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Hypertension (HTN)

Daniel Motta-Calderon

Background

  • Elevated systolic blood pressure and diastolic blood pressure are associated with increased cardiovascular disease (CVD) risk

  • HTN is the most prevalent modifiable risk factor for premature CVD

Definitions

  • ACC/AHA definition of HTN: taking antihypertensive medication or having a systolic pressure ≥130 mmHg and/or a diastolic pressure ≥80 mmHg

  • Resistant HTN**:** Uncontrolled BP despite taking 3 antihypertensive medications including a diuretic OR 4 total medications

  • Whitecoat HTN: Mean BPs lower than threshold of HTN based on out-of-office measurements (falsely elevated measurements during visits). If SBP > 130 but \< 160, consider screening for white coat HTN with home monitoring

  • Masked HTN: Mean BP at/above threshold for hypertension based upon out-of-office measurements (falsely decreased measurements during visits). If office SBPs consistently 120-129, consider screening for masked HTN with home monitoring

Screening

  • Grade A USPTF rec: Screen all adults >18. Screen adults at least semiannually if have risk factors for HTN (obesity, AA), or if previously measured SBP 120-129

Diagnosis

  • Proper BP measurement:  legs uncrossed, supported arm at level of heart, after 5 minutes of rest and with empty bladder; avoid caffeine or tobacco 30 minutes prior

  • Ideally, primary detection in clinical setting (BP ≥130/80) followed by confirmation with ambulatory blood pressure monitoring (ABPM): 

    • 24hrs mean of systolic ≥125 or diastolic ≥75mmHg 

    • Daytime mean systolic ≥130mmHg or diastolic ≥80mmHg  

    • Nighttime mean systolic ≥110 mmHg or ≥65 diastolic mmHg 

  • If ABPM not possible, 2-3 outpatient measurements at 1-4 week intervals are required to confirm diagnosis  

  • BP >160/100mmHg in the outpatient setting with evidence of end-organ damage (ischemic CMP, CVA, hypertensive retinopathy, LV hypertrophy, CKD) 

  • Any patient presenting with hypertensive emergency or severe asymptomatic hypertension (>180/120mmHg) 

Evaluation

  • Assess target organ damage as pertinent: CVA, retinopathy, LV hypertrophy/dysfunction, HF, CAD, CKD, PAD.  

    • BMP, CBC, lipid panel, UA, TSH, EKG. Consider additional testing including TTE, urine Alb:Cr ratio, or uric acid, ABI 

    • Calculate ACSVD 10y risk

  • Distinguish between primary (90% incidence) and secondary HTN (10%): 

    • Suspect 1º if gradual onset, family hx, associated with weight gain & lifestyle factors 

    • Suspect 2º if drug-resistant, abrupt onset, onset \<30yo, exacerbation of previously controlled HTN, onset of diastolic hypertension in older adults >65yo, unprovoked or excessive hypokalemia

Common 2o Causes Suggestive Features Diagnostic Testing
Primary Kidney Disease Hypervolemia, ↑ Cr, abnormal UA, family history of PKD UA, Urine Alb:Cr ratio, Renal US
Renovascular disease (RAS or FMD) Renal bruit, ↑ Cr after ACE-I or ARB, young age Doppler renal US
OSA Apneic events, somnolence, obesity Polysomnography
Primary Hyperaldosteronism Hypokalemia, metabolic alkalosis, resistant HTN, etc. Start with plasma aldosterone/renin levels
Drug or Alcohol Induced H/o substance use (cocaine, caffeine, nicotine, medications) UDS, BP improvement after withdrawal of suspected agent
Uncommon 2o causes: Pheochromocytoma, Cushing’s syndrome, thyroid dysfunction, aortic coarctation, primary hyperparathyroidism, acromegaly, congenital adrenal hyperplasia

Management

ACA-AHA guidelines (2017) (based on SPRINT trial)
Elevated BP systolic 120-129 mmHg AND diastolic \<80 mmHg Non-pharmacological interventions and reassess in 3-6 months
Stage 1 systolic 130-139 mmHg OR diastolic 80-89 mmHg If 10-y CVD risk ≥10%, non-pharm intervention + BP-lowering medication. Reassess monthly until BP goal met, then every 3-6 months
Stage 2 systolic ≥140 mmHg OR diastolic ≥90 mmHg Non-pharmacological intervention + BP lowering medication. Reassess monthly until BP goal met, then every 3-6 months

Non-pharmacological interventions: regardless of stage

  • 8-14 mmHg ↓: DASH diet (fresh produce, whole grains, low-fat dairy) 

  • 5-10 mmHg ↓: Weight loss (10 kg or 22 lbs), expect 1mm Hg for every 1kg reduction in body weight 

  • 3-9 mmHg ↓: Na+ restriction (1.5 g / day), aerobic exercise for 90-150 min/week, increased intake of K+ rich foods 

  • 2-4 mmHg ↓: Moderate EtOH (2 drinks/day for men; 1 drink/day for women) 

  • Consider deprescribing or switching amphetamines, antidepressants (MAOi, SNRIs, TCAs), atypical antipsychotics (clozapine, olanzapine), caffeine, decongestants (phenylephrine, pseudoephedrine), cyclosporine, oral contraceptives, NSAIDs, steroids

Pharmacologic therapy

  • Three main classes of drugs use for initial monotherapy for primary hypertension include: ACE-Is/ARBs, CCBs (most frequently a dihydropyridine), and thiazide diuretics

  • Note that there is wide variability among patients as some will respond to one antihypertensive drug but not another

  • Black patients often respond best to CCBs or thiazides

  • Individualize therapy depending on comorbidities

Drug Class  Common Drugs  Side effects/ comments 
Thiazide diuretics  HCTZ 12.5-50 mg  
Chlorthalidone 12.5-25 mg: preferred agent based on RCT evidence though inc risk electrolyte abnormalities

HypoNa, HypoMg, HypoK, increased uric acid, hypovolemia, 

Orthostatic hypotension 
ACE-I 

Lisinopril, benazepril, fosinopril, quinapril (all 5-40 mg daily)

Ramipril, 2.5-20 mg in 1-2 doses 

 Angioedema (more common in AA) AKI, hyperkalemia, cough 
ARBs 

Losartan 25-100 mg in 1-2 doses 

Candesartan 8-32 mg in 1-2 doses 

Irbesartan 150-300 mg 
Valsartan 80-320 mg 

 AKI, hyperkalemia 
Angioedema (less frequent than ACE-I) 
CCB 

Dihydropyridine: 
Amlodipine 2.5-10 mg 1-2 doses Nifedipine 30-120 mg in 1-2 doses 

Nondihydropyridine: 

Diltiazem ER 120-480 mg Verapamil ER 100-480 mg 

Dihydropyridine:  
Peripheral edema  
Worsening proteinuria 

 Nondihydropyridine:  
Constipation 
Heart block if used with BB  
Contraindicated in HFrEF 
Aldosterone receptor antagonists  Spironolactone 12.5-50 mg  
Eplerenone 25-50 mg 

Good choice for resistant HTN 

AKI, hyperkalemia 
Spironolactone—gynecomastia & sexual side effects 
BB  Carvedilol 6.25-25 mg bid  
Metoprolol succinate 25-200 mg qd 
Nebivolol 5-10 mg 
Labetalol 100-300 bid 		 Reserve for CHF/CAD  
Hyperglycemia, fatigue, ↓ HR 
β 1-selective may be safer in pts with COPD, asthma, diabetes 
Vasodilators  Hydralazine 25-100 mg bid or tid Minoxidil 5-10 mg  Reflex tachycardia, fluid retention 
Centrally- acting agents (alpha 2 agonists) 

Clonidine 0.1-0.2 qd, (Weekly transdermal patch is preferred to avoid non- compliance and subsequent reflex HTN) 

Methyldopa 250-500 mg qd 

 Rebound hypertension, withdrawal -Reserved for resistant hypertension due to unfavorable side effect profile 
**Conditions ** **Drug Class **
Heart failure  ACE-I/ARB or ARNI + BB + spironolactone + diuretics  
CAD  ACE-I or BB 
Diabetes  All first line agents, ACE-I/ARB if presence of albuminuria  
CKD  ACE-I/ARB 
Recurrent stroke prevention  ACE-I, thiazide diuretic  

If not meeting goals, combination therapy > doubling single agent (more effective, less side effects) 

  • Preferred combinations 

    • ACEi/ARB + CCB 

    • ACEi/ARB + CCB + thiazide. 

    • ACEi/ARB + CCB + MRA 

    • Do not combine beta-blockers with non-dihydropyridines. 

    Therapy goals 

    • General population: \<130/80mmHg 

    • Frail patients with orthostatic hypotension, limited life expectancy: consider less aggressive goal \<140/90 

Additional Information

  • VA Specific Guidance: https://www.healthquality.va.gov/guidelines/CD/htn/

  • Agents that require PADR:

    • ACEIs - Quinapril

    • ARBs – Candesartan, Irbesartan, Olmesartan, Telmisartan

    • Beta blockers – Labetalol, Nebivolol

    • DHP – Nifedipine SA

    • Aldosterone Receptor Antagonist – Eplerenone

    • Alpha2 Agonist – Clonidine patch

  • How to get BP cuff at the VA

    • Prosthetics consult BP Cuff TVHS. *Must answer all questions in the consult, including blood pressure cuff size

Low-cost options

  • Publix: Free (amlodipine, lisinopril), $7.50 x 90 days (losartan, metoprolol tartrate, HCTZ)

  • Walmart: $4/month (amlodipine, carvedilol, enalapril, hydralazine, HCTZ, irbesartan, lisinopril, losartan, ramipril)

Last update: 2022-06-24 15:46:56