Block 3: clinical aspects of antihypertensive therapy
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- what is the most common contributory factor for morbidity and mortality from CVD, CVA, and renovascular disease
- essential hypertension
- if untreated, a 35 yo man with BP of 150/100 has his life expectancy reduced by...
- 28 years
- individuals who are normotensive at age 55 have a __% lifetime risk for developing hypertension
- 90%
- What percentage of individuals have inadequate control of their hypertension
- 66%
- Name three populations where hypertension (HTN) is most prevalent
-
men
elderly
African-Americans - Has HTN related mortality increased or decreased significantly in the last two decades
- decreased significantly
- How often do HTN clusters with metabolic abnormalities of obesity, glucose intolerance, and dyslipidemia occur?
- less than 20% of the time
- what appears to be the common hormonal inciting event for HTN
- insulin resistance
- again BP =
-
CO x PVR
= HRxpreload/afterload x contractility x PVR - What is salt sensitive BP related to (increased sodium intake increases BP)
- low renin BP (as opposed to high renin BP)
- what's the work up for HTN
-
PE- fundi, carotids, thyroid, lungs, heart, abdomen, pulses, lower extremities
Lab- CBC, CHEM-7, calcium, lipid profile, U/A, 12 lead EKG -
what is prehypertension (in terms of systolic pressure, diastolic)
when would you use drugs -
120-139 over
80-89
use drugs to treat BP to 130/80 for kidney disease and diabetes -
what is hypertension stage 1?
what drugs to use? -
140-159 over
90-99
thiazide type diuretics
consider ACEI, ARB, BB, CCB, or combo -
what is hypertension stage 2?
what drugs regimen? -
>160 over
>100
two-drug combos - Name five classes of drugs acceptable for heart failure
-
diuretic
beta blocker
ACE inhibitor
angiotensin receptor blocker
aldosterone antagonist - Name three classes of drugs for post MI
-
beta blocker
ACEI
aldosterone antagonist - Name four classes of drugs for high coronary disease risk
-
diuretic
beta blocker
ACEI
calcium channel blocker - Name five classes of drugs for diabetics
-
diuretic
beta blocker
ACEI
angiotensin receptor blocker
calcium channel blocker - name two classes of drugs for chronic kidney disease
-
ACEI
angiotensin receptor blocker - name two classes of drugs for recurrent stroke prevention
-
diuretic
ACEI - treatment goal for HTN is
- <140/90
-
quantify the lifestyle modification shown to reduce blood pressure
weight reduction by...
regular physical activity of...
reduced alcohol intake to ...
reduced dietary sodium to... -
weight 10 lbs or more
work out 30 minutes most days
<1 oz ethanol per day
<2.4 gm sodium per day - Name five components for the HTN treatment algorithm
-
1. lifestyle modification
2. drug monotherapy
3. substitute new class of drug or add second drug
4. add third drug
5. begin with two drugs if BP stage 2 - this class of drug decreases PVR; is good with young athletes, in situations of mild renal failure, but drawbacks include cough, hyperkalemia, and precipitation of acute renal faiulre if used in HTN secondary to renal artery stenosis
-
ACEI
(the "ils") - this class of drugs has a low incidence of side effects, no potentiation of bradykinin system, no cough, and may be helpful in young athletes, mild renal failure, CHF, DM, and renal disease
- angiotensin II receptor blockers (the "sartans")
- this class of drugs decreases heart rate and cardiac output; they are cadioprotective post MI and are also useful in migraine and angina patients because of this physiology; they may however aggravate asthma and CHF or cause impotence and depression
- beta blockers
- this class of drug has a PROVEN IMPACT ON MORBIDITY AND MORTALITY IN HYPERTENSION
- beta blockers
- this class of drugs decreases PVR, lowers heart rate and contractility; is useful in the elderly and patients with angina, or dyslipidemia; side-effects include constipation, AV block, and flushing or edema
- calcium channel blocker
- What did the Puget sound study show
- 60% increase in MI for hypertensive patients on short acting dihydropyridines (nifedipine, amlodipine)--> long acting agents should be used instead
- this class of drugs is one of the original and still among the best for HTN; reduces extracellular fluid volume; works particularly well in African Americans and elderly; BEST DOCUMENTED REDUCTIONS IN MORBIDITY AND MORTALITY; disadvantages include lipide
- diuretics
- this class of drugs is useful in prostatic hypertrophy and dyslipidemia
- alpha-1-blockers
- this class of drugs is not first line but may have other advantages such as a weekly patch
- central alpha-2 agonists
- Name four common co-morbid ailments found in hypertensives
-
arthritis
DM
COPD
CHF - what class would you give a type I diabetic
- ACEI
- what class would you give to patient with heart failure
- ACEI, diuretic
- what classes would you give with isolated systolic hypertension
- diuretic, calcium channel blocker
- what classes would you give for MI
-
beta blocker
ACEI - ___ has been virtually unsurpassed in preventing the CV complication of HTN but remains underutilized
- diuretics
- What is normal follow up for HTN
-
initial follow up in 1-2 mo
then 3-6 mo if HTN well controlled - what is "step-down" care
-
when BP is well controlled for 1 yr and the patient has no evidence of target organ damage, medication may be tapered and thn stopped if BPs remain below 130 over 85
follow should continue every 2 mo - in hypertensive emergency- which requires immediate control to prevent/reduce target organ damage- what drug is used for MI? for aortic dissection? for eclampsia?
-
NTG for acute MI
esmolol in aortic dissection
hydralazine in eclampsia - what is the goal of hypertensive emergency treatment
- reduce mean arterial pressure by 20-25% within minutes to 2 hours, then gradually to 160/100
- what drug is completely unacceptable in treating urgent hypertension
- short acting nifedipine- may precipitate acute MI or hypotension
- what is defined as inability to lower blood pressure despite maximal doses of 3 antihypertensive agents
- refractory hypertension
- what causes 43% of refractory hypertension
- sub-optimal therapy
- in persons older than 50, systolic pressure greater than ___ is much more important CVD risk factor than diastolic BP
- 140
- risk of CVD beginning at 115/75 doubles with each increment of ___
- 20/10 mmHg
- individuals with systolic BP of 120-139 or diastolic BP of 80-89 should be considered ___ and require ___
-
pre-hypertensive;
health-promoting lifestyle modifications - ___ should be used in drug treatment for most patients with uncomplicated HTN
- thiazide diuretics
- most patients with HTN will require ___ to achieve goal BP (<140/90, or <130/80 for patients with diabetes or chronic kidney disease)
- two or more antihypertensive drugs
- if blood pressure is ___ above goal BP, consideration should be given to initiating therapy with two agents, one of which usually should be a thiazide type diuretic
- >20/10 above goal
- the most effective therapy presecribed by the most careful clinician will control hypertension only if patients are ___
- motivated