Outpatient / Cardiology

Hypertension

Last Updated: 3/4/2023

# Hypertension - ***

-- BP: ***

-- Stage: *** Elevated (SBP >120), Stage 1 (>130/80), Stage 2 (>140/90)

-- At goal? *** (generally <130/80)

Intake:

-- Co-Morbidities: *** CHF, CAD, DM, obesity, OSA, gout

-- Symptoms: *** headache, dizziness, tinnitus

-- Lifestyle: *** diet, salt, caffeine, alcohol, exercise, smoking

-- Medications: *** NSAIDs, steroids, OCPs, stimulants

-- Anti-HTN Adherence: ***

Secondary HTN DDx: 

Consider if BP controlled with 4 agents, uncontrolled on 3+ agents (including diuretic), if an acute rise in previously well controlled BP, age <30 without known risk factors, elevated disatolic BP, labile BP, serious electrolyte derangements

-- Medications: NSAIDs, steroids, OCPs, stimulants, d/c HTN meds

-- OSA: sleep study

-- Renal Artery Stenosis: rise in creatinine after starting ACE, duplex doppler US

-- Primary Aldosteronism: hypokalemia, aldo:renin ratio >30

-- Pheochromocytoma: 24-hour urine metanephrines, plasma metanephrines

-- Rare: Cushing Disease, Hyperthyroidism, coarctation of the aorta

Plan:

-- Lifestyle: *** exercise (5-8 mmHg), weight loss (1mmHg per kg lost), DASH diet (8-14 mmHg), salt<2g/day (2-8 mmHg), caffeine <2 cups/day (2-5mmHg), alcohol <2-3 drinks/day (2-4 mmHg), smoking cessation (3-5 mmgHg 1 year, 6-7mmHg 3 years)

-- Medical: *** if BP >140/90 or >130/80 with other risk factors (ASCVD >10%); start 1 drug if <150/90, 2 if >150/90

First Line: CCB (amlodipine 2.5-10mg daily), ACE/ARB (valsartan 80-320mg daily, losartan 50-100 daily, lisinopril 10-40mg daily), thiazide (chlorthalidone 12.5-25mg daily, HCTZ 25-50mg daily)

Second Line: BB, hydralazine (50-100mg in 2-3 doses), isosorbide dinitrate, clonidine, alpha blockers (prazosin, doxazosin)

-- Initial Workup: *** BMP, UA, Protein/Creatinine Ratio, CBC, glucose, TSH, lipids, EKG

-- Monitoring: *** next BP check, next BMP; check BP and BMP/Mg (for ACE/ARB and diuretic) 2-4 weeks after any change, then once yearly

-- Secondary HTN: *** meds, TSH, sleep study, aldo:renin, renal artery dopplers

-- Referral: *** consider referral to HTN expert if resistant or secondary HTN suspected

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Pharmacology of Hypertension

Table of the Pharmacology of Hypertension

Patient Guidance and Information

General Info

High blood pressure affects almost half the population in the United States. Unless severely high, elevated blood pressure does not usually cause any symptoms, but over time can lead to damage in the blood vessels. This is why high blood pressure is the most common cause of cardiovascular disease including heart disease, stroke, and kidney failure.

Treatment is based around loweing blood pressure to reduce the long-term risk of developing the above diseases. All patients with high blood pressure should consider lifestyle changes including diet (lower salt, alcohol, caffiene intake), exercise/weight loss, and quitting smoking. However, despite our best intentions, many patients will need to take medicines that can help lower their blood pressure.

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Lifestyle Changes

Hello ***. You have high blood pressure, also called hypertension. Lifestyle changes that can help lower blood pressure include weight loss, exercise (moderate activity for 40 minutes 3-4 times per week), the DASH diet, reducing salt, caffeine, and alcohol intake, and quitting smoking.

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Taking Blood Pressure at Home

We would like you to monitor your blood pressure at home. Steps to most accurately record your blood pressure:

  1. Take it at the same time each day.
  2. Ideal times are after waking up and urinating, and before bedtime.
  3. Sit in a quiet space without talking for 5 minutes.
  4. Keep your back supported and feet on the floor. Do not cross your legs.
  5. Place your arm on an armrest or side-table at the level of your heart, and keep it loose (don't squeeze your muscles).
  6. Put the cuff over your bare arm, not over clothing.
  7. Ensure you are using an appropriately sized cuff (if too small, it can make your pressure seem higher)
  8. Record your blood pressure twice, and use the lower number.
  9. Write the number down in a journal or on your phone.

Here is a YouTube video that includes some of these tips for your reference.

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Starting Medication

To help control your blood pressure, we'd like to start a new medication called ***.

Please take *** mg, ***.

We will plan to have you back in clinic in *** 2-4 weeks to recheck your blood pressure and check labwork. At that time, we may decide to increase the dosage.

Side effects of this medicine can include ***.  Please let us know if you develop any of these symptoms.

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Amlodipine - pedal edema, nausea, flushing

ACE - dry cough, angioedema, prerenal AKI

ARB - prerenal AKI

Thiazide - urgency, electrolyte derangements

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If You Remember Nothing Else

Hypertension is one of the most common outpatient condiditions you will manage. Unless severely high, elevated blood pressure does not usually cause any symptoms, but over time can lead to damage of the blood vessels. This is why high blood pressure is the most common cause of cardiovascular disease including heart disease, stroke, and kidney failure. Most cases are from essential hypertension, but patients with severely elevated BP or those who are resistant to initial treatments should be worked up for secondary hypertension which can be caused by medications, OSA, renal artery stenosis, primary aldosteronism, and other rare tumors. Proper blood pressure reading includes sitting quietly for 5 minutes, arm supported at heart-level, using a properly sized cuff over the patient's bare arm. Lifestyle modifications include weight loss, exercise (moderate activity for 40 minutes 3-4 times per week), the DASH diet, reducing salt, caffeine, and alcohol intake, and quitting smoking. Medications should be considered if BP >140/90 or >130/80 with other risk factors (ASCVD >10%). Start 1 drug if <150/90, 2 if >150/90. First Line treatments include calcium channel blockers, ACE/ARBs, and thiazides. Second Line treatments include beta blockers, hydralazine, isosorbide dinitrate, clonidine, and alpha blockers.

Clinical Pearls

  • 33-46% of U.S patients have hypertension; 95% have essential HTN (no detectable cause) and 15% will have resistant HTN
  • HTN most common risk factor for cardiovascular disease (hypertrophic cardiomyopathy, CHF, CAD/MI, afib, dissection, stroke, hypertensive nephrosclerosis
  • HTN is often asymptomatic, but leads to damage of the vasculature which in turn leads to the above cardiovascular events which can be life-threatening and debilitating
  • Primary hypertension is caused by any combination of the following: increased HR, increased myocardial contractility, increased blood volume, increased arterial constriction
  • The two major pyshiologic systems that lead to hypertension include RAAS and the sympathetic nervous system - all treatments for HTN will act on one of those systems
  • White Coat HTN is prevalent in 30-40% of people >65 years old; still have increased risks of cardiac events paper; 1-5% convert per year to sustained HTN; paper
  • In otherwise healthy patients, getting BP to the lower range of normal leads to better outcomes - even if not officially HTN, still can have worse outcomes if elevated (meta-analysis)
  • Screening should be done every 3-5 years in those 18-39 years old, and annually in those >40 years old
  • Diagnosing HTN requires 2 separate checks greater than 1 week apart and ideally with ambulatory readings to correlate with those done in the office
  • Correct way to take a BP - after sitting quietly for 5 minutes with arm supported on a desk or armrest at heart level, using a correctly sized cuff over bare skin
  • It’s not unusual to see a 20 mmHg drop once a patient has been seated for 5 minutes after being roomed
  • In patients with Stage I hypertension (>130/80, but less than 140/90) who are young or have low ASCVD risk, lifestyle changes should be trialed for ~6 months - if still hypertensive after that time, medication should be started
  • Resistant hypertension is inadequate control despite 3+ antihypertensives
  • In patients who seem to have resistant hypertension, can trial adding spironolactone (since a lot of the resistance is driven by aldosterone), loop diuretics, or beta blocker
  • Medication selection can be tailored to the patient's comorbidities: Heart failure - BB, ACE/ARB, diuretic, spironolactone; T2DM and CKD - ACE/ARB; CAD - BB; Pregancy - methyldopa, labetalol, hydralazine; BPH - alpha blockers; Osteoporosis - thiazide; Gout - losartan, avoid thiazides (increases uric acid)
  • Historically, age >60 had more lenient BP goal of <150/90 but the 2017 guidelines treat older patients the same with overall goal of <130/80; this should be individualized - patients with severe comorbidities or short expected lifespan can likely have a more liberal BP target
  • Asymptomatic orthostatic hypotension should not be a reason to liberalize the BP goal in older patient - some data suggests better BP control IMPROVES orthostatic hypotension due to improved baroreceptor functioning; this of course should be reconsidered in patients with syncope or pre-syncope and in those who are frail with high risk of fall

Trials and Literature

  • 2017 ACC/AHA Treatment Guidelines
  • JACC 2014 Lifestyle Modification Reccs
  • SPRINT Trial - NEJM 2015; 2 Minute Medicine; targeting an SBP goal <120 vs 135-139 decreased cardiovascular events and all-cause mortality in high-risk patients, but increased hypotension, syncope, lyte abnormalities, AKI
  • STEP Study (NEJM, 2021) - SBP 110-130 vs 130-150 in Chinese patients age 60-80 - showed fewer CVD events in the lower SBP goal‍
  • ACCORD Trial - NEJM 2010 - intensive vs. regular control of BP in T2DM; No benefit for CV mortality for DM patients of SBP goal <120 vs <140‍
  • ALLHAT Trial - JAMA 2002 - Thiazide as first-line; Thiazides are just as good as ACE or CCB and are the cheapest (at the time of the trial); Chlorthalidone vs. amlodipine vs. lisinopril for 4-8 years followup; Outcomes: combined fatal CHD and nonfatal MI. all-cause mortality, stroke; Chlorthalidone favored for heart failure (unsurprisingly)
  • DASH Diet - NEJM 1997 Rationale: can diet lower BP?; 3 diets - “control” avg American diet, fruits/vegetable just added some fruits and veggies, and F/V with low-fat dairy was “healthiest” - all three had 3g sodium per day to control for sodium intake; control diet had way more snacks and sweets; Told to not have more than 3 caffeinated beverages and 2 drinks of alcohol per day, but no way to make sure; Kept weight the same by changing calorie levels and adding cookies and muffins to those who were losing weight!; BP <160/90 not on antihypertensives; excluded poorly controlled DM, HLD, BMI >35; not everyone had HTN; All subjects started with 3 weeks of “control” average American diet with BP was taken at end of the run-in; the interventional phase was 8 weeks of experimental diet; 60% of subjects were black, which was done purposefully; Among the 133 patients who were hypertensive at the start and were in the combo group, average change was 11mmHg; Just adding fruits and vegetables and cutting out some snacks and sweets in the setting of an otherwise crappy diet could lower your blood pressure by 7 mmHg; Were able to see the differences between 2-6 weeks - only followed for 11 weeks, not meant to show effects were long-lasting
  • SSaSS Trial - Effect of Salt Substitution of Cardiovascular Events and Death (NEJM, 2021) - using salt substitutes (with 75% NaCl and 25% KCl) vs usual NaCl salt led to reductions in BP and fewer cardiovascular events; note that this was done in rural China and inclusion criteria were those with histor of stroke or age >60
  • HYVET Trial (NEJM 2008) - Meta-Analysis HTN therapy in 80+ year-olds; HYVET (Hypertension in the Very Elderly Trial) showed benefits to treating (stroke, HF, death), but meta-analysis showed no difference in all-cause mortality; The ultimate recommendation of the meta-analysis was to keep thiazide and max of 2 agents which is basically what the HYVET trial recommended
  • ACCOMPLISH Trial - 2 Minute Medicine
  • ONTARGET Trial - 2 Minute Medicine
  • Symplicity HTN-2 Trial - renal denervation - 2 Minute Medicine‍
  • There is some discussion of whether lowering BP at night helps improve outcomes - reverse dippers (those who have BP actually go up at night) have increased mortality - giving BP meds at night helps restore the “dipping” effect; MAPEC Trial looked into this, but overall showed a weak effect

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