HypertensionTreatment Guidelines. Michaelene Urban APRN, MSN, ACNS-BC, ANP-BC

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1 HypertensionTreatment Guidelines Michaelene Urban APRN, MSN, ACNS-BC, ANP-BC

2 Objectives: Review the definition of the different stages of HTN. Review the current guidelines for treatment of HTN. Provided information on the recommended pharmacologic management to be initiated in the setting of HTN in relationship to under lying medical issues. Review the key points of patient education. Review the need for follow up appointments and labs with the initiation of HTN agents.

3 JNC history JNC 1 published 1976 JNC 2 published in 1980 JNC 3 published 1984 JNC 4 published 1988 JNC 5 published 1992 JNC 6 Published 1997 JNC 7 Published 2003 JNC 8 Published 2014

4 Comparison JNC 6 to 7 stages of Hypertension JNC 6 SBP/DBP JNC 7 Optimal <120/80 Normal Normal Borderline / PreHypertension Hypertension >140/90 Hypertension Stage 1 Stage 2 Stage / / >180/110 Stage 1 Stage 2 Stage 2

5 JNC 8 Age Goal BP Of note /90 If achieved SBP <140 and tolerate w/o adverse effects then continue DBP < 90 < 60 target SBP < DBP < w/ CKD 140/90

6 So What Next

7 So here are the latest Guidelines

8 ACC/ AHA Guidelines

9 Stages of Hypertension BP Category SBP And /Or DBP Normal <120 mm Hg And <80 mm Hg Elevated mm Hg And <80 Mm Hg Hypertension Stage mm Hg Or mm HG Stage 2 >140 mm Hg Or > 90 mm HG

10 Guidelines of Hypertension JNC 7 SBP/DBP 2017 ACC/AHA Normal <120/80 Normal PreHypertension Hypertension / Elevated /80 Hypertension Stage / /80-89 Stage / >180/110 >140 or >90

11 Management of Hypertension

12 Causes of Hypertension Genetic predisposition Environmental Factors Overweight & Obesity Sodium intake Potassium intake Physical Fitness Alcohol

13 Life style modification

14 Non Pharmacological

15 Nonpharmacological Nonpharmacological Intervention Nonpharmacological Intervention Dose Hypertensive Normotensive Weight loss Weight/body fat Best goal is ideal body weight, but aim for at least a -5 mm Hg -2/3 mm Hg 1-kg reduction in body weight for most adults who are overweight. Expect about 1 mm Hg for every 1- kg reduction in body weight. Healthy diet Dash Diet Consume a diet rich in fruits, vegetables, -11 mm Hg` -3 mm Hg whole grains, and low-fat dairy products, with reduced content of saturated and total fat. Reduced intake of dietary Dietary Sodium Optimal goal is <1500 mg/d, but aim for at -5/6 mm Hg -2/3 mm Hg sodium least a 1000-mg/d reduction in most adults. Enhanced intake of dietary Dietary Potassium Aim for mg/d, preferably by -4/5 mm Hg 2 mm Hg potassium consumption of a diet rich in potassium. Physical activity Aerobic Dynamic resistance Isometric resistance min/week with HR Heart are reserve min / week 8-10 week -4 mm Hg -5 mm Hg -4 mm Hg 2 mm Hg -4 mm Hg -3 mm Hg Moderation in alcohol intake Alcohol consumption Men: 2 drinks daily Women: 1 drink daily -4 mm Hg -3 mm Hg

16 Primary vs Secondary Hypertension

17 Primary Hypertension Gradual increase BP, with slow rate of rise in BP Lifestyle factors that favor higher BP (e.g., weight gain, high-sodium diet, decreased physical activity, job change entailing increased travel, excessive consumption of alcohol) Family history of Hypertension

18 Secondary Hypertension BP lability, episodic pallor and dizziness (pheochromocytoma) Snoring, hypersomnolence (obstructive sleep apnea) Prostatism (chronic kidney disease due to post-renal urinary tract obstruction) Muscle cramps, weakness (hypokalemia from primary aldosteronism or secondary aldosteronism due to renovascular disease) Weight loss, palpitations, heat intolerance (hyperthyroidism) Edema, fatigue, frequent urination (kidney disease or failure) History of coarctation repair (residual hypertension associated with coarctation) Absence of family history of Hypertension

19 Secondary Hypertension

20 Labs and Testing Basic testing Fasting blood glucose CBC Lipid profile Optional testing Echocardiogram Uric Acid Urinary Albumin to Creatinine Serum Creatinine with GFR Serum Sodium,Potassium, calcium TSH Urinalysis EKG

21 ASCVD Risk Estimator Plus

22 Treatment of Blood Pressure

23 Treatment Recommendations

24 Pharmacologic Therapy Considerations Prior to Initiation Start with a single agent unless patient is in Stage 2 then consider 2 drugs from a different class Think about Patient s specific factors: Age Current medication Drug adherence Drug interactions Out of pocket expenses Comorbidities

25 When Choosing your Agents Many patients will need > 2 agents to reach blood pressure goals. Pick drugs regiments with complementary activity. Drug combinations with similar mechanisms or action or clinical effects should be avoided. 2 drugs from the same class should be avoided.

26 Primary Agents in the treatment of Hypertension Thiazide diuretics ACE inhibitors ARB Calcium channel blockers

27 Primary Agents Thiazide or thiazide type diuretics Chlorathalidone mg/d HCTZ mg/d Indapamide mg/d Metolazone mg/d

28 Primary Agents ACE inhibitors Benazepril mg/d -Daily/ BID Captopril BID/ TID Enalapril 5-40 mg/d- Daily/ BID Fosinopril mg/d -Daily/ BID Lisinopril mg/d Daily/ BID Ramipril mg/d Daily/ BID

29 Primary Agents ARBs Losartan mg.d -Daily/BID Valsartan mg/d- Daily Irbesartan mg/d -Daily

30 Primary Agents CCB - dihydropyridines Amlodipine mg/d -Daily Nicardipine SR 5-20 mg/d- Daily Nifedipine LA mg/d- Daily CCB- non dihyropyridines Diltiazem SR mg/d - BID Diltiazem ER mg/d - Daily Verapamil Ir mg/d - TID Verapamil SR mg/d- Daily / BID Verapamil ER md/d - Daily evening

31 Primary Agents Thiazide or thiazide type diuretics Chlorathalidone mg/d HCTZ mg/d Indapamide mg/d Metolazone mg/d

32 Secondary Agents Diuretics- loop Diuretics - potassium sparing Diuretics- aldosterone antagonists Beta Blockers- cardioselective cardioselective and vasodilatory noncardioselective Intrinsic sympathonim Combined alpha and beta receptor Direct renin inhibitors Alpha 1 blockers Central alpha agonist and other centrally acting drug

33 Secondary Agents Diuretics- loop Bumetanide 0.5-4mg/d -BID Furosemide mg/d - BID Torsemmide 5-10 mg/d - Daily Diuretics - potassium sparing Amiloride 5-10 mg/d - Daily /BID Triamterene mg/d - Daily /BID Diuretics- aldosterone antagonist Spironolactone Daily

34 Secondary Agents Beta Blockers cardioselective Atenolol mg/d- Daily/ BID Bisoprolol mg/d Daily Metoprolol tratrate mg/d BID Metoprolol succinate mg/d - Daily Beta Blockers cardioselective and vasodilatory Nebivolol 5-40 mg/d - Daily

35 Secondary Agents Beta Blockers noncardioselective Nadolol mg/d Daily Propranolol IR BID Propranolol LA mg/d - Daily Beta Blockers intrinsic sympathominatic activity ( rarely used) Beta Blockers combined alpha and beta receptors Carvedilol mg/d BID Cardvedilol phosphate mg.d - Daily Labetalol mg/d BID

36 Secondary Agents Diret renin inhibitors Aliskiren mg/d- Daily Alpha 1 blockers Doxazosin 1-8 mg/d - Daily Prazosin 2-20 mg/d - BID/ TID Terazosin 1-20 mg/d - Daily/BID Central alpha agonist and other centrally acting drugs Clonidine oral mg/d -BID Clonidine patch mg/d weekly Methyldopa mg/d BID

37 Secondary Agents Central alpha agonist and other centrally acting drugs Clonidine oral mg/d -BID Clonidine patch mg/d weekly Methyldopa mg/d BID Vasodilators Hydralazine mg/d BID- TID Minoxidil mg/d daily- TID

38 Pharmacological approach based on Diagnosis Stable Ischemic Heart disease (SIHD) Heart Failure CKD Ischemic Stroke / secondary prevention Afib

39 Treatment Based on Medical Conditions

40 Treatment for SIHD

41 Hypertension with SIHD

42 Heart Failure Goal optimal BP less than 130/80 mm Hg HF with reduce EF GDMT to obtain optimal BP goals and nondihydroyridine CCB are not recommended. HF with preserved EF with symptoms of volume overload: Diuretic therapy ACE or ARB and BB to achieve optimal BP goals

43 CKD Goal optimal BP less than 130/80 mm Hg Hypertension and CKD treatment with an ACE inhibitor is reasonable to slow kidney disease progression or ARB if ACE is not tolerated.

44 Diabetes DM and HTN start antihypertensive mediations to achieve BP less than 130/80 mm Hg All first line drugs are useful and effective, ACE inhibitors or ARBs may be considered in the presences of albuminuria

45 Acute Ischemic Stroke

46 Ischemic Stroke

47 Secondary Stroke Prevention

48 Hypertension with Previous Stroke

49 Afib Afib and hypertension are most common and both increase with age. Hypertension is present in more than 80% of patients with Afib. Management starts with restoration of sinus rhythm when appropriate, rate control if the patient is unable to maintain sinus rhythm and of course use of anticoagulation. ACE inhibitors have shown superiority over other agents

50 What are the next steps

51 Have the Conversation about Hypertension

52 Education Properly prepare the patient Use proper technique for BP measurements Take the proper measurements needed for Diagnosis and treatment of Hypertension Properly document accurate BP measurements Average the readings Provide BP readings to the patient

53 Proper BP Measurements

54 Follow Up

56 CVD Risk Factors with Hypertension Modifiable Risk Factors Smoking or second hand smoking DM HLD Overweight / Obesity Exercise Unhealthy diet Fixed (relatively ) Risk Factors CKD Family History Increase age Low socioeconomic / educational status Male sex OSA Psychosocial Stress

57 It always helps to have a great bunch of people helping you through your day

58 Questions?

Hypertension (JNC-8)

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