HYPERTENSION OVERVIEW

Why should a hypertension diagnosis be based on multiple readings obtained on separate occasions?

A hypertension diagnosis should be based on an average of at least two readings obtained on at least two separate occasions to avoid inaccuracies.

What drugs can increase blood pressure by increased sympathomimetic activity?

ADHD drugs (e.g., amphetamine), Decongestants (e.g., pseudoephedrine, phenylephrine), Recreational substances (e.g., cocaine, caffeine), Antidepressants (e.g., TCAs, SNRIs, MAO inhibitors)

How should patients with hypertension and specific comorbid conditions be treated?

According to specific disease-state guideline recommendations

Why is accurate measurement of blood pressure essential for diagnosing hypertension?

Accurate measurement of BP is essential for diagnosing hypertension and assessing if medication titration is needed.

What is recommended when titrating medications to treat hypertension effectively with fewer side effects?

Adding a second drug before reaching the maximum dose of the first medication

What should be selected first before considering alternative drug classes?

Agents from the four preferred drug classes

How is drug treatment initiation determined based on hypertension stage?

Based on hypertension stage

Why should ACE inhibitors and ARBs not be used in combination?

Do not use in combination

What drugs can increase blood pressure by increasing blood viscosity?

Erythropoiesis-stimulating agents (e.g., epoetin alfa)

What natural medicines might some patients use to supplement drug treatment for blood pressure?

Garlic and fish oil

How should you prepare for blood pressure monitoring at home?

Go to the restroom, sit with back supported, relax for 5 minutes, use correct cuff size, support arm at heart level, wait between measurements

What are the key pathophysiological mechanisms of hypertension?

Hypertension involves activation of the sympathetic nervous system (SNS) and the renin-angiotensin-aldosterone system (RAAS), leading to increased levels of neurohormones like norepinephrine, angiotensin II, and aldosterone that contribute to elevated blood pressure.

Which drugs can increase blood pressure by increasing sodium and water retention?

Immunosuppressants (e.g., cyclosporine), Systemic steroids

What risk should patients be aware of when using garlic and fish oil for blood pressure management?

Increased bleeding risk

What is emphasized throughout the treatment according to ACC/AHA guidelines?

Lifestyle modifications

What are the four categories of blood pressure defined by the ACC/AHA for adults?

The four categories are Normal, Elevated, Hypertension Stage 1, and Hypertension Stage 2, based on systolic and diastolic BP readings.

What additional modifications are recommended for overall cardiovascular health?

Tobacco cessation, adequate control of blood glucose and cholesterol

How many drugs do most patients with hypertension require?

Two or more drugs

HYPERTENSION GUIDELINE RECOMMENDATIONS

WHEN TO START TREATMENT • Stage 1 HTN (SBP 130-139 mmg or DBP 80-89 mmHg) and any of the following: • Clinical CVD (stroke, heart failure, or coronary heart disease) • 10-year ASCVD risk ≥ 10% • Does not meet BP goal after 6 months of lifestyle modifications • Stage 2 HTN (SBP ≥ 140 mmHg or DBP ≥ 90 mmHg) BP GOAL • < 130/80 mmHg INITIAL DRUG SELECTION • Use an agent from one of the preferred classes: • Thiazide diuretic • Dihydropyridine calcium channel blocker (DHP CCB) • Angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) • CKD***: ACE inhibitor or ARB • Start 2 drugs from the preferred classes when baseline average BP is > 20/10 mmHg above goal (e.g., > 150/90 mmHg) MONITORING • Check BP every month and titrate medication if not at goal *The KDIGO 2021 Blood Pressure in CKD Guideline recommends a goal SBP ‹ 120 mmg (if tolerated) for patients with hypertension and CKD (see Renal Disease chapter). *May be preferred in self-identified black patients without CKD. Stage 3 CKD (eGFR < 60 mL/min/1.73 m2) or albuminuria (for exam purposes, defined as urine albumin ≥ 30 mg/day or albumin: creatinine ratio ≥ 30 mg/g)

What lifestyle interventions are effective in lowering blood pressure?

Weight loss, heart-healthy diet, adequate potassium intake, reduced sodium intake, routine physical activity, limited alcohol consumption

What is white coat hypertension and how can it affect clinical decisions?

White coat hypertension refers to falsely elevated BP readings in a clinical office setting, which can lead to inaccurate clinical decisions related to patient risk and treatment.

What is ambulatory blood pressure monitoring?

A device worn continuously for 24 hours during daily activities and sleep, obtaining readings every 15-60 minutes

What is the DASH diet?

A heart-healthy diet high in fruits, vegetables, fiber, and low-fat dairy products, and low in saturated fats and sugar

What are the recommended alcohol consumption limits for managing hypertension?

≤ 1 drink daily for women and ≤ 2 drinks daily for men

How does weight loss affect blood pressure?

1 kg of weight loss decreases BP by ~1 mmHg

What are the key steps to follow during blood pressure monitoring at home?

Measure and record the average of at least 2 readings in the morning and evening before eating or taking any medications

How do most hypertension medications work?

Most medications used to treat hypertension target the neurohormonal pathways involving the sympathetic nervous system (SNS) and the renin-angiotensin-aldosterone system (RAAS) to lower blood pressure.

What is primary (essential) hypertension?

Most patients (~90%) have primary hypertension, which has an unknown cause but is associated with risk factors like obesity, sedentary lifestyle, excessive salt intake, smoking, family history, diabetes, and dyslipidemia.

What is preferred for medication adherence in terms of drug regimens?

Once-daily regimens and/or combination products

Name some other drugs that can increase blood pressure.

Oral contraceptives (with higher estrogen content), VEGF inhibitors (e.g., bevacizumab, sunitinib)

Why is reduced sodium intake important for managing hypertension?

Reduced sodium intake (< 1,500 mg daily) helps lower blood pressure

What is secondary hypertension?

Secondary hypertension has an identifiable underlying cause, such as renal disease, adrenal disease (e.g., excess aldosterone secretion), obstructive sleep apnea, or certain drugs.

What should you avoid doing during blood pressure monitoring?

Talking, lying down or sitting without back support, drinking caffeine, exercising, smoking 30 minutes prior, using a finger monitor or wrist monitor

PREGNANCY AND HYPERTENSION

Teratogenic drugs can cause fetal harm and should be discontinued if planning a pregnancy. ACE inhibitors, ARBs, and the direct renin inhibitor (aliskiren have a boxed ) warning for fetal toxicity in pregnancy and should be stopped immediately. proteinuria oOther oral hypertensive disorders of pregnancy include gestational hypertension and preeclampsia, which are both defined as new-onset hypertension after 20 weeks gestation. Preeclampsia is further characterized by the presence of r significant end-organ dysfunction. Other oral antihypertensive drugs can be used to treat non- These conditions can be treated with the aforementioned oral severe chronic hypertension (hypertension occurring before agents, however the use of intravenous antihypertensives pregnancy or 20 weeks gestation); drug treatment should be (e.g., labetalol, hydralazine) may be required for severe initiated if SBP ≥ 140 mmHg or DBP ≥ 90 mmHg. presentations. Additionally, in patients at high risk for preeclampsia (e.g., pre-existing hypertension, renal disease, Labetalol, nifedipine extended-release and methyldopa are diabetes, previous preeclampsia), daily low-dose aspirin is recommended first-line treatments, although methyldopa recommended after the first trimester. may be less effective at lowering BP. The SBP should be maintained between 120 - 139 mmHg and the DBP between 80 - 89 mmHg.