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Hypertension Classification BP of hypertension targets Basic evaluation When to evaluate for secondary causes Which drug(s) you should use Classes of antihypertensives Classification of blood pressure in adults BP classification SBP (mmHg) DBP (mmHg) < 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 Patients with diabetes and CKD – 130/80 Everybody else – 140/90 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 Initial labs BUN, creat(eGFR), urinalysis Calcium K TSH 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 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 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 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 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) 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 – neg inotrope and chronotrope Verapamil – glomerular pressure in CKD – neg inotrope and chronotrope – all older patients get constipated ACE inhibitors 16% get dry cough, can start > 1 year after starting ACE Angioedema Captopril is short acting Work great with diuretic 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 Renin antagonists (aliskiren) Very few clinical trials Very expensive No cough Can cause angioedema 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 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 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 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 βblocker unopposed α stimulation can increase the BP – rash frequent with patch 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 tid antihypertensives