01 Hypertension 2013 Final

8/13/2019 01 Hypertension 2013 Final

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Hypertension

Pharmacotherapy IFirst Semester 2013-2014


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References Ch. 19 (Hypertension) in Pharmacotherapy; a pathophysiologic approach. 8th edition 2011.

Ch. 14 (Essential hypertension) in pplied !herape"tics# !he Clinical $se o% &r"gs' ed. oda im*le' 10thedition' 201+.

,oint -ational Committee on Pre ention' &etection' E al"ation' and !reatment o% High /lood Press"re. !hese enth report o% the ,oint -ational Committee on Pre ention' &etection' E al"ation' and !reatment o% High/lood Press"re. (,-C ) , 200+; 289#2 30 2.

201+ E H5E C 6"idelines %or the management o% arterial hypertension# the !as7 orce %or the managemento% arterial hypertension o% the E"ropean ociety o% Hypertension (E H) and o% the E"ropean ociety o%Cardiology (E C). , Hypertens. 201+ ,"l;+1( )#1281 +

H Position rticle. Com*ination therapy in hypertension. ,o"rnal o% the merican ociety o% Hypertension4(1) (2010) 42 0.

CC 5 H 2011 E:pert Consens"s &oc"ment on Hypertension in the Elderly. ,o"rnal o% the mericanCollege o% Cardiology ol. ' -o. 20' 2011.

Hypertension in the Elderly# Pharmacotherapy oc"s. Pharmacist


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Learning Objectives1. &escri*e arterial *lood press"re (/P)' the reg"lation o% /P' and the pathophysiology o% hypertension.2. >denti%y cardio asc"lar (C ) complications that are associated ?ith hypertension (hypertension related target

organ damage) and list ma@or C ris7 %actors.+. Classi%y /P as o"tlined *y the e enth Aeport o% the ,oint -ational Committee on Pre ention' &etection'

E al"ation' and !reatment o% High /lood Press"re (,-C ).4. &escri*e the appropriate proced"res and criteria needed to diagnose hypertension.

. tate the o erall p"rpose o% treating hypertension.3. >denti%y appropriate /P goals that are determined *ased on patient speci%ic presentations.

. >denti%y /P goals recommended *y the ,-C .8. Aecommend li%estyle modi%ications %or the management o% hypertension' and descri*e the e%%ecti eness o% these

modi%ications.9. B"tline recommended management o% patients ?ith prehypertension and hypertension.

10. Compare and contrast the clinical characteristics (pharmacology5mechanism o% action' *ene%its' ad erse e%%ects'interactions' "ni "e dosing considerations' contraindications' and monitoring) o% antihypertensi e dr"gs.11. >denti%y %irst line dr"g therapy options %or hypertension according to the ,-C .12. B"tline dr"g therapy recommendations %or patients ?ith hypertension and compelling indications (i.e.' le%t

entric"lar dys%"nction' post >' coronary artery disease' dia*etes' chronic 7idney disease' and rec"rrent stro7epre ention)' and descri*e s"pporting e idence %or these recommendations.

1+. &escri*e special considerations %or antihypertensi e management in older indi id"als and those at ris7 %or

orthostatic hypotension.14. >denti%y the clinical "se and characteristics o% alternati e antihypertensi e agents.1 . =ist important components o% patient co"nseling regarding hypertension' li%estyle modi%ication' and dr"g therapy.13. >denti%y potential ca"ses %or lac7 o% responsi eness to therapy.1 . &escri*e the rationale' *ene%its' and appropriate "se o% com*ination dr"g therapy %or hypertension.18. &e ise appropriate therapy and monitoring plans %or patients ?ith hypertension.

19. Compare and contrast the goals o% treatment and pharmacotherapy %or managing hypertensi e "rgency andemergency.20. >denti%y patients ?ith resistant hypertension and recommend pharmacotherapy %or these patients. 3


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Definition

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Hypertension: Persistent elevation in arterial blood pressure.


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Terminology Arterial BP is the press"re in the arterial ?allmeas"red in millimeters o% merc"ry (mm Hg). Systolic pressure: the pea7 press"re e:erted in

the arteries ?hen *lood is p"mped into themd"ring entric"lar systole.

Diastolic pressure: the lo?est press"re e:erted inthe arteries ?hen *lood is draining o%% into the

essels do?nstream d"ring entric"lar diastole. Pulse pressure: the di%%erence *et?een the

systolic and diastolic press"re (normallyD 40 mmHg).

Mean arterial bloo pressure !MAP": the a erage

press"re responsi*le %or the dri ing *lood%or?ard thro"gh the arteries into the tiss"esthro"gho"t the cardiac cycle

PD (15+ /P) (25+ &/P)PD diastolic press"re 15+ p"lse press"re

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#ote: Historically more emphasis ?as placed on diastolic than on systolic *lood press"re as a predictor o%

cardio asc"lar mor*id and %atal e ents. Ho?e er' a large n"m*er o% o*ser ational st"dies has demonstrated that cardio asc"lar mor*idity

and mortality *ear a contin"o"s relationship ?ith *oth systolic and diastolic *lood press"res.


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$pi emiology Forld?ide prevalence o% hypertension is estimated to incl"de 1

*illion indi id"als. !here are an estimated million deaths per yearthat may *e related to the diagnosis o% hypertension.

!he pre alence o% hypertension di%%ers *ased on age% se&% anet'nicity

/P al"es increase (it' age .

ost patient ha e pre'ypertension BP al"es *e%ore they arediagnosed ?ith hypertension.

ost hypertension diagnoses occ"r *et?een the t'ir an fift'eca es of life)

*p to t'e age of ++ years ' more men than ?omen ha e hypertension. ,rom t'e ages of ++ to -. years ' slightly more ?omen ha e

hypertension than men' ?ith this se: di%%erence *ecoming greater inthe ery elderly (G years).

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$tiology !he ca"se o% hypertension is "n7no?n in the ma@ority o%

cases (primary hypertension)' *"t %or those ?ith secondaryhypertension' speci%ic ca"ses are indicated.

$ssential or primary 'ypertension # 90I patients'hypertension res"lts %rom an "n7no?n pathophysiologicetiology . !his %orm o% hypertension cannot *e c"red' but itcan be controlle )

Secon ary 'ypertension : small percentage o% patientsha e a speci%ic ca"se o% their hypertension; eitherconc"rrent medical conditions or are endogeno"slyind"ced. >% the ca"se can *e identi%ied' hypertension in

these patients 'as t'e potential to be cure .

Pseu o'ypertension

/'ite01oat 2ypertension an Mas3e 2ypertension

Resistant 'ypertension 8


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Secon ary 1auses of 2ypertension

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Secon ary 1auses of 2ypertension !cont4 "

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Coarctation o% the aorta is a *irth de%ect in ?hich the aorta' the ma@or artery %rom theheart' is narro?ed. !he narro?ing res"lts in high *lood press"re *e%ore the point o%coarctation and lo? *lood press"re *eyond the point o% coarctation. ost commonly'coarctation is located so that there is high *lood press"re in the "pper *ody and arms

and lo? *lood press"re in the lo?er *ody and legs. ymptoms can incl"de localiJedhypertension' cold %eet or legs' decreased e:ercise per%ormance' and heart %ail"re

1oarctation of t'e aorta


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P'eoc'romocytoma

Pheochromocytoma is a rare t"mor in part o% the adrenal gland. >n most cases' the

t"mors are not cancero"s and do not spread to other parts o% the *ody. /"t' ina*o"t +0 percent o% cases' the t"mors are cancero"s.

ost people ?ith pheochromocytoma ha e hypertension *eca"se the t"morca"ses the adrenal gland to prod"ce too m"ch adrenaline or noradrenaline.

Patients can ha e attac7s o% high *lood press"re that occ"r in s"dden' short *"rsts'or the high *lood press"re can *e more contin"o"s and long lasting.


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Renovascular isease

Aeno asc"lar disease is aprogressi e condition thatca"ses narro?ing or *loc7ageo% the renal arteries or eins.>tKs the general term "sed %or

three disorders#renal artery occl"sion'renal ein throm*osis'renal atheroem*olism


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Pat'op'ysiology !he pat'op'ysiology of primary 'ypertension is heterogeneo"s'

*"t "ltimately e:erts its e%%ects thro"gh the t?o primarydeterminants o% *lood press"re# car iac output an perip'eral

resistance ) "ltiple %actors that control /P are potential contri*"ting

components in the de elopment o% essential hypertension. h"moral (i.e.' the renin angiotensin aldosterone system LA M) asodepressor mechanisms ( asc"lar Endothelial echanisms)' a*normal ne"ronal mechanisms' de%ects in peripheral a"toreg"lation'

and dist"r*ances in sodi"m' calci"m' and natri"retic hormones.

most anti'ypertensives specifically target t'ese mec'anisms ancomponents of t'e RAAS)

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,actors involve in t'e pat'ogenesis of 'ypertension


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50 2umoral !role of t'e RAAS"


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6) #euronal Regulation

Pathologic dist"r*ances in any o% the %o"r ma@orcomponents o% the ne"roreg"lation system co"ldconcei a*ly lead to chronically ele ated /P. !hese

systems are physiologically interrelated# a"tonomic ner e %i*ers adrenergic receptors N1'N2' O1' O2 *aroreceptors' thro"gh the ninth cranial ner e and

ag"s ner es central ner o"s system# stim"lation o% certain areas

?ithin the central ner o"s system (n"cle"s tract"ssolitari"s' agal n"clei' asomotor center' and the areapostrema) can either increase or decrease /P


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7) Perip'eral Autoregulatory 1omponents:1. Aenal2. =ocal o:ygen tension

.) 8ascular $n ot'elial Mec'anisms: a de%iciency in the local

synthesis o% asodilating s"*stances (prostacyclin and*rady7inin' nitric o:ide) or e:cess asoconstrictings"*stances (angiotensin >> and endothelin >)

+) $lectrolytes an Ot'er 1'emicals: Pop"lation *asedst"dies indicate that high salt diets are associated ?ith a

high pre alence o% stro7e and hypertension.ome st"dies sho? that dietary calci"m s"pplementation

res"lts in a modest /P red"ction in patients ?ith H!-.

Potassi"m (Potassi"m depletion may increase peripheralasc"lar resistance ) 19


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1lassification of BP 9 #1- !he ,-C classi%ication o% /P in ad"lts (age 18 years) is base on t'e average o%

t?o or more properly meas"red seated /P readings %rom t?o or more clinicalenco"nters

>t incl"des four categories #normal% pre'ypertension% stage 5 'ypertension% anstage 6 'ypertension)

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>% systolic and diastolic *lood press"re al"es yield di%%erent classi%ications' the highest category is "sed %orthe p"rpose o% determining a classi%ication .

Prehypertension is not considered a disease category' *"t identi%ies patients ?hose /P is li7ely to increaseinto the classi%ication o% hypertension in the %"t"re.

or certain patients' /P al"es ?ithin the prehypertension range are considered a*o e goal.


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2ypertensive crises

2ypertensive crises are clinical sit"ations ?here/P al"es are ery ele ated' typically greater than

1805110 mm Hg.

Hypertensi e crisis can *e di ided into#5) 2ypertensive emergencies are e:treme ele ations in/P that are accompanied *y ac"te or progressing

target organ damage.6) 2ypertensive urgencies are high ele ations in /P

?itho"t ac"te or progressing target organ in@"ry.

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1ar iovascular Ris3 an Bloo Pressure Ais7 o% stro7e' myocardial in%arction' angina' heart %ail"re'

7idney %ail"re' or early death %rom a C ca"se are irectlycorrelate (it' BP .

tarting at a /P o% 11 5 mm Hg' ris7 o% C diseasedo"*les ?ith e ery 20510 mm Hg increase.

E en patients ?ith prehypertension ha e an increased ris7

o% C disease.

!reating patients ?ith hypertension ?ith antihypertensi edr"g therapy pro ides signi%icant *ene%its . 22


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1ar iovascular Ris3 an Bloo Pressure

/P is a stronger predictor o% C disease than &/P inad"lts older than 0 years o% age and is the mostimportant clinical /P parameter %or most patients.

Patients (it' ;solate systolic 'ypertension (&/P al"es

less than 90 mm Hg and /P al"es Q140 mm Hg) ha ehigher p"lse press"re al"es.

>n these patients pathophysiologic changes in their

arterial asc"lat"re are consistent ?ith aging. !hesechanges decrease the compliance o% the arterial ?all andR ris7 o% C mor*idity and mortality.

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1linical Presentation of 2ypertension


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Diagnostic $valuation of BP Diagnostic proce ures aim at:1. esta*lishing *lood press"re le els;

2. identi%ying secondary ca"ses o% hypertension;

+. e al"ating the o erall cardio asc"lar ris7 *y searching %or otherris7 %actors' target organ damage and concomitant diseases oraccompanying clinical conditions.

T'e iagnostic proce ures comprise: repeated *lood press"re meas"rements

medical history (%amily and clinical) physical e:amination la*oratory and instr"mental in estigations.

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50 Measuring bloo pressure

>n general the diagnosis o% hypertension sho"ld *e *ased on m"ltiple*lood press"re meas"rements (2) ' ta7en on separate occasions (2 +) o era period o% time' altho"gh in partic"larly se ere cases the diagnosis can*e *ased on meas"rements ta7en at a single isit.

/lood press"re can *e meas"red *y a merc"ry sphygmomanometer orother non in asi e de ices (a"sc"ltatory or oscillometric semia"tomaticde ices).

o%%ice *ased /P meas"rements are considered the gold standard al"esthat g"ide antihypertensi e dr"g therapy.

Correct /P meas"rements re "ire that the clinician listen thro"gh astethoscope that is placed o er the *rachial artery %or the appearance o%the %i e phases o% the orot7o%% so"nds

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Recommen ations for measuring BP

Patients sho"ld re%rain %rom nicotine or ca%%eine ingestion %or +0 min"tes and *e seated?ith the lo?er *ac7 s"pported in a chair and ?ith their *are arm s"pported and restingnear heart le el.

eet sho"ld *e %lat on the %loor (?ith legs not crossed). eas"ring /P in the s"pine or standing position may *e re "ired "nder special

circ"mstances (s"spected orthostatic hypotension' ol"me depletion' or dehydration). !he meas"rement en ironment sho"ld *e relati ely "iet and pro ide pri acy. eas"rement sho"ld *egin only a%ter a min"te period o% rest . properly siJed c"%% (pediatric' small' reg"lar' large' or e:tra large) sho"ld *e "sed.

f ff ( l


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P'ases of t'e >orot3off soun s 'ear ('en in irectlymeasuring bloo pressure)

Virtual_Sphyg[1].swf


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Ambulatory an self bloo pressure monitoring

Either o% these may *e ?arranted in patients ?ith s"spected ?hite coathypertension (?itho"t hypertension related target organ damage) todi%%erentiate ?hite coat %rom essential hypertension.

!hey may *e help%"l in patients ?ith#

apparent dr"g resistance' hypotensi e symptoms ?hile on antihypertensi e therapy' episodic hypertension' a"tonomic dys%"nction' 5and to identi%y SnondippersS ?hose /P does not decrease *y Q10I d"ring sleep and ?hich

may portend increased ris7 o% /P related complications

As a comparison% t'e normal upper limit for BP in most patients is: 140590 mm Hg %or o%%ice *ased meas"rement' 1+0580 mm Hg %or /P (1+ 58 mm Hg ?hile a?a7e and 1205 mm Hg ?hile

asleep)' 1+ 58 mm Hg %or sel% /P meas"rements.

-ote# the threshold %or accepta*le al"es is lo?er than that o*tained d"ring o%%ice *ased

meas"rements30


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ain indications %or am*"latory /P monitoring are %orpatients in ?hom the diagnosis o% hypertension or responseto therapy is "nclear %rom o%%ice isits. "rther indications

incl"de s"spected syncope or hypotensi e disorders'e al"ation o% ertigo' and diJJiness.

m*"latory /P monitoring is also important %or a oidingo ertreatment in the elderly ?ith ?hite coat hypertensionand also to ens"re diagnosis and treatment o% those ?ithmas7ed hypertension

m*"latory /P is a *etter predictor o% ris7 than clinic oro%%ice /P meas"rement in older patients ?ith isolatedsystolic hypertension

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Pseu o'ypertension Pse"dohypertension is ?hen *lood press"re meas"rements

are ele ated *"t the *lood press"re is act"ally normal. Pse"dohypertension is not ery common' and it is almost

al?ays %o"nd in older patients !/2?@" Pseu o'ypertension is usually suspecte in cases ('ere: !he *lood press"re reading is ery high o er time' *"t the

patient has no signs o% organ damage or other complications

ttempting to treat the meas"red high *lood press"re ca"sessymptoms o% lo? *lood press"re (diJJiness' con%"sion'decreased "rine o"tp"t)

Fhile a %inger *lood press"re meter or other similar de icesmay pro ide some "se%"l data in cases o% s"spectedpse"dohypertension' the only ?ay to con%irm the diagnosisis *y directly meas"ring the intraarterial bloo pressure)!his is done inserting a needle directly into a small artery.

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f


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T'e 1oncept of /'ite 1oat an

Mas3e 2ypertension

Office SBP mmHg

H

o m e

/ A m

b u

l a t o r y

S B P

m

m H g

Truehypertensive

TrueNormotensive White Coat HTN

as!e" HTN

TrueNormotensive

as!e" HTNTruehypertensive

#$$

%&$

%'$

%($

%#$

%$$

%$$ %#$ %($ %'$ %&$ #$$

%)*

Masked HTN:

people who are trulyhypertensive but inwhom the diagnosisis missed by office

BP measurements.

White-coat HTN :BP may be elevatedin the office but noton ambulatory BP


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Resistant 2T#

Aesistanthypertension isde%ined as that in?hich patients %ailto attain their /Pgoal ?hile treated?ith a three dr"gregimen that "tiliJes%"ll (ma:im"m)

antihypertensi edoses' one o% ?hichis a di"retic.

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l f l l


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Diagnostic algorit'm for 'ig' Bloo Pressure inclu ingOffice% ABPM an 2ome Bloo Pressure Measurement

BP: 140-179 / 90-109

ABPM ( If available)Clinic BPM HBPM

Yes

Hypertension Visit 2Target Organ Damage

or Diabetesor Chronic Kidney Disease

or BP 180/110?

Hypertension Visit 1BP Measurement,

History and Physicalexamination

HypertensiveUrgency /

Emergency

Diagnosisof HTN

No

In the absence of end-organdamage, the diagnosis ofmild hypertension should

not be made until the bloodpressure has been measuredon at least three to six visits,spaced over a period ofweeks to months.


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Diagnostic algorit'm for 'ig' Bloo Pressure inclu ingOffice% ABPM an 2ome Bloo Pressure Measurement

BP: 140-179 / 90-109

ABPM ( If available)Clinic BP HBPM

Diagnosisof HTN

Awake BP 135 SBP or

85 DBPOr 24-hour

130 SBP or 80 DBP

Awake BP< 135/85 and

24-hour< 130/80

Continue tofollow-up

Diagnosisof HTN

Hypertension visit 3 160 SBP or 100 DBP

140 SBP or 90 DBP

< 140 / 90

Diagnosisof HTN


< 160 / 100

Hypertension visit 4-5

ABPM or HBPMor

135SBP or DBP 85

< 135/85

Diagnosisof HTN


or


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1linical $valuation !1ont4 " Once it 'as been etermine t'at t'e patient 'as persistent

'ypertension% an evaluation s'oul be performe to ascertain t'efollo(ing information:

!o determine the e:tent o% target organ damage. !o assess the patientKs o erall cardio asc"lar ris7 stat"s. !o r"le o"t identi%ia*le and o%ten c"ra*le ca"ses o%

hypertension.

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/ i 1i f M


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Courtesy J.P. Desprs 2006

Mid distance

Last rib margin

Iliac crest

/aist 1ircumference Measurement

0 L b i i i !$S1"


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.0 Laboratory investigations !$S1"

!he patient may ha e normal al"es and still ha e hypertension. Ho?e er' some may ha ea*normal al"es consistent ?ith either additional C ris7 %actors or H!- related damage.


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1 t 1li i l $ l ti


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1omments on 1linical $valuation

any g"idelines ad ocate Tro"tine la*oratory testingU ine al"ation o% patients ?ith high /P. &espite s"chrecommendations' there is little e idence to s"pport ro"tine

la*oratory testing' and clinicians sho"ld ta7e a more deli*erati eand reasoned approach to ordering tests. Ao"tine testingincreases costs and may ha e ad erse e%%ects s"ch as an:iety'pain5discom%ort' additional testing' complications %rom s"chtesting' and time and tra el *"rden.

!he most important role %or testing in an elderly patient ?ithhypertension is to assess %or organ damage and modi%ia*le C &ris7 %actors' incl"ding to*acco smo7ing' hypercholesterolemia'dia*etes mellit"s' and e:cessi e alcohol inta7e.

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2 pertension Management !


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2ypertension Management !


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2ypertension0Associate 1omplications At'erosclerotic 8ascular Disease:

Coronary artery5heart disease yocardial in%arction L >M

c"te coronary syndromes Chronic sta*le angina

Carotid artery disease#

>schemic stro7e !ransient ischemic attac7

Peripheral arterial disease

*dominal aortic ane"rysm Ot'er forms of 18 isease

=e%t entric"lar dys%"nction (heart %ail"re)

1'ronic 3i ney isease 47

Ris3 factors for 'ypertension0associate complications


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Ris3 factors for ypertension0associate complications

T'ese are consi ere major 18 ris3 factors t'at increase t'e li3eli'oo ofeveloping 'ypertension0associate complications% not 'ypertension)

/ >' *ody mass inde:; C ' cardio asc"lar; 6 A' glomer"lar %iltration rate.48

Hypertension Cigarette smo7ing B*esity (/ > Q+0 7g5m2)

Physical inacti ity &yslipidemia &ia*etes mellit"s idney disease

icroal*"min"ria orestimated 6 A V 30 ml5min

d anced age ales Q yrs emales Q 3 yrs

amily history o% premat"reatherosclerotic asc"lar disease ales V yrs emales V 3 yrs

raming'am Ris3 Scoring


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,raming am Ris3 Scoring $stimating in ivi ual ris3 for 18 isease is essential for all patients (it'

'ypertension)

,raming'am ris3 scoring is considered an appropriate ?ay to predict indi id"al10 year ris7 %or coronary artery disease (C &)' &yslipipidemias' therosclerosis'

and Coronary Heart &isease). ll patients ?ith hypertension ?ho do not ha e a history o% hypertension

associated complications or dia*etes' (considered a C & ris7 e "i alentcondition) sho"ld ha e ramingham ris7 scoring *eca"se their 10 year ris7 can

*e# lo( or mo erate ris3 ! 5 C"% mo erately 'ig' ris3 !5 C96 C"% or 'ig' ris3 ! 6 C")

; entifying patients (it' ,raming'am ris3 scores E5 C is clinically relevantbecause more aggressive anti'ypertensive treatment is nee e in t'ispopulation .

or patients ?ith hypertension associated complications or dia*etes'

ramingham ris7 scoring is not needed *eca"se 10 year ris7 o% C & is ass"med to*e Q20I. 49


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,raming'am Point Scale for $stimating 5 0?ear 12DRis3 if 6 ris3 factors !MenF/omen"


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2ome(or3

Fhat is the , c"r e phenomenon

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Benefits of Lo(ering BP


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Benefits of Lo(ering BP

Fhy treat H!- + 40I in stro7e mor*idity and mortality

20 2 I C & e ents 21I asc"lar mortality 2I in CH + I in = H

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Dietary Approaches toStop Hypertension

The effects of implementing these modifications are dose and time dependent, and could be greater for some individuals.

For overall cardiovascular risk reduction, stop smoking.

Lifestyle Recommen ations for 2ypertension:


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Dietary So ium

=ess than 2+00mg 5 day( ost o% the salt in %ood is Whidden) calc"lated %or all ad"lts.

Hypertensive and all patients

BMI over 25- Encourage weight reduction- Healthy BMI: 18.5-24.9 kg ! 2

Waist Circumference Men Women- Euro"id# $u%-$aharan &'rican# Middle Ea(tern )94 c! )8* c!- $outh &(ian# +hine(e# ,a"ane(e )9* c! )8* c!

or "atient( "re(cri%ed "har!acological thera"y: weight lo(( ha(

additional antihy"erten(i e e''ect(. /eight lo(( (trategie( (houlde!"loy a !ultidi(ci"linary a""roach and include dietary education#increa(ed "hy(ical acti ity and %eha iour !odi'ication

CMAJ 2007;176:1103-6



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Exercise should be prescribed as an adjunctive to pharmacologicaltherapy

P'ysical Activity

Should be prescribed to reduce blood pressure

Type Cardiorespiratory Activity- Walking, jogging- Cycling

- Non-competitive swimming

Time - 30-60 minutes

Intensity - Moderate

Frequency - Four to seven days per week FI

T

T



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Alco'ol

Low risk alcohol consumption

Women: maximum of 9 standard drinks/week

Men: maximum of 14 standard drinks/week

0-2 standard drinks/day

A standard drink is about 142 ml or 5 oz of wine (12% alcohol). 341 mL or 12 oz ofbeer (5% alcohol) 43 mL or 1.5 oz of spirits (40% alcohol).



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Stress Management

Hy"erten(i e "atient(in who! (tre(( a""ear( to %e an i!"ortant i((ue

Indi iduali0ed cogniti e %eha iouralinter ention( are !ore likely to %ee''ecti e when rela ation techni ue(are e!"loyed.

Beha iour Modi'ication

s'oul lifestyle mo ifications be t'e primary@


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treatment@ =i%estyle modi%ications are germane to the appropriate

treatment o% hypertension' *"t they ha e not *eensho?n to pre ent C disease in patients ?ithhypertension.

s recommended in the H and the E C g"idelines%rom 200 ' initiation o% dr"g therapy sho"ld not *edelayed "nnecessarily' especially %or patients ?ith Cris7 %actors.

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P'armacological management of


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2ypertensionany effective rugs are a aila*le.

ost antihypertensi e dr"gs lo?er*lood press"re *y red"cing cardiaco"tp"t and5or decreasing peripheralresistance.

>no(le ge o% their antihypertensi emechanisms and sites o% action allo?sacc"rate prediction o% e%%icacy andto:icity.

rational use o% these agents' alone or incom*ination' can lo?er *lood press"re?ith minimal ris7 o% serio"s to:icity inmost patients.

1ategories of anti2T# rugs:


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!5" Diuretics 9 rugs t'at alter so ium G (ater balance: H /P *y depleting *ody o% -a YZ *lood ol"me Y perhaps *y other mechanisms.

!6" Sympat'oplegic agents 9 red"ce the e%%ect o% the sympathetic ner o"s system# Z/P*y Z P;A' inhi*i[ng cardiac %"nc[on' Y R eno"s pooling in capacitance essels. (!helatter 2 e\ects Z CB). !hese agents are %"rther s"*di ided.Centrally acting sympathoplegic dr"gs6anglion *loc7ing agents (o*solete)Postganglionic sympathetic ner e terminal *loc7ers

drenoceptor *loc7ersPraJosin Y other alpha 1 *loc7ers/eta *loc7ers

!7" Direct vaso ilators% ?hich Z press"re *y rela:ing asc"lar smooth m"scle ]dilateresistance essels R capacitance as ?ell.Bral asodilators

Calci"m channel *loc7ersParenteral asodilators

!." Agents t'at bloc3 pro uction or action of angiotensin ]Z P;A Y (poten[ally) *loodol"me.ngiotensin con erting enJyme (ace) inhi*itors

ngiotensin receptor *loc7ing agents

P'armacot'erapy:Primary agents


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Primary agents iuretic (primarily a thiaJide type)' A1$ in'ibitor ( CE >)'

angiotensin ;; receptor bloc3er ( A/)' or calcium c'annelbloc3er (CC/) are considered primary

!hese agents sho"ld *e "sed to treat the ma@ority o% patients?ith hypertension *eca"se e idence %rom o"tcomes data ha edemonstrated C ris7 red"ction *ene%its ?ith these classes.

e eral ha e s"*classes ?here signi%icant di%%erences inmechanism o% action' clinical "se' side e%%ects' or e idence %romo"tcomes st"dies e:ist.

B 0Bloc3ers are e%%ecti e antihypertensi e agents thatpre io"sly ?ere considered primary agents. !hey are no? pre%erred either to treat a speci%ic compelling

indication' or in com*ination ?ith one o% the a%orementionedprimary antihypertensi e agents %or patients ?itho"t a

compelling indication. 65

Diuretics


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Fell st"died# Class o% agents %or H!- "se%"l in Heart ail"re =o? ac "isition cost' cost e%%ecti e Pro en mortality *ene%it in hypertension E%%ecti e in ?hites and %rican mericans Mec'anism # &ecrease P A in the long term

Monitor for # Hypo7alemia (lo? potassi"m)' hyper"racemia'hyperglycemia' hypercalcemia' ad erse lipid e%%ects'gynecomastia (spirionlactone)

Fhich gent (!hiaJides or =oops) ClCr Q +0 ml5min thiaJide (all pro*a*ly ?or7 e "ally ?ell) ClCr V +0 ml5min loop di"retics or com*ination

66


66/140

67


67/140

68


68/140

69


69/140

70


70/140

71


71/140

72


72/140

73


73/140

74


74/140

75

A1$ ;n'ibitors


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Practical note # >nitiate ?ith small doses Contin"e %or 2 4 ?ee7s *e%ore assessing *ene%its ay ta7e + 3 months %or ma:im"m *ene%it (H ) *"t 1 2 months %or H!-

Mec'anism # /loc7 con ersion o% ngiotensin > to angiotensin >> and *loc7s*rea7do?n o% *rady7inin ( asodilator)

Si e $ffects # Hypotension (monitor /P) Aenal >ns"%%iciency (monitor cr) Potassi"m retention (monitor ) Co"gh (especially in ?omen and elderly) Aare# angioedema

Contraindicated in A and angioedema >ey option for dia*etics (?ith nephropathy)' patients ?ith heart %ail"re'

myocardial in%arction

&ecreased e%%icacy in older %rican mericans.76

Angiotensin ;; Receptor Bloc3ers !ARBs"


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imilar anti H!- e%%icacy to CE inhi*itors and atenolol(perhaps less E


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78


78/140

79


79/140

80


80/140

81


81/140

82

1omments on t'e previous table


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p

83

1alcium 1'annel Bloc3ing Agents !11B4s"


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Mec'anism # red"ce cardiac ?or7 *y negati echronotropic (heart rate)' negati e inotropic (contractility)and systemic asodilation (rela: sm. m"scles o% arterioles)

P'armacologic ;ssues # relati e e%%ects on cond"ctionsystem' negati e inotropism' asodilatation

Monitor # HA' /P' EC6' P P& interaction ?ith dr"gs. ;ssues # Edema ?ith higher doses o% dihydropriydines'

C^P+ 4 inhi*ition o% erapamil5diltiaJem

84


84/140

85


85/140


86/140

87

B0Bloc3ers


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Mec'anism # red"ce cardiac ?or7 *y negati e inotropic' negati echronotropic and hypotensi e (central and renin *loc7ing) e%%ects

P'armacologic ;ssues # &i erse gro"p# %irst pass e%%ect' modest hal% li%e'aria*le protein *inding' cardioselecti ity (dose dependent)' intrinsic

sympathomimetic acti ity' alpha *loc7ade Monitor # E


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89


89/140

90

/ *l 7 h * " d % h i ' *" id %


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/eta *loc7ers ha e *een "sed %or hypertension' *"t e idence %ora *ene%it in the elderly has not *een con incing. !hey may ha e arole in com*ination therapy' especially ?ith di"retics. /eta*loc7ers are indicated in the treatment o% elderly patients ?ho

ha e hypertension ?ith C &' H ' certain arrhythmias' migraineheadaches' and senile tremor. ltho"gh earlier *eta *loc7ersha e *een associated ?ith depression' se:"al dys%"nction'dyslipidemia' and gl"cose intolerance' these side e%%ects are lessprominent or a*sent ?ith ne?er agents.

alpha *eta *loc7ers are important in hypertensi e "rgencies(la*etalol) and congesti e H (car edilol).

!hereA and A) m"st *e ta7en ?ith %ood. Car edilol is only

a aila*le orally.

91

P'armacot'erapy:Alternative agents

>t i t " th t " h I0bl 3 % t l 60


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>t is necessary to "se other agents s"ch as I0bloc3ers% central a60agonists% a irect renin in'ibitor !Alis3iren"% a renergic in'ibitors!Reserpine"% an vaso ilators !Mino&i il% 2y ralaJine" in somepatients.

these agents are potent' many o% them ha e a m"ch greater incidence o% ad erse e%%ects. they do not ha e compelling o"tcomes data sho?ing red"ced

mor*idity and mortality in hypertension.

!hey are generally reser ed %or patients ?ith resistanthypertension' and sho"ld only *e "sed as add on therapy ?ith

other primary antihypertensi e agents.

92


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93

Alp'a50Bloc3ers

Agents #


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Agents # &o:aJosin (Card"ra_)' PraJosin ( inipress_)' !eraJosin (Hytrin_)' !ams"losin

( loma:_)

A vantages $se%"l in patients ?ith dyslipidemia# ne"tral or *ene%icial e%%ect on lipids $se%"l in patients ?ith hypertension and *enign prostatic hypertrophy

Disa vantages

Can prod"ce %irst dose syncope Common Es ( 20I)# &iJJiness' headache' lethargy' palpitations Brthostatic hypotension can occ"r Early termination o% do:aJocin arm o% ==H ! d"e to negati e o"tcome

(higher H ' stro7e' C & ris7) o% do:aJocin s. chlorthalidone (,2000#28+;193 )

94

Alis3iren

B l di t l i i hi*it ?hi h d


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Bral direct plasma renin inhi*itor ?hich decreasesplasma renin acti ity *y inhi*iting con ersion o%angiotensinogen to ng 1

ppro ed %or H!- (alone or in com*ination) P># *sorption "n7no?n' Cma: ?ithin 1 + hrs' $C

decreased *y 0I ?ith high %at meals' 2 I eliminated"nchanged' some C^P+ 4 meta*olism

;ssues # Contraindicated in pregnancy' angioedema

potential' co"gh V CE inhi*itors *"t early Dose # 1 0mg5once daily "p to +00mg5d

95

1entrally acting alp'a60Agonists

Agents #


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Agents # Clonidine (Catapress_)' 6"ana*enJ ' 6"an%acine' ethyldopa

( ldomet_)

A vantages Clonidine# ery "ic7 onset and "se%"l %or hypertensi e "rgencies Clonidine# as a patch is applied once a ?ee7 impro ing adherence ethyldopa is a "se%"l antihypertensi e d"ring pregnancy

Disa vantages any %re "ent ( 40I) Es limit the "se o% these agents (e.g. &ry

mo"th' dro?siness' diJJiness' constipation' ?ea7ness' na"sea Y

omiting' agitation' orthostatic hypotension) *r"pt ?ithdra?al o% therapy res"lts in a rapid (24 48hr) re*o"nd

hypertension

96

Perip'erally Acting A renergic Bloc3ers

Agents:


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Agents: 6"anadrel' 6"anethidine' Aeserpine

A vantages

Aeserpine is generally ?ell tolerated at lo? doses =o? Cost

Disa vantages

Common Es ( 40I) %or 6"anadrel' 6"anethidine# signi%icantorthostatic hypotension' syncope' diarrhea' dro?siness' %atig"e'decreased e@ac"lation' peripheral edema' nasal st"%%iness' co"gh'palpitations' B/' leg cramps

Aeserpine Es# -asal congestion' acti ation o% P$& oid in P$&patients. Possi*le dose related depression oid in patients ?ithdepression history

97

Direct 8aso ilators

Agents:


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Agents: HydralaJine' ino:idil

A vantages /oth are potent asodilators HydralaJine > is a sa%e choice %or eclampsia ino:idil co"ld *e added to a regimen in case o% a resistant

hypertension Disa vantages

ino:idil Es# Hirs"tism' transient EC6 (! ?a e) changes

HydralaJine common Es# Headache' na"sea 5 omiting'diarrhea'

Ae%le: tachycardia and A acti ation %or *oth98

1ombination Drug T'erapy


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99

Notes: Treatment is determined by highest BP category. Initial combined therapy should be used cautiously in those at risk

for orthostatic hypotension.

Drug 1ombinations

Fhen com*ining dr"gs' "se %irst line therapies.


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Fhen com ining dr gs se %irst line therapies. !?o dr"g com*inations o% *eta *loc7ers' CE inhi*itors and angiotensin

receptor *loc7ers ha e not *een pro en to ha e additi e hypotensi ee%%ects. !here%ore these potential t?o dr"g com*inations sho"ld not *e"sed "nless there is a compelling (non *lood press"re lo?ering) indication

Com*inations o% an CE> ?ith an A/ do not red"ce cardio asc"lar e entsmore than the CE> alone and ha e more ad erse e%%ects there%ore arenot generally recommended

Ca"tion sho"ld *e e:ercised in com*ining a non dihydropyridine CC/ anda *eta *loc7er to red"ce the ris7 o% *radycardia or heart *loc7.

onitor ser"m creatinine and potassi"m ?hen com*ining sparing

di"retics' CE inhi*itors and5or angiotensin receptor *loc7ers. >% a di"retic is not "sed as %irst or second line therapy' triple dr"g therapy

sho"ld incl"de a di"retic' ?hen not contraindicated.

Preferred: fully additive effects

Acceptable: Partially additive


100/140

Less effective: little or no additionalreduction in BP


101/140

102


102/140

103


103/140

104


104/140

105


105/140

106


106/140

107

;nitiation of Drug T'erapy 9 #o 1ompelling ;n ications !he initial antihypertensi e dr"g sho"ld *e starte at t'e lo(est ose an

ll i i t' BP t t' &i


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gra ually increase epen ing on t'e BP response to t'e ma&imumtolerate ose)

>% the antihypertensi e response to the initial dr"g is inade "ate a%ter reachingfull ose !not necessarily ma&imum recommen e ose"% a secon rugfrom anot'er class s'oul be a e % pro ided the initial dr"g is tolerated.

>% the person is ha ing no therape"tic response or signi%icant ad erse e%%ects' adr"g %rom another class sho"ld *e s"*stit"ted. ;f a iuretic is not t'e initial

rug% it is usually in icate as t'e secon rug) >% the antihypertensi e response is inade "ate a%ter reaching the %"ll dose o% 2

classes o% dr"gs' a third dr"g %rom another class sho"ld *e added. /'en t'e BP is 6 F5 mm 2g above goal% rug t'erapy s'oul generally be

initiate (it' 6 anti'ypertensive rugs% one of ('ic' s'oul be a t'iaJi eiuretic ; ho?e er' in the elderly' treatment m"st *e indi id"aliJed

Choice o% antihypertensi e agent may *e less important than getting to *lood

press"re goal. /e%ore adding ne? antihypertensi e dr"gs' possi*le reasons %or inade "ate /Presponse sho"ld *e e:amined.

108

1onsi erations in primary anti'ypertensive rug c'oice

ntihypertensivegent

Situations with

Potentially FavorableEffects

Situations with

Potential UnfavorableEffects void Use


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gCE> =o? normal potassi"m'

predia*etes'microal*"min"ria inpatients ?itho"t dia*etes

High normalpotassi"m orhyper7alemia

Pregnancy'*ilateral renalartery stenosis'history o%angioedema

A/ =o? normal potassi"m'predia*etes'

microal*"min"ria inpatients ?itho"t dia*etes

High normalpotassi"m or

hyper7alemia

Pregnancy'*ilateral renal

artery stenosis

!hiaJide di"retic Bsteoporosis or atincreased ris7 %or

osteoporosis' high normalpotassi"m

6o"t' hyponatremia'predia*etes (as

monotherapy)' lo?normal potassi"m

High normal re%ers to patients in the high end o% the normal range' *"t not a*o e the range.=o? normal re%ers to patients in the lo? end o% the normal range' *"t not *elo? the range.

1O#T4D 109

ntihypertensivegent

Situations withPotentially FavorableEffects

Situations withPotential UnfavorableEffects void Use

CC/#dihydropyridine Aayna"dKs syndrome'elderly patients ?ith Peripheral edema' le%tentric"lar dys%"nction


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isolated systolichypertension'cyclosporine ind"cedhypertension

(all e:cept amlodipineand %elodipine)' highnormal heart rate ortachycardia

CC/#nondihydropyridine

Aayna"dKs syndrome'migraine headache'arrhythmias' high

normal heart rate ortachycardia

Peripheral edema' lo?normal heart rate

econd or thirddegree heart*loc7' le%t

entric"lardys%"nction

110

Think about:The costs: affordable regimens that do not compromise efficacy shouldbe designed. Generic antihypertensive products are less expensive thanbrand-name products.The frequency of administration: since it can influence patients'

adherence to regimens.

1ontrain ications


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Treatment Algorit'm for ;solate Systolic 2ypertension (it'outOt'er 1ompelling ;n ications

TARGET


111/140

INITIAL TREATMENT AND MONOTHERAPY

Thiazide diureticLong-actingDHP CCB

Lifestyle modification

therapy

ARB

The reason that an ACEinhibitor is not includedis due to the lack ofrandomized controlledtrials with hard clinical

outcomes in patientswith isolated systolichypertension.

CONSIDER

Nonadherence Secondary HTN Interfering drugs or

lifestyle White coat effect

If partial response to monotherapy

Triple therapy

Dual combinationCombine first line agents

If blood pressure is still not controlled, or there are adverse effects,other classes of antihypertensive drugs may be combined (such asACE inhibitors, alpha adrenergic blockers, centrally acting agents, or

nondihydropyridine calcium channel blocker).

T'iaJi e0type iuretics: a tra itional first0line t'erapyfor most patientsK

#1- gui elines recommend thiaJide type di"retics ?hene erpossi*le' as %irst line therapy %or most patients' ?hich is


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p py pconsistent ?ith the traditional pharmacotherapy o%hypertension.

Ho?e er' A2A gui elines do not recommend thiaJide typedi"retics as pre%erred o er an CE inhi*itor' A/' or CC/ %or %irstline therapy.

!reatment ?ith either an CE>' A/' CC/ or thiaJide di"retic isconsidered accepta*le according to the most recent e idence *asedg"idelines

!he *nite >ing om gui elines strati%y patients *ased on ageand race; they recommend# an CE inhi*itor %irst line %or patients yo"nger than age years' and either a CC/ or thiaJide type di"retic %irst line %or patients age

years or older and %or *lac7 patients.

113

B0bloc3ers versus ot'er first0line rug t'erapies

Clinical trials data c"m"lati ely s"ggests that O *loc7ers may notred"ce C e ents to the e:tent that CE inhi*itors' CC/s' or A/s


113/140

red ce C e ents to the e:tent that CE inhi itors CC/s or A/sdo. !hese data are %rom three meta analyses o% clinical trialse al"ating / *loc7er *ased therapy %or hypertension.

$sing a O *loc7er as a primary antihypertensi e agent is optimal?hen a thiaJide type di"retic' CE inhi*itor' A/' or CC/ cannot *e"sed as the primary agent.

$sing a O *loc7er in a yo"ng patient ?ith hypertension that istho"ght to ha e high adrenergic dri e' as e idenced *y an ele atedheart rate' may still *e clinically reasona*le.

O /loc7ers still ha e an important role as an alternati e add onagent to red"ce /P in patients ?ith hypertension *"t ?itho"tcompelling indications.

114

Patients (it' 1ompelling ;n ications

Compelling indications represent speci%ic comorbi con itions?here e idence %rom clinical trials s"pports "sing speci%ic


114/140

pp g pantihypertensi e classes to treat *oth the compelling indication andhypertension.

!he ,-C report identi%ies si& compelling in ications .

&ata %rom clinical trials demonstrate a red"ction in C mor*idityand5or mortality that @"sti%ies "se in patients ?ith hypertension and?ith s"ch a compelling indication.

ome compelling indications incl"de recommendations that arepro ided *y other national treatment g"idelines' or %rom ne?erclinical trials' ?hich are complementary to the ,-C g"idelines.

115

2,Post0M;

2ig' 1AD ris3DM

1'ronic >i ney DiseaseRecurrent stro3e Prevention

Treatment of 2ypertension in Patients (it' #on Diabetic1'ronic >i ney Disease

Target BP: < 130/80 mmHg


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Chronic kidneydisease andproteinuria *

ACEI/ARB:Bilateral renalartery stenosis

ACEI or ARB (if ACEI not tolerated)

Combination with other agents

Additive therapy: Thiazide diuretic.Alternate: If volume overload: loop diuretic

* albumin:creatinine ratio [ACR] > 30 mg/mmolor urinary protein > 500 mg/24hr

Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB

+o!%ination( o' a &+EI and a &3B are ("eci'ically not reco!!ended in the a%(ence o' "roteinuria

Treatment of 2ypertension in association (it'Diabetes Mellitus

Threshold equal or over 130/80 mmHg and TARGET below 130/80 mmHg


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More than 3 drugs may be needed to reach target values for diabetic patients

If Creatinine over 150 mol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic shouldbe substituted for a thiazide diuretic if control of volume is desired

Diabetes

withNephropathy

> 2-drugcombinations

ACE Inhibitoror ARB

withoutNephropathy

1. ACEInhibitor orARB

or

2. Thiazide diureticor DHP-CCB

Monitor (eru! "ota((iu! and creatinine care'ully in "atient( with + "re(cri%ed an &+EI or &3B

+o!%ination( o' an &+EI with an &3B are ("eci'ically not reco!!ended in the a%(ence o' "roteinuria

A combination of 2 first linedrugs may be considered asinitial therapy if the blood

pressure is >20 mmHg systolicor 6 10 mmHg diastolic abovetarget

Treatment of 2ypertensionfor Patients with 1erebrovascular Disease


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$trongly con(ider %lood "re((ure reduction

in all "atient( a'ter the acute "ha(e o'(troke or 7I& .

An ACEI / diureticcombination is preferred

StrokeTIA

Combinations of an ACEI with an ARB are not recommended

Treatment of 2ypertension in Patients with Recent STSegment $levation0M; or non0ST Segment $levation0M;


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Long-actingDihydropyridine

CCB*

Beta-blocker andACEI or ARB

Recentmyocardialinfarction

HeartFailure

?

NO

YES

Long-acting CCB

If beta-blockercontraindicated ornot effective

*Avoid non dihydropyridine CCBs (diltiazem, verapamil)

Treatment of 2ypertension in Patients (it' ;sc'emic2eart Disease

1 Bet blocker


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Caution should be exercised when combining a non DHP-CCB and a beta-blocker If abnormal systolic left ventricular function: avoid non DHP-CCB (Verapamil or

Diltiazem) Dual therapy with an ACEI and an ARB are not recommended in the absence of

refractory heart failure The combination of an ACEi and CCB is preferred

1. Beta-blocker2. Long-acting CCBStable angina

ACEI are recommended for mostpatients with established CAD*

ARBs are not inferior to ACEI in IHD

Short-actingnifedipine

*Those at low risk with well controlled risk factors may not benefit from ACEI therapy

Treatment of 2ypertension (it' Left 8entricular SystolicDysfunction

ACEI and Beta blocker


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Beta-blockers used in clinical trials were bisoprolol, carvedilol andmetoprolol.

If additional therapy is needed: Diuretic (Thiazide for hypertension; Loop for volume control) for CHF class III-IV or post MI: Aldosterone Antagonist

Systoliccardiac

dysfunction

ACEI and Beta blocker if ACEI intolerant: ARBTitrate doses of ACEI or ARB to those used in clinical trials

If ACEI and ARB are contraindicated: Hydralazine and Isosorbide

dinitrate in combination

If additional antihypertensive therapy is needed: ACEI / ARB Combination Long-acting DHP-CCB (Amlodipine)

Nondihydropyridine

CCB

Special Populations:5) 2ypertension in Ol er People

red"ctions in C mor*idity and mortality in older patients ?ithisolated systolic hypertension' ?ith t'iaJi e0type iuretics andl 0 ti i' i i 11B


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long0acting i'y ropyri ine 11Bs .

1entrally acting agents an alp'a50bloc3ers sho"ld generally *ea oided or "sed ?ith ca"tion in the elderly *eca"se they are%re "ently associated ?ith diJJiness and post"ral hypotension.

Diuretics an A1$ in'ibitors pro ide signi%icant *ene%its and can

sa%ely *e "sed in the elderly' *"t smaller than "s"al initial dosesmight *e needed.

initial rug oses may *e lo?er' and dosage titrations sho"ld occ"ro er a longer period o% time to minimiJe the ris7 o% hypotension.

n interim goal of a SBP o% *elo? 130 mm Hg may *e necessary %orthose ?ith ery high initial /P' *"t the ultimate goal sho"ld still *eless than 140 mm Hg' less than 1+0 mm Hg' or less than 120 mm

Hg' depending on C ris7 and comor*id conditions o% the patient. 122

Special populations:6) Patients at ris3 for ort'ostatic 'ypotension

Ort'ostatic 'ypotension is a signi%icant drop in /P ?hen standingand can *e associated ?ith diJJiness and5or %ainting. >t is de%ined as


122/140

a /P decrease o% greater than 20 mm Hg or &/P decrease o%greater than 10 mm Hg ?hen changing %rom s"pine to standing.

$se o% enodilators (N *loc7ers' mi:ed N5O *loc7ers' nitrates' andphosphodiesterase inhi*itors) increase ris7 o% orthostatichypotension.

>n patients ?ith these ris7s' antihypertensi e agents sho"ld *estarte in lo( oses ' especially di"retics' CE inhi*itors' and A/s.

123

Special populations:7) 2ypertension in c'il ren an a olescents

Define as: /P and5or &/P that is greater than 9 th percentile %or se:' age' andheight on at least three occasions. /P *et?een the 90 th and 9 th percentile' ore "al to or greater than 120580 mm Hg in adolescents' is considered


123/140

prehypertension tage > hypertension is diagnosed i% a child


124/140

125

90th 116 116 117 119 120 121 122 75 75 75 76 77 78 78

95th 119 120 121 123 124 125 126 79 79 79 80 81 82 8299th 127 127 128 130 131 132 133 86 86 87 88 88 89 90

SBP (mmHg) DBP (mmHg)Age BP Percentile of Height Percentile of Height

(Year) Percentile 5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th

12 50th 101 102 104 106 108 109 110 59 60 61 62 63 63 64

90th 115 116 118 120 121 123 123 74 75 75 76 77 78 79

95th 119 120 122 123 125 127 127 78 79 80 81 82 82 83

99th 126 127 129 131 133 134 135 86 87 88 89 90 90 91

BP Levels for


125/140

140590 mm Hg that appears a%ter 20 ?ee7s gestation accompanied*y ne? onset protein"ria (+00 mg524 ho"rs)' can lead to li%ethreatening complications %or *oth mother and %et"s.

6) $clampsia ' the onset o% con "lsions in preeclampsia' is a medicalemergency.

7)


126/140

an close monitoring)

ntihypertensi e agents are "sed prior to ind"ction o% la*or i% &/Pis greater than 10 to 110 mm Hg ?ith a target &/P o% 9 to 10mm Hg.

;ntravenous 'y ralaJine is most commonly "sed' and intravenouslabetalol is also e%%ecti e.;mme iate0release oral nife ipine has*een "sed' *"t it is not appro ed *y the ood and &r"g

dministration ( & ) %or hypertension and "nto?ard %etal andmaternal e%%ects (hypotension ?ith %etal distress) ha e *eenreported.

127

Special populations:.) Pregnancy 9 c'ronic 'ypertension

>t is contro ersial ?hether treating ele ated /P in patients ?ithchronic hypertension in pregnancy is *ene%icial. Ho?e er' ?omen?ith chronic hypertension prior to pregnancy are at increase ris3


127/140

?ith chronic hypertension prior to pregnancy are at increase ris3of a number of complications ' incl"ding#

s"perimposed preeclampsia'

preterm deli ery' %etal gro?th restriction or demise' placental a*r"ption' heart %ail"re' ac"te 7idney %ail"re.

128

Special populations:.) Pregnancy 9 c'ronic 'ypertension

Met'yl opa is still considered the dr"g o% choice. &ata indicate that "teroplacental *lood %lo? and %etal hemodynamics aresta*le ?ith methyldopa oreo er' it is ie?ed as ery sa%e' *ased on long


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sta le ?ith methyldopa. oreo er it is ie?ed as ery sa%e ased on longterm %ollo? "p data ( . years) that has not demonstrated ad erse e%%ects on

childhood de elopment. B0Bloc3ers% labetalol an 11Bs are also reasona*le alternati es. A1$ in'ibitors an ARBs are 7no?n teratogens and are a*sol"tely

contraindicated.

Alis3iren also sho"ld not *e "sed in pregnancy.

129


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2T# an ot'er concomitant con itions5) Pulmonary isease an perip'eral arterial isease

&ata s"ggests that car ioselective 0bloc3ers can sa%ely *e "sed inpatients ?ith asthma or chronic o*str"cti e p"lmonary disease. Peripheral arterial disease' noncoronary atherosclerotic asc"lar disease'


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Peripheral arterial disease noncoronary atherosclerotic asc lar diseaseis a coronary artery disease ris7 e "i alent. !he 200 H g"idelines no?

recommend a /P goal o% less than 1+0580 mm Hg in this pop"lation. A1$ in'ibitors may *e ideal in patients ?ith symptomatic lo?er e:tremity

peripheral arterial disease ?ho also ha e hypertension' as they decreaseC e ents in these patients. 11Bs may also *e *ene%icial *eca"se o% their

asodilatory e%%ects on the peripheral arteries. B0Bloc3ers ha e traditionally *een considered pro*lematic in patients

?ith peripheral arterial disease *eca"se o% possi*le decreased peripheral*lood %lo? secondary to "nopposed stim"lation o% receptors thatres"lts in asoconstriction. Ho?e er' / *loc7ers are not contraindicated inperipheral arterial disease and ha e not *een sho?n to ad ersely a%%ect?al7ing capa*ility.

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2T# an ot'er concomitant con itions6) $rectile ysfunction

ost antihypertensi e agents are associated ?ith erectiledys%"nction in men. Centrally acting agents are associated ?ith higher rates o% se:"al


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Centrally acting agents are associated ?ith higher rates o% se: aldys%"nction and sho"ld *e a oided in men ?ith erectiledys%"nction.

st"dy o% men prospecti ely screened %or erectile dys%"nction a%ter*eing re%erred %or n"clear stress test imaging sho?ed that erectile

ysfunction (as a stronger pre ictor of severe coronary 'eartisease t'an tra itional ris3 factors (age' smo7ing' hypertension'

dia*etes' and dyslipidemia).

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2ypertensive urgency

>deally managed *y ad@"sting maintenance therapy *y adding a ne?antihypertensi e and5or increasing the dose o% a presentmedication. !his is the pre%erred approach to these patients as it


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medication. !his is the pre%erred approach to these patients as itpro ides a more gra ual re uction in /P.

Ae "ires /P red"ctions ?ith oral antihypertensi e agents to stage 1al"es o er a period o% se eral ho"rs to se eral days. ll patients

?ith hypertensi e "rgency sho"ld *e ree al"ated ?ithin days

(pre%era*ly a%ter 1 to + days). c"te administration o% a short acting oral antihypertensi e

(captopril' clonidine or la*etalol) %ollo?ed *y care%"l o*ser ation%or se eral ho"rs to ass"re a grad"al red"ction in /P is an option %orhypertensi e "rgency.

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2ypertensive emergencies


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2ome(or3: /'at parenteral agents can be use for t'e treatment of'ypertensive emergencies

o"rce# chapter 2 in Pharmacotherapy Principles Y Practice


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Patient $ ucation ssess patientKs "nderstanding and acceptance o% the diagnosis o%

hypertension &isc"ss patientKs concerns and clari%y mis"nderstandings Fhen meas"ring /P' in%orm the patient o% the reading *oth er*ally and


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Fhen meas ring /P in%orm the patient o% the reading oth er ally andin ?riting

ss"re patient "nderstands their goal /P al"e s7 patient to rate (1 10) his or her chance o% staying on treatment >n%orm patient a*o"t recommended treatment' incl"ding li%estyle

modi%ication. Pro ide speci%ic ?ritten in%ormation "sing standard

*roch"res ?hen a aila*le Elicit concerns and "estions and pro ide opport"nities %or patient tostate speci%ic *eha iors to carry o"t treatment recommendations

EmphasiJe# the need to contin"e treatment that control does not mean c"re ele ated /P is "s"ally not accompanied *y symptoms

136

;n ivi ualiJe Treatment Regimens

>ncl"de the patient in decision ma7ing impli%y the regimen to once daily dosing' ?hene erpossi*le


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possi le >ncorporate treatment into patientKs daily li%estyle et realistic short term o*@ecti es %or speci%ic components

o% the medication and li%estyle modi%ication plan Enco"rage disc"ssion o% diet and physical acti ity' ad erse

dr"g e%%ects and concerns Enco"rage sel% monitoring ?ith alidated /P de ices inimiJe the cost o% therapy' ?hen possi*le &isc"ss adherence at each clinical enco"nter Enco"rage grad"al s"stained ?eight loss

137

,ollo(0up an Monitoring ,our aspects of treatment must al(ays be consi ere #

a) /P response to attain goal'*) adherence ?ith li%estyle modi%ications and pharmacotherapy'

c) progression to hypertension associated complications'


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d) dr"g related to:icity.

T'erefore: Bnce antihypertensi e dr"g therapy is initiated' most patients sho"ld ret"rn %or

follo( up an a justment of me ications at appro:imately monthly inter als "ntilthe /P goal is reached.

ore %re "ently %or those ?ith tage >> H!- or comor*id conditions %ter /P goal achie ed contin"e %ollo? "p e ery + 3 months

Serum potassium an creatinine sho"ld *e monitored at least 1 2 times5year. Laboratory mar3ers at least semi ann"ally

ore o%ten i% necessary d"e to speci%ic dr"g Cardio asc"lar ris7 %actors sho"ld *e treated to their respecti e goals' and to*acco

a oidance sho"ld *e promoted igoro"sly.

Contin"ally monitor %or si e effects or a verse rug reactions138

Monitoring Drug T'erapy

Therapeutic Toxic

Example: Beta blocker


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&ependent on anypresenting symptoms

atig"e' =ethargyCon%"sion

T&epressedU

hortness o% *reath

/P and HA=a*oratory data

/P' HA and AA&epression cale

"sc"ltation5P !

Therapeutic Toxic

Subjective

Objective

1ase stu y ,!' a year old %rican merican ?oman' comes to yo"r clinic

?ith a recent diagnosis o% hypertension. he is < U (13 cm) tall and ?eighs 130 po"nds ( 2. 7g) ?ith a

* d i d (/ ) % 23 3 7 5 2


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*ody mass inde: (/ >) o% 23.3 7g5m2.

,! does not "se to*acco or drin7 alcohol' and e:ercises a*o"t oncea ?ee7. Physical e:am ?as "nremar7a*le' *"t an electrocardiogram

re ealed le%t entric"lar hypertrophy.

/aseline la*oratory tests ?ere signi%icant %or %asting *lood gl"coseo% 124 mg5d= (3.88 mmol5=)' ser"m creatinine o% 1. mg5d= (1++mmol5=)' total cholesterol o% 200 mg5d= ( .18 mmol5=)' highdensity lipoprotein cholesterol o% 40 mg5d= (1.04 mmol5=)'triglycerides o% 200 mg5d= (2.23 mmol5=)' and lo? densitylipoprotein cholesterol o% 120 mg5d= (+.11 mmol5=). $rinalysis ?aspositi e %or microal*"min"ria.

/lood press"re today ?as 13 583 mm Hg.

1ase stu y ! uestions" Fhat signs o% target organ damage does ,! e:hi*it >s more e:tensi e testing %or identi%ia*le ca"ses o% hypertension

indicated at this time


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/ased on the in%ormation presented' create a care plan %or ,!

01 Hypertension 2013 Final

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