Hypertension

Hypertension (HTN) – Jonathan Davis

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

 

ACA-AHA guidelines (2017) (based on SPRINT trial)

Normal

<120/80 mmHg

Elevated BP

systolic 120-129 mmHg AND diastolic <80 mmHg

Stage 1

systolic 130-139 mmHg OR diastolic 80-89 mmHg

Stage 2

systolic ≥140 mmHg OR diastolic ≥90 mmHg

 

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

 

Common 2o Causes

Suggestive Feature

Diagnostic Testing

Primary Kidney Disease

Hypervolemia, ↑ Cr, abnormal UA, fhx of PKD

UA, Urine Alb:Cr ratio, Renal US

Renovascular disease (RAS or FMD)

Renal bruit, ↑ Cr after ACE-I or ARB, young age

Doppler renal US

OSA

Apneic events, somnolence, obesity

Polysomnography

Primary Hyperaldosteronism

Hypokalemia, metabolic alkalosis, resistant HTN, etc.

Start with plasma aldosterone/renin levels

Drug or Alcohol Induced

Hx of substance use (cocaine, caffeine, nicotine, medications)

UDS, BP improvement after withdrawal of suspected agent

 

 

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)

 

 

Drug Class

Common Drugs

Side effects/ comments

Thiazide diuretics

HCTZ 12.5-50 mg
Chlorthalidone 12.5-25 mg (Preferred agent based on RCT evidence)

- HypoNa, HypoMg, HypoK, increased uric acid, hypovolemia,

orthostatic hypotension

Ok to use in pregnancy per ACOG (2019), but considered 2nd or 3rd line

ACE-I

Lisinopril, benazepril, fosinopril, quinapril (all 5-40 mg daily) Ramipril, 2.5-20 mg in 1-2 doses

-Angioedema (more common in AA) AKI, hyperkalemia, cough
-Don’t use with ARB
-Contraindicated in pregnancy

ARBs

Losartan 25-100 mg in 1-2 doses

Candesartan 8-32 mg in 1-2 doses

Irbesartan 150-300 mg
Valsartan 80-320 mg

-AKI, hyperkalemia
-Angioedema

(less frequent than ACE-I)
-Don’t combine with ACE-I
-Contraindicated in pregnancy

CCB

Dihydropyridine:
Amlodipine 2.5-10 mg 1-2 doses Nifedipine 30-120 mg in 1-2 doses

 

Nondihydropyridine:

Diltiazem ER 120-480 mg Verapamil ER 100-480 mg

Dihydropyridine:
-Peripheral edema
-Worsening proteinuria

 

Nondihydropyridine:
-Constipation
-Heart block if used with BB
-Contraindicated in HFrEF

Aldosterone receptor antagonists

Spironolactone 12.5-50 mg
Eplerenone 25-50 mg

-Good choice for resistant HTN

-AKI, hyperkalemia
-Spironolactone—gynecomastia

& sexual side effects
-Contraindicated in pregnancy

BB

Carvedilol 6.25-25 mg bid
Metoprolol succinate 25-200 mg qd
Nebivolol 5-10 mg
Labetalol 100-300 bid

Reserve for CHF/CAD
-Hyperglycemia, fatigue, HR
β 1-selective may be safer in pts with COPD, asthma, diabetes

Vasodilators

Hydralazine 25-100 mg bid or tid Minoxidil 5-10 mg

Reflex tachycardia, fluid retention

Centrally- acting agents (alpha 2 agonists)

Clonidine 0.1-0.2 qd,

(Weekly transdermal patch is preferred to avoid non- compliance and subsequent reflex HTN)

Methyldopa 250-500 mg qd

Rebound hypertension, withdrawal Reserved for resistant hypertension due to unfavorable side effect profile

Conditions

Drug Class

Heart failure

ACE-I/ARB or ARNI + BB + spironolactone + diuretics

CAD

ACE-I or BB

Diabetes

All first line agents, ACE-I/ARB if presence of albuminuria

CKD

ACE-I/ARB

Recurrent stroke prevention

ACE-I, thiazide diuretic

Pregnancy

Labetalol (first-line), nifedipine, methyldopa, hydralazine