Treatment of Hypertension
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- Why is the blood pressure goal lower for patients with diabetes, chronic kidney disease, and coronary artery disease?
- Because these patients are at a higher risk for CV disease than others with the same BP values and no secondary diseases.
- Treatment recommendations: normal BP
- Lifestyle modifications: yes Pharmacological Tx: no
- Treatment recommendations: prehypertensive BP
- Lifestyle modifications: yes Pharmacological Tx: no, unless they have diabetes, CAD, or chronic kidney disease and are not at goal (i.e. not less than <130/80)
- Tx recommendations: stage 1 hypertensive
- Lifestyle modifications: yes Pharm Tx: yes
- Tx recommendations: stage 2 hypertensive
- Lifestyle modifications: yes Pharm Tx: yes
- What 5 lifestyle modifications are recommended?
- 1. Weight loss 2. Adopt DASH eating plan 3. Restrict dietary Na+ intake 4. Physical activity 5. Moderation of alcohol consumption
- Which lifestyle modification has the greatest influence on decreasing BP?
- Weight loss. 10 kg weight loss = 5-20 mmHg drop in BP.
- DASH eating plan
- Eating plan for lowering BP that is low in fat and high in fiber
- Algorithm for treatment of HTN: what is the first thing to do?
- Lifestyle modifications
- If a patient tries lifestyle modifications and does not reach goal BP (<140/90 or <130/80 for those with CAD, diabetes, CKD), what is the next step?
- Pharmacological therapy
- Pharmacological therapy is divided into two arms. What are they?
- Without compelling indications With compelling indications
- Drug choices- Without compelling indications: Stage 1 HTN
- Thiazide diuretics. (May consider ACEI, ARB, BB, CCB, or combination)
- Drug choices- without compelling indications: Stage 2 HTN
- Combination of thiazide diuretic + ACEI/ARB/BB/CCB
- Drug choices- compelling indications
- Other hypertensive drugs (diuretics, ACEI, ARBs, CCBs, BBs) as needed
- What happens if people receiving pharm Tx for HTN still do not reach goal BP?
- Optimize dosages or add additional drugs until goal is achieved
- Name the most common hypertension drugs (5)
- 1. Thiazide diuretics 2. ACE-inhibitors 3. ARBs 4. Beta blockers 5. Calcium channel blockers
- Stage 1 hypertensives without compelling indications: drugs
- Thiazide diuretics
- Stage 2 hypertensives without compelling indications: drugs
- Thiazide diuretics + ACEI/ARB/BBs/CCBs
- Reconciling ALLHAT with ACCOMPLISH study results
- ALLHAT result: diuretics are the best initial therapy for HTN. ACCOMPLISH result: calcium channel blocker + ACE-inhibitor is the best combination of drugs for treatment of HTN. One interpretation is that diuretics should be a third-line therapy after combo of ACE-inhibitor and calcium channel blocker. Opposing interpretation is that diuretics should be first-line therapy, but choice of diuretic is critical.
- HYVET study
- This study showed that treating HTN in the elderly is beneficial. Used to think antihypertensives could cause hypoperfusion and falls in the elderly, but this study showed that antihypertensives had clear benefits in people over 80. Conclusion: treat elderly HTN!
- Which antihypertensives are the best tolerated? Worst tolerated?
- Best tolerated- ARBs Worst tolerated- thiazide diuretics
- T/F. Most patients with hypertension usually have no other risks.
- FALSE. Usually have other risk factors in conjunction with HTN.
- How should you treat a patient with HTN and other risks as well?
- Treat not only the HTN but the other risks too, because together they have a compounded effect on increasing risk of CV disease.
- T/F. Just as there is a compounding effect to increasing the risk for CV disease, there\'s also a compounding effect to reducing risk for CV disease.
- True. Even small reductions in different risk factors (i.e. lowering BP and stopping smoking) can greatly reduce the risk for mortality.
- Benefit of treatment of hypertension
- Significantly lowers CV risk, including the very elderly
- Treatment of hypertension- components
- 1. Pharmacological (ACE inhibitors, ARBs, aldosterone inhibitors, calcium channel blockers, beta blockers, diuretics) 2. Non-pharmacological- lifestyle modifications
- What is the benefit of antihypertensive treatment attributed to?
- The amount of lowering of the BP and less to the types of agents used. So the drugs used don\'t have as much an effect on lowering CV mortality as the actually reduction in BP itself.
- Most patients will require _________ agents to treat HTN
- 2-3; the order of agents is unresolved
- What must you also assess when treating hypertension?
- Other risk factors- treat these too, because the compounding effect on reducing risk for CV mortality.
- What is the biggest impediment to blood pressure control?
- Poor adherence