1. Initial Treatment of Hypertension Darwin Deen, MD, MS Family Medicine Clerkship

2. Objectives Review the JNC VII diagnostic criteria for hypertension Consider the impact of lifestyle changes on blood pressure Review the available pharmacologic agents available for the initial treatment Review reasons for selecting specific agents

3. Fast Facts about HT Hypertensive population: 42 x 10 6 Controlled hypeertensives: 27% Those unaware of Dx: 13 x 10 6 Aware but untreated: 7 x 10 6 Of those treated: 58% uncontrolled 73% of HT have BP 140-160/<90

4. Initial Drug Therapy BP Classification SBP* (mm Hg) DBP* (mm Hg) Lifestyle Modificatio n Without Compelling Indications With Compelling Indications Normal<120and <80Encourage No antihypertensive drug indicated. Drug(s) for compelling indications. Prehypertensi on 120–139 or 80– 89 Yes Stage 1 hypertension 140–159 or 90– 99 Yes Thiazide-type diuretic for most. May consider ACEI, ARB, BB, CCB, or combination. Drug(s) for compelling indications. Other antihypertensive drugs (diuretic, ACEI, ARB, BB, CCB) as needed. Stage 2 hypertension  160or  100 Yes Two-drug combination for most (usually thiazide-type diuretic and ACEI or ARB or BB or CCB). JNC 7: Classification and Management of Blood Pressure for Adults JNC 7. May 2003. NIH publication 03-5233.

5. Diagnostic Workup Assess risk factors and comorbidities Reveal identifiable causes of HT Assess presence of target organ damage Thorough history and physical Labs: UA, glucose, Hct, lipids, K + Cr, Ca Optional: Urinary alb/Cr ratio EKG

6. CVD Risk Factors HT OB HL DM Cigarette Smoking Inactivity Microalbuminuria Age –>55 in men –>65 in women FH of premature CVD

7. JNC 7: Treatment Algorithm for Hypertension SBP=systolic blood pressure; DBP=diastolic blood pressure; ACEI=angiotensin- converting enzyme inhibitor; ARB=angiotensin receptor blocker; BB=  -blocker; CCB=calcium channel blocker JNC 7. May 2003. NIH publication 03-5233. Optimize dosages or add additional drugs until goal blood pressure is achieved. Consider consultation with hypertension specialist. Not at goal blood pressure Without compelling indications Stage 1 hypertension (SBP 140–159 or DBP 90–99 mm Hg) Thiazide-type diuretic for most. May consider ACEI, ARB, BB, CCB, or combination. Stage 2 hypertension (SBP  160 or DBP  100 mm Hg) Two-drug combination for most (usually thiazide-type diuretic and ACEI or ARB or BB or CCB). Lifestyle modifications Not at goal blood pressure (<140/90 mm Hg) (<130/80 mm Hg for those with diabetes or chronic kidney disease) Initial drug choices With compelling indications Drugs for compelling indications Other antihypertensive drugs (diuretic, ACEI, ARB, BB, CCB) as needed. ® © 2003 Thomson Professional Postgraduate Services ® www.lipidhealth.org

8. Compelling Indications Heart Failure Post- MI High CVD risk DM CRF –Cr > 1.5 in men –Cr > 1.3 in women S/P CVA Thiaz/loop, BB, ACE, ARB, Aldo ant BB, ACE, Aldo ant Thiaz, BB, ACE, CCB Thiaz, BB, ACE, ARB, CCB ACE, ARB (push to 35% increase in Cr. For Cr 2-3 try loop diuretic. Thiaz, ACE

9. Lifestyle Modifications to Manage HTN ModificationRecommendations Approximate Systolic Blood Pressure Reduction Weight Reduction Maintain normal body weight (BMI 18.5-24.9) 5-20 mm Hg for each 10 kg weight loss Adapt DASH eating plan Consume diets rich in fruits, vegetables, low fat dairy and low saturated fat 8-14 mm Hg Dietary sodium reduction Reduce sodium to no more than 2.4 g/day sodium or 6 g/day NaCl 2-8 mm Hg Increase physical activity Engage in regular aerobic activity such as walking (30 min/day on most days) 4-9 mm Hg Moderate alcohol consumption Limit alcohol to no more than 2 drinks/d for men and 1 drinks/day for women. 2-4 mm Hg Source: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure JNCVII. JAMA. 2003;289:2560-2572.

10. Failures of Patient Education 50% of patients discontinue their anti- hypertensive within 1 year of initiating treatment. DASH diet for hypertension: –limit sodium –Increase fruits and vegetables (8-10/d) –Increase low fat dairy (3-4/d) Focus on diet history for HT patients

11. Key Diet History Questions for Patients with HTN Do you use a salt shaker? Do you taste your food before you add salt? How often do you eat salty foods, such as chips, pretzels, salted nuts, canned and smoked foods? Do you read labels for sodium content? How many servings of fruits and vegetables do you eat everyday? How often do you eat or drink dairy products? What kind? How often do you eat out? What kinds of restaurants? Do you like to drink alcohol? How much? How often do you exercise, including walking?

12. TIPS on drugs for HT CCB OK for ISH For DM: ACE or ARB with or without diuretic then add BB or CCB When ACE causes cough, substitute ARB Don’t use short acting CCB (increases deaths due to arrhythmias). Alpha blockers (e.g. clonidine) only as second line (more side effects).

13. Most patients should start with a diuretic as they enhance the effectiveness of other agents. Most patients will require more than one agent. Add a baby aspirin to improve cardiovascular outcomes.

14. Special Populations Minorities Women Aged Blacks have greater prevalence, severity, and impact and poorer response to monotherapy. ACE induced angioedema is more common BCPs elevate BP, Aldomet, BB, and vasodilators OK in pregnancy Higher prevalence, ISH more common, more frequent complications from ACE, CCB

15. Thiazides Chlorothiazide(Diuril) Chlorthalidone Hydrochlorthiazide(Microzide, Hydrodiuril) Polythiazide(Renese) Indapamide(Lozol) Metolazone(Mykrox, Zaroxolyn)

16. Benefits of Thiazide Diuretics Evidence-based support for end points that matter (prevention of CV and all- cause mortality). Reduce calcium excretion potential benefit for osteoporosis prevention.

17. Loop Diuretics Bumetanide(Bumex) Furosemide(Lasix) Torsemide(Demadex) Potassium-sparing Diuretics Amiloride (Midamor) Triamterene (Dyrenium)

18. Aldosterone Receptor Blockers Eplerone (Inspra) Spironolactone (Aldactone) Combined alpha- and beta- blockers Carvediol(Coreg) Labetalol(Normodyne, Trandate)

19. Beta-blockers Atenolol(Tenormin) Betaxolol(Kerlone) Bisoprolol(Zebeta) Metoprolol(Lopressor, Toprol XL) Nadolol(Corguard) Propranolol(Inderal and XL) Timolol(Blocadren)

20. Beta-blockers with intrinsic sympathomimetic activity Acebutolol(Sectral) Penbutolol(Levatol) Pindolol(generic)

21. ACE inhibitors Benzapril(Lotensin) Captopril(Capoten) Enalpril(Vasotec) Fosinopril(Monopril) Lisinopril(Prinivil, Zestril) Moexipril(Univasc) Perindopril(Aceon) Quinapril(Accupril) Ramipril (Altace) Trandolapril(Mavik)

22. Angiotensin II antagonists Candesartan (Atacand) Eprosartan (Tevetan) Irbesartan (Avapro) Losartan (Cozaar) Olmesartan (Benicar) Telmisartan (Micardis) Valsartan (Diovan)

23. Calcium channel blockers Dihyropyridines –Amlodipine(Norvasc) –Felodipine(Plendil) –Isradipine(Dynacirc CR) –Nicardipine(Cardene SR) –Nifedipine(Adalat CC, Procardia XL) –Nisoldipine(Sular) non-Dihyropyridines Diltiazem(Cardizem CD, Dilacor XR, Tiazac, Cardizem LA) Verapamil (CalanSR, Isoptin SR)

24. Alpha 1 blockers Doxazosin (Cardura) Prazosin(Minipress) Terazosin(Hytrin) Direct Vasodilators Hydralazine(Apresoline) Minoxidil(Loniten)

25. Centrally acting drugs Clonidine(Catapres) Methyldopa(Aldomet) Reserpine(generic) Guanfacine(generic)

26. Treatment Algorithm Lifestyle Modification Not at goal BP Initial Drug Choices W/O Compelling Indications Stage 1 Thiaz, ACE, ARB, BB, CCB Stage 2 2 Drug Combo With Compelling Indications Drug for Indication Not at Goal BP Adjust Dose or add additional agents