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p2019b1 Sample PDF
p2019b1 Sample PDF
Learning Objectives
1. Distinguish between the recommendations for hypertension management among recent hypertension- and disease-specific
guidelines.
2. Justify blood pressure goals for individual patients on the basis of the primary literature and hypertension guidelines.
3. Apply understanding of blood pressure results and measurement technique to a patient case.
4. Design an evaluation and treatment plan for a patient presenting with hypertension.
Introduction
Abbreviations in This Chapter
Hypertension Overview
AAFP American Academy of Family
Physicians Blood pressure elevations are associated with an increased risk of
ABPM Ambulatory blood pressure cardiovascular (CV) disease in a linear fashion. Starting at a blood
monitoring pressure of 115/75 mm Hg, every increase of 20 mm Hg in systolic
ACC American College of Cardiology blood pressure (SBP) and/or increase of 10 mm Hg in diastolic blood
ACP American College of Physicians pressure (DBP) is associated with a doubling of the risk of death from
AHA American Heart Association stroke, heart disease, or other vascular disease (Lewington 2002).
AOBP Automated office blood pressure Increases in SBP have the strongest link with CV disease, though
ASCVD Atherosclerotic cardiovascular other blood pressure components have been linked to CV disease as
disease well, including DBP, pulse pressure, blood pressure variability, and
CV Cardiovascular mean arterial blood pressure (Whelton 2018; Muntner 2015).
JNC Joint National Committee This chapter will review the new recommendations for blood pres-
MRA Mineralocorticoid receptor sure management and will focus on the pharmacotherapy of hyper-
antagonist
tension. Because hypertension is largely managed with drug therapy,
RAS Renin-angiotensin system
clinical pharmacists often participate in management, especially
TOD Target organ damage
when hypertension may be difficult to manage because of factors
such as adverse effects or resistant hypertension.
Table of other common abbreviations.
Hypertension Epidemiology
The prevalence of hypertension in U.S. adults has continued to
increase. In 2018, the American Heart Association (AHA) heart dis-
ease and stroke statistics update reported that about 34% of U.S.
adults had hypertension, using a diagnostic SBP/DBP threshold of
140/90 mm Hg (Benjamin 2018). However, the American College of
Cardiology and AHA (ACC/AHA) 2017 blood pressure guidelines low-
ered the threshold for the diagnosis of hypertension to an SBP/DBP
of 130/80 mm Hg, which led to a new hypertension prevalence of 46%
of U.S. adults. Despite the 12 percentage point increase in prevalence
with the lower diagnostic threshold, the 2017 ACC/AHA blood pres-
sure guideline estimates that only an additional 2% of patients will
be recommended antihypertensive medications because the new
guideline does not recommend that all patients with blood pressure
BP Categoriesa
SBP DBP
BP Targets (mm Hg) (mm Hg)
JNC 8, 2014 < 150/90 mm Hg for patients ≥ 60 Was not a comprehensive set of recommendations, and did
< 140/90 mm Hg for patients < 60, diabetes, not discuss hypertension diagnostic thresholds
and chronic kidney disease
ACP/AAFP, 2017 < 150/90 mm Hg for patients ≥ 60 Was not a comprehensive set of recommendations and did
< 140/90 mm Hg for patients at higher CV not discuss hypertension diagnostic thresholds
risk, or with a history of stroke or TIA Did not address recommendations in patients < 60
Stage 1 hypertension b
130–139 80–89
a
Patients with SBP and DBP in two different categories should be classified in the higher category.
b
Antihypertensive medication should be initiated in stage 1 hypertension only in patients with clinical CV disease, a 10-year risk of
ASCVD of 10% or higher, diabetes mellitus, or chronic kidney disease.
BP = blood pressure; TIA = transient ischemic attack.
MRA Hypokalemia, HFrEF, Advanced kidney disease, hyperkalemia, hormonal Spironolactone is better studied in
proteinuria, edema effects with spironolactone resistant hypertension; consider
eplerenone for spironolactone
intolerance because of
antitestosterone effects
β-Blocker HFrEF, MI, atrial Bradycardia, asthma
fibrillation,
tachycardia, migraine
prophylaxis, tremor
α-Blocker BPH, ED, PTSD/ Orthostatic hypotension
nightmares
Hydralazine HFrEF (in combination Adherence problems with TID dosing, drug-induced
with nitrates) lupus, increased BP variability, reflex tachycardia
Minoxidil Very resistant Often profound salt and water retention. Reflex Give in conjunction with loop
hypertension tachycardia, hirsutism, pericardial effusion diuretic and rate control agent
Central Anxiety disorders, Anticholinergic effects, sedation, and cognitive
α-agonist ADHD effects may be especially pronounced in older
adult patients. Rebound hypertension and/
or bradycardia may be exacerbated in patients
receiving β-blockers. Skin irritation and/or
adhesion problems with clonidine patch
ADHD = attention-deficit/hyperactivity disorder; BPH = benign prostatic hyperplasia; ED = erectile dysfunction; HFrEF = heart failure with
reduced ejection fraction; MRA = mineralocorticoid receptor antagonist; PTSD = posttraumatic stress disorder; TID = three times daily.
Answer
The first step in determining the best modification to the The patient is hyponatremic, likely from hydrochlo-
patient’s regimen is to confirm the accuracy of the blood rothiazide. Therefore, hydrochlorothiazide cannot be
pressure results. For example, ensure that the patient was titrated to treat the uncontrolled hypertension and should
resting for at least 5 minutes before blood pressure mea- be discontinued. If this patient were not hyponatremic,
surement, that she was properly positioned, and that she changing from hydrochlorothiazide to chlorthalidone as
was not talking during measurement. Furthermore, if the the more effective thiazide diuretic could be considered.
blood pressure reading is a single measurement, repeat it The most rational adjustments to her regimen would
and use the average of two readings. be to discontinue the fixed-dose lisinopril/hydrochloro-
Next, assess adherence, especially before the ED thiazide and to change to lisinopril at the higher dose of
visit. If antihypertensives have been discontinued, rein- 40 mg daily. Given that this alone is unlikely to lower blood
stating medication rather than adding or increasing pressure sufficiently to her goal of less than 130/80 mm
doses may be best. It is also important to determine Hg, titration of amlodipine to 10 mg daily is also needed.
how much “as-needed” clonidine she has taken since However, that adjustment could be done at a follow-up
the ED visit. visit within 1–2 weeks if there are concerns about making
additional medication changes in one visit.
1. W helton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the pre-
vention, detection, evaluation, and management of high blood pressure in adults. J Am Coll Cardiol 2018;71:e127-e248.
2. Leung AA, Wright A, Pazo V, et al. Risk of thiazide-induced hyponatremia in patients with hypertension. Am J Med 2011;124:1064-72.
Clevidipine Avoid in those with allergy to soy or eggs, those with severe aortic stenosis
or with defective lipid metabolism
Effects occur within 2–4 min
Cost may affect availability
Dopamine agonist Fenoldopam Ideal for nephropathic emergencies. Cost may affect availability
ACEI Enalaprilat Does not require hepatic activation; enalaprilat is the active form of enalapril
and is 10–20 times as potent as captopril
Avoid in acute coronary syndrome
DHP = dihydropyridine.
Information from: Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA
guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. J Am Coll Cardiol
2018;71:e127-e248.
also raise blood pressure. Corticosteroids raise blood pres- treating hypertension related to VEGF inhibitors; in refractory
sure through their mineralocorticoid effects; MRAs may be cases, nitrates or nebivolol may be appropriate because they
especially beneficial in patients with resistant HTN related to specifically address the nitric oxide deficiency (Touyz 2018).
chronic corticosteroid use. Atypical antipsychotics, particu-
larly olanzapine and clozapine, cause a variety of metabolic
Difficult-to-Treat
derangements, including hypertension. If alternative drugs
Hypertension
cannot be substituted, aggressive lifestyle interventions and
intensification of pharmacotherapy are usually necessary. Resistant Hypertension
Vascular endothelial growth factor (VEGF) inhibitors such Resistant hypertension is defined as blood pressure that
as bevacizumab induce nitric oxide deficiency. Endothelial remains above goal despite the concurrent use of three anti-
nitric oxide deficiency inhibits arterial vasodilation; inhibiting hypertensive agents of different classes. Ideally, one of these
renal nitric oxide signaling adds salt and fluid retention as an agents should be a diuretic, and the other agents should be
additional mechanism for exacerbating hypertension. Hyper- prescribed at maximally tolerated doses. A companion defini-
tension is well recognized as a problem among patients using tion of resistant hypertension is blood pressure that requires
these drugs for cancer treatment. However, smaller-dose, intra- four or more medications to maintain control (Calhoun 2008).
vitreal injections of VEGF inhibitors used for retinal disorders The exact prevalence of resistant hypertension is unknown,
are also commonly associated with hypertension (Fiebai 2017). in part because of pseudoresistance, in which blood pressure
Calcium channel blockers and diuretics are often effective for is uncontrolled because of factors such as nonadherence,
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