User:Justinberk/Hypertension

Hypertension (HTN), also known as high blood pressure (HBP), is a long-term medical condition in which the blood pressure in the arteries is persistently elevated.The Eighth Joint National Committee (JNC-8) recommends a goal blood pressure < 140 / 90 or <150/90 if age > 60. [Guidelines] [Controversy] The SPRINT trial suggests more intensive blood pressure control (even among the elderly) improved CV outcomes and overall survival while modestly increasing the risk of some serious adverse events. [Article] [Discussion] [ Podcast ]. Different numbers apply to children.

Every 5mm Hg increase in DBP and every 10mm Hg increase in SBP is associated with a 28% increase in the risk of death from coronary heart disease. A 10mm Hg drop in SBP and 5mm Hg drop in DBP was associated with 25% fall in cardiovascular disease, 25% reduction in CHF, and 33% reduction of strokes.

Urgency vs. Emergency
Hypertensive urgency is usually defined as SBP > 180 and DBP > 110 without symptoms. Asymptomatic hypertensive urgency does not require ED treatment. [1]

Hypertensive emergency is defined as elevated blood pressure with evidence of end-organ damage (e.g. retinopathy, myocardial ischemia, encephalopathy, kidney damage). This requires immediate treatment in the Emergency Department with a goal of reducing blood pressure by 25% in 4-6 hours.

Diagnosis and Work-up
Essential (primary) hypertension is due to nonspecific lifestyle and genetic factors. This accounts for 90-95% of hypertension cases.

Secondary hypertension makes up the remaining 5-10% of cases. This includes chronic kidney disease, narrowing of renal arteries, endocrine disorders (pheochromocytoma, hyperaldosteronism, hyperparathyroidism) or drug-induced hypertension.

How To Take a Blood Pressure: Measurements of blood pressure outside of a clinic environment are better correlated with long-term outcomes [6–8]. It remains controversial if “white coat hypertension” is associated with cardiovascular risk and should therefore be treated. [9] Confounders that may elevate BP include pain, medications (NSAIDs, SSRIs, OCPs, steroids), caffeine, tobacco, stress.

Lifestyle Changes
The 2004 British Hypertension Society guidelines proposed lifestyle changes consistent with those outlined by the US National High BP Education Program in 2002 for the primary prevention of hypertension: The DASH Diet: fruits, vegetables and low-fat dairy foods can reduce SBP by 11mm Hg and diastolic blood pressure by 5mm Hg. [13] A follow up study added sodium restriction to the DASH diet and further reductions in blood pressure were seen. [14]. The PREMIER trial showed behavioral intervention (weight loss, exercise, limited sodium and alcohol) reduced SBP by 3.7mmHg with behavior plus DASH decreasing SBP by 3.7mmHg. [15]
 * maintain normal body weight for adults (e.g. body mass index 20–25 kg/m2)
 * reduce dietary sodium intake to <100 mmol/ day (<6 g of sodium chloride or <2.4 g of sodium per day)
 * engage in regular aerobic physical activity such as brisk walking (≥30 min per day, most days of the week)
 * limit alcohol consumption to no more than 3 units/day in men and no more than 2 units/day in women
 * consume a diet rich in fruit and vegetables (e.g. at least five portions per day);

Frozen dinners and packaged foods comprise about 75% of daily salt intake, so patients who don't add salt to their food will typically still have a high salt intake. [16] Exercise has shown to coronary heart disease by 6% and increase life expectancy by 0.68 years with a modest reduction in BP (2-4mmHg). [17]

Medication Management
Per JNC-8, there are 3 strategies of management:

1)* Add a second medication before max dose 2) Maximize first med 3) Start with 2 if SBP > 160

* Starting second drug offers 5x better BP lowering than doubling dose of current medication [18]

JNC 8: Therapy should be given one month to work before advancing regimen.

Treatment Algorithm per JNC8:

First line treatment: thiazide, CCB or ACEI/ARB are equivalent unless:

If CKD or proteinuria: start ACEI/ARB

If black with CKD and NO proteinuria: CAN start ACE/ARB as equivalent to thiazide or CCB

In patients with HFrEF: ACE-I / ARB should be replaced with Entresto (secubitril / valsartan)

Blood Pressure Goal < 140 / 80 per JNC-8, SPRINT [10,11]
 * OK to delay treatment for 1 year if no signs of end-organ damage or other CVD risks
 * No morbidity or mortality benefit from treating SBP 140-159 / DBP 80-89 [12]

Trial Summaries
ALLHAT: Improved CV and stroke outcomes in blacks treated with thiazide diuretics and CCBs Thiazides, ACE-I, and CCBs have equivalent outcomes in non-black population.[19] VALUE: Valsartan is inferior for BP control vs. amlodipine but has similar CV event rate. [20]

ACCOMPLISH: In pts with CKD or CVD (including LVH), adding a CCB to ACE-I is potentially better than adding a thiazide to ACE-I for CVD outcomes. [21] On subanalysis thiazides may be less effective in obese populations [22]

ACCORD BP: In patients with T2DM, lower SBP goals did not improve outcomes [23]

Top Pearls

 * The #1 cause of resistant hypertension is medication non-adherence. [24]
 * Chlorthalidone is a better thiazide than HCTZ [25]
 * Switching blood pressure medications to night-time may offer improvement[26–28]
 * If you need a 4th line HTN agent, spironolactone is probably best.[29] [30]
 * OSA treatment can help with HTN treatment and reduce CV risk [31] but maybe not [32]
 * Losartan can help decrease uricemia in patients with gout
 * High salt diets can void the vasodilatory effects of thiazides
 * Adding an ACE inhibitor or ARB avoids the edema of amlodipine monotherapy
 * Nifedipine is contraindicated in CHF ([33]. Amlodipine is safe in CHF [34]
 * Self-titration of antihypertensive medication can result in lower systolic blood pressure [35]
 * Thiazides may help reduce hip and pelvic fractures in older adults [36]