Hypertension (HTN)
Audrey White
Background
- 47% of adults in the US have HTN, yet only 24% of adults with HTN have adequate BP control (2021)
- HTN is associated with ↑CVD risk and is the most prevalent modifiable risk factor for CVD
Definitions
- ACC/AHA 2017: BP ≥ 130/80 or taking antihypertensive mediation
- Resistant HTN: uncontrolled BP despite taking 3 antihypertensive medications (including a diuretic) OR ≥ 4 total medications
- Whitecoat HTN: elevated office BP but normal readings when measured with ambulatory or home blood pressure monitoring (ABPM/HBPM)
Drug |
Dosing |
Benefits |
Side Effects |
|---|---|---|---|
| Metoprolol | 5mg IV q5m x3 PO metoprolol tartrate 12.5mg q6 hours ↑ every 6 hr to target |
Good 1st line agent Less BP effect than dilt |
Hypotension, Negative inotropy |
| Diltiazem | 10-20 mg IV over 2m q15m x2 drip = 5-15 mg/hr |
Good 1st line w/ normal EF with drip needed | Hypotension Avoid in HFrEF |
| Esmolol | 500 mcg/kg bolus drip = 50-200 mcg/kg/min |
Rapid onset/offset RBC metabolism |
Hypotension |
| Amiodarone | 150 IV over 10-30m, then 1 mg/m for 6h, then 0.5mg/m for 18h | Minimal BP effects Long lasting; Relatively fast onset (acute effect is mostly beta blockade) |
Pulmonary and thyroid toxicity Cardioversion |
| Digoxin | 500mcg IV x1, then 250mcg IV q6h x2-3 | Great for reduced EF, positive inotropy | Slow onset Depends on vagal tone – poor in hyper- adrenergic states |
| Procainamide | 20-50 mg/min loading, 1-4 mg/min maintenance | Use in pre-excitation syndromes (i.e. WPW), does not inhibit AV nodal conduction | Lupus-like syndrome Hypotension |
Screening
- Screen all adults >18. Less frequent screening (q3-5 yrs) is appropriate for adults 18-39 without risk factors and previously normal BP. More frequent screening (q6-12mo) for adults ≥40 or with risk factors (USPSTF Grade A)
- Risk factors: older age, black race, family history, excess weight/obesity, lifestyle habits (lack of physical activity, stress, tobacco use, alcohol use), dietary factors (high salt or high fat diet)
- Consider screening for masked HTN with ABPM/HBPM if SBP 120-129 mmHg in office + risk factors (ACC/AHA 2017)
Diagnosis
- Proper measurement: Avoid caffeine/smoking 30 min prior and empty bladder. Have pt sit quietly at rest for 5 min with legs uncrossed. Place proper sized cuff on exposed arm, supported at heart level.
- Hypertension by office BP (≥130/80) and hypertension out of officeconfirmed by ABPM or HBPM, as follows:
- Daytime mean: SBP ≥ 130 or DBP ≥ 80
- Nighttime mean: SBP ≥ 110 or DBP ≥ 65
- 24 hr mean: SBP ≥ 125 or DBP ≥ 75
- If ABPM not possible, 2-3 outpt measurements at 1-4 week intervals are required to confirm diagnosis
- A diagnosis can be made without confirmatory readings in these circumstances
- HTN urgency or emergency: SBP ≥ 180 or DBP ≥ 120
- Initial SBP ≥ 160 or DBP ≥ 100 and evidence of end-organ damage (LV hypertrophy, HTN retinopathy, ischemic CVD, CKD)
Evaluation
- Perform in all pts with newly diagnosed HTN o BMP, fasting glucose, CBC, lipid profile, UA, TSH, EKG
- Calculate 10 yr ASCVD risk
- Distinguish between primary (90% incidence) vs. secondary HTN (10%)
- Suspect 1º (essential) HTN: gradual onset, family hx, associated risk factors
- Suspect 2º: unusual presentation (new diagnosis in young/elderly, abrupt, exacerbation in previously controlled HTN), drug-resistant, or the presence of clinical clue (abdominal bruit in renovascular HTN, hypokalemia in hyperaldosteronism)
- Assess for end organ damage: retinopathy (eye exam), CVD/LV hypertrophy, HF (TTE), CKD (urine Alb:Cr), PAD (ABI)
Common 2o Causes |
Suggestive Features |
Diagnostic Testing |
|---|---|---|
| Drug or alcohol induced | History of substance use (cocaine, caffeine, nicotine, medications) | UDS, BP improvement after withdrawal of suspected agent |
| Medication induced | Steroids, OCP, sympathomimetic, SNRI/TCA, atypical antipsychotics | BP improvement after withdrawal of suspected substance |
| OSA | Apneic events, somnolence, obesity, ↑ neck circumference | Polysomnography |
| Primary hyperaldosteronism | Hypokalemia, metabolic alkalosis, | Plasma aldosterone/renin levels* |
| Primary kidney disease | Hypervolemia, ↑ Cr, abnormal UA, family history of kidney disease | UA, urine Alb:Cr ratio, renal US |
| Renovascular disease (RAS or FMD) | Abdominal bruit, ↑ Cr after ACE-I or ARB, young age, severe HTN with onset >55, flash pulmonary edema | Doppler renal US |
| Uncommon 2o causes: Pheochromocytoma, Cushing’s syndrome, thyroid dysfunction, aortic coarctation, primary hyperparathyroidism, acromegaly, congenital adrenal hyperplasia *Not reliable if taking MRA. Adjust diagnostic threshold level if taking ACEi/ARB. |
||
Management
ACA-AHA guidelines (2017) (based on SPRINT trial) | ||
|---|---|---|
| Elevated BP | SBP 120-129 mmHg AND DBP <80 mmHg | Lifestyle modifications. Reassess in 3-6 months |
| Stage 1 | SBP 130-139 mmHg OR DBP 80-89 mmHg | Lifestyle modification. If CVD, T2D, CKD, age ≥ 65 or ASCVD risk ≥ 10%, add anti-HTN medication. Reassess monthly until BP goal is met, then measure q3-6 mo |
| Stage 2 | SBP ≥140 mmHg OR DBP ≥90 mmHg | Lifestyle modification and 1-2 anti-HTN medications. Reassess monthly until BP goal is met, then measure q3-6 mo. |
Therapy goals
- Adults over 60 years: target BP varies by guideline. Consider CVD risk and co-morbidities (e.g., stroke) to decide target BP.
- White coat HTN: lifestyle modification & CVD risk reduction
- Masked HTN: treatment guided by out-of-office BP measurements
- Diastolic HTN: treat to prevent LVH and HFpEF - BP target:
- <130/80 mmHg: general population
- <140/90 (less aggressive goal): frail pts with orthostatic hypotension, limited life expectancy
- If not meeting goals, combination therapy > doubling a single agent. Preferred combinations
- ACEi/ARB + CCB
- ACEi/ARB + CCB + thiazide
- ACEi/ARB + CCB + MRA
- Do NOT combine BB and non-dihydropyridine CCB
Non-pharmacological lifestyle interventions: indicated for all pts regardless of stage
- 8-14 mmHg ↓: DASH diet (fresh produce, whole grains, low-fat dairy)
- 5-10 mmHg ↓: weight loss (10kg or 22lbs), expect 1 mmHg for every 1kg reduction in body weight
- 3-9 mmHg ↓: Na+ restriction (1.5g/d), 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)
- Medication changes: consider transitioning offending medications
- Tobacco cessation: smoking increases risk of masked HTN, renovascular HTN, severe hypertensive retinopathy, and arterial stiffness
Pharmacologic therapy
- Initial monotherapy: ACEi/ARB, dihydropyridine CCB, or thiazides
- Degree of BP reduction (not type of medication) is the major determinant of CVD risk reduction
- There is controversial evidence in using race to determine therapy. Some studies suggest the benefit of CCB or thiazides in black pts
Drug Class |
Common Drugs |
Side effects/ comments |
|---|---|---|
| Thiazide diuretics |
HCTZ 12.5-50 mg Chlorthalidone 12.5-25 mg (preferred agent based on RCT, but ↑ risk electrolyte abnormalities) |
HypoNa, hypoMg, hypoK, ↑ uric acid, hypovolemia, orthostatic hypotension Contraindicated in pregnancy |
| Angiotensin-converting enzyme inhibitor (ACEi) |
Lisinopril, benazepril, fosinopril, quinapril (all 5-40 mg daily) Ramipril, 2.5-20 mg in 1-2 doses |
Angioedema (more common in AA), AKI, hyperK, cough Contraindicated in pregnancy |
| Angiotensin receptor blocker (ARB) |
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). Less side effects than ACEi Contraindicated in pregnancy |
| Calcium channel blocker (CCB) |
Dihydropyridine: Nondihydropyridine: |
Dihydropyridine: peripheral edema, worsening proteinuria Nondihydropyridine: constipation, heart block if used with BB Amlodipine is safe but not first line for HFrEF. Other CCBs may worsen outcomes in HFrEF. |
| Mineralocorticoid receptor antagonist (MRA) |
Spironolactone 12.5 - 50 mg Eplerenone 25 - 50 mg |
Good choice for resistant HTN AKI, hyperkalemia Spironolactone—gynecomastia and secondary sexual side effects |
| Beta blocker (BB) |
Atenolol 25- 100mg in 1-2 doses Carvedilol 6.25-25 mg BID Metoprolol succinate 25 - 200 mg QD Nebivolol 5 - 10 mg Labetalol 100 - 300 bid |
Reserve for CHF/CAD/arrhythmia Hyperglycemia, fatigue, ↓ HR β 1-selective (atenolol, bisoprolol, metoprolol) may be safer in pts with COPD, asthma, diabetes |
| Vasodilators |
Hydralazine 25-100mg in 2–4 doses Minoxidil 5-10mg in 3-4 doses |
Reserve for HTN resistant to optimized 4 drug regimen Reflex tachycardia, fluid retention, SLE-like reaction |
| Centrally- acting agents (alpha 2 agonists) |
Clonidine 0.1-0.6 mg QD, (Weekly transdermal patch 0.1- 0.3mg is preferred to avoid nonadherence and subsequent reflex HTN) Methyldopa 250-500 mg QD |
Reserve for resistant HTN Rebound HTN and withdrawal |
| Loop diuretics |
Furosemide 20-160 mg QD Torsemide 10 – 100 mg QD Bumetanide 0.5 – 3.0 mg QD |
Reserve for HTN and volume overload states AKI, hypovolemia, hypoK, hypoMg |
Conditions | Drug Class |
|---|---|
| Heart failure | ACE-I/ARB or ARNI + BB + MRA + diuretics |
| CAD | ACEi/ARB or BB |
| Diabetes | All first line agents, ACEi/ARB if presence of albuminuria |
| CKD | ACEi/ARB |
| Recurrent stroke prevention | ACEi/ARB, thiazide |
| Pregnancy | nifedipine, labetalol, methyldopa |
Additional information
- Refer to Nephrology or HTN specialist when HTN resistant to >3 meds and negative secondary work-up
- VA Specific Guidance: https://www.healthquality.va.gov/guidelines/CD/htn/
- Agents that require PADR: quinapril, candesartan, irbesartan, olmesartan, telmisartan, labetalol, nebivolol, nifedipine SA, eplerenone, clonidine patch
- Walmart: $4/mo for amlodipine, atenolol, benazepril, clonidine, carvedilol, enalapril, furosemide, hydralazine, HCTZ, Irbesartan, isosorbide mononitrate, lisinopril, lisinopril/HCTZ, losartan, losartan/HCTZ, metoprolol, ramipril
- Validated BP cuffs: validatebp.org
- How to get BP cuff at the VA: Prosthetics consult BP Cuff TVHS. *Must answer all questions in the consult, including blood pressure cuff size