Hypertension -goals of treatment. This is long but you may end up with more than 3-4
qestions from this page - so please read it.
Explanation: I recommend that you absolutely know the following but also review the guidelines from the JNC VII (2003)
In the past it used to be believed that patient's age defines the normal BP for the patient and a higher BP was accepted as normal in the elderly. This no longer holds true. The Joint national commission (JNC7) gave its report in May 2003 and has laid out guidelines.
No matter how old a patient is, he/she should have a BP less than 135/85.
HTN increases the risk of stroke, MI, heart failure, renal failure, diabetic nephropathy and aortic dissection.
The first line agents that should be used in patients should be Thiazide diuretics or beta blockers. Diuretics have proven to be the best. One can use other agents too but only if the above two give an inadequate response or if there is a reason not to use them.
Some pre-existing conditions in patients make some agents preferable.
Examples include
Prostatic hypertrophy - Alpha blockers.
Peripheral vascular disease - Calcium channel blockers
Diabetes - ACE inhibitors
Heart failure - ACE inhibitors and nowadays even beta blockers
LVH (Left ventricular hypertrophy) - ACE inhibitors
It is extremely important to know that good blood pressure control in a diabetic is even more important than good blood sugar control.
When one finds high BP in a previously undiagnosed patient, one should recheck twice again at intervals at least 20 minutes apart before calling the patient hypertensive.
One should also suspect secondary causes for HTN in patients <35 years of age.
They include:
Renal cause- Renal artery stenosis (high renin and adosterone- diagnosed best using a renal radionucleide flow scan with Captopril challenge.)
Angioplasty is Rx of choice for fibromuscular dysplasia (FMD) which is seen as a distal lesion whereas
Surgery is Rx of choice for artherosclerosis which occurs proximally - adjacent to the atherosclerosis seen in the aorta.
Endocrine cause- Aldosteronism, Pheochromocytoma, Cushing's and acromegaly.
Drugs- ETOH -5-10 % HTN; NSAID; NSAIDs- decreases anti HT effect of B block + Ca Chromosome block, Cyclosporin- decreases diuretics, Ca, Channel block, ACE I
TREATMENT MODALITIES
Non pharmacologic, wt loss- if >10% over the idealbody weight, low salt diet, low ETOH- <2 drinks/D,
decreased Na intakealso enhances the effect of diuretics and ACE I
PHARMACOLOGICAL
If stage 1 HTN doesn't improve after non pharmacologic treatment, diuretics and beta blockers are preferred agents. Medicine which is affordable has most compliance. B block + diuretics improve quality of life.
Thiazide-12.5 mg/D -25/D B blocker
Reserpine-depression not significant problem,
ACE I- DM +CHF
Ca Channel block-if short acting- increases CVS events
A2 receptor blocker - lowers proteinuria, - cough, reserved for pts who cannot tolerate ACE I, if p 2mo no/poor response-add agent
If HTN controlled x 1yr BP meds may be decreased or even rarely stopped
If not controlled think non compliance, inadequate drug, interaction e.g. NSAIDs
In patients with renovascular HTN - cause is Artherosclerosis in 2/3 >50 yrs age
In patients with hypertension of all causes under the age of 30, FMD will be found in 1/3
BP goal 135/85 (The latest concept which is also important for exams is that the lower one can get BP without hypotensive symptoms - the better it is.)
LVH + HTN common in African-americans
LVH on EKG- strong predictor of outcome
Ace antihypertensive low LVH if BP controlled
Isolated systolic HTN-diuretics
African-americans- Younger onset, more incidence of end organ damage, diuretics + Ca channel block good
Pregnancy
Criteria: SBP increases by >30 when compared to non pregnant state OR DBP increases by >15
OR an absolute reading of BP >140/90
Drugs acceptable for treatment during pegnancy:
1. Methyldopa
Never give Ace I in a pregnant patient
Ambulatory Monitoring is helpful in the following situations:
White coat HTN, borderline hypertension, abrupt onset, resistant BP