Categories for classifying BP as set forth by the JNC VII - Seventh Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure
Normal: Systolic < 120, Diastolic < 80, no drug therapy needed
Prehypertension: Systolic 120-139, Diastolic 80-89, no drug therapy needed
Stage 1 HTN: Systolic 140-159, Diastolic 90-99, Drug therapy = thiazide or other monotherapy
Stage 2 HTN: Systolic >/= 160, Diastolic >/= 100, Drug therapy = 2 drug combo
Goals of therapy for HTN
Uncomplicated HTN - BP goal < 140/90
Diabetes mellitus - < 130/80
Chronic kidney disease - < 130/80
CAD, high CAD risk (CAD risk equivalent or 10 year Framingham risk score > 10%), HF - < 130/80
What are the high risk conditions with compelling indications?
high coronary disease risk
chronic kidney disease
recurrent stroke prevention
Which antihypertensive class is recommended for all compelling indications?
What are lifestyle modifications to reduce HTN?
diet (reduced fat)
moderation of alcohol intake (men NMT 2 drinks/day, women NMT 1 drink/day)
moderation of dietary sodium
potassium intake (caution in pts susceptible to hyperkalemia - renal insufficiency, ACEIs or ARBs)
caffeine - causes an ACUTE rise in BP
Guidelines for pharmacological treatment of HTN
1. Begin with lowest dose of antihypertensive
2. If BP is uncontrolled after 2 months, pt is compliant, and no intolerable effects, increase dose
3. If response is inadequate after reaching full dose, a. add 2nd drug if tolerating 1st, b. d/c and start new agent if pt is not tolerating d/t SEs or had no response
4. BP measurement in early AM covers surge in BP after rising, measurement in late PM ensures adequate coverage throughout the day
5. Once controlled, follow up q 3-6 months
6. Monitoring parameters - a. efficacy - BP, compliance; b. safety - SEs, DIs, CIs, allergies
7. Resistant HTN: assess med adherence, lifestyle factors, white-coat syndrome, drug regimen
8. Pt counseling: a. won't feel BP if too high, maybe if too low; b. compliance is important to prevent stroke, AMI, etc; c. ask about OTCs that can interfere with BP meds; d. SEs of individual meds, dizziness; e. what to do for missed doses; f. do not abruptly stop taking BP meds
5 types of diuretics and examples of each
Loops (bumetanide, ethacrynic acid, furosemide, torsemide) - primary in HF, not really used for HTN
Thiazides (chlorothiazide, HCTZ, metolazone, chlorthalidone, indapamide) - primarily used for HTN
Potassium-sparing (amiloride, triamterene) - not usually used alone - not often used for HTN
Aldosterone Antagonists (AAs) (eplerenone, spironolactone) - not usually used alone - not often used for HTN
Carbonic anhydrase inhibitors (acetazolamide) - very rarely used in HTN
Conditions favoring use of diuretics
Chronic renal failure (loops - don't increase K+)
Osteoporosis prevention (thiazides - can increase calcium in body) (don't work well in pts with renal failure)
Unfavorable effects of diuretics
hyperkalemia - avoid AAs and potassium-sparing
Renal insufficiency - avoid AAs and potassium-sparing
diabetes (high dose)
What effect do loop diuretics have on potassium and calcium?
they decrease both
What effect do thiazide diuretics have on potassium and calcium?
decrease potassium and increase calcium
Which 6 Beta-blockers work on only beta-1 receptors?
nebivolol (< 10 mg)
Which 6 beta-blockers work on both beta-1 and beta-2 receptors?
Which 2 beta-blockers work on alpha-1, beta-1, and beta-2 receptors?
What is ISA and which 5 beta-blockers can cause it?