SLIDE 1 HYPERTENSION
BUFFY POWELL, DNP, RN, ACNP-BC
no disclosures
SLIDE 2 HYPERTENSION-HOW DO WE DEFINE IT?
BLOOD PRESSURE =CARDIAC OUTPUT X SYSTEMIC VASCULAR RESISTANCE
¡
BLOOD PRESSURE IS PRIMARILY AFFECTED BY
¡ SYMPATHETIC NERVOUS SYSTEM ¡ RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM ¡ PLASMA
VOLUME (MEDIATED BY KIDNEYS)
SLIDE 3
JNC 8 2014 GOAL BLOOD PRESSURE
¡ AGE 60
YRS OR OLDER, NO DIABETES OR CKD, GOAL BP <150/90 mmHg
¡ AGE 18-59
YRS, NO COMORBIDITIES OR 60 YRS OR OLDER WITH DM, CKD OR BOTH, GOAL OF <140/90
SLIDE 4
AHA 2017 GUIDELINES AND DEFINITIONS
¡ Normal BP <120/<80 ¡ Elevated blood pressure: 120-129/<80 ¡ Hypertension Stage I: 130-139/80-89 ¡ Hypertension Stage II: >140/>90 ¡ Hypertensive Urgency: >180/>120 ¡ Hypertensive Emergency: >180 + Target Organ Damage/ >120 +Target
Organ Damage
SLIDE 5
SPRINT TRIAL 2017
¡ Systolic blood pressure intervention trial (SPRINT) published ¡ Compared safety and efficacy of lowering systolic <120 versus usual <140 ¡ 9361 participants: >50 yrs old, SBP>130 mmhg, and at least one of the following risk
factors: cardiovascular disease other than CVA, CKD, Framigham risk >15%, age >75 yrs
¡ Terminated early due to overwhelming evidence of benefit ¡ Decreased MI, ACS, CHF, CV death in <120 systolic arm of study compared to <140
*** Excluded residents of nursing homes or assisted living
SLIDE 6
CONSIDERATIONS WITH MEASUREMENT
¡ CUFF SIZE ¡ MANUAL
VS AUTOMATIC
¡ DIFFERENCE IN RIGHT
VS LEFT READINGS *** >15 mmHg DIFFERENCE MAY INDICATE SUBCLAVIAN STENOSIS AND/OR PVD
¡ AMBULATORY BP MONITORING: ¡ WHITE COAT ¡ SUSPECTED EPISODIC HTN (EX:
PHEOCHROMOCYTOMA)
¡ MONITORING RESPONSE TO
MEDICATION
¡ AUTONOMIC DYSFUNCTION
DIAGNOSIS OF HTN IS MADE WITH THREE DIFFERENT ELEVATED READINGS
SLIDE 7 PRIMARY HTN
AGE
WEIGHT GENETICS HIGH SODIUM DIET
ETOH
SEDENTARY LIFESTYLE
RACE
REDUCED NEPHRONS
SLIDE 8 SECONDARY HTN
MEDICATION ILLICIT DRUGS
RENAL DISEASE
PRIMARY ALDOSTERONISM
RENALVASCULAR HTN
SLEEP APNEA
PHEOCHROMOCYTOMA
CUSHINGS
THYROID DISORDER COARTATION OF AORTA
SLIDE 9 EFFECTS OF HYPERTENSION
¡ Left
Ventricular Hypertrophy (LVH)
¡ Congestive Heart Failure ¡ Cerebral
Vascular Accident
¡ Ischemic Heart Disease ¡ Chronic Kidney Disease ¡ For every 20 mmhg systolic
and every 10 mmhg diastolic
- ver 115/75, the risk of death
from heart disease or CVA doubles
SLIDE 10
HOW DO WE TREAT HYPERTENSION?
SLIDE 11 KEY TAKE AWAYS FROM JNC 8
¡ First line treatment should be limited
to 4 classes of medications:
¡ Thiazide Diuretics ¡ Calcium Channel Blockers (CCBs) ¡ Ace Inhibitors ¡ ARBs
¡
2nd and 3rd Line Treatment:
¡ Higher Doses Or Combos Of Top 4 ¡ Beta Blockers ¡ Alpha Blockers ¡ Alpha 1/Beta Blockers (Carvedilol) ¡ Vasodilating Beta Blockers (Nebivolol) ¡ Central Alpha 2/Adrenergic Agonists
(Clonidine)
¡ Direct
Vasodilators (Hydralazine)
¡ Loop Diuretics ¡ Aldosterone Antagonists (Spironolactone)
SLIDE 12
¡ Use of ACE/ARB recommended in all
patients with CKD
¡ African descent without CKD ¡ Use CCB and Thiazide Diuretic
instead of ACE
¡ Do not use ACE and ARB in same
patient
¡ CCBs and Thiazide Diuretics should be
used instead of ACE/ARB in patients >75 yrs of age with impaired renal function
SLIDE 13 AHA TAKE AWAYS
¡ BP 120-129/<80: Lifestyle changes ¡ BP 130-139/80-89: Assess 10 year
ASCVD risk
¡ <10%: Lifestyle changes ¡ >10% or known CVD, DM, CKD-
Lifestyle and 1 BP medication
¡ >140/>90 ¡ Lifestyle ¡ 2 meds of different classes
¡
Emphasis on cardiovascular disease
¡
No more pre-hypertension
¡
Focus on accurate measurement
¡
Focus on self monitoring
¡
New targets for comorbidities
¡
Lifestyle recommendations
¡
DASH diet
¡
Increased K+ when safe
¡
Ideal body weight (BP lowered 1 mmHg PER 1 Kg lost)
¡
Activity 90-150 minutes aerobic activity per week
¡
Decrease ETOH to 2 or less drinks per day for men and 1 for women
SLIDE 14 LIFESTYLE MODIFICATION-FOR EVERY STAGE OF HYPERTENSION
TREAT SLEEP APNEA WEIGHT LOSS ROUTINE EXERCISE DECREASE ETOH LOW SODIUM
SLIDE 15
IF TREATING ISOLATED HYPERTENSION
FOUR FIRST LINE CHOICES
¡ Thiazide diuretic (ex: HCTZ,
Chlorthalidone)
¡ Dihydropyridine calcium channel
blocker (ex: Amlodipine, Nifedipine XL)
¡ ACE (ex: Lisinopril) ¡ ARB (ex: Losartan, Olmesartan,
Telmisartan, Valsartan, Irbesartan) FOR AFRICAN AMERICAN PATIENTS
¡ Thiazide diuretic ¡ Dihydropyridine calcium channel
blocker Beta blockers not recommended as first line therapy for isolated HTN
SLIDE 16
SPECIAL POPULATIONS
¡ CHF-ACE/ARB, Beta Blocker, Diuretic,
spironolactone
¡ Diabetes-ACE/ARB for renal protection
(monitor K+)
¡ CAD-Beta blocker ¡ Angina-Beta Blocker, CCB ¡ Need rate control-beta blockers, non-
dihydropyridine CCB
¡ Edema-Diuretic
SLIDE 17
DIURETICS
¡ Hydrochlorothiazide (HCTZ) 12.5-50mg-Impotence ¡ Chlorthalidone 12.5-25mg-Hypokalemia ¡ Spironolactone 25-50mg-Hyperkalemia, gynecomastia ¡ Triamterene 50-100mg (or in combo with HCTZ)-
Hyperkalemia
¡ Furosemide 20-80mg, Bumex,1-2mg Torsemide 10-40mg-Not
best BP agents
SLIDE 18 ACE/ARB
ACE
¡
Lisinopril
¡
Benazapril
¡
Fosinopril
¡
Quinapril
¡
Ramipril
¡
Trandolapril
¡
Edarbi*
Ø Angioedema Ø ACE cough in 15-20% Ø Hyperkalemia
ARB
¡
Olmesartan
¡
Telmisartan
¡
Irbesartan
¡
Valsartan
¡
Losartan
¡
Candesartan
Ø Hyperkalemia
Monitor Renal Function
SLIDE 19
CALCIUM CHANNEL BLOCKERS
Dihydropyridines
¡ Amlodipine ¡ Nifedipine ER
Non-Dihydropyridines
¡ Diltiazem ¡ Verapamil
Ø Reduce heart rate
BOTH CAN CAUSE EDEMA
SLIDE 20
BETA BLOCKERS
BETTER FOR BP
¡ Carvedilol ¡ Nebivolol ¡ Labetalol ¡ Bisoprolol*
BETTER FOR RATE CONTROL
¡ Metoprolol Tartrate and Succinate* ¡ Atenolol ¡ Propranolol
CAUTION IN DIABETICS FATIGUE BRADYCARDIA COPD*
SLIDE 21
VASODILATORS
Alpha Blockers
¡ Terazosin ¡ Doxazosin
Ø May cause orthostatic hypotension
¡ Hydralazine (reflex tachycardia) ¡ Minoxidil (edema, facial hair)
SLIDE 22
CENTRALLY ACTING AGENTS
¡ Clonidine (pill and patch)-dry mouth ¡ Methyldopa
SLIDE 23 CASE 1
¡ 51 year old Caucasian male ¡ Blood pressure in clinic 164/92 ¡ BMI 40 ¡ HgbA1c 6.5 ¡ T
- tal Cholesterol 281, LDL 140, TRG 302
¡ Accountant ¡ On no medications ¡ States “I really do not think I have that high of
blood pressure. I do not want any medications because I am planning to lose 50 pounds and start exercising.”
SLIDE 24 Negotiate
medication
basis” Lifestyle
diet, exercise, sleep apnea test Medication Choice
SLIDE 25
CASE 2
¡ 34 year old African American male ¡ Blood pressure 152/90 in clinic (home readings range 130-160/80-98) ¡ BMI 20 ¡ Works out everyday, mostly weights ¡ Family history-”everyone has high blood pressure, mom died of a stroke”
SLIDE 26
little
weights- more cardio
diet
Education
Diuretic?
Medication Choice
Close follow up for awhile
Follow UP
SLIDE 27 CASE 3
¡ 78 year old Caucasian female ¡ Blood pressure 180/70 heart rate 51 bpm in clinic ¡ Medications: Clonidine .1mg BID, losartan 100mg QD, Metoprolol succinate 50mg QD ¡ Home log for day before shows BP readings at 0230, 0235, 0700, 0703, 0705, 1023, 1026, 1030, 1900,
1903, 1915
¡ 120 lbs ¡ Allergy list is two pages long ¡ History of CAD ¡ Lives at an independent senior living facility ¡ Carvedilol made her “bones to hurt”, Lisinopril caused a headache,
Valsartan caused “bones to hurt”, Had ankle edema on amlodipine
¡ C/O fatigue, dizziness with standing, has fallen twice in past few months
SLIDE 28 Sell It!!!!
Talk up new drug choice-”best drug ever!” Encourage exercise Only check BP twice a day
Medication Choices
Hydralazine, HCTZ not good choice Change Losartan to Olmesartan?
Possibly Nifedipine XL Last ditch effort-Methyldopa
Examine Her Regimen
Bradycardic Stop Clonidine slowly, decease Metoprolol
SLIDE 29
BUFFY’S PEARLS
¡ Bring BP down slowly when you can ¡ Less pills is better for adherence ¡ Lifestyle change really helps-especially
in younger people-encourage it and give them tools/ideas that fit their life.
¡ Treat sleep apnea ¡ Salesmanship is EVERYTHING ¡ Edema from CCB is less is a combo pill
with HCTZ (ex: Tribenzor)
¡ Not a Clonidine fan ¡ Avoid HCTZ in elderly ¡ For stubborn HTN, especially in older
women, Methyldopa seems to work
SLIDE 30 REFERENCES
Cartoon Stock. (n.d.). [Cartoon]. Retrieved from www.CartoonStock.com American Heart Association Task Force on Clinical Practice Guidelines. (2017). Highlights from the 2017 guideline for the prevention, detection, evaluation and management of high blood pressure in adults. Hypertension. http://dx.doi.org/10.1161/HYP .0000000000000065 James, P ., Ortiz, E., & et al (2014). Evidence-based guideline for the management of high blood pressure in adults (JNC8). Journal of the American Medical Association, 311(5), 507-520. Kovell, L., Ahmed, H., Misra, S., Whelton, S., Prokopowicz, G., Blumenthal, R., & McEvoy, J. (2015). US hypertension management guidelines: A review of the recent past and recommendations for the future. Journal of the American Heart Association. http://dx.doi.org/10.1161/JAHA.115.002315 Mann, J. (2020). Choice of drug therapy in primary (essential) hypertension. Retrieved April 16, 2020, from https//www.uptodate.com Page, M. (2014). The JNC 8 hypertension guidelines: An in-depth guide. American Journal of Managed Care. Retrieved from https//www.ajmc.com
