Hypertension Study Guide 2024 PDF

Hypertension Study Guide Yasmin Grace, B.S., Pharm.D. Palm Beach Atlantic University Cardiovascular Phar...

Hypertension Study Guide Yasmin Grace, B.S., Pharm.D. Palm Beach Atlantic University Cardiovascular Pharmacotherapy Objectives 1. Define systolic and diastolic blood pressure, pulse pressure, and mean arterial pressure. 2. Describe the factors contributing to the etiology of primary and secondary hypertension. 3. List benefits of treating hypertension & list the specific BP goals 4. Describe the diagnosis of hypertension and the purpose of ambulatory blood pressure monitoring 5. Recommend lifestyle modifications for the management of hypertension and describe the effectiveness of these modifications. 6. Describe the management of hypertension as outlined in the 2017 ACC/AHA High Blood Pressure Clinical Practice Guidelines. 7. Compare and contrast the characteristics of antihypertensive drug classes including place in therapy, adverse effects, drug interactions, contraindications, and monitoring. 8. Define and list potential causes of resistant hypertension. 9. Identify non-prescription drug therapies and dietary supplements that contribute to hypertension. 10. Design antihypertensive treatment regimens for patients with compelling indications. 11. Describe treatment considerations for elderly and pregnant patients. 12. Define orthostatic hypotension and recommend counseling points for managing symptoms. Introduction Hypertension means high blood pressure Most significant risk factor for cardiovascular disease (CVD) In 2010, high BP was the leading cause of death and disability worldwide In 2012, hypertension was the second leading cause of ESRD, behind diabetes mellitus – Accounted for 34% of incident ESRD cases in the U.S. population Epidemiology 2018 (American Heart Association heart disease and stroke statistics update) - 34% of US adults had HTN 2017 American college of Cardiology/American Heart Association (ACC/AHA) with lower BP thresholds estimate: – 46% prevalence of hypertension in U.S. adults – Prevalence based on age Ages 20-44 years: 30% in men and 19% in women Ages 65-74 years: 77% in men and 75% in women – Prevalence varies with ethnicity and sex Black: men 59% and women 56% White: 47% in men and women 41% Asian: 45% in men and women 36% Hispanic: 44% in men and women 42% Definitions Systolic blood pressure (SBP) – Pressure in the arterial wall during cardiac contraction – Measured in mmHg – Based on cardiac output (CO) determined by stroke volume, heart rate, and venous capacitance Diastolic blood pressure (DBP) – Pressure in arterial wall during filling of the ventricles – Measured in mmHg – Based on total peripheral resistance (TPR) 1  Isolated systolic hypertension – Elevated SBP but normal DBP – Due to old age, patients are at an increased risk of morbidity and mortality Pulse pressure – Difference b/w SBP and DBP – Indicates arterial wall stiffness – High pulse pressures are correlated with increased risk of cardiovascular morbidity & mortality Mean arterial pressure (MAP) – Average pressure throughout a cardiac cycle of contraction – 2/3 of time spent in diastole & 1/3 in systole – Equation: MAP = 1/3 (SBP) + 2/3 (DBP) Etiology Primary Hypertension Secondary Hypertension Hypertension with an unknown cause Hypertension with an identifiable cause Environmental and genetic factors Unhealthy diet Low physical activity Family history Alcohol consumption Cigarette smoking Obesity and weight gain Non-pharmacotherapy and patient education are critical to decrease high risk behaviors 2 Frequently used Agents/ Medications that can Elevate Blood Pressure Alcohol Limit alcohol to ≤1 drink daily for women and ≤2 drinks for men Amphetamines (e.g., amphetamine, methylphenidate Discontinue or decrease dose dexmethylphenidate, dextroamphetamine) Consider behavioral therapies for ADHD Antidepressants (e.g., MAOIs, SNRIs, TCAs) Consider alternative agents (e.g., SSRIs) depending on indication Avoid tyramine-containing foods with MAOIs Atypical antipsychotics (e.g., clozapine, olanzapine) Discontinue or limit use when possible Consider behavior therapy where appropriate Recommend lifestyle modification (see Section 6.2) Consider alternative agents associated with lower risk of weight gain, diabetes mellitus, and dyslipidemia (e.g., aripiprazole, ziprasidone) Caffeine Generally, limit caffeine intake to 50 % of adults in US unaware they have hypertension o Hypertension aka “Silent Killer” Persistently elevated blood pressure à Target organ damage Target Organ Damage Brain (Stroke, transient ischemic attack, dementia) Retinopathy Heart (Left ventricular hypertrophy, heart failure, angina, myocardial infarction) Chronic kidney disease Peripheral arterial disease (PAD) 3 Diagnosis Average of ≥ 2 BP measurements taken during ≥ 2 clinical encounters o Confirm the diagnosis of HTN at a subsequent visit one to four weeks after the first Measure BP in both arms (the higher value should be used) Note: If blood pressure is very high (e.g., SBP >180 mmHg), or timely follow-up unrealistic, treatment can be started after just one set of measurements. If BP >160/>100 mmHg with TOD diagnosis can be made. White Coat Hypertension Masked Hypertension Elevated office blood pressure and normal out-office Office blood pressure is normal and elevated out-of- blood pressure office blood pressure More common in children, older adults, women and pts More common in men, AA, DM, CKD, OSA with office BP closer to thresholds Associated with higher CV risk Home blood pressure monitoring (HBPM) Ambulatory blood pressure monitoring (ABPM) Self-monitoring tool patients can incorporate at home BP readings over a continuous period Improves BP control, diagnosis of white-coat and masked Taken every 20-30 minutes during the day & at night HTN & prediction of CV risk Measures changes in BP and HR Less expensive and more convenient than ABPM BP distribution pattern according to daily activities & sleep Allows patients to be more involved in HTN management Can determine effects of antihypertensives on BP Detects BP variability Allows for dose adjustments or time for medication administration Predictor for cardiovascular and cerebrovascular disease Detects target organ damage Definition of HTN According to Office, Ambulatory, and Home BP Office HBPM Daytime ABPM Nighttime ABPM 24-hr ABPM >130/80 >130/80 >130/80 >110/65 >125/75 Tips for proper blood pressure measurements: ▪ Blood pressure should be measured after the patient has emptied their bladder and has been seated for five minutes with back supported and legs resting on the ground (not crossed). ▪ The arm used for measurement should rest on a table, at heart-level. ▪ Use a stethoscope or automated electronic device with the correct size arm cuff. ▪ Take two readings one to two minutes apart and average the readings. ▪ Measure blood pressure in both arms at initial evaluation then use the higher reading for measurements thereafter. 4 Benefits of Lowering BP Average Percent Reduction Stroke Incidence 35-40% Myocardial Infarction 20-25% Heart Failure 50% ▪ The blood pressure relationship to the risk of cardiovascular disease (CVD) is continuous, consistent, and independent of other risk factors. ▪ Each increment of 20/10 mmHg doubles the risk of CVD across the entire BP range starting from 115/75 mmHg. ▪ Pre-hypertension signals the need for increased education to reduce BP to prevent hypertension. Patient Evaluation Evaluation of patients with HTN has three objectives: ▪ Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guides treatment. ▪ Identify causes of hypertension. ▪ Assess the presence or absence of target organ damage and CVD. Cardiovascular Risk Factors in Patients with Hypertension ** Age (>55 men, >65 women) ** Family history of premature CVD (men age 180 >110-120 *Presence of target organ damage Goals of Therapy Clinical Condition(s) BP Threshold, mm Hg BP Goal, mm Hg General Clinical CVD or 10-year ASCVD risk ≥10% ≥130/80