Hypertension

Background

• #SBP >20 or #DBP >10 doubles risk of stroke and CVD
• Prevalence ~45% with new cutoff (≥130/80); control achieved in ~50%
• Definitions
  • Resistant HTN: Uncontrolled BP despite taking 3 antihypertensive medications including a diuretic, OR 4 total medications
  • Whitecoat HTN:  Mean BPs lower than threshold of HTN based upon out-of-office measurements (falsely elevated measurements during visits). If SBP > 130 but < 160, consider screening for white coat HTN with home monitoring
  • Masked HTN: Mean BP at/above threshold for hypertension based upon out-of-office measurements (falsely decreased measurements during visits). If office SBPs consistently 120-129 consider screening for masked HTN with home monitoring
• Diagnosis
  • Requires ≥2 elevated pressures on ≥2 occasions
    • Home and ambulatory BP monitoring recommended to confirm diagnosis
    • Ideally, measurements with legs uncrossed, arm at level of heart, after 5 minutes of rest and with empty bladder; avoid caffeine or tobacco 30 minutes prior
    • Screening
  • Grade A USPTF rec: Screen all adults >18. Screen adults at least semiannually if have risk factors for HTN (obesity, AA), or if previously measured SBP 120-129

Evaluation

• BMP, CBC, lipid panel, UA, TSH, EKG. Consider additional testing including TTE, urine Alb:Cr ratio, or uric acid.
• Distinguish between primary (90% incidence) and secondary HTN (10%):
  • Suspect 1º if gradual onset, family hx, associated with weight gain & lifestyle factors
  • Suspect 2º if early onset (< 30yo), late onset (> 65 y/o), abrupt onset, disproportionate end-organ damage, resistant HTN
• Uncommon causes: Pheochromocytoma, Cushing’s syndrome, thyroid dysfunction, aortic coarctation, primary hyperparathyroidism, acromegaly, congenital adrenal hyperplasia

Management

• JNC 8 recommends treating to a goal BP <140/90 in all pts < 60
• Consider intervenable contributing factors:
  • Obesity, High Na diet (canned foods, fast foods, processed meats)
  • Excess alcohol intake
  • Medications (e.g., NSAIDs, decongestants, MAOs, clonidine withdrawal, cyclosporine, steroids)
  • Substance use (e.g., caffeine, cocaine, amphetamines)
     
• Lifestyle interventions (first line for any stage of elevated BP):
  • 8-14 mmHg ↓: DASH diet (fresh produce, whole grains, low-fat dairy)
  • 5-10 mmHg ↓: Weight loss (10 kg or 22 lbs), expect 1mm Hg for every 1kg reduction in body weight
  • 3-9 mmHg ↓: Na+ restriction (1.5 g / day), aerobic exercise for 90-150 min/week, increased intake of K+ rich foods
  • 2-4 mmHg ↓:Moderate EtOH (2 drinks/day for men; 1 drink/day for women)
     
• Medications (See table below):
  • Initiate pharmacological therapy with Hypertension Stage I (ACC/AHA guideline) and ASCVD score > 10% or Stage II pts (regardless of ASCVD score)
  • Use first line agents from the following classes
    • ACE-I or ARB
    • Thiazide Diuretics (preferred in AAs)
    • Dihydropyridines CCB (preferred in AAs)

Additional Information

VA Specific Guidance: https://www.healthquality.va.gov/guidelines/CD/htn/

• Preferred Agents/Agents that don’t require PADR:
  • Diuretics – Any
  • ACEIs – Lisinopril, Benazepril, Enalapril, Ramipril, Captopril
  • ARBs – Losartan, Valsartan
  • Beta Blockers – Carvedilol, Metoprolol tartrate/succinate, atenolol, propranolol
  • DHP – Amlodipine
  • Non-DHTs – Verapamil, Diltiazem
  • Aldosterone Receptor Antagonist – Spironolactone
  • Alpha1 Antagonist – Doxazosin, Prazosin, Terazosin
  • Direct Acting Vasodilators – Minoxidil, Hydralazine
  • Alpha2 Agonist – Clonidine tablet, methyldopa
• Agents that require PADR:
  • ACEIs - Quinapril
  • ARBs – Candesartan, Irbesartan, Olmesartan, Telmisartan
  • Beta blockers – Labetalol, Nebivolol
  • DHP – Nifedipine SA
  • Aldosterone Receptor Antagonist – Eplerenone
  • Alpha2 Agonist – Clonidine patch
• How to get BP cuff at the VA
  • Consult tab: New Consult → Select Campus → Select Inpatient or Outpatient → Prosthetics Main
  • Consult Menu → Select Y/N for requirement of discharge → BP Cuff TVH
  • *Must answer all questions in the consult, including blood pressure cuff size.

Cost:

• Publix: Free (amlodipine, lisinopril), $7.50 x 90 days (losartan, metoprolol tartrate, HCTZ)
• Walmart: $4/month (amlodipine, carvedilol, enalapril, hydralazine, HCTZ, irbesartan, lisinopril, losartan, ramipril)