HypertensionTreatment Guidelines Michaelene Urban APRN, MSN, ACNS-BC, ANP-BC
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.
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
Comparison JNC 6 to 7 stages of Hypertension JNC 6 SBP/DBP JNC 7 Optimal <120/80 Normal Normal Borderline 120-129/80-84 130-139-85-98 PreHypertension Hypertension >140/90 Hypertension Stage 1 Stage 2 Stage 3 140-159/90-99 160-179/100-109 >180/110 Stage 1 Stage 2 Stage 2
JNC 8 Age Goal BP Of note 60 150/90 If achieved SBP <140 and tolerate w/o adverse effects then continue 30-59 DBP < 90 < 60 target SBP <140 18-29 DBP < 90 18 w/ CKD 140/90
So What Next
So here are the latest Guidelines
ACC/ AHA Guidelines
Stages of Hypertension BP Category SBP And /Or DBP Normal <120 mm Hg And <80 mm Hg Elevated 120-129 mm Hg And <80 Mm Hg Hypertension Stage 1 130-139 mm Hg Or 80-89 mm HG Stage 2 >140 mm Hg Or > 90 mm HG
Guidelines of Hypertension JNC 7 SBP/DBP 2017 ACC/AHA Normal <120/80 Normal PreHypertension Hypertension 120-129/80-84 130-139-85-98 Elevated 120-129/80 Hypertension Stage 1 140-159/90-99 130-139/80-89 Stage 2 160-179/100-109 >180/110 >140 or >90
Management of Hypertension
Causes of Hypertension Genetic predisposition Environmental Factors Overweight & Obesity Sodium intake Potassium intake Physical Fitness Alcohol
Life style modification
Non Pharmacological
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 3500 5000 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 90-150min/week with HR 65-755 Heart are reserve 90-150 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
Primary vs Secondary Hypertension
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
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
Secondary Hypertension
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
ASCVD Risk Estimator Plus
Treatment of Blood Pressure
Treatment Recommendations
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
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.
Primary Agents in the treatment of Hypertension Thiazide diuretics ACE inhibitors ARB Calcium channel blockers
Primary Agents Thiazide or thiazide type diuretics Chlorathalidone 12.5-25 mg/d HCTZ 25-50 mg/d Indapamide 1.25-2.5 mg/d Metolazone 2.5-10 mg/d
Primary Agents ACE inhibitors Benazepril 10-40 mg/d -Daily/ BID Captopril 12.5-150 -BID/ TID Enalapril 5-40 mg/d- Daily/ BID Fosinopril 10-40 mg/d -Daily/ BID Lisinopril 10-40 mg/d Daily/ BID Ramipril 2.5-10 mg/d Daily/ BID
Primary Agents ARBs Losartan 50-100 mg.d -Daily/BID Valsartan 80-320 mg/d- Daily Irbesartan 150-300 mg/d -Daily
Primary Agents CCB - dihydropyridines Amlodipine 2.5-10 mg/d -Daily Nicardipine SR 5-20 mg/d- Daily Nifedipine LA 60-120mg/d- Daily CCB- non dihyropyridines Diltiazem SR 180-360 mg/d - BID Diltiazem ER 120-480 mg/d - Daily Verapamil Ir 40-80 mg/d - TID Verapamil SR 120-480 mg/d- Daily / BID Verapamil ER 100-480 md/d - Daily evening
Primary Agents Thiazide or thiazide type diuretics Chlorathalidone 12.5-25 mg/d HCTZ 25-50 mg/d Indapamide 1.25-2.5 mg/d Metolazone 2.5-10 mg/d
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
Secondary Agents Diuretics- loop Bumetanide 0.5-4mg/d -BID Furosemide 20-80 mg/d - BID Torsemmide 5-10 mg/d - Daily Diuretics - potassium sparing Amiloride 5-10 mg/d - Daily /BID Triamterene 50-100 mg/d - Daily /BID Diuretics- aldosterone antagonist Spironolactone 25-100 - Daily
Secondary Agents Beta Blockers cardioselective Atenolol 25-100 mg/d- Daily/ BID Bisoprolol 2.5-10 mg/d Daily Metoprolol tratrate 100-400 mg/d BID Metoprolol succinate 50-200 mg/d - Daily Beta Blockers cardioselective and vasodilatory Nebivolol 5-40 mg/d - Daily
Secondary Agents Beta Blockers noncardioselective Nadolol 40-120 mg/d Daily Propranolol IR 160-480 - BID Propranolol LA 80-320 mg/d - Daily Beta Blockers intrinsic sympathominatic activity ( rarely used) Beta Blockers combined alpha and beta receptors Carvedilol 12.5-50 mg/d BID Cardvedilol phosphate 20-80 mg.d - Daily Labetalol 200-800 mg/d BID
Secondary Agents Diret renin inhibitors Aliskiren 150-300 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 0.1-0.8 mg/d -BID Clonidine patch 0.1-0.3 mg/d weekly Methyldopa 250-1000 mg/d BID
Secondary Agents Central alpha agonist and other centrally acting drugs Clonidine oral 0.1-0.8 mg/d -BID Clonidine patch 0.1-0.3 mg/d weekly Methyldopa 250-1000 mg/d BID Vasodilators Hydralazine 250-200 mg/d BID- TID Minoxidil 5-100 mg/d daily- TID
Pharmacological approach based on Diagnosis Stable Ischemic Heart disease (SIHD) Heart Failure CKD Ischemic Stroke / secondary prevention Afib
Treatment Based on Medical Conditions
Treatment for SIHD
Hypertension with SIHD
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
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.
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
Acute Ischemic Stroke
Ischemic Stroke
Secondary Stroke Prevention
Hypertension with Previous Stroke
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
What are the next steps
Have the Conversation about Hypertension
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
Proper BP Measurements
Follow Up
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
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