Chronic hypertension resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ayokunle Olubaniyi, M.B,B.S [2]

Hypertension Resident Survival Guide Microchapters
Overview
Classification
Causes
Diagnosis General Complete
Treatment Prehypertension Stage 1
Medical Therapy Choice of Regimen Drug List
Don'ts

Overview

Hypertension (HTN) is defined as a systolic blood pressure (SBP) ≥ 140 mmHg and diastolic blood pressure (DBP) ≥ 90 mmHg. It is usually detected during the screening of an asymptomatic individual, but the diagnosis is based on persistent elevation of blood pressure after an average of 2 or more blood pressure measurements taken during 2 or more health care visits. Hypertension is classified as either primary (or essential) when the etiology cannot be identified; or secondary, when the etiology (e.g., hyperthyroidism, pheochromocytoma, renal artery stenosis) is known. The presence of diabetes mellitus, cigarette smoking, excessive sodium intake, obesity, and sedentary lifestyle increases the risk of developing essential hypertension. Lifestyle modifications such as weight reduction, reduction in alcohol consumption, exercises, and reduction in salt intake are recommended to all patients in addition to pharmacological therapy, when required.

Classification

The ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA 2017 clinical practice guidelines, executive summary, and underlying systematic review by the ACC/AHA taskforce recommend a treatment goal for everyone is <130/80 mm Hg:

	Definition	Treatment
Normal blood pressure	<120/80 mmHg	Lifestyle
Elevated blood pressure	Systolic BP, 120–129 mm Hg - and - Diastolic BP, <80 mm Hg	Lifestyle
Stage 1 hypertension	Systolic BP, 130–139 mm Hg - or - Diastolic BP, 80–89 mm Hg	Lifestyle and Medications if high risk*
Stage 2 hypertension	Systolic BP, ≥140 mm Hg - or - Diastolic BP, ≥90 mm Hg	Lifestyle and Medications
* High risk defined as existing cardiovascular disease or 10-year cardiovascular risk ≥10% (calculator and alternative calculator with facts box)

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• Aortic coarctation
• Cocaine or amphetamine overdose
• Pheochromocytoma
• Preeclampsia

Common Causes

Primary or Essential Hypertension

• No underlying cause is identified. Risk factors include: high sodium intake, obesity, sedentary lifestyle, and excessive alcohol intake.

Secondary Hypertension

• Aortic coarctation
• Chronic kidney disease
• Cocaine or amphetamine overdose
• Cushing's syndrome
• Hyperthyroidism
• Hypothyroidism
• Medications (e.g., oral contraceptive pills, NSAIDs)
• Nephrotic syndrome
• Pheochromocytoma
• Polycystic kidney disease
• Preeclampsia
• Renal artery stenosis
• Sleep apnea

Pseudohypertension

• White coat hypertension

Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

Boxes in red signify that an urgent management is needed.

For patient presenting with symptoms suggestive of the following: ❑ Cerebral infarction ❑ Intracerebral hemorrhage ❑ Subarachnoid hemorrhage ❑ Hypertensive encephalopathy ❑ Acute left ventricular failure ❑ Myocardial infarction ❑ Aortic dissection ❑ Acute pulmonary edema ❑ Acute renal failure ❑ Hypertensive retinopathy

Measure the blood pressure

BP ≥ 180/120

BP < 180/120

Does the patient have any evidence of end organ damage?

Continue with the diagnosis below

Yes

No

Hypertensive emergency

Hypertensive urgency

Click here of hypertensive crisis resident survival guide

Diagnosis

Shown below is an algorithm summarizing the diagnosis of hypertension based on the seventh report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and 2013 ESH/ESC guidelines for the management of arterial hypertension.

Abbreviations: ABPM: Ambulatory blood pressure monitoring; BP: Blood pressure; CKD: Chronic kidney disease; DBP: Diastolic blood pressure; DM: Diabetes mellitus; SBP: Systolic blood pressure

General Approach

Suspected hypertension BP > 140/90 mmHg

Blood pressure measurement Before taking the BP ❑ Sit patient quietly in a chair for 5 minutes ❑ Avoid caffeine, exercise, smoking for at least 30 minutes ❑ Ensure appropriate cuff size ❑ Take 2 readings and find the average ❑ Take repeated measurements in patients with arrhythmia ❑ Measure blood pressure at both arms at first visit to detect possible differences Click here for more information regarding blood pressure measurement

For office BP >140/90 mmHg on 2-3 visits

Does the patient have any evidence of target organ damage, DM, or CKD?

Yes

No

Proceed to hypertensive crisis resident survival guide

Perform home BP/out-of-office monitoring

Is the average home BP measurement <140/90?

Yes

Inconclusive

No

Perform 24-hour ABPM

Is the 24-hour ABPM ≤135/85?

Yes

No

Hypertension confirmed

White coat hypertension confirmed

Classify the patient based on the BP reading

SBP 120-139 mmHg DBP 80-89 mmHg

SBP 149-159 mmHg DBP 90-99 mmHg

SBP >160 mmHg DBP >110 mmHg

Prehypertension

Stage 1 hypertension Proceed to the complete diagnostic approach below

Stage 2 hypertension Proceed to hypertensive crisis resident survival guide

Complete Diagnostic Approach

Shown below is an algorithm summarizing the diagnosis of hypertension based on the seventh report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and 2013 ESH/ESC guidelines for the management of arterial hypertension.

Abbreviations: BMI: Body mass index; BP: Blood pressure; CNS: Central nervous system; CT: Computed tomography; CVD: Cardiovascular disease; eGFR: Estimated glomerular filtration rate; EKG: Electrocardiogram; HTN: Hypertension; LVH: Left ventricular hypertrophy; MI: Myocardial infarction; NSAIDs: Non steroidal anti-inflammatory drugs; TSH: Thyroid stimulating hormone; UTI: Urinary tract infection

Obtain a detailed history: History of present hypertension ❑ Time of first diagnosis ❑ Current and past BP measurements ❑ Current and past antihypertensive medications Identify secondary causes of hypertension: Family history: ❑ Chronic kidney disease (suggestive of polycystic kidney disease) ❑ Premature CVD or HTN History of renal disease: ❑ Hematuria ❑ UTI ❑ Analgesic abuse (suggestive of renal parenchymal disease) ❑ Flank pain Medication/substance abuse: ❑ Amphetamines ❑ Cocaine ❑ Cyclosporine ❑ Erythropoietin ❑ Liquorice ❑ NSAIDs ❑ Oral contraceptive pills ❑ Steroids History suggestive of pheochromocytoma: ❑ Recurrent episodes of sweating, palpitation and hypertension History suggestive of hyperaldosteronism: ❑ Muscle weakness and tetany History suggestive of thyroid disease: ❑ Hypothyroidism ❑ Hyperthyroidism History to assess risk factors ❑ Personal and family history of: ❑ HTN and CVD ❑ Dyslipidemia ❑ Diabetes mellitus ❑ Excessive sodium intake >2.4g per day ❑ Tobacco usage ❑ Obesity ❑ Alcoholism >1.5 drinks/day ❑ Metabolic syndrome ❑ Physical inactivity ❑ Sleep apnea History to assess presence of organ damage/complications CNS: ❑ Headache ❑ Vertigo ❑ Transient ischemic attack ❑ Stroke Eyes: ❑ Loss or blurring of vision Cardiovascular: ❑ History of MI or syncope ❑ Chest pain ❑ Shortness of breath ❑ Leg swelling ❑ Palpitation ❑ Arrhythmia ❑ Sexual dysfunction Kidneys: ❑ Polyuria ❑ Hematuria ❑ Proteinuria

Examine the patient: General examination: ❑ Calculate BMI ❑ Moon face, truncal obesity, striae (suggestive of Cushing's disease) ❑ Goitre, exophthalmus, pretibial myxedema (suggestive of Graves' disease) ❑ Dry skin (suggestive of hypothyroidism) Eyes: ❑ Fundoscopy to diagnose hypertensive retinopathy ❑ Hemorrhage ❑ Papilledema ❑ Cotton wool spots Neck: ❑ Carotid bruits ❑ Thyroid gland enlargement (suggestive of hyperthyroidism) Cardiovascular examination: ❑ Evidence of long-standing hypertension: ❑ Cardiomegaly ❑ Displaced apex beat (suggestive of enlarged left ventricle) Respiratory examination: ❑ Crackles/crepitations/rales Abdominal examination: ❑ Bruits over abdominal aorta (suggestive of aortic aneurysm) ❑ Bruits over renal artery (suggestive of renal artery stenosis) Extremity examination: ❑ Absent or diminished femoral pulsation (suggestive of coarctation of aorta) ❑ Pedal edema (suggestive of congestive heart failure) Neurological examination: ❑ Delayed return of deep tendon reflexes (suggestive of hypothyroidism) ❑ Findings suggestive of hypertensive encephalopathy ❑ Confusion ❑ Altered mental status

Order tests: Routine ❑ 12-lead EKG (for evidence of LVH or old infarct) ❑ CBC ❑ Anemia (associated with chronic renal failure) ❑ Urinalysis ❑ Proteinuria (suggestive of end organ damage) ❑ Serum potassium ❑ Hypokalemia (suggestive of hyperaldosteronism) ❑ Serum calcium (high in hyperparathyroidism) ❑ Serum creatinine with estimated glomerular filtration rate (eGFR) ❑ Serum uric acid ❑ Fasting blood sugar ❑ Hyperglycemia (suggestive of diabetes mellitus) ❑ Fasting lipid profile Additional tests based on results of the routine tests above: ❑ Echocardiography (may reveal LVH or left ventricular mass) ❑ 24-hour urinary metanephrine and normetanephrine (elevated in pheochromocytoma) ❑ Plasma renin activity (PRA) (low renin suggests hyperaldosteronism) ❑ Plasma aldosterone (elevated in hyperaldosteronism) ❑ TSH (may be high or low in hypo- and hyperthyroidism, respectively) ❑ Serum parathyroid hormone (PTH) (To evaluate parathyroid disease) ❑ Dexamethasone suppression test ❑ Unchanged levels of cortisol to high dose dexamethasone suggests Cushing's syndrome ❑ 24-hour free urinary cortisol (elevated in Cushing's syndrome) ❑ Renal duplex ultrasound and magnetic resonance angiography (MRA) of renal arteries ❑ To evaluate renal artery stenosis ❑ Chest CT angiography (To evaluate aortic coarctation) ❑ Sleep study with O2 saturation (To evaluate sleep apnea)

Does the patient have an identifiable secondary etiology?

No

Yes

Primary hypertension

Secondary hypertension

Treatment

Shown below is an algorithm summarizing the treatment of hypertension based on the 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8), ESH/ESC guidelines for the management of arterial hypertension, and the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.

Prehypertension

Prehypertension SBP 120-139 mmHg DBP - 80-89 mmHg

❑ Initiate lifestyle modification ❑ Follow-up/recheck blood pressure in one year ❑ Ensure self-monitoring of blood pressure

Stage 1 Hypertension

Shown below is an algorithm summarizing the treatment of hypertension based on the 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8) and the 2013 ESH/ESC guidelines for the management of arterial hypertension.

Abbreviations: ACEI: ACE inhibitors; ARBs: Angiotensin II receptor blockers; BMI: Body mass index; BP: Blood pressure; CCBs: Calcium channel blockers; CKD: Chronic kidney disease; DASH: Dietary Approaches to Stop Hypertension; DM: Diabetes mellitus

The following categories require pharmacological treatment according to JNC 8?: ❑ BP ≥ 150/90 mmHg in patients ≥ 60 years ❑ BP ≥ 140/90 mmHg in patients < 60 years ❑ BP ≥ 140/90 mmHg in patients ≥ 18 years with CKD or DM

Review BP goals: General population ❑ BP < 150/90 mmHg in patients ≥ 60 years ❑ BP < 140/90 mmHg in patients < 60 years Patients with DM or CKD ❑ BP < 140/90 mmHg

Initiate lifestyle modification: ❑ Weight reduction ❑ Maintain a waist circumference of <40 inches (102cm) for men <35 inches (88cm) for women BMI of ≤25 kg/m2 ❑ Adopt healthy diet ❑ DASH diet (rich in fruits, vegetables, whole grains, low sodium, low-fat proteins) ❑ Dietary sodium intake of ≤ 100 mmol/day (2.4g Na or 6g NaCl) ❑ Limit alcohol consumption ❑ ≤ 2 drinks/day for men (24oz beer or 10oz wine or 3oz 40% whisky ❑ ≤ 1 drink/day for women ❑ Regular aerobic physical activity (brisk walking, jogging, cycling, swimming) for at least 30 mins per day

Does the patient have DM or CKD?

Yes

No

CKD ± DM

DM only

Consider the race of the patient

Black population

Non-black population

Initiate: ❑ ACE inhibitors alone, OR ❑ ARBs alone, OR ❑ ACEI or ARBs in combination with other drug class e.g., Avoid the combined use of ACEIs and ARBs in a patient

Initiate: ❑ Thiazide diuretic alone, OR ❑ CCB alone, OR ❑ Combination of the two classes

Initiate: ❑ Thiazide diuretic alone, OR ❑ ACEI alone, OR ❑ ARBs alone, OR ❑ CCB alone, OR ❑ Combination of all the classes Avoid the use of ACEIs and ARBs in combination

Has the target BP been reached?

Yes

No

Click here for further therapeutic options

Monitoring and follow-up: Monitor: ❑ Serum potassium and creatinine at least 1-2 times per year Follow-up visits ❑ Schedule 2-4 weekly visits to assess: ❑ Compliance and BP control ❑ Occurrence of side effects to medications ❑ Asymptomatic end organ damage ❑ 3-6 monthly visits when BP goal is achieved ❑ Reinforce strategies to improve compliance to medication usage ❑ Self-monitoring of blood pressure ❑ Simplification of drug regimen ❑ Telephone follow-up, reminders, home visits ❑ Consider low dose aspirin only when BP is controlled

Medical Therapy

Choice of Regimen

Assess BP and cardiovascular risk

Mild elevation of BP Low CV risk

Severe elevation of BP High CV risk

Consider starting with a single agent

Consider 2-drug combination

Target BP achieved?

Target BP achieved?

Continue with current regimen

Yes

No

No

Yes

Continue with current regimen

Switch to a different drug Titrate until maximum dose is reached, if necessary

Increase dose of present drug and titrate accordingly

Increase dose of present combination

Add a third drug and titrate to maximum dose, if necessary

If BP goal is not achieved Add a second drug

Maximum dose of 2-drug combination reached

If BP goal is not achieved Switch to a different 2-drug combination and titrate to the maximum dose, if necessary OR Add a third drug and titrate to the maximum dose, if necessary

Drug List

Drug Class	Drug	Initial daily dose, target dose (mg)	Preferred use	Preferably combined with
Thiazide diuretics	Chlorthalidone	12.5, 12.5-25	Heart failure, isolated systolic hypertension, black population	ACE inhibitors, ARBs, calcium channel blockers
	Hydrochlorothiazide	12.5-25, 25-100
	Bendroflumethiazide	5, 10
	Indapamide	1.25, 1.25-2.5
ACE inhibitors	Enalapril	5, 20	Left ventricular hypertrophy, atherosclerosis, renal insufficiency, previous myocardial infarction, heart failure, atrial fibrillation (prevention), peripheral artery disease, metabolic syndrome, diabetes mellitus	Calcium channel blockers, thiazide diuretics
	Lisinopril	10, 40
	Captopril	50, 150-200
ARBs	Candesartan	4, 12-32	Left ventricular hypertrophy, renal insufficiency, previous myocardial infarction, heart failure, atrial fibrillation (prevention), metabolic syndrome, diabetes mellitus	Calcium channel blockers, thiazide diuretics
	Losartan	50, 100
	Valsartan	40-80, 160-320
	Eprosartan	400, 600-800
	Irbesartan	75, 300
Beta blockers	Atenolol	25-50, 100	Previous myocardial infarction, atrial fibrillation (prevention and ventricular rate control), heart failure, angina pectoris, aortic aneurysm, pregnancy	Thiazide diuretics (with limitations) Only dihydropyridine calcium channel blockers should be combined with beta blockers
	Metoprolol succinate	50, 100-200
Calcium channel blockers	Amlodipine	2.5, 10	Left ventricular hypertrophy, pregnancy (nifedipine), previous myocardial infarction, atrial fibrillation (verapamil, diltiazem), metabolic syndrome, peripheral artery disease, atherosclerosis, angina pectoris, isolated systolic hypertension, black population	ACE inhibitors, ARBs, thiazide diuretics
	Diltiazem extended release	120-180, 360
	Nitrendipine	10, 20

Don'ts

• The combination of ACE inhibitors and ARBs in a patient is not recommended.

References