Under what circumstances/which patients should you initiate anti-hypertensives?
- All patients w/ Stage 2 HTN
- Patients w/ Stage 1 HTN w/ 1+ of the following:
- ASCVD (atherosclerotic cardiovascular disease)
- DM type 2
- CKD (chronic kidney disease)
- 10 year ASCVD risk at least 10%
What is the goal BP of a patient on anti HTN meds?
< 130 / 80
What is the goal BP for a patient with “low risk Stage 1 HTN” who does not qualify for medications?
< 140 / 90
Patients over age 60 yrs w/ isolated systolic HTN, what BP value do you need to be careful with?
Why?
- CAUTION, do not lower DBP <55 to 60 mmHg
- Low DBP is assocated w/ increassed risk of MI and stroke
3 treatment options for HTN
- Patient Education
- 20% unaware of dx
- 54% who have HTN do not have it controlled
- Lifestyle changes / “Non-Pharm”
- Pharmacologic interventions
What are 3 “Dietary Modifications” HTN patients can make?
- Salt restriction (decrease of 5/3)
- DASH diet (decrease of 6/4)
- ETOH reduction (decrease of 2-4 SBP)
DASH - dietary approach to stop HTN
What are 3 Non-Pharm tx options for HTN other than dietary changes?
- Weight loss (1 mmHg per 1 lb)
- Exercise (4-6 / 3 mmHg)
- Smoking cessation
8 pharmacologic tx options for HTN
“BRADACAA”
B: Beta Blockers
R: Direct Renin Inhibitor
A: ACE-I
D: Diuretics
A: ARB
C: Calcium Channel Blockers
A: Central Alpha Agonists
A: Alpha Blockers
Which med for HTN?
- works well for most people/good starting point
- Inhibits Na reabsorption in the nephron (increasing Na and H2O excretion)
Diuretics
Which med for HTN?
- Will control BP in 50% of pts w/ mild - moderate HTN
- Can effectively be used in combo w/ ALL other agents
- More potent in blacks, elderly, obese, smokers
Diuretics
What are the 4 types of Diuretics?
- Thiazides
- Loop diuretics
- K sparing
- Aldosterone antagonists
Which HTN med?
- Side effects:
- Hyperuricemia (gout)
- Dyslipidemia
- Hypokalemia
- **If pt is placed on this med, consider regular screening of glucose and lipids**
- **DO NOT supplement w/ potassium**
Thiazide Diuretics
(Hydrochlorothiazide)
(Hydrodiuril)
Contraindications of Thiazide Type Diuretics?
Hypersensitivity to sulfonamide derived drugs
Which HTN med?
- Side Effects:
- Hypokalemia
- Hypercholesterolemia
- **SUPPLEMENT w/ potassium**
- Poor antihypertensive
- Reserved for patients w/ what 2 things??
Loop Diuretics
- Reserved for pts w/ kidney disease or fluid retention
Which HTN med?
- Not AS GOOD at lowering HTN (weak anti-HTN)
- Not commonly 1st line (usually)
- Usually an “add on” to Loop Diuretic
- Side effects:
- Nephrolithiasis
- Renal dysfunction
- Hyperkalemia (esp w/ CKD or DM)
Potassium Sparing Diuretics
(Triamterene)
(Dyrenium)
What are 4-ish contraindications of Potassium Sparing Diuretics?
- CAUTION combining w/:
- ACE-I
- ARB
- DRI (direct renin inhibitor)
- K supplements
- Hepatic disease
- Renal failure
- Hyperkalemia
Which HTN med?
- “Add on” / not 1st line
- Rx for HTN which is hard to control
- Side effects:
- Gynecomastia
- Hyperkalemia
- This drug is technically a K sparing diuretic, but is more potent as an anti-HTN
Aldosterone Antagonists
(Spironolactone)
(Aldactone, Aldactazide)
3 Contraindications for Aldosterone Antagonists
- Renal impairment
- DM w/ proteinuria
- Hyperkalemia
Calcium Channel Blockers
- Inhibition of Ca influx into which 2 types of cells?
- Decreased Ca inhibits the contractile process leading to what? What effect does it have?
- Myocardial cells
- Vascular smooth muscle cells
- Leads to Vasodilation
- Effect: reduced peripheral vascular resistance
What are the 2 types of Calcium Channel Blockers?
- Non-dihydropyridines (verapamil, diltiazem)
- Dihydropyridines
Which type of CCB?
- More of a “cardiac depressant effect”
- Decrease HR
- Decrease CO
Non-dihydropyridines
(verapamil, diltiazem)
Which type of CCB?
- More selective as vasodilators
- Less cardiac depressant effect
Dihydropyridines
“dipine”
Ends in “dipine”
CCB - Dihydropyridines
(selective vasodilators)
Has an increased efficacy in blacks and elderly
CCB
