1. Hypertension  Classification of hypertension  BP targets  Basic evaluation  When to evaluate for secondary causes  Which drug(s) you should use  Classes of antihypertensives

2. Classification of blood pressure in adults BP classification SBP (mmHg) DBP (mmHg) Normal < 120 and < 80 Prehypertension120-139 or 80-89 Stage 1 hypertension 140-159 or 90-99 Stage 2 hypertension >=160 or >= 100

3. Target BP  Patients with diabetes and CKD – 130/80  Everybody else – 140/90

4. Basic evaluation  History –HPI – onset of hypertension, antihypertensives (which ones used, side effects), severity of hypertension –PMH – all drugs used including OTC meds, herbals; other medical conditions –FH – specifically hypertension, renal disease –SH – EtOH, salt intake, increase in weight –ROS – HA, palpitations, sweating, thyroid sxs  Physical –BP in both arms –fundoscopic exam –thyroid exam –heart, lungs –abd – specifically listen for bruits –ext – pulses, edema

5. Initial labs  BUN, creat(eGFR), urinalysis  Calcium  K  TSH

6. When to eval for secondary causes  When basic eval suggests a secondary cause – e.g. variable BP, HA, palpitations, sweating – pheo; severe hypertension in a young female or sudden worsening of hypertension in an older person – renovascular hypertension  When history is not consistent with essential hypertension (positive FH, onset in 20’s, initially mild)  For resistant hypertension – elevated BP when patient is reliably taking adequate doses of three antihypertensives, one of which is a diuretic

7. First drug with no other medical problems  Anything would work (the most important thing is to control the blood pressure)  Diuretics have been the most thoroughly studied and are safe, effective and inexpensive  I recommend starting with chlorthlidone 12.5 qd; if the BP is not controlled I would add lisinopril

8. Compelling indications  CHF – ACE, ARB, BB, Aldo ant; also diuretics  Post-MI – BB, ACE  High CAD risk – BB, ACE; also diuretics, CCB  Diabetes – BB, ACE, ARB; also diuretics, CCB  CKD – ACE, ARB  Recurrent stroke prevention – ACE; also diuretics  BPH (not in JNC VII) – α-blocker

9. Second and third drugs  If first drug is not a diuretic second one should be (almost all non-diuretic antihypertensives result in sodium retention which limits their efficacy)  Best 3 drug combo is appropriate dose of a diuretic, an ACE inhibitor and a calcium channel blocker

10. Diuretics  Thiazides –qd for BP; chlorthalidone making a comeback  Loop –GFR < 30 - 50 –bid for BP (except for torsemide which is qd)  Aldo antagonists –primary aldo and aldo mediated hypertension more common than previously thought so consider these drugs in resistant BP –spironolactone – 25 qd is usually sufficient –eplerenone has few hormonal side effects but is very expensive (is half as potent as spironolactone)

11. Calcium channel blockers  Decrease tone of LES/dose-dependent edema/can be used together  Dihydropyridines – glomerular pressure in CKD so don’t use as first BP drug; OK if patient already on ACE or ARB –amlodipine is generic and has long half life without delivery system  Diltiazem – glomerular pressure in CKD –neg inotrope and chronotrope  Verapamil – glomerular pressure in CKD –neg inotrope and chronotrope –all older patients get constipated

12. ACE inhibitors  16% get dry cough, can start > 1 year after starting ACE  Angioedema  Captopril is short acting  Work great with diuretic

13. Angiotensin receptor blockers  No cough  8% of patients who get angioedema with ACE get it with ARB  Probably like an ACE without the cough  ONTARGET trial (25,000 patients with vascular disease or DM with end-organ damage) – proteinuria was decreased but CV outcomes and renal function were worse in patient treated with combo ACE/ARB as opposed to either drug alone

14. Renin antagonists (aliskiren)  Very few clinical trials  Very expensive  No cough  Can cause angioedema

15. ß-blockers  Use metoprolol, not atenolol  Metoprolol XL is now generic so is probably the preferred ß-blocker  Lower BP by decreasing renin levels so add little BP lowering to ACEs or ARBs

16. α-blockers  Some risk of precipitating CHF  Only indication is BPH  First dose syncope can occur after stopping/restarting med or increasing dose  Tamsulosin is much better than doxazosin or terazosin for BPH so often times I am switching metoprolol to carvedilol instead of using doxazosin or terazosin

17. Direct vasodilators  Hydralazine rarely indicated –frequent dosing –drug induced lupus –possibly indicated in patient with CHF who gets angioedema on ACE/ARB  Minoxidil –Extremely potent and effective –Hirsutism is a problem in females –Can cause severe fluid retention, tachycardia and pericarditis so should probably only be used by hypertension specialists

18. Centrally acting agents  Clonidine –short acting so good for EtOH withdrawal or hypertensive urgencies –bedtime dose can be used for patients with PTSD –clonidine withdrawal can be severe – it is caused by rebound increase in centrally mediated α and β adrenergic stimulation; when patients are also on a β- blocker unopposed α stimulation can increase the BP –rash frequent with patch

19. Rules of thumb  Never use ß-blocker and clonidine together  Never use ß-blocker and verapamil together  Be careful when using a ß-blocker and dilt together  Never use 10 mg of furosemide  A 25% increase in creat after starting an ACE is good, not bad  Don’t increase doses of long acting BP meds daily  Never use tid antihypertensives