1 Hypertension Management for Advanced Practice Nurses Ruth Ann Fritz APRN-CNS BC April 13, 2019 1 Objectives Participant will be able to: • Discuss new Hypertension guideline recommendations • List 2 secondary causes of hypertension and recommended evaluation and treatment • Review action and precautions of medications for hypertension 2 1 2
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10-Fritz-Hypertension Management for Advanced Practice …...– Screen for secondary hypertension • 8. Treatment of High BP – Pharmacological treatment in context of CVD risk
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1
Hypertension Management for
Advanced Practice Nurses
Ruth Ann Fritz APRN-CNS BC
April 13, 2019
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Objectives
Participant will be able to:
• Discuss new Hypertension guideline recommendations
• List 2 secondary causes of hypertension and recommended evaluation and treatment
• Review action and precautions of medications for hypertension
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UpToDate 2019
• NHANES (National health and nutrition examination survey) 2011-2014 - adjusted to new guidelines
– 46% adults in USA have HTN
– 103 million adults
• Will increase as population ages and with the rising incidence of obesity
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Causes of Hypertension
• Essential hypertension
– Genetic
– Decline in healthy life style
• Secondary causes
– Kidney disease
– Malfunction of certain glands
– Substance/medication intake-ETOH/steroids
– Rare tumor – pheochromocytoma
– Sleep apnea
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Hypertensive Crisis
• Hypertensive Emergency- elevation of DBP accompanied by acute target organ damage
– Encephalopathy
– Intracranial hemorrhage
– Acute left ventricular failure with Pulmonary edema
– Dissecting aortic aneurysm
– Unstable angina
• Hypertensive Urgency – severe hypertension without organ damage
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Classifications of Blood Pressure
JNC 7• Normal -
– SBP < 120 and DBP <80
• Prehypertension
– SBP 121-139 or DBP 80-89
• Hypertension stage 1
– SBP139-159 or DBP 90-99
• Hypertension stage 2
– SBP >/= 160 or DBP >/=100
Treatment to <140/90 but <130/80 DM, CKD
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Compelling Indications – JNC7
• Compelling indications for Individual Drug Classes
hydralazine/nitrates) titrated to <130/80 – do not use nondihydropyridine CCB
• HFpEF – if fluid overload – diuretics, persistent – ACE or ARB and BB to <130/80
• (r=reduced, p=preserved)
– Chronic Kidney Disease• Treat to <130/80
• CKD 3 or more – with albuminuria >=300mg/g or alb/creat ratio>=300 – treatment with ACE or ARB if ACE not tolerated
• Renal Transplant - treat with Calcium antagonist
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2017 ACC/AHA/AAPA/ABC/ACPM/AGS/
APhA/ASH/ASPC/NMA/PCNA
Guideline for the Prevention, Detection, Evaluation,
and Management of High Blood Pressure in Adults
• 9. Hypertension in patients with comorbidities cont.
– Cerebrovascular disease• Acute cerebral Hemorrhage (ICH) >220/s – IV med and monitoring to lower, but
if BP 150-220 immediate lowering to <140/s - not benefit could be harmful
• Acute ischemic Stroke – if eligible for TPA BP slowly lowered to <185/110 before TPA, then maintain below 180/105 for at least 24hr, may start or restart meds on patients with BP >140/90 if neurologically stable, If no TPA –>220/s benefit uncertain, but reasonable to lower BP by 15% first 24 hrs
• Secondary Stroke prevention – TIA or CVA – restart meds after few days of event – treat with thiazide diuretic, ACE or ARB or combination – reasonable goal <130/80, if been untreated and BP <140/90 – usefulness of starting med not well established
• Peripheral Artery Disease- Treat same as pt without PAD
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2017 ACC/AHA/AAPA/ABC/ACPM/AGS/
APhA/ASH/ASPC/NMA/PCNA
Guideline for the Prevention, Detection, Evaluation, and
Management of High Blood Pressure in Adults
• 9. Hypertension in patients with co-morbidities cont.
– Diabetes• Goal to <130/80
• All first line medications (thiazide diuretics, ACE, ARB, CCB) good to use
• If albuminuria ACE or ARB preferred
– Metabolic Syndrome – lifestyle, medications not established
– Atrial Fib – treatment with ARB can be useful prevention of recurrence of Atrial fib
• Do not treat with ACE, ARB or direct renin inhibitor
– Age related• Older persons - goal <130/80 for noninstutionalized ambulatory community-dwelling
adults >= 65,
• But if high burden comorbitity and limited life expectancy, clinical judgment, pt preference, and team-based approach to assess risk/benefit if reasonable regarding intensity of BP lowering and choice of medications
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2017 ACC/AHA/AAPA/ABC/ACPM/AGS/
APhA/ASH/ASPC/NMA/PCNA
Guideline for the Prevention, Detection, Evaluation, and
Management of High Blood Pressure in Adults
• 11. Other considerations
– Resistant hypertension • Confirm resistance – BP>130/80 on 3 meds or <130/80 but on 4 meds
• exclude pseudoresistance – accurate BPs, check nonadherence
• Indentify and reverse lifestyle factors
• Dc or minimize interfering substances –drugs, licorice
• Screen for secondary causes
• Pharmacological treatment
• Refer to specialist
– Hypertensive Crisis - Emergency/Urgencies• ICU monitoring - BP and target organ damage and IV meds
• Compelling condition – aortic dissection, sever preeclampsia or eclampia or pheochromocytoma crisis – SBP to <140 first hour or <120 if aortic dissection
• No compelling – SBP reduce no more than 25% first hour, then if stable to 160/100 in 2-6 hrs then cautiously to normal in 24-48hrs
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2017 ACC/AHA/AAPA/ABC/ACPM/AGS/
APhA/ASH/ASPC/NMA/PCNA
Guideline for the Prevention, Detection, Evaluation, and
Management of High Blood Pressure in Adults
• 11. Other considerations continued
– Cognitive Decline and Dementia – BP lowering is reasonable to prevent cognitive decline and dementia – Class IIa
– Patients undergoing surgery • If major surgery and been on BB keep on BB, but pre-op dc of ACE or ARB may be
considered
• Planned elective OR – reasonable to keep on meds until surgery, but if BP>= 180/110 deferring surgery may be considered
• Harmful – to abruptly dc BB or clonidine pre op
• Harmful to start BB on day of surgery in BB naïve pts
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2017 ACC/AHA/AAPA/ABC/ACPM/AGS/
APhA/ASH/ASPC/NMA/PCNA
Guideline for the Prevention, Detection, Evaluation, and
Management of High Blood Pressure in Adults
• 12. Strategies to Improve HTN treatment and control
– Adherence strategies • Medications -Once daily, and Combination pills are useful
• Promote lifestyle modifications – behavioral and motivational ( stop smoking, wt loss, mod alcohol intake, more physical activity, less Na, healthy diet)
– Structured, Team-based, care interventions
– Heath information technology – EHR and Telemedicine
– Improving quality of care – performance measures
– Financial Incentives • Paid to providers useful in achieving improvements
• Heath system financing strategies ( insurance coverage and co-pay benefit)
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Response to 2017 Guidelines
• AAFP declined to endorse guideline
– Did not look at harm with treating to lower BP
– Questions about the evidence used
– Use of ASCVD tool –no evidence it helps outcomes
– Conflict of interest
• AHA – developing tools for providers and patients based on
guidelines
– HTN guideline toolkit
– Education for patients
• Cleveland Clinic Journal of Medicine Jan 2019
– “Treat patients, not numbers” as some at risk of adverse events
– Good review of history of guidelines and research used
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2018 ESC/ESH Guidelines for Management of
Arterial Hypertension
• Evidence – RCTs and meta-analysis – more conservative
• Diagnosis – office BPs, home BPs
– Range
– Normal <120/80 – to Grade 3 180/110
• Treatment thresholds
– High normal (130-139/85-89) – Meds if CV risk very high
– Grade 1 HTN (SBP 140/159)- low/mod risk, med if high after lifestyle, >65 <80 age lifestyle/ medications if tolerated
• BP Targets - compliance, discussions with pt
– First objective is all to <140/90 and if tolerated to 130/80 most pts
– <65 age – SBP 120-129, =>65 age- SBP 130-139
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Diagnosis of HTN
• Not on one reading – white coat
• Measure correctly
– Sprint trial – used auto BP cuff set to do more than 1 reading without person in room
– Correct cuff size, position
– Average
• Evaluation
• Assess risk factors
• Look for causes of hypertension
• Assess for organ damage signs
• H/P, lab tests, EKG, echo
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Secondary causes of HTN
• Renal disease
– UTI, obstruction, hematuria, analgesic abuse,
– Glomerular, vascular, family hx PKD
– Acute /CKD
– Treatment – Renal US, treat cause if possible, manage
fluid, if ESRD dialysis and BP med as needed
• Renovascular Dx - renal artery stenosis
– Renal US and stents if needed in renal arteries
– Creatinine significant increase after add ACEI
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Secondary HTN
• Drug Induced –
– NSAIDS, antidepressants, drug and ETOH abuse
– Decongestants, caffeine, nicotine, cyclosporine or
tacrolimus, neuropsychiatric, ESA, Clonidine withdrawal
– Management – limit or avoid, alternatives
• Oral contraceptives/hormone therapy
– Rises BP in normal range but can cause HTN
– Avoid, or low dose agents, or alternate birth control
claudication or Raynaud’s, increase triglycerides,
decrease HDL, depression, and impotence, rarely
contribute to confusion
– Need to taper drug off over 14 days
– Caution in diabetics – may mask signs of hypoglycemia
except for diaphoresis
– Avoid Clonidine with Beta Blocker – or withdraw Beta
blocker first
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Alpha 1 Blockers
• RCT – Alpha Blockers resulted in inferior CV outcomes compare with use of a diuretic so not for initial therapy
• Action – “Peripheral alpha-1 receptor blockers” selectively block the alpha-1 receptors in the arterioles and venules, (bladder neck and prostate)
– Doxazosin – Cardura 1mg-16mg
– Terazosin – Hytrin 1mg-20mg
– Prazosin – Minipress 1mg-20mg
– (Tamsulosin – Flomax)
– (Phentolamine – Regitine) (alpha 1 and 2 – has
limited use)
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Alpha 1 Blockers
• Indications – Not for initial therapy, but may be second line for patients with BPH
• Adverse Effects – “first dose phenomenon” transient dizziness/faintness, palpitations, and possible syncope with orthostatic hypotension
• Contraindicated in presence of volume depletion and CHF - decreases venous return and cause significant heart failure
• Beers list 2019 avoid in the elderly
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Alpha 1 Blockers
• Adverse Effects cont: may cross blood/brain barrier and CNS effects – lassitude, vivid dreams, depression, rare priapism, and at larger doses may cause Na and fluid retention
• Have pt take initial / increased dose at bedtime to assist with orthostatic hypotension
• Warn if get up during night to sit on bed a while, then get up slowly
• Beneficial effects of lipid profile
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Centrally acting agents
• Action – “Central alpha 2 receptor agonist” – acts as an agonist at the presynaptic alpha-2 receptor to decrease sympathetic outflow and an increase in vagal tone – HR, CO, and TPR are lowered, renin activity reduced – (CNS/brain effects)
– Clonidine – Catapres oral .1mg-.8mg
– Methyldopa – Aldomet 250mg-1000mg
• Indications - reserved last line as CNS SE, Methyldopa used in pregnancy
• Adverse reactions – dry mouth, drowsiness, depression, retention of Na and fluid
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Centrally acting agents
• Caution – do not stop Clonidine abruptly as can cause rebound hypertension – sudden increase in BP often in excess of pretreatment BP – wean gradually
• Methyldopa rarely can cause hepatitis or hemolytic anemia
• Clonidine comes as patch which has fewer side effects and improved compliance – but cost issue and 2-3 day delay of onset
• Beers list 2019 avoid in elderly
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Direct Vasodilators
• Action – Increase intracellular concentrations of cGMP which cause direct arteriolar smooth muscle relaxation – little effect on venous side
– Minoxidil – Loniten – 5mg-40mg - max 100mg
– Hydralazine 100mg-200mg
– Nipride (dilute D5, cyanide toxicity, not in pregnancy)
• Indications – resistant hypertension
• Adverse Effects –
– Activates the baroreceptor reflexes - increases SNS –
elevated HR, CO, renin, and retention Na and fluid -
edema (precipitate angina) so needs BB or other SNS
inhibitor and diuretic if needed.
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Direct Vasodilators
• Adverse Effects cont:
– Hydralazine – headache, nausea, angina, Lupus like
syndrome (reversible), drug fever, dermatitis
– Minoxidil – hirsutism– hair growth on face, arms, back
and chest (reverses when drug stopped), pericardial
effusion, non-spec T wave changes on EKG, need
loop diuretic
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Postganglionic Blockers
• Action – Act indirectly on adrenergic neurons by inhibiting release of norepinephrine from synaptic nerve endings – depletes CNS of catecholamines and serotonin
– Reserpine – Serpasil
– Guanadrel – Hylorel
– Guanethidine - Ismelin
• Indications – used as sympathetic inhibitor -used in trials