Initial Treatment of Hypertension

Darwin Deen, MD, MS

Family Medicine Clerkship

Objectives

• Review the JNC VII diagnostic criteria for hypertension

• Consider the impact of lifestyle changes on blood pressure

• Review the available pharmacologic agents available for the initial treatment

• Review reasons for selecting specific agents

Fast Facts about HT

• Hypertensive population: 42 x 106

• Controlled hypeertensives: 27%• Those unaware of Dx: 13 x 106

• Aware but untreated: 7 x 106

• Of those treated: 58% uncontrolled• 73% of HT have BP 140-160/<90

Initial Drug Therapy

BP Classification

SBP* (mm Hg)

DBP* (mm Hg)

Lifestyle Modificatio

n

Without Compelling Indications

With Compelling Indications

Normal <120 and <80 Encourage

No antihypertensive drug indicated.

Drug(s) for compelling indications.

Prehypertension

120–139or 80–

89Yes

Stage 1 hypertension

140–159or 90–

99Yes

Thiazide-type diuretic for most. May consider ACEI, ARB, BB, CCB, or combination.

Drug(s) for compelling indications.

Other antihypertensive drugs (diuretic, ACEI, ARB, BB, CCB) as needed.

Stage 2 hypertension

160 or 100 Yes

Two-drug combination for most (usuallythiazide-type diuretic

and ACEI or ARB or BB or CCB).

JNC 7: Classification and Management of Blood Pressure for Adults

JNC 7. May 2003. NIH publication 03-5233.

Diagnostic Workup

• Assess risk factors and comorbidities

• Reveal identifiable causes of HT

• Assess presence of target organ damage

• Thorough history and physical

• Labs: UA, glucose, Hct, lipids, K+ Cr, Ca

• Optional: Urinary alb/Cr ratio

• EKG

CVD Risk Factors

• HT

• OB

• HL

• DM

• Cigarette Smoking

• Inactivity

• Microalbuminuria

• Age– >55 in men– >65 in women

• FH of premature CVD

JNC 7: Treatment Algorithm for Hypertension

SBP=systolic blood pressure; DBP=diastolic blood pressure; ACEI=angiotensin- converting enzyme inhibitor; ARB=angiotensin receptor blocker; BB=-blocker; CCB=calcium channel blocker

JNC 7. May 2003. NIH publication 03-5233.

Optimize dosages or add additional drugs until goal blood pressure is achieved.Consider consultation with hypertension specialist.

Not at goal blood pressure

Without compelling indications

Stage 1 hypertension(SBP 140–159 or DBP 90–99 mm Hg)Thiazide-type diuretic for most.May consider ACEI, ARB, BB, CCB, or combination.

Stage 2 hypertension(SBP 160 or DBP 100 mm Hg)Two-drug combination for most (usually thiazide-type diuretic and ACEI or ARB or BB or CCB).

Lifestyle modifications

Not at goal blood pressure (<140/90 mm Hg)(<130/80 mm Hg for those with diabetes or chronic kidney disease)

Initial drug choices

With compelling indications

Drugs for compelling indicationsOther antihypertensive drugs (diuretic, ACEI, ARB, BB, CCB) as needed.

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Compelling Indications

• Heart Failure

• Post- MI• High CVD risk• DM

• CRF– Cr > 1.5 in men– Cr > 1.3 in women

• S/P CVA

• Thiaz/loop, BB, ACE, ARB, Aldo ant

• BB, ACE, Aldo ant• Thiaz, BB, ACE, CCB

• Thiaz, BB, ACE, ARB, CCB

• ACE, ARB (push to 35% increase in Cr. For Cr 2-3 try loop diuretic.

• Thiaz, ACE

Lifestyle Modifications to Manage HTN

Modification Recommendations Approximate Systolic

Blood Pressure Reduction

Weight Reduction Maintain normal body weight (BMI 18.5-24.9)

5-20 mm Hg for each 10 kg weight loss

Adapt DASH eating plan Consume diets rich in fruits, vegetables, low fat dairy and low saturated fat

8-14 mm Hg

Dietary sodium reduction Reduce sodium to no more than 2.4 g/day sodium or 6 g/day NaCl

2-8 mm Hg

Increase physical activity Engage in regular aerobic activity such as walking (30 min/day on most days)

4-9 mm Hg

Moderate alcohol consumption Limit alcohol to no more than 2 drinks/d for men and 1 drinks/day for women.

2-4 mm Hg

Source: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure JNCVII. JAMA. 2003;289:2560-2572.

Failures of Patient Education

• 50% of patients discontinue their anti-hypertensive within 1 year of initiating treatment.

• DASH diet for hypertension: – limit sodium– Increase fruits and vegetables (8-10/d)– Increase low fat dairy (3-4/d)

• Focus on diet history for HT patients

Key Diet History Questions for Patients with HTN

• Do you use a salt shaker?

• Do you taste your food before you add salt?

• How often do you eat salty foods, such as chips, pretzels, salted nuts, canned and smoked foods?

• Do you read labels for sodium content?

• How many servings of fruits and vegetables do you eat everyday?

• How often do you eat or drink dairy products? What kind?

• How often do you eat out? What kinds of restaurants?

• Do you like to drink alcohol? How much?

• How often do you exercise, including walking?

TIPS on drugs for HT

• CCB OK for ISH

• For DM: ACE or ARB with or without diuretic then add BB or CCB

• When ACE causes cough, substitute ARB

• Don’t use short acting CCB (increases deaths due to arrhythmias).

• Alpha blockers (e.g. clonidine) only as second line (more side effects).

• Most patients should start with a diuretic as they enhance the effectiveness of other agents.

• Most patients will require more than one agent.

• Add a baby aspirin to improve cardiovascular outcomes.

Special Populations

• Minorities

• Women

• Aged

• Blacks have greater prevalence, severity, and impact and poorer response to monotherapy. ACE induced angioedema is more common

• BCPs elevate BP, Aldomet, BB, and vasodilators OK in pregnancy

• Higher prevalence, ISH more common, more frequent complications from ACE, CCB

Thiazides

• Chlorothiazide (Diuril)

• Chlorthalidone

• Hydrochlorthiazide(Microzide, Hydrodiuril)

• Polythiazide (Renese)

• Indapamide (Lozol)

• Metolazone (Mykrox, Zaroxolyn)

Benefits of Thiazide Diuretics

• Evidence-based support for end points that matter (prevention of CV and all-cause mortality).

• Reduce calcium excretion potential benefit for osteoporosis prevention.

Loop Diuretics

• Bumetanide (Bumex)

• Furosemide (Lasix)

• Torsemide (Demadex)

Potassium-sparing Diuretics

•Amiloride (Midamor)•Triamterene (Dyrenium)

Aldosterone Receptor Blockers

• Eplerone (Inspra)

• Spironolactone (Aldactone)

Combined alpha- and beta- blockers•Carvediol (Coreg)•Labetalol (Normodyne, Trandate)

Beta-blockers

• Atenolol (Tenormin)

• Betaxolol (Kerlone)

• Bisoprolol (Zebeta)

• Metoprolol (Lopressor, Toprol XL)

• Nadolol (Corguard)

• Propranolol (Inderal and XL)

• Timolol (Blocadren)

Beta-blockers with intrinsic sympathomimetic activity

• Acebutolol (Sectral)

• Penbutolol (Levatol)

• Pindolol (generic)

ACE inhibitors

• Benzapril (Lotensin)• Captopril (Capoten)• Enalpril (Vasotec)• Fosinopril (Monopril)• Lisinopril (Prinivil, Zestril)• Moexipril (Univasc)• Perindopril (Aceon)• Quinapril (Accupril)• Ramipril (Altace)• Trandolapril (Mavik)

Angiotensin II antagonists

• Candesartan (Atacand)

• Eprosartan (Tevetan)

• Irbesartan (Avapro)

• Losartan (Cozaar)

• Olmesartan (Benicar)

• Telmisartan (Micardis)

• Valsartan (Diovan)

Calcium channel blockers

• Dihyropyridines– Amlodipine (Norvasc)– Felodipine (Plendil)– Isradipine (Dynacirc

CR)– Nicardipine (Cardene

SR)– Nifedipine (Adalat

CC,

Procardia XL)

– Nisoldipine (Sular)

• non-Dihyropyridines• Diltiazem (Cardizem

CD, Dilacor XR,

Tiazac, Cardizem LA)

• Verapamil (CalanSR,

Isoptin SR)

Alpha1 blockers

• Doxazosin (Cardura)

• Prazosin (Minipress)

• Terazosin(Hytrin)

Direct Vasodilators

Hydralazine (Apresoline)

Minoxidil (Loniten)

Centrally acting drugs

• Clonidine (Catapres)

• Methyldopa (Aldomet)

• Reserpine (generic)

• Guanfacine (generic)

Treatment Algorithm

Lifestyle Modification

Not at goal BP

Initial Drug Choices

W/O Compelling Indications

Stage 1 Stage 2

With Compelling Indications

Drug for Indication

Thiaz, ACE, ARB, BB, CCB 2 Drug Combo Not at Goal BP

Adjust Dose or add additional agents