chapter
HYPERTENSION
Lifestyle Changes for Hypertension
• Weight loss:
Losing just 5-10% of body weight can reduce SBP by 5-20 mmHg.
• Dietary changes:
Following the DASH (Dietary Approaches to Stop Hypertension) diet, which emphasizes fruit, vegetables, whole grains, low-fat meals and salt intake, can reduce SBP by 8-14 mmHg.
• Physical activity:
Regular physical activity such as brisk walking, cycling, or swimming can reduce SBP by 4-9 mmHg.
• Limiting alcohol consumption:
Reducing alcohol consumption to no more than one drink per day for women and no more than two drinks per day for men can reduce SBP by 2-4 mmHg.
• Quitting smoking:
Quitting smoking can reduce SBP by 2-8 mmHg.
It should be noted that reductions in SBP through lifestyle modifications can vary among individual patients with hypertension and depend on the severity of their hypertension.
Table Diet Recommendation
Diet Recommendation | Recommendation |
Reduced-salt diet | <6 g NaCl or <2.4 g Na/d, ~20% of patients may respond |
Alcohol consumption | Limit to <1 oz/day |
DASH diet | Consider Dietary Approaches to Stop HTN (DASH) diet |
Determining blood pressure value to treat
Blood pressure is typically measured using a sphygmomanometer, which consists of an inflatable cuff, a pressure gauge, and a stethoscope or electronic sensor.
The American Heart Association (AHA) recommends that blood pressure be measured at least once every two years for adults who have a blood pressure reading lower than 120/80 mmHg, and more frequently for those with higher readings or those at risk for developing hypertension.
Blood pressure readings are typically reported as two numbers, the systolic pressure and the diastolic pressure. The systolic pressure is the pressure in the arteries when the heart contracts, while the diastolic pressure is the pressure in the arteries when the heart is relaxed between beats.
A blood pressure reading of 120/80 mmHg or lower is considered normal.
The AHA recommends that treatment be initiated for patients with a blood pressure reading of 130/80 mmHg or higher who have a high risk of cardiovascular disease, such as those with diabetes or a history of stroke or heart attack.
For patients without these risk factors, treatment may be initiated for those with a blood pressure reading of 140/90 mmHg or higher.
It is important to note that blood pressure readings can vary throughout the day and may be affected by factors such as stress, exercise, and medication use. Therefore, it is recommended that blood pressure be measured on multiple occasions and at different times of the day to obtain an accurate value of a patient's blood pressure.
In addition to blood pressure measurements, other factors are important when determining treatment plans for hypertension, such as the patient's age, race, medical history, and other health conditions.
Table Outline of normal expectation of blood pressure:
DIAGNOSIS | Systolic Blood Pressure (mmHg) | Diastolic Blood Pressure (mmHg) |
Optimal | Less than 120 | Less than 80 |
Elevated | 120-129 | Less than 80 |
Stage 1 | 130-139 | 80-89 |
Stage 2 | 140 or higher | 90 or higher |
Table of the blood pressure categories according to the American Heart Association:
Detailed explanation of each blood pressure category in the table:
- Optimal: This category includes blood pressure readings that are considered normal and healthy. A systolic blood pressure reading of less than 120 mmHg and a diastolic blood pressure reading of less than 80 mmHg are both considered optimal.
- Elevated: This category includes blood pressure readings that are higher than optimal but not yet in the hypertension range. A systolic blood pressure reading between 120 and 129 mmHg, and a diastolic blood pressure reading below 80 mmHg are considered elevated. Patients with an elevated blood pressure may be advised to make lifestyle changes to lower their blood pressure, such as losing weight, eating a healthy diet, and increasing physical activity.
- Stage 1 hypertension: This category includes blood pressure readings that indicate mild to moderate hypertension. A systolic blood pressure reading between 130 and 139 mmHg, or a diastolic blood pressure reading between 80 and 89 mmHg, are both considered stage 1 hypertension. Patients with stage 1 hypertension may be advised to make lifestyle changes and/or prescribed blood pressure medication to lower their blood pressure.
- Stage 2 hypertension: This category includes blood pressure readings that indicate more severe hypertension. A systolic blood pressure reading of 140 mmHg or higher, or a diastolic blood pressure reading of 90 mmHg or higher, are both considered stage 2 hypertension. Patients with stage 2 hypertension are typically prescribed blood pressure medication in addition to lifestyle changes to lower their blood pressure and reduce their risk of cardiovascular disease.
To determine the medication for a patient with stage 1 hypertension, it is important to know their 10-year risk of developing atherosclerotic cardiovascular disease (ASCVD).
If the patient's risk of developing ASCVD is low (less than 10%), the initial treatment approach will be to support healthy lifestyle changes and reassess them in 3-6 months. This is similar to the approach for patients in the optimal or elevated categories.
However, if the risk of ASCVD is high (greater than 10%), the patient may need to start medications to lower their blood pressure while also making lifestyle changes to reduce their risk of developing cardiovascular disease.
If a patient already has coronary artery disease, congestive heart failure, or a previously defined stroke, the risk calculator can be skipped altogether, and medications can be prescribed immediately.
For diabetic patients, it is generally safe to assume that they have a greater than 10% risk of developing ASCVD. Therefore, if a diabetic patient has a blood pressure reading of 130 mmHg or higher, medications to lower blood pressure should be started promptly.
It is important to note that the treatment approach for hypertension should be individualized based on each patient's unique circumstances and medical history.
Age factor
Age Group | Systolic BP | Diastolic BP |
Adults < 60 years old | < 140 mmHg | < 90 mmHg |
Adults ≥ 60 years old | < 150 mmHg | < 90 mmHg |
Adults with diabetes or CKD | < 140 mmHg | < 90 mmHg |
Stage 1 Hypertension (ACC/AHA) | 130-139 mmHg | 80-89 mmHg |
ACC/AHA guidelines recommend using different blood pressure thresholds for treatment in patients over the age of 65.
For patients aged 65 and older with hypertension, the guidelines recommend a systolic blood pressure goal of less than 130 mmHg.
The reason for this difference is that lower blood pressure goals may be associated with an increased risk of falls and other adverse events in older adults. It is important to monitor for orthostatic hypotension in older adults.
ASCVD Risk Estimator Plus The ASCVD (atherosclerotic cardiovascular disease) Risk Estimator Plus is an online tool that is used to estimate a patient's 10-year risk for ASCVD. This tool is available at https://tools.acc.org/ASCVD-risk-estimator-plus.
Types of Hypertension
Primary hypertension:
Primary hypertension, also known as essential hypertension, is the most common type of hypertension, accounting for 90-95% of all cases. The exact cause of primary hypertension is unknown, but several factors can contribute to its development, including age, genetics, and lifestyle factors such as diet and exercise.
Secondary hypertension:
Secondary hypertension is caused by an underlying medical condition, such as kidney disease or endocrine disorders. It accounts for 5-10% of all cases of hypertension. Treating the underlying condition can often bring blood pressure back to normal levels.
Isolated systolic hypertension:
Isolated systolic hypertension is a condition in which only the systolic blood pressure is elevated, with a normal diastolic blood pressure. This type of hypertension is more common in older adults and is associated with an increased risk of heart disease and stroke.
Malignant hypertension:
Malignant hypertension is a severe and potentially life-threatening form of hypertension. It is characterized by a rapid and significant increase in blood pressure, often to 180/120 mmHg or higher. Malignant hypertension requires urgent medical attention to prevent complications such as heart attack, stroke, and kidney failure.
Risk Factors for Hypertension
Risk factors are any factors that increase a person's likelihood of developing hypertension. These include:
Diet: Consuming a diet high in sodium and low in potassium, fruits, and vegetables can contribute to the development of hypertension.
Physical inactivity: Lack of exercise or a sedentary lifestyle can increase the risk of hypertension.
Tobacco use: Smoking and exposure to secondhand smoke can contribute to the development of hypertension.
Alcohol consumption: Drinking excessive amounts of alcohol can raise blood pressure.
Medical conditions
Several medical conditions can increase the risk of developing hypertension, including:
Obesity: Being overweight or obese can increase the risk of hypertension.
Diabetes: High blood sugar levels can damage blood vessels, leading to hypertension.
Kidney disease: The kidneys play a key role in regulating blood pressure, and kidney disease can lead to hypertension.
Sleep apnea: This condition, characterized by interrupted breathing during sleep, can contribute to the development of hypertension.
DIAGNOSTIC TESTS, PANELS
Initial Tests:
1. Hemoglobin or hematocrit or complete blood count
2. Potassium, calcium, creatinine, and uric acid levels
3. Complete urinalysis including proteinuria and hematuria
4. Lipid panel
5. Fasting blood glucose or hemoglobin A1c
6. Consideration of sleep apnea with high BMI
7. ECG to evaluate possible presence of left ventricular hypertrophy (LVH) or rhythm abnormalities
Follow-Up Tests and Special Considerations:
1. ABPM (ambulatory blood pressure monitoring) or HBPM (home blood pressure monitoring) if “white coat” HTN is suspected, episodic HTN, or autonomic dysfunction
2. Ambulatory measurement may be especially helpful if there is suspected autonomic dysfunction
3. Perform cardiovascular risk assessment
4. The AHA/ACC risk tool overestimates risk, especially in older patients, by 50% or more
5. A definition of “low risk” excludes patients with a history of CVD, diabetes mellitus, CKD, and familial hypercholesterolemia or familial premature coronary artery disease.
Treatment Goals:
1. Age <60 years: SBP <140 and DBP <90 g (for HBPM <135/85)
2. Age ≥60 years: SBP <150 and DBP <90 (for HBPM <140/90)
3. Age ≥60 years with CKD or diabetes: SBP <140 and DBP <90 (for HBPM <135/85)
4. More aggressive treatment may be considered in high-risk patients meeting enrollment criteria for SPRINT because aggressive treatment shows improvement in outcomes, but 61 nondiabetic patients would need to be treated (NNT) for 3 years to a goal SBP of <120mm Hg to prevent one major cardiovascular outcome and 90 such patients treated over 3 years to prevent one death (NNT 90).
5. Even in secondary prevention, no firm conclusions can yet be drawn regarding the comparative effectiveness of intensive versus standard therapy.
6. Individual treatment goals should be jointly established with patients after discussion of the anticipated potential benefits and harms.
7. Recommend lifestyle improvements, including diet, exercise, and reducing or eliminating tobacco/alcohol.
8. Benefit of pharmacologic treatment of low-risk patients with class I HTN (140-150/90-99) remains uncertain, with harms including syncope, kidney injury, and electrolyte abnormalities. Individualize decisions.
9. Treating patients with CKD or diabetes to lower-than-standard BP targets, <140/90, does not appear to further reduce mortality or morbidity. Individualize goal BP based on risk factors and patient preferences.
10. The majority of treatment benefit is attained by lowering very high SBP (e.g. from 190 to 150, as compared with the benefit of lowering from 150 to 136). Striving for small additional drops in BP by adding 4th or 5th medications to achieve a “target” is less clinically beneficial and more likely to cause adverse effects.
11. Lower than standard JNC-8 DBP targets are not associated with decreased morbidity/mortality.
Monitoring | Recommended Frequency |
Electrolytes, BUN/creatinine | 3-6 weeks after initiating certain medications (thiazide diuretics, ARBs, or ACEi) |
Blood pressure (BP) | Every 3-6 months until stable, then every 6-12 months |
Creatinine and potassium | At least annually for patients on diuretics, ACE inhibitors, and ARBs |
Quality-of-life issues | Monitor, including sexual function |
Medication Table:
Medication Class | First-Line Indication | Second-Line Indication | Special Considerations |
Thiazide diuretics or CCB | General Black Population | --- | First-line in Black population |
ACE inhibitors | Diabetes, proteinuria, atrial fibrillation, or HFrEF | --- | Not for use in pregnancy |
ARBs | --- | --- | Alternative to ACE inhibitors in some patients |
β-Blockers | Ischemic heart disease, atrial fibrillation, CHF, migraine, or history of STEMI | --- | No longer strongly recommended as first-line |
α-Adrenergic blockers | --- | Benign prostatic hypertrophy (BPH) | Second-line after combination therapy |
CCB | Isolated systolic HTN, atherosclerosis, angina, migraine, or asthma | --- | Well-documented to reduce risk of stroke |
Treatment plan at the first visit | Second Possible Treatment Plan | Third Possible Treatment Plan | The fourth possible Treatment drug | |
Standard Population with Hypertension | Thiazid | CCBs | ACE inhibitors | ARBs |
CCB's | ACE i or ARBs | | | |
Patients with Chronic Kidney Disease, Diabetic nephropathy, microalbuminuria | ACE inhibitors or ARBs | Thiazides or CCBs | ||
Black patients with ISH systolic blood pressure | CCB's | Thiazid | ACE inhibitors or ARBs | |
Patients who have recently suffered from myocardial infarction or heart failure | Beta-blockers | ACE inhibitors or ARBs | CCB's | Thiazid |
Patients with stable coronary artery disease | ACE inhibitors or ARBs | Beta-blockers or CCBs |
TABLE
Hypertension Medication Guidelines
|
Step 1 (Initial Monotherapy) |
(Sequential Monotherapy) Sequential
monotherapy attempts should be tried with different classes because
individual responses vary. Many patients will require multiple medications. |
|
|
·
General Population |
ACE inhibitors, ARBs, CCBs, or diuretics Thiazide diuretics or CCB preferred |
|
|
·
Diabetes |
ACE inhibitors |
|
|
·
Proteinuria |
ACE inhibitors |
|
|
· AtrialFibrillation |
ACE inhibitors |
|
|
·
HFrEF |
ACE inhibitors |
|
|
·
Ischemic Heart Disease |
β-blockers |
|
|
·
Migraine |
β-blockers, CCBs |
|
|
·
STEMI |
β-blockers |
It is important to note that combination therapy may be necessary to achieve adequate blood pressure control in some patients. Combinations of drugs from different classes may be used to address multiple mechanisms of blood pressure regulation. However, it is important to be aware of potential drug interactions and contraindications when prescribing multiple antihypertensive medications.
ACE inhibitor or ARB can be optimized with a Calcium Channel Blockers. Combining an ACE inhibitor and CCB with a thiazide has been shown to have a bigger effect on Blood Pressure than simply using an ACE inhibitor and a thiazide.
Thiazides and CCBs are preferred for most patients, and then ACE inhibitors and ARBs may be added as needed based on individual patient factors. It is important to note that the choice of medication should be individualized based on the patient's comorbidities, medication allergies, and other factors.
Beta-blockers are no longer considered a first-line therapy for the general population due to their association with adverse metabolic effects such as hypoglycemia, dyslipidemia, and weight gain. In addition, they may increase the risk of cardiovascular events compared to other antihypertensive medications.
When treating patients with diabetes and hypertension, it is important to consider their individual needs and comorbidities. For patients with diabetes, ACE inhibitors and ARBs are preferred due to their renal protective effects and the reduction of microalbuminuria. Thiazides and CCBs may also be used, but caution should be exercised in patients with coexisting heart failure or renal impairment.
Beta-blockers may be used in selected patients with diabetes but should be used with caution as they may worsen glucose control and mask hypoglycemia symptoms.
For patients with diabetes, first-line options will be the same as for the general population. However, if patient has albuminuria, may consider starting with an ACE inhibitor or ARB since these drugs have been shown to slow the progression of albuminuria and help preserve kidney function.
In patients with diabetes, medications that have been shown to improve cardiovascular outcomes in patients with diabetes should be prioritized. These include ACE inhibitors, angiotensin receptor blockers (ARBs), and dihydropyridine calcium channel blockers. Medications that may have adverse metabolic effects, such as beta blockers and thiazide diuretics, should be used with caution in patients with diabetes.
For patients with chronic kidney disease (CKD), the choice of first-line antihypertensive agent will depend on the patient's level of kidney function and the degree of proteinuria. For patients with mild to moderate CKD, ACE inhibitors and ARBs are usually the first choice due to their ability to slow the progression of kidney disease.
Hypertension is both a cause and consequence of CKD. Elevated blood pressure can contribute to the development and progression of CKD through various mechanisms, such as damage to the renal vasculature and glomeruli. Conversely, CKD can lead to hypertension through activation of the renin-angiotensin-aldosterone system and other pathophysiological mechanisms.
For patients with a recent myocardial infarction or heart failure, beta-blockers will be first choice medications, followed by an ACE inhibitor or ARB.
Beta-blockers have been shown to reduce mortality and morbidity in patients with a recent myocardial infarction or heart failure. After beta-blockers, ACE inhibitors or ARBs can be added to reduce the risk of future cardiac events and slow the progression of heart failure. In some cases, a combination of these medications may be necessary to achieve optimal blood pressure control and improve outcomes. It's important to note that the choice of medication will depend on individual patient factors, and a cardiologist should be consulted in these cases.
For patients with stable coronary artery disease, the first-line medications are usually an ACE inhibitor or ARB, followed by a beta-blocker or calcium channel blocker. These medications help to reduce the risk of future cardiovascular events and improve symptoms such as chest pain. In some cases, a combination of these medications may be necessary to achieve optimal control of blood pressure and prevent further damage to the heart.
1. Thiazide 2. Thiazide-like 3. Loop
Another diuretic group is Potassium-Sparing Diuretics.
Thiazide diuretics, such as hydrochlorothiazide, are the most commonly prescribed diuretics for hypertension. They are usually administered in low doses and have been shown to reduce blood pressure by up to 15 mmHg systolic and 5-6 mmHg diastolic. Loop diuretics, such as furosemide, are used for the treatment of resistant hypertension or in patients with renal impairment. Potassium-sparing diuretics are often used in combination with other diuretics to prevent hypokalemia.
If a patient is on HCTZ and aren’t getting the desired control, consider switching to chlorthalidone.
If a patient has chronic kidney disease and their estimated glomerular filtration rate (eGFR) is less than 30, they should be on a loop diuretic.
Consider adding other agents
If the patient still has resistant hypertension after optimizing the diuretic and adding an ACE inhibitor (or ARB) with a CCB and mineralocorticoid receptor antagonist, there are other options to consider. These include:
• Beta-blockers
• Alpha-blockers
• Direct renin inhibitors
• Vasodilators, such as hydralazine or minoxidil
• Central alpha agonists, such as clonidine or methyldopa
• Combination drugs, such as fixed-dose combinations of an ACE inhibitor with a calcium channel blocker or a thiazide diuretic with a potassium-sparing diuretic.
Potassium-sparing diuretics
Potassium-sparing diuretics are often used in combination with thiazide or loop diuretics to counteract the potassium loss associated with these medications. Unlike thiazide and loop diuretics, which increase the excretion of both sodium and potassium, potassium-sparing diuretics selectively block the effects of aldosterone, a hormone that promotes sodium and water retention in the body, without affecting potassium excretion.
Spironolactone is the most commonly used potassium-sparing diuretic. It works by binding to aldosterone receptors in the kidney, blocking the effects of aldosterone and promoting the excretion of sodium and water while retaining potassium. Because spironolactone can cause hyperkalemia, it is usually prescribed in lower doses than thiazides or loop diuretics and is often used in combination with these medications to minimize the risk of electrolyte imbalances.
Hyperkalemia is a potentially serious complication of potassium-sparing diuretics. Hyperkalemia is defined as a serum potassium level above the upper limit of the normal range (typically 3.5 to 5.0 mmol/L). Hyperkalemia can cause muscle weakness, paralysis, cardiac arrhythmias, and even sudden death.
The risk of hyperkalemia with potassium-sparing diuretics is higher in patients with renal impairment or those taking other medications that increase potassium levels, such as ACE inhibitors and ARBs.
To minimize the risk of hyperkalemia, patients taking potassium-sparing diuretics should have their serum potassium levels monitored regularly, especially during the first few weeks of treatment or following dose adjustments. Patients should also be advised to avoid high-potassium foods, such as bananas, oranges, potatoes, and tomatoes, and to inform their healthcare provider if they experience symptoms such as muscle weakness, fatigue, or irregular heartbeat.
In conclusion, potassium-sparing diuretics are another important class of medications for the treatment of hypertension and edema.
Some commonly used medication combinations for hypertension include:
1. ACE inhibitors and diuretics: This combination is often used in patients with hypertension and heart failure.
ACE inhibitors help to relax blood vessels, while diuretics help to reduce fluid buildup in the body and lower blood pressure.
2. Calcium channel blockers and ACE inhibitors or ARBs: This combination is often used in patients with hypertension and diabetes or kidney disease. Calcium channel blockers help to relax blood vessels, while ACE inhibitors and ARBs help to protect the kidneys.
3. Beta-blockers and diuretics: This combination is often used in patients with hypertension and angina or heart failure. Beta-blockers help to slow down the heart rate and reduce the workload on the heart, while diuretics help to reduce fluid buildup and lower blood pressure.
4. ARBs and diuretics: This combination is often used in patients with hypertension and diabetes or kidney disease. ARBs help to relax blood vessels and protect the kidneys, while diuretics help to reduce fluid buildup and lower blood pressure.
5. Calcium channel blockers and diuretics: This combination is often used in patients with hypertension and peripheral artery disease. Calcium channel blockers help to relax blood vessels and improve blood flow, while diuretics help to reduce fluid buildup and lower blood pressure.
It is important to note that combination therapy may increase the risk of side effects and drug interactions. Patients should be closely monitored for any adverse effects, and medication doses may need to be adjusted based on blood pressure readings and any side effects that arise. Additionally, patients should continue to make lifestyle modifications, such as diet and exercise changes, to help lower their blood pressure in conjunction with medication therapy.
Hypertension Emergency patient groups
There are several different emergency patient groups related to hypertension, including:
1. Hypertensive urgency: This is when a patient's blood pressure is severely elevated (usually above 180/120 mmHg) but there is no evidence of acute end-organ damage. These patients can often be managed with oral antihypertensive medications in an outpatient setting.
2. Hypertensive emergency: This is when a patient's blood pressure is severely elevated and there is evidence of acute end-organ damage, such as acute myocardial infarction, acute heart failure, acute kidney injury, or acute neurological deficits. These patients require immediate hospitalization and aggressive blood pressure management.
3. Postoperative hypertension: Some patients may experience hypertension after undergoing surgery, particularly those with a history of hypertension or cardiovascular disease. In these cases, careful blood pressure monitoring and management is necessary to prevent complications.
4. Pregnancy-related hypertension: Pregnant patients may experience hypertension, such as gestational hypertension, preeclampsia, or eclampsia, which require careful monitoring and management to prevent maternal and fetal complications.
5. Hypertension in the setting of acute ischemic stroke: Patients with acute ischemic stroke may also experience elevated blood pressure, which may require careful management to prevent complications and improve outcomes.
The following table summarizes the classifications of EMERGENCY HYPERTENSION :
Classification | Systolic Blood Pressure (mmHg) | Diastolic Blood Pressure (mmHg) |
Normal | Less than 120 | Less than 80 |
Elevated | 120-129 | Less than 80 |
Stage 1 hypertension | 130-139 | 80-89 |
Stage 2 hypertension | 140 or higher | 90 or higher |
Hypertensive crisis | Higher than 180 | Higher than 120 |
Hypertensive emergencies are defined by a systolic blood pressure of 180 mmHg or higher, or a diastolic blood pressure of 120 mmHg or higher, with evidence of acute target organ damage. Examples of target organ damage include acute myocardial infarction, acute left ventricular failure with pulmonary edema, aortic dissection, acute ischemic stroke, hypertensive encephalopathy, acute kidney injury, or retinopathy with papilledema.
Table of First Line Antihypertensive Medications:
Class of Medication |
| Medication | Dose Range |
Thiazide diuretics | Chlorthalidone | 12.5 to 25.0 mg/day | |
Hydrochlorothiazide | 12.5 to 50.0 mg/day | ||
Indapamide | 1.25 to 2.50 mg/day | ||
ACE i | Lisinopril | 5 to 40 mg/day | |
Enalapril | 5 to 40 mg/day | ||
Ramipril | 2.5 to 20.0 mg/day | ||
Benazepril | 10 to 40 mg/day | ||
CCBs | Amlodipine | 2.5 to 10 mg/day | |
Nifedipine (sustained release) | 30 to 90 mg/day | ||
Diltiazem CD | 180 to 360 mg/day | ||
Verapamil (sustained release) | 120 to 480 mg/day | ||
ARBs | Losartan | 25 to 100 mg in 1 or 2 doses | |
Valsartan | 80 to 320 mg/day | ||
Irbesartan | 75 to 300 mg/day | ||
Candesartan | 4 to 32 mg/day | ||
Telimisartan | 20 to 80 mg/day | ||
Renin inhibitor | Aliskiren | 150 to 300 mg daily |
Table summarizing the theory of action for the four first-line antihypertensive drug classesclasses
Drug Class | Theory of Action |
Angiotensin-converting enzyme inhibitors (ACEi) | Inhibits the conversion of angiotensin I to angiotensin II, which reduces vasoconstriction and aldosterone secretion, leading to decreased blood pressure. |
Angiotensin II receptor blockers (ARBs) | Blocks the action of angiotensin II on its receptor sites, which reduces vasoconstriction and aldosterone secretion, leading to decreased blood pressure. |
Beta-adrenergic blocking agents (beta-blockers) | Blocks the effects of adrenaline on the heart and blood vessels, which reduces heart rate and cardiac output, leading to decreased blood pressure. |
Calcium channel blockers (CCBs) | Blocks the movement of calcium into the muscle cells of the heart and blood vessels, which causes relaxation of arterial smooth muscle, leading to decreased peripheral resistance and decreased blood pressure. |
Diuretics | Increases urine output, which reduces the volume of fluid in the blood vessels and decreases blood pressure. Diuretics work by inhibiting the reabsorption of sodium and chloride ions in the kidneys, which increases the excretion of water and electrolytes. |
Note: Thiazide diuretics may not be effective with creatinine clearance <30. Chlorthalidone has the strongest evidence base among thiazides but causes more hyponatremia and hypokalemia. ACE inhibitors should be used in patients with diabetes, proteinuria, atrial fibrillation, or HFrEF but not in pregnancy. β-Blockers should be used with caution in asthma, heart block, diabetes, and peripheral vascular disease, and avoided in patients with metabolic syndrome or insulin-requiring diabetes. Diltiazem or verapamil should not be used with systolic dysfunction or heart block. Amlodipine causes peripheral edema.
Table. Commonly prescribed antihypertensive medications grouped by class, including generic names, brand names, dosage ranges, and dosing frequency.
Medication Class | Generic Name | Brand Name | Dosage Range | Dosing Frequency |
Angiotensin-Converting Enzyme (ACE) Inhibitors | Lisinopril | Prinivil, Zestril | 10-40 mg once daily | Once daily |
Enalapril | Vasotec | 2.5-40 mg once daily | Once daily | |
Ramipril | Altace | 2.5-20 mg once daily | Once daily | |
Captopril | Capoten | 12.5-150 mg twice daily | Twice daily | |
Angiotensin II Receptor Blockers (ARBs) | Losartan | Cozaar | 25-100 mg once daily | Once daily |
Valsartan | Diovan | 80-320 mg once daily | Once daily | |
Irbesartan | Avapro | 75-300 mg once daily | Once daily | |
Candesartan | Atacand | 8-32 mg once daily | Once daily | |
Calcium Channel Blockers (CCBs) | Amlodipine | Norvasc | 2.5-10 mg once daily | Once daily |
Nifedipine | Procardia, Adalat | 10-120 mg once or twice daily | Once or twice daily | |
Diltiazem | Cardizem | 120-480 mg once daily | Once or twice daily | |
Verapamil | Calan, Verelan | 120-480 mg once daily | Once or twice daily | |
Beta-Blockers | Metoprolol | Lopressor | 25-100 mg twice daily | Twice daily |
Atenolol | Tenormin | 25-100 mg once daily | Once daily | |
Propranolol | Inderal | 20-320 mg once or twice daily | Once or twice daily | |
Carvedilol | Coreg | 3.125-25 mg twice daily | Twice daily | |
Thiazide Diuretics | Hydrochlorothiazide | Microzide | 12.5-50 mg once daily | Once daily |
Chlorthalidone | Hygroton | 12.5-50 mg once daily | Once daily | |
Indapamide | Lozol | 1.25-5 mg once daily | Once daily |
Table: Commonly Used ARBs
Generic Name | Brand Name | Dosing Range |
Losartan | Cozaar | 25-100 mg once daily |
Valsartan | Diovan | 80-320 mg once daily |
Irbesartan | Avapro | 75-300 mg once daily |
Candesartan | Atacand | 8-32 mg once daily |
Olmesartan | Benicar | 20-40 mg once daily |
Telmisartan | Micardis | 20-80 mg once daily |
Commonly prescribed antihypertensive medications grouped by class, including generic names, brand names, dosage ranges, and dosing frequency
Class of Drug | Compelling Indications | Possible Indications | Compelling Contraindications | Possible Contraindications | Adverse Effects |
Diuretics | Heart failure, Systolic hypertension, Edema | Elderly pts, Chronic renal parenchymal disease | Gout, Bilateral renal artery stenosis, Hyperkalemia | Pregnancy | Hypokalemia, Dehydration, Electrolyte imbalances |
Beta blockers | Heart failure, After MI, Tachyarrhythmias | Angina, Systolic hypertension, Elderly pts | Heart block, COPD, Asthma | Peripheral vascular disease, Athletes and physically active pts | Bradycardia, Hypotension, Fatigue |
ACE inhibitors | Heart failure, LV dysfunction, Diabetic nephropathy | Hypertension, After MI, Chronic renal parenchymal disease | Pregnancy, Angioedema | Bilateral renal artery stenosis, Hyperkalemia | Cough, Hypotension, Hyperkalemia |
Angiotensin receptor blockers | Heart failure, LV dysfunction, Diabetic nephropathy | Hypertension, Chronic renal parenchymal disease | Pregnancy | Bilateral renal artery stenosis, Hyperkalemia | Hypotension, Hyperkalemia, Dizziness |
Calcium channel blockers | Angina, Hypertension, Tachyarrhythmias | Elderly pts, Pregnancy | Second- or third-degree atrioventricular block, Heart failure | Peripheral vascular disease, COPD | Hypotension, Bradycardia, Edema |
TABLE: Combinations of Hypertension Medications.
|
Hypertensive
Medication Combination |
Brand
Name |
Drug
Class |
Dosages
(mg) |
|
Amlodipine/benazepril |
Lotrel |
ACE inhibitor/CCB |
Amlodipine: 2.5/5/10_Benazepril:
10/20/40 |
|
Lisinopril/amlodipine |
Zestoretic,
Prinzide |
ACE
inhibitor/CCB |
Lisinopril:
10/20/30_Amlodipine: 2.5/5/10 |
|
Losartan/hydrochlorothiazide |
Hyzaar |
ARB/diuretic |
Losartan: 50/100_Hydrochlorothiazide:
12.5/25 |
|
Valsartan/amlodipine |
Exforge |
ARB/CCB |
Valsartan:
80/160_Amlodipine: 5/10 |
|
Nebivolol/valsartan |
Byvalson |
ARB/beta blocker |
Nebivolol: 5_ Valsartan:
80/160 |
Geriatric Considerations for Hypertension Treatment
- Isolated systolic hypertension is common in older adults
- Therapy is effective in preventing stroke, cardiovascular morbidity, and all-cause mortality
- Target SBP for seniors is higher than in younger patients (~150 mm Hg systolic)
- Adverse reactions to medications are more frequent in older patients
- Benefit of therapy is conclusively demonstrated for SBP ≥160
- Very elderly patients may be at high risk of adverse events associated with pharmaceutical treatment of HTN
- Strongest evidence of benefit shown with use of thiazide diuretics
Pediatric Considerations:
Age group Blood pressure percentile 3-12 years <90th percentile 13-18 years <120/80 mmHg
Defined as SBP or DBP ≥95th percentile on repeated measurements. Measure BP during routine exams beginning at age 3 years. Pre-HTN: SBP or DBP between 90th and 95th percentile. Treatment options depend on the age, presence of comorbidities, and severity of hypertension.
Pregnancy Considerations:
Elevated BP during pregnancy may represent chronic HTN, pregnancy-induced HTN, or preeclampsia. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) are contraindicated. Maternal and fetal mortality are reduced with treatment of severe HTN (see topic “Preeclampsia and Eclampsia (Toxemia of Pregnancy)”). Preferred agents: labetalol, nifedipine, methyldopa, or hydralazine.
Endocrine hypertension
Endocrine hypertension refers to high blood pressure that is caused by an underlying endocrine disorder. There are several types of endocrine disorders that can lead to hypertension:
1. Primary aldosteronism: This is the most common cause of endocrine hypertension. It occurs when the adrenal gland produces too much aldosterone, a hormone that regulates sodium and potassium balance in the body.
2. Cushing's syndrome: This condition occurs when the body produces too much cortisol, a hormone that regulates metabolism and the body's response to stress.
3. Pheochromocytoma: This is a rare tumor of the adrenal gland that produces excess amounts of adrenaline and noradrenaline, leading to high blood pressure and other symptoms.
4. Hyperthyroidism: This occurs when the thyroid gland produces too much thyroid hormone, which can lead to increased metabolism, weight loss, and high blood pressure.
5. Hypothyroidism: This occurs when the thyroid gland produces too little thyroid hormone, which can lead to weight gain, fatigue, and high blood pressure.
EXAMPLE FLOWCHART ON MEDICATION
FLOWCHART FOR EXAMPLE PATIENT
Cardiology and Hypertension Medication Guidelines
TABLE
A table showing the relationship between heart health and commonly used
hypertension medications:
|
Heart Health Condition |
Hypertension Medication |
Benefits |
|
Good ejection
fraction, no angina, only blood pressure problem |
Calcium channel
blockers (CCBs) |
Well-documented
to reduce the risk of stroke; effective in patients with isolated systolic
hypertension, atherosclerosis, angina, migraine, or asthma |
|
Good ejection fraction, no angina, only blood
pressure problem |
Beta-blockers |
May
benefit patients with ischemic heart disease, atrial fibrillation, congestive
heart failure (CHF), migraine, and patients with a history of ST-segment
elevation myocardial infarction (STEMI) |
|
Reduced
ejection fraction, heart failure with reduced ejection fraction (HFrEF) |
ACE inhibitors |
Should be used
in patients with heart failure with reduced ejection fraction (HFrEF),
diabetes, proteinuria, atrial fibrillation, but not in pregnancy |
|
Reduced ejection fraction, heart failure with
reduced ejection fraction (HFrEF) |
ARBs |
May be
used in patients who cannot tolerate ACE inhibitors |
|
Hypertrophic
cardiomyopathy |
Beta-blockers |
Can reduce
symptoms and improve exercise tolerance |
|
Arrhythmia (e.g., atrial fibrillation) |
Calcium
channel blockers (CCBs) |
Can be
effective in controlling heart rate |
|
Arrhythmia
(e.g., atrial fibrillation) |
Beta-blockers |
Can be
effective in controlling heart rate |
|
Benign prostatic hypertrophy (BPH) |
Alpha-adrenergic
blockers |
May
benefit males with BPH but not a first choice for monotherapy, remain as
second line after combination therapy of first-line agents |
It is important to note that the choice of medication may also depend on
other factors, such as comorbidities, drug interactions, and medication
tolerability. Therefore, it is essential to individualize therapy for each
patient based on their specific medical history, risk factors, and medication
tolerability.
TABLE
|
Heart Health Condition |
Hypertension Medication |
Benefits |
Diuretics (no renal, electrolyte problem) |
|
Good ejection
fraction, angina present |
Calcium channel
blockers (CCBs) |
Can be
effective in controlling angina; well-documented to reduce the risk of
stroke; effective in patients with isolated systolic hypertension,
atherosclerosis, migraine, or asthma |
Can be
effective in reducing blood pressure; may enhance the antihypertensive effect
of other medications |
|
Good ejection fraction, angina present |
Beta-blockers |
Can be
effective in controlling angina; may benefit patients with ischemic heart
disease, atrial fibrillation, CHF, migraine, and patients with a history of
STEMI |
Can be
effective in reducing blood pressure; may enhance the antihypertensive effect
of other medications |
|
Reduced
ejection fraction, heart failure with reduced ejection fraction (HFrEF), angina
present |
Calcium channel
blockers (CCBs) |
Can be
effective in controlling angina and improving symptoms of heart failure;
well-documented to reduce the risk of stroke |
Can be
effective in reducing blood pressure; may enhance the antihypertensive effect
of other medications |
|
Reduced ejection fraction, heart failure with
reduced ejection fraction (HFrEF), angina present |
Beta-blockers |
Can be
effective in controlling angina and improving symptoms of heart failure; may
benefit patients with ischemic heart disease, atrial fibrillation, CHF,
migraine, and patients with a history of STEMI |
Can be
effective in reducing blood pressure; may enhance the antihypertensive effect
of other medications |
|
Hypertrophic
cardiomyopathy, angina present |
Beta-blockers |
Can reduce
symptoms and improve exercise tolerance; can be effective in controlling
angina |
Can be
effective in reducing blood pressure; may enhance the antihypertensive effect
of other medications |
|
Arrhythmia (e.g., atrial fibrillation), angina
present |
Calcium
channel blockers (CCBs) |
Can be
effective in controlling heart rate and controlling angina |
Can be
effective in reducing blood pressure; may enhance the antihypertensive effect
of other medications |
|
Arrhythmia
(e.g., atrial fibrillation), angina present |
Beta-blockers |
Can be
effective in controlling heart rate and controlling angina |
Can be
effective in reducing blood pressure; may enhance the antihypertensive effect
of other medications |
|
Benign prostatic hypertrophy (BPH), angina present |
Alpha-adrenergic
blockers |
May
benefit males with BPH but not a first choice for monotherapy; remain as
second line after combination therapy of first-line agents |
Can be
effective in reducing blood pressure; may enhance the antihypertensive effect
of other medications |
It is important to note that diuretics may have an additive effect on
reducing blood pressure and may enhance the antihypertensive effect of other
medications. However, the use of diuretics should be carefully monitored in
patients with renal or electrolyte problems, as they may lead to electrolyte
imbalances or worsening of renal function. Therefore, the use of diuretics
should be individualized based on the patient's medical history, renal
function, and electrolyte balance.
TABLE
|
Heart Health Status |
Medication Options |
Benefits |
|
Good ejection
fraction, no angina, BP > 139/85 |
Thiazide
diuretics |
Effective as
first-line therapy in general population, reduces risk of stroke, CHD, heart
failure, and cardiovascular mortality |
|
Good ejection fraction, no angina, BP > 139/85 |
Calcium
channel blockers |
Effective
in reducing blood pressure, reduce risk of stroke in patients with isolated
systolic hypertension |
|
Good ejection
fraction, no angina, BP > 139/85 |
Beta-blockers |
May benefit
patients with ischemic heart disease, atrial fibrillation, CHF, migraine, or
patients with history of STEMI |
|
Good ejection fraction, no angina, BP > 139/85 |
ACE
inhibitors |
Indicated
in patients with diabetes, proteinuria, atrial fibrillation, or heart failure
with reduced ejection fraction (HFrEF) |
|
Good ejection
fraction, no angina, BP > 139/85 |
ARBs |
Effective in
reducing blood pressure and may offer renoprotective effects in patients with
diabetic nephropathy |
|
Good ejection fraction, no angina, BP > 139/85 |
Alpha-adrenergic
blockers |
Not a
first choice for monotherapy but may benefit males with BPH |
|
Good ejection
fraction, no angina, BP > 139/85 |
Thiazide
diuretics (no renal, electrolyte problem) |
Effective as
first-line therapy in general population, reduces risk of stroke, CHD, heart
failure, and cardiovascular mortality |
|
Angina present |
Calcium
channel blockers |
Effective
in reducing angina frequency, reduces risk of stroke in patients with
isolated systolic hypertension |
|
Angina present |
Beta-blockers |
Effective in
reducing angina frequency, may benefit patients with ischemic heart disease,
atrial fibrillation, CHF, migraine, or patients with history of STEMI |
|
Angina present |
ACE inhibitors |
May
improve symptoms of angina, indicated in patients with diabetes, proteinuria,
atrial fibrillation, or heart failure with reduced ejection fraction (HFrEF) |
|
Angina present |
ARBs |
May improve
symptoms of angina, effective in reducing blood pressure and may offer
renoprotective effects in patients with diabetic nephropathy |
|
Angina present |
Alpha-adrenergic
blockers |
Not a
first choice for monotherapy but may benefit males with BPH |
|
Angina present |
Thiazide
diuretics (no renal, electrolyte problem) |
Effective as first-line
therapy in general population, reduces risk of stroke, CHD, heart failure,
and cardiovascular mortality |
TABLE
|
Patient Characteristics |
Recommended Medications |
Possible Combinations |
Benefits |
|
No cardiac
disease, diabetes, proteinuria, atrial fibrillation, or heart failure |
Thiazide
diuretics or calcium channel blockers (CCBs) |
Thiazide
diuretic + CCB |
Reduce risk of
stroke |
|
Diabetes, proteinuria, atrial fibrillation, or heart
failure with reduced ejection fraction (HFrEF) |
ACE
inhibitors |
ACE
inhibitor + diuretic |
Improve
kidney function, decrease proteinuria, and reduce the risk of heart failure |
|
Isolated
systolic hypertension, atherosclerosis, angina, migraine, or asthma |
CCBs |
CCB + ACE
inhibitor or CCB + thiazide diuretic |
Reduce the risk
of stroke, angina attacks, and migraines |
|
History of ST-segment elevation myocardial
infarction (STEMI), ischemic heart disease, atrial fibrillation, or CHF |
β-Blockers |
β-Blocker
+ ACE inhibitor or β-Blocker + diuretic |
Improve
cardiac function, reduce the risk of heart failure, and decrease mortality |
|
Presence of
angina |
β-Blockers or
calcium channel blockers (CCBs) |
β-Blocker + CCB
or β-Blocker + ACE inhibitor |
Improve cardiac
function and reduce the risk of angina attacks |
|
Thiazide Diuretics (no renal or electrolyte problem) |
Thiazide
diuretics |
Thiazide
diuretic + ACE inhibitor or thiazide diuretic + CCB |
Reduce
blood volume and lower blood pressure |
Note: The medications listed under "Recommended Medications" are
classified as first-line antihypertensive drugs and are labeled A, B, C, or D.
The possible combinations listed under "Possible Combinations" are
not exhaustive and individual responses may vary.
Here are some additional recommendations based on specific heart problems
that patients with essential hypertension may present:
|
Patient Characteristics |
Recommended Medications |
Possible Combinations |
Benefits |
|
Essential
hypertension with left ventricular hypertrophy (LVH) |
ACE inhibitors
or ARBs |
ACE
inhibitor/ARB + β-Blocker or ACE inhibitor/ARB + CCB |
Improve cardiac
function, reduce the risk of heart failure, and decrease mortality |
|
Essential hypertension with atrial fibrillation |
CCBs or
β-Blockers |
CCB + ACE
inhibitor or β-Blocker + ACE inhibitor |
Reduce
heart rate, improve cardiac function, and decrease mortality |
|
Essential
hypertension with heart failure with preserved ejection fraction (HFpEF) |
Diuretics |
Diuretic + ACE
inhibitor or diuretic + CCB |
Reduce fluid
buildup, improve symptoms, and decrease hospitalizations |
It's important to note that these recommendations are not exhaustive and
individual responses may vary. Treatment decisions should always be made
upon individual evaluation.
Chronic use of certain hypertension medications, particularly diuretics,
can lead to electrolyte imbalances that can harm the heart. Here are some
possible electrolyte imbalances that can occur with long-term use of
hypertension medications:
1. Hypokalemia (low potassium levels): This can
occur with the use of loop and thiazide diuretics, which can increase the
excretion of potassium in the urine. Low potassium levels can increase the risk
of arrhythmias and can worsen heart failure.
2. Hyponatremia (low sodium levels): This can occur
with the use of thiazide diuretics and can lead to symptoms such as confusion,
seizures, and coma.
3. Hyperkalemia (high potassium levels): This can
occur with the use of ACE inhibitors, ARBs, and aldosterone antagonists. High
potassium levels can increase the risk of arrhythmias and can be particularly
dangerous in patients with kidney disease.
4. Hypomagnesemia (low magnesium levels): This can
occur with the use of loop and thiazide diuretics, and can increase the risk of
arrhythmias and worsen hypertension.
It's important to note that these electrolyte imbalances may not occur in
all patients, and their occurrence may depend on individual responses to
medications and dietary factors. Monitoring of electrolyte levels is an
important part of long-term management of hypertension to ensure that potential
imbalances are detected early and appropriately managed.
TABLE for patients with essential hypertension and electrolyte imbalances, with a focus on how the imbalances can affect the heart:
|
Hypokalemia (low potassium) |
Loop and thiazide diuretics |
Increased risk of arrhythmias and worsening of heart failure |
T-wave flattening, U waves, ST segment depression, and prominent U waves |
|
Hyponatremia (low sodium) |
Thiazide diuretics |
Possible confusion, seizures, coma, and worsening of hypertension |
Possible QT interval prolongation and T-wave changes |
|
Hyperkalemia (high potassium) |
ACE inhibitors,
ARBs, aldosterone antagonists |
Increased risk
of arrhythmias, particularly in patients with kidney disease |
Peaked T waves,
prolonged PR interval, and widened QRS complex |
|
Hypomagnesemia (low magnesium) |
Loop and thiazide diuretics |
Increased risk of arrhythmias and worsening of hypertension |
QT interval prolongation and ST segment depression |
It's important to note that not all patients will develop these electrolyte imbalances, and that individual responses to medications and dietary factors can vary. Monitoring of electrolyte levels, particularly in patients at higher risk of developing imbalances, is an important part of long-term management of hypertension to ensure that potential imbalances are detected early and appropriately managed.
EXAMPLE-II PRESCRIPTION PLAN (increasing dosages over 4 months )
An example plan (EXAMPLE-II) prescribed by a primary care physician MD (Pratisyen Hekim ) for a 56 years old male patient to manage his hypertension over a period of 4 month. The patient presents to her primary care physician MD (Pratisyen Hekim ) with complaints of headaches, fatigue, and occasional dizziness. His blood pressure readings at home have been consistently high, with the latest reading being 150/95 mmHg. The patient has a history of hypertension, but has not been on any medications for the past year due to insurance coverage issues. His BMI is 28 kg/m2, and he has a family history of hypertension and cardiovascular disease. During the initial visit, the MD orders several lab tests, including a complete blood count, comprehensive metabolic panel, and lipid panel. The results show no abnormalities. The physician decides to start the patient on a medication regimen to lower his blood pressure. After considering the patient's medical history, comorbidities, and potential drug interactions, the MD prescribes the above table medication plan that involves gradually increasing the dosage and adding a diuretic as necessary.
In the first month, the patient is prescribed Losartan at a dosage of 25 mg for 4 weeks. If the patient's blood pressure remains uncontrolled, in the fourth month, the dosage is increased to Losartan/Hydrochlorothiazide 100 mg/25 mg for 4 weeks.
EXAMPLE - III PRESCRIPTION PLAN.
Dr.
Pratisyen Hekim, Tabip, MD, Physician
Tıp Doktoru Diploma No:
Tıp Doktoru Diploma Tescil No:
REFERENCES U.S Prevention Services Task Force. Hypertension in Adults: Screening. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hypertension-in-adults-screening. Published April 27, 2021.
1. What is the first-line
therapy for the general population with hypertension? a) ACE inhibitors b)
Thiazides c) ARBs d) Beta-blockers
2. What is the recommended medication for low-renin, salt-sensitive, volume-expanded black hypertensive patients with diabetes? a) ACE
inhibitors b) CCBs c) ARBs d) Thiazides
3. Which medication is
better at preventing heart failure than CCBs? a) ACE inhibitors b) ARBs
c) Thiazides d) Beta-blockers
4. What is the first-line
medication for patients with diabetes and hypertension? a) CCBs b) ACE
inhibitors or ARBs c) Thiazides d) Beta-blockers
5. What is the first-line
medication for patients with chronic kidney disease and hypertension? a) CCBs
b) ACE inhibitors or ARBs c) Thiazides d) Beta-blockers
6. What is the first-line
therapy for Black patients with hypertension? a) ACE inhibitors or ARBs b) CCBs
or Thiazides c) Beta-blockers d) ARBs
7. Which medication is less
effective at preventing stroke in Black patients? a) Thiazides b) ACE
inhibitors c) ARBs d) Beta-blockers
8. Which medication is the
first choice for patients with recent myocardial infarction or heart failure?
a) Thiazides b) Beta-blockers c) CCBs d) ARBs
9. Which medication is
preferred as the first-line medication for patients with stable coronary artery
disease? a) Beta-blockers b) CCBs c) Thiazides d) ACE inhibitors or ARBs
10. What is the recommended medication if you have to choose only one for Black patients with diabetic nephropathy? a) ARBs b) CCBs c) Thiazides d) ACE inhibitors
ANSWERS QUIZ-1
1. b) Thiazides
2. b) CCBs
3. a) ACE inhibitors
4. b) ACE inhibitors or
ARBs
5. b) ACE inhibitors or
ARBs
6. b) CCBs or Thiazides
7. d) Beta-blockers
8. b) Beta-blockers
9. d) ACE inhibitors or
ARBs
10. a) ARBs
QUIZ-2 Questions here
