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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
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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
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Table 3-2 Hypertension Treatment Approach
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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
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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
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