HT Handout 2024 PDF

1 DRUG TREATMENT OF HYPERTENSION: Antihypertensive drugs. Dr. Luigi X. Cubeddu. Although the severity of hypertension (HT) and its progression if untreated varies greatly between patients, we...

1 DRUG TREATMENT OF HYPERTENSION: Antihypertensive drugs. Dr. Luigi X. Cubeddu. Although the severity of hypertension (HT) and its progression if untreated varies greatly between patients, we may conclude that: HT is mostly a chronic disease. Patients with elevated BP, stage I and even stage 2 HT are commonly asymptomatic. Signs and symptoms of HT appear late, once extensive, and often irreversible damage to blood vessels, heart and kidneys have occurred (End-Organ Damage). Long-term treatment with BP-lowering drugs is commonly required to treat hypertension. Healthy lifestyle, including exercise, caloric restriction, healthy food diet, low salt intake, sufficient sleep, and stress reduction and meditation are the initial and essential part of the treatment. These lifestyle adjustments often control the HT, and may avoid or reduce the use of antihypertensive drugs. When untreated, HT would damage the blood vessels, the heart, and the kidneys. It is known that the higher the BP, the larger the risk of developing end-organ affectation. Vascular damage: HT accelerates the atherosclerosis of arterial vessels. Advance atherosclerosis of the cerebral arteries presents as transient ischemic attacks and/or thrombotic or hemorrhagic strokes. Atherosclerosis of the coronary arteries presents as angina pectoris and acute coronary syndromes such as unstable angina and myocardial infarction, arrhythmias, and even sudden death. Chronic cardiac ischemia leads to weakening of the cardiac muscle, and heart failure. Atherosclerosis of the renal arteries affects renal function leading to chronic kidney disease, requiring dialysis and renal transplants. Atherosclerosis of the peripheral arteries, for example the legs arteries, lead to peripheral artery disease affecting, presenting with decrease pulses in the legs and leg pain when walking. Heart muscle damage: may initially present as left ventricular hypertrophy, followed, if untreated, by left ventricular dilation and heart failure. The high arterial BP makes the left ventricle work harder, becoming thicker, a condition known as left ventricular hypertrophy (LVH). LVH is risk factor for the development of fatal arrhythmias and sudden death. As described above, sustained high BP also accelerates the process of atherosclerosis of the coronary arteries, leading to insufficient blood supply (ischemia) to the heart. Chronic ischemia together with chronic hypertension leads to heart failure. Heart failure is defined as the inability of the heart to pump sufficient blood flow to cover for the body demands. Hypertension and other risk factors for cardiovascular diseases. HT is commonly associated with other risk factors, such as older age, obesity, low HDL cholesterol, high triglycerides, and insulin resistance leading to hyperinsulinemia, impaired glucose tolerance and diabetes mellitus. The coexistence of these risk factors greatly increases the likelihood of developing cardiovascular complications; therefore, all the cardiovascular risk factors or comorbidities, should be considered when treating a patient with HT. The major goal of treatment is to prevent end-organ damage and to reduce the rate of adverse cardiovascular events, such as heart failure, myocardial infarction, and death. More aggressive BP lowering is required for patients who in addition of HT have with risk factors, such as diabetes. 1  2 More than 11 million Americans have both HT and type 2-diabetes mellitus. Not only the prevalence of HT is increased in diabetics, but also HT augments the risk of developing diabetes. This combination markedly increases the risk of strokes, heart attacks, renal insufficiency, dialysis, and renal transplants. Remember, when HT and diabetes mellitus coexist, all efforts should be made to lower the BP to levels on the normotensive range. Lowering BP or even better "Normalization of BP" slows down the development of vascular and cardiac lesions and reduces cardiovascular morbidity and mortality. Because of its silent course, essential HT has been named “The Silent Killer”. Since subjects with mild to moderate HT are mostly asymptomatic, lowering of BP does not produce evident well-being. Additionally, antihypertensive drugs may produce side effects in otherwise asymptomatic patients. Therefore, poor medication compliance is a common problem of antihypertensive therapy. Patient education about the natural course of the disease and of its complications, is needed to improve compliance with antihypertensive therapy, and lifestyle modifications. Epidemiology. High blood pressure is the most common cardiovascular disease. It has been estimated that 50 to 60 million subjects in the US are hypertensive and nearly two million new cases are diagnosed each year. About one quarter of the adult world population (ONE BILLION people) have hypertension. A reduction of 4-6 mmHg for 3 to 5 years in people with HT has been shown to reduce the risk of stroke by 42%, the risk of myocardial infarction by 16%, and total vascular mortality by 21 %. High blood pressure increases the risk of strokes, heart attacks and kidney disease. Therefore, hypertension MUST be treated! 13.5% of the world’s premature deaths are attributed to high blood pressure. 54% of strokes worldwide are attributed to high blood pressure. 47% of ischemic heart disease worldwide is attributed to high blood pressure. Most of the high blood pressure related mortality is observed in low- and middle-income countries. We have not all been successful in treating hypertension. Nearly 30% of HT are not aware of their condition, 14% of HT are not treated, 27% receive inadequate treatment and only 26% receive adequate treatment. Hypertension requires long-term treatment, it is costly to the patient and the health system. Even though there are many drug entities in the market, the cause of essential hypertension is unknown. The mortality rate for myocardial infarction, strokes, and other vascular diseases increases progressively with a rise in BP levels, starting at levels as low as 115/75 mmHg; with a doubling of mortality risk for every 20/10 mm Hg rise in BP above this level. BP levels and Hypertension. Blood pressure categories in the new guideline are: Normal: Less than 120- and 80 mmHg. Elevated: Systolic 120-129 and diastolic less than 80. Stage 1: Systolic 130-139 or diastolic between 80-89. Stage 2: Systolic at least 140 or diastolic at least 90 mmHg. 2  3 Medication is prescribed for Stage I hypertension if the patient had a cardiovascular event such as a heart attack or stroke or is at high risk of heart attack or stroke based on age, or has diabetes mellitus, or has chronic kidney disease or has a high atherosclerotic risk (using the same risk calculator employed for evaluating high cholesterol). Medications combined on a single pill (valsartan + HCTZ) are useful to improve compliance, because patients often need two or more medications to control their BP. Identifying socioeconomic status and psychosocial stress as risk factors for high blood pressure should be considered in a patient's plan of care. Commonly employed terms: Fix vs. labile hypertension. Paroxysmal hypertension Hypertensive crisis, urgency, and emergency Borderline hypertension Isolated systolic hypertension White coat hypertension Dippers and non-dippers BLOOD PRESSURE MEASUREMENTS. On the first visit, BP should always by measured on the three positions (supine, standing and sitting); as well as in both arms and one leg. The arm with higher BP readings should be used for future follow-ups. The practitioner must stick to that arm and must always employ the correct cuff size for the measurements. Using a regular (standard) cuff size on a large arm will give falsely elevated BP readings. Standing BP should be taken as soon as patients stands (from the supine position) and at either 2 or 5 minutes after standing. Pulse rate or heart rate should also be measured in supine, sitting, and standing positions. BP should drop at night and increase from 2 to 6 a.m. Automated BP instruments are used for ambulatory BP recordings, which allow to record BP automatically for 24 hours. These instruments are mostly used to establish the presence of hypertensive crisis, define dippers (when the BP drops at night) and non-dippers (when the BP does not drop at night), white-coat hypertension (high BP during Doctor’s visits), as well as therapy efficacy and duration of action of the medications. Causes of Hypertension: *Essential or Primary Hypertension (90% of hypertensives). *Secondary Hypertension (renal disease, renovascular disease, sleep-apnea/obesity/metabolic syndrome, drug-induced hypertension, Cushing syndrome, pheochromocytoma, aldosterone- producing tumors, and other endocrine tumors, are the most common causes of secondary hypertension). The following drugs may increase BP and/or may antagonize the effects of antihypertensive medications: Alpha1-agonists (phenylephrine, phenylpropanolamine) are commonly found in nasal decongestant products associated or not with antihistaminic. Steroids (high dose steroids increase BP due to the mineralocorticoid action). NSAIDS: non-steroidal anti-inflammatory drugs. By inhibiting prostaglandin production, the NSAIDs impair vasodilation and sodium excretion. Prostaglandins are natriuretic. 3  4 Cocaine, amphetamines, tricyclic antidepressants: increase BP by blocking the reuptake of NE and/or increasing its release. Examples: Venlafaxine, Bupropion. Birth control pills. Increase BP most likely by increasing the synthesis of angiotensinogen. Licorice: It is transformed in the body to a metabolite with mineralocorticoid activity. Erythropoietin Cyclosporine, Tacrolimus High dose caffeine Estrogens Tyrosine kinase inhibitors (sunitinib) Treatment of Hypertension. All patients whose BP is above normal range (120/80) should be targeted for lifestyle modifications and/or drug therapy depending on the presence or absence of risk factors. The presence of risk factors in addition to high BP determines the therapeutic strategy to be followed. Non-Pharmacological Treatment (life-style modifications). Among the modifiable factors are stress, sedentary lifestyle, excessive salt intake, overweight, abdominal obesity, glucose intolerance, type 2 diabetes mellitus, hyperinsulinemia, insulin resistance, and excessive alcohol intake. Among the non-modifiable factors are age, gender (males), race (African-Americans), and family history of hypertension. Reducing salt intake (