Hypertension

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

2. Classification of blood pressure in adults

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

4. Basic evaluation • 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 – EtOH, salt intake, increase in weight • ROS – HA, palpitations, sweating, thyroid sxs • Physical • BP in both arms • fundoscopic exam • thyroid exam • heart, lungs • abd – specifically listen for bruits • ext – pulses, edema

5. Initial labs • BUN, creat(eGFR), urinalysis • Calcium • K • TSH

6. When to eval for secondary causes • 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

7. First drug with no other medical problems • 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

8. Compelling indications • 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

9. Second and third drugs • 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

10. Diuretics • Thiazides • qd for BP; chlorthalidone making a comeback • Loop • GFR < 30 - 50 • bid for BP (except for torsemide which is qd) • 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)

11. Calcium channel blockers • 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 • Diltiazem •  glomerular pressure in CKD • neginotrope and chronotrope • Verapamil •  glomerular pressure in CKD • neginotrope and chronotrope • all older patients get constipated

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

13. Angiotensin receptor blockers • 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

14. Renin antagonists (aliskiren) • Very few clinical trials • Very expensive • No cough • Can cause angioedema

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

16. α-blockers • 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

17. Direct vasodilators • Hydralazine rarely indicated • 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

18. Centrally acting agents • Clonidine • short acting so good for EtOH 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 β-blocker unopposed α stimulation can increase the BP • rash frequent with patch

19. Rules of thumb • 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 tidantihypertensives