1. So Many Pills, So Little Time! An Update on Hypertension Management
David Thomas, MD
University Hospitals
Internal Medicine Center
Independence, OH

3. Objectives
Understand the importance of diagnosing and treating hypertension
Identify types of hypertension
Understand the various therapeutic treatment options for HTN
Use the JNC 8 guidelines to make appropriate HTN management decisions
Identify clinical situations that warrant urgent treatment

4. What is Hypertension (HTN)?
Blood pressure elevated beyond normal range

5. HTN Definitions
Normal BP: systolic <120 mmHg and diastolic <80 mmHg
Prehypertension: systolic mmHg or diastolic mmHg
HYPERTENSION!!:
Stage 1: systolic mmHg or diastolic mmHg
Stage 2: systolic >/160 or diastolic >/100
Ref: JNC 7

6. European Definitions, FYI
3 Categories prior to HTN:
“optimal”
“normal”
“high normal”

7. Prevalence 29-31% of adults in the US*
76.4 million Americans over age 20
~8% of adults have undiagnosed hypertension
Of those with HTN, only 50% have BP under control**
Why? – “Therapeutic Inertia?”
*NHANES (National Health and Nutrition Examination Survey )
**JNC 8 in JAMA 2014; 311:507

8. Prevalence Most common reason for office visit
Most common use of prescriptions
Most common risk factor for MI or stroke

9. Risk Factors Age Kidney Disease Obesity High Sodium Diet
Excessive Alcohol
Diabetes
Family History
Race
Personality Traits
(Hostile, Impatient, Depressed)

10. Drugs That Cause HTN SSRIs Glucocorticoids NSAIDs OCPs
Decongestants (e.g., pseudephedrine)
ADHD meds (e.g., methylphenidate)
Weight loss meds (e.g., phentermine)

11. Why Is This Important? HTN will kill you…Eventually Heart attack
Heart Failure
Renal Failure
Stroke (most important risk factor!)

12. Interesting
Systolic pressure is greater predictor of risk in patients >50*
Diastolic pressure is better predictor of mortality <50*
*J. Gen Intern Med 2011; 26:685

13. Screening Adults >/40 should have BP checked at least annually
Adults BP checked at least annually if risk factors (e.g., obesity) or if BP /85-89
Adults with BP <130/80 should have BP checked at least every 3 years

14. Diagnosis
2 or more properly measured readings at each of 2 or more office visits after an initial screening
Readings spread out over time

15. Proper BP Measuring Technique
Quiet room
Sitting for 5 minutes
Back supported
Arm supported at heart level
Legs uncrossed
Feet flat on floor
No talking
Hand not clenched

16. Initial Testing BMP Fasting glucose Urinalysis Lipid profile EKG
Can consider Echo, albuminuria

17. Non-Pharmacological Therapy
MORE
LESS
LESS

18. Non-Pharmacological Therapy
Salt Restriction
Normotensive individual reduction: 1.9/1.1 mmHg
Hypertensive individual reduction: 4.8/2.5
Weight Loss
Roughly 1 mmHg for every 1 pound lost!!!!!
Limit alcohol to 2 drinks/day in men and no more than 1/day in women: ~3/1

20. Non-Pharmacological Therapy
DASH Diet
High in veggies, fruits, low-fat dairy, whole grains, poultry, fish, nuts (thus high in K, Mg, Ca, protein, fiber…low in saturated fat, total fat, cholesterol)
Low in sweets, sugary beverages, red meats
Decreased BP by 6/4 compared with typical American diet despite containing same amount of Na and same calories

22. Non-Pharmacological Therapy
EXERCISE
40 minutes of aerobic exercise (e.g., brisk walking) 3-4 times/week decreases BP by ~5/3, independent of weight loss

24. Pharmacological Therapy
Degree of blood pressure reduction matters, not the choice of drug
Most patients will require more than one BP med
J Hypertens 2013;21:1281

25. Which Med to Choose???

26. Initial Monotherapy FIRST LINE TREATMENT
OFFICIAL ANSWER
**Any of these according to JNC 8/ESH**
Long Acting Calcium Channel Blocker
Angiotensin-Converting Enzyme (ACE) Inhibitor
Angiotensin Receptor Blocker
Thiazide Diuretics

27. IMPORTANT!
NOTE: Beta blockers are no longer recommended for initial monotherapy unless there is a specific reason (e.g., ischemic heart disease; systolic HF)

28. Initial Monotherapy FIRST LINE TREATMENT
Long Acting Calcium Channel Blocker
Angiotensin-Converting Enzyme (ACE) Inhibitor
Angiotensin Receptor Blocker
Thiazide Diuretics

29. Medication Examples: Long Acting Calcium Channel Blocker
Amlodipine 5-10mg daily
Start 5mg
Caution with leg swelling or constipation at higher dose
Pearl: don’t have to monitor labs as much
Nifedipine ER 30-90mg daily
Start mg
Don’t use immediate release form for HTN

30. Which Med to Choose?? FIRST LINE TREATMENT
Long Acting Calcium Channel Blocker
Angiotensin-Converting Enzyme (ACE) Inhibitor
Angiotensin Receptor Blocker
Thiazide Diuretics

31. Medication Examples: ACE-Inhibitor
Lisinopril 5-40 mg daily
Start usually 10mg daily
Caution with hyperkalemia, angioedema
Check BMP ~1 week after starting to monitor K and renal function
Pearl: if dry cough, can switch to ARB
Other options: Ramipril, benazepril, trandolapril

32. Which Med to Choose?? FIRST LINE TREATMENT
Long Acting Calcium Channel Blocker
Angiotensin-Converting Enzyme (ACE) Inhibitor
Angiotensin Receptor Blocker
Thiazide Diuretics

33. Medication Examples: ARB
Losartan mg daily
Start 50mg
Caution: hyperkalemia, angioedema, dry cough
Check BMP ~1 week after starting to monitor K and renal function
Other examples: irbesartan, olmesartan, valsartan, cadesartan

34. Which Med to Choose?? FIRST LINE TREATMENT
Long Acting Calcium Channel Blocker
Angiotensin-Converting Enzyme (ACE) Inhibitor
Angiotensin Receptor Blocker
Thiazide Diuretics

35. Medication Examples: Thiazide Diuretic
Hydrochlorothiazide (HCTZ) mg daily
Start mg
Caution: hyponatremia, hypokalemia, hypercalcemia, gout, muscle cramps
Monitor metabolic panel periodically
Pearl: duration of action is <24 hours
Chlorthalidone mg daily
Start mg
Pearl: actually works for 24 hours
Pearl: ~twice as strong as HCTZ
Most studies were actually done with this medication, not HCTZ!

36. Initial Monotherapy SPECIAL CASES
African Americans: Thiazide or long-acting calcium channel blocker
Diabetic Nephropathy: ACE/ARB

37. Dual Therapy
If BP is more than 20/10 mmHg above goal, should start 2 meds
Combo therapy with drugs from different classes has substantially greater BP-lowering effect than doubling dose of single agent*
*Circulation 2007; 115:2761

38. Goal BP* General population age <60 yo: <140/90 mmHg
Age 60-79: <150/90, but consider 140/90 lower based on individual
Age 80 and older: <150/90
If CKD, DM, <140/90 regardless of age
*JNC 8

39. Monitoring
After starting BP meds, patient should be reevaluated and therapy should be increased every 2 to 4 weeks until adequate BP control is achieved.
After adequate control, monitor patients every 3 to 6 months

40. Refractory HTN Other Options
Beta Blockers (carvedilol, metoprolol, atenolol, propranolol,labetalol)
Vasodilators/nitrates (hydralazine, isosorbide mononitrate)
Central Alpha Agonist (clonidine, methyldopa)
Alpha Blocker, Peripheral: (doxazosin, prazosin, terazosin)

41. Twofers- Elegance and Style Points
Migraines + HTN: Beta blocker
Essential Tremor: non-cardioselective beta blocker (propranolol)
Osteoporosis: Thiazide diuretic
Raynaud’s: Dihydropyridine Ca channel blocker (nifedipine)
BPH: alpha blocker (doxazosin)
Pregnancy: labetalol, methyldopa

42. Which Med to Choose?? My Opinion
First choice: Amlodpine (Norvasc)
Then Lisinopril
Use Chlorthalidone instead of HCTZ
Lasix is not a BP med
***NOTE: If taking 3 antihypertensive meds, 1 of them should be a diuretic***

43. Hypertensive Urgency BP >180/110
If HA, EKG changes, vision changes, then need ED
Do not decrease MAP by more than 25-30% over short period of time
Can restart home meds if non-compliant
Can use clonidine 0.2mg x 1
Initial goal is <160/100
Eventual goal <140/90

44. Thank you! Questions? David Thomas, MD University Hospitals Internal Medicine Center Independence, OH