Skip to Main Content
Home Books Internal Medicine: A Guide to Clinical Therapeutics

Chapter 3. Hypertension

Allison M. Bell; William Linn

(Hypertension 2003;42:1206)

  • Hypertension (HTN) staged by systolic & diastolic BP (Stages 1 & 2 HTN necessitate drug therapy)
  • Baseline evaluation: detailed medication history (including side effects & compliance) with current & previous regimens; identify coronary heart disease (CHD), risk factors & comorbidities with compelling indications
  • Identify ECG conduction abnormalities, left ventricular hypertrophy (LVH), ischemia, infarction
  • Pertinent labs: BUN, SCr, K, glucose, urinary albumin/creatinine ratio

Table 3-1 Secondary Causes of Hypertension
View Table|Favorite Table|Download (.pdf)
Table 3-1 Secondary Causes of Hypertension

Idiopathic

Medications or illicit drugs:

Obstructive sleep apnea

NSAIDS & COX-2 inhibitors

Chronic kidney disease

Stimulants

Primary aldosteronism

Sympathomimetics

Cushing's syndrome

Steriods

Thyroid/parathyroid disease

Contraceptives

Pheochromocytoma

Cyclosporine & tacrolimus

Aortic coarctation

Erythropoetin-stimulating agents

  • Initiate therapy based on CV risk
  • Chlorthalidone: preferred thiazide-type diuretic (J Am Coll Cardiol 2011;57:590)
  • β-Blockers: monotherapy not indicated for HTN (Cochrane Reviews 2007;1:CD002003)
  • Target BP for most patients is <140/90mmHg (Cochrane Reviews 2009;3:CD004349)
    • Aggressive BP ↓ (<130/80mmHg) associated with ↑ rate of cardiac events, especially in patients with DM (N Engl J Med 2010;362:1575)

Table 3-2 Hypertension Treatment Approach
View Table|Favorite Table|Download (.pdf)
Table 3-2 Hypertension Treatment Approach
image

Reproduced with permission from Mancia G, DeBacker G, Dominiczak A, et al. 2007 Guidelines for the management of arterial hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of hypertension (ESH) and of the European Society of Cardiology (ESC), Eur Heart J 2007;Jun;28(12):1462.

Table 3-3 Compelling Indications & Recommended Therapy
View Table|Favorite Table|Download (.pdf)
Table 3-3 Compelling Indications & Recommended Therapy

Compelling Indication

Recommendation

Comments

Heart failure with ↓ EF (Hypertension 2003;42:1206)

Diuretic, BB, ACEI, or ARB, aldosterone antagonist

Use furosemide in patients with volume overload

Aldosterone antagonists have proven mortality benefit in NYHA classes III, IV (recommended in class II but no demonstrated mortality benefit)

Post-MI

(Circulation 2007;115:2761)

BB, ACEI, or ARB

Multiple large RCTs showing morbidity & mortality reduction with each class of drugs

CHD risk reduction

(N Engl J Med 2003;349:1893; J Am Coll Cardiol 2001;38:2101)

Diuretic, ACEI, or ARB, dihydropyridine CCB

Aggressive ↓ systolic BP (<130mmHg) shown to ↑ cardiac events

Diabetes

(Diabetes Care 2003;26[Suppl 1]:S80)

Diuretic, ACEI, or ARB, dihydropyridine CCB

Target systolic BP 130–135mmHg

Chronic kidney disease

(Am J Kidney Dis 2002;39 [Suppl 2]:S1)

ACEI or ARB; thiazide-type diuretics should not be used if CrCl <30mL/min

Dual RAS blockade or more aggressive BP reduction not been shown to offer any benefit in ↓ progression to ESRD

Recurrent stroke prevention (Lancet 2001;358:1033)

Diuretic plus ACEI or ARB

Consider combination ACEI & indapamide refenerence? From lancet article?

Target SBP 130–140mmHg had lowest risk of recurrent stroke

Combination Therapy

  • Certain combination therapies have synergistic effects &/or are proven regimens

Table 3-4 Recommended Combination Therapy
View Table|Favorite ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.

This site uses cookies to provide, maintain and improve your experience. MHE Privacy Center Close