-blocker

Second and third drugs u u If first drug is not a diuretic second one should be (almost all non-diuretic antihypertensives result in sodium retention which limits their efficacy) Best 3 drug combo is appropriate dose of a diuretic, an ACE inhibitor and a calcium channel blocker

Diuretics u Thiazides – qd for BP; chlorthalidone making a comeback u Loop – GFR < 30 - 50 – bid for BP (except for torsemide which is qd) u Aldo antagonists – primary aldo and aldo mediated hypertension more common than previously thought so consider these drugs in resistant BP – spironolactone – 25 qd is usually sufficient – eplerenone has few hormonal side effects but is very expensive (is half as potent as spironolactone)

Calcium channel blockers u u Decrease tone of LES/dose-dependent edema/can be used together Dihydropyridines – glomerular pressure in CKD so don’t use as first BP drug; OK if patient already on ACE or ARB – amlodipine is generic and has long half life without delivery system u Diltiazem – glomerular pressure in CKD – neg inotrope and chronotrope u Verapamil – – – glomerular pressure in CKD neg inotrope and chronotrope all older patients get constipated

ACE inhibitors u u 16% get dry cough, can start > 1 year after starting ACE Angioedema Captopril is short acting Work great with diuretic

Angiotensin receptor blockers u u No cough 8% of patients who get angioedema with ACE get it with ARB Probably like an ACE without the cough ONTARGET trial (25, 000 patients with vascular disease or DM with end-organ damage) – proteinuria was decreased but CV outcomes and renal function were worse in patient treated with combo ACE/ARB as opposed to either drug alone

Renin antagonists (aliskiren) u u Very few clinical trials Very expensive No cough Can cause angioedema

ß-blockers u u u Use metoprolol, not atenolol Metoprolol XL is now generic so is probably preferred ß-blocker Lower BP by decreasing renin levels so add BP lowering to ACEs or ARBs the little

α-blockers u u Some risk of precipitating CHF Only indication is BPH First dose syncope can occur after stopping/restarting med or increasing dose Tamsulosin is much better than doxazosin or terazosin for BPH so often times I am switching metoprolol to carvedilol instead of using doxazosin or terazosin

Direct vasodilators u Hydralazine rarely indicated – – – u frequent dosing drug induced lupus possibly indicated in patient with CHF who gets angioedema on ACE/ARB Minoxidil – Extremely potent and effective – Hirsutism is a problem in females – Can cause severe fluid retention, tachycardia and pericarditis so should probably only be used by hypertension specialists

Centrally acting agents u Clonidine – short acting so good for Et. OH withdrawal or hypertensive urgencies – bedtime dose can be used for patients with PTSD – clonidine withdrawal can be severe – it is caused by rebound increase in centrally mediated α and β adrenergic stimulation; when patients are also on a βblocker unopposed α stimulation can increase the BP – rash frequent with patch

Rules of thumb u u u u Never use ß-blocker and clonidine together Never use ß-blocker and verapamil together Be careful when using a ß-blocker and dilt together Never use 10 mg of furosemide A 25% increase in creat after starting an ACE is good, not bad Don’t increase doses of long acting BP meds daily Never use tid antihypertensives