Hypertension Update Sarah J. Payne, MS, PharmD, BCPS Assistant Professor, Department of Pharmacotherapy UNT System College of Pharmacy
Introduction 1/3 of US adults have HTN More prevalent in non-hispanic blacks HTN and CV disease: 69% of people with first MI 77% of people with first stroke 74% of people with HF Cost: $51 billion in direct and indirect cost in 2009 2
Evaluation Category SBP (mmhg) DBP (mmhg) Normal < 120 AND < 80 Prehypertension 120-139 OR 80-89 Hypertension, stage 1 140-159 OR 90-99 Hypertension, stage 2 160 OR 100 Assess for Cardiovascular Risk Factors: Hypertension Physical Inactivity Obesity Albuminuria, egfr < 60 ml/min Dyslipidemia Age (men > 55, women > 65) Diabetes mellitus Family history of premature CVD Cigarette smoking 3
Evaluation Diagnostic Work-Up Assess risk factors & comorbidities Reveal identifiable causes of HTN Assess presence of target organ damage Conduct history and physical exam Obtain laboratory tests Urinalysis Blood glucose Hematocrit Lipid panel Chem-7 Obtain electrocardiogram Identifiable HTN Causes Sleep apnea Drug-induced/related Chronic kidney disease Primary aldosteronism Renovascular disease Cushing s syndrome or steroid therapy Pheochromocytoma Coarctation of the aorta Thyroid/parathyroid disease 4
Treatment: Lifestyle Principles: Encourage healthy lifestyles for all individuals Prescribe lifestyle modifications for all individuals with pre-htn and HTN Components listed below Modification Recommendation Avg. SBP Weight reduction Maintain normal body weight 5-20 mmhg / 10 kg DASH eating plan Fruits and vegetables, low-fat dairy products, saturated and total fat 8-14 mmhg Dietary sodium restriction Na + to 2.4 g Na + or 6 g NaCl 2-8 mmhg Aerobic physical activity Moderation of alcohol Regular activity at least 30 min per day, most days of the week Men: 2 drinks/day Women: 1 drink/day 4-9 mmhg 2-4 mmhg 5
Lifestyle Modifications Not at Goal Blood Pressure (<140/<90 mmhg; Adults > 60 years: <150/<90 mmhg Initial Drug Choices Nonblack individuals: Thiazide, CCB, ACEI, ARB Black individuals: Thiazide or CCB Individuals with CKD: ACEI or ARB Not at Goal Blood Pressure Maximize up to 3 drug regimen. If goal not achieved, refer to HTN specialist 6
Causes of Resistant HTN Improper BP measurement Excess sodium intake Inadequate diuretic therapy Medication Inadequate doses Drug actions and interactions (e.g., NSAIDs, illicit drugs, sympathomimetics, oral contraceptives) OTC and herbal supplements Excess alcohol intake Identifiable causes of HTN 7
Thiazide Diuretics Hydrochlorothiazide Chlorthalidone Indapamide Common side effects: Hypokalemia Hyponatremia Hyperuricemia Metabolic alkalosis Hyperglycemia Photosensitivity Potential Interactions: Lithium NSAIDs Hypoglycemic agents Corticosteroids Precautions: Electrolyte abnormalities Dehydration DM/SLE Elderly patients Pregnancy / Lactation Contraindications: Hypersensitivity Anuria 8
Calcium Channel Blockers (CCB) Non-dihydropyridines: Diltiazem Verapamil Non-DHPs + BB = slow HR Adverse Effects: AV heart block Peripheral edema Headache Dizziness Gingival hyperplasia Constipation Dihydropyridines: Amlodipine Nefidipine Felodipine Contraindications: Hypersensitivity 2 nd or 3 rd degree heart block Wolfe-Parkinson-White Sick sinus syndrome Heart failure 9
ACE-Inhibitors (ACEI) Adverse Effects / Contraindications: Cough Angioedema / Agranulocytosis Potassium excess Taste change Orthostatic hypotension Pregnancy (contraindication) Renal artery stenosis (contraindication) Increases vascular permeability Leukopenia / Liver toxicity 10
Angiotensin Receptor Blockers (ARBs) Adverse effects: Orthostatic hypertension, angioedema HA, dizziness, fatigue Dyspepsia, diarrhea Muscle cramping Rash Decreased renal function 11
Hypertension Update Sarah J. Payne, MS, PharmD, BCPS Assistant Professor, Department of Pharmacotherapy UNT System College of Pharmacy