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REF:  ACP Medicine Best Dx/Best Rx 2006

Essential Hypertension  (Keep BP < 130/80)    RX              

See also  Hypertension Crisis  | Secondary Hypertension  | Resistant Hypertension   

hypertension2009.pdf  |  Hypertension in Pregnancy 2011.pdf

Systolic Hypertension in Elderly 2007    

Essential Hypertension:

Secondary Hypertension

Lab Tests hypertension screening:
1.  Potassium (electrolytes), BUN, Creat, glucose, calcium, UA, TSH, CBC
2. Identify CV risk factors: lipid profile, glucose
3. Identify target-orgen injury: chest x-ray, ECG, UA, BUN, Creat, uric acid

Screening Tests for Secondary Hypertension:  see Secondary Hypertension section

The Reference Card of the Joint National Committee (JNC VII) 2003

BP Scheme for Adults (in mm Hg)

The Essential Points of JNC 7:

Lifestyle Modification

Treatment for Patients with Essential Hypertension

Initial Drug Choices

1. Uncomplicated Hypertension:  Diuretics, ACE-I, Beta-blockers

2. Compelling Indications  for Individual Drug Classes, unless contraindicated:
In Diabetes:  ACE-I, HCTZ, BB, ARB, CCB
In Chronic Kidney Disease:
 ACE-I, ARB
In CHF:  ACE-I, diuretics, BB, ARB, Aldactone
In recurrent stroke prevention:
 HCTZ, ACE-I
In isolated systolic HTN (older pts):  diuretics, Ca-blockers (long-acting Dihydropyridine)
In post Myocardial Infarction:  Beta-blocker (non-ISA), ACE-I , Aldactone
In high CVD risk:
 HCTZ, BB, ACE-I, CCB
In prostatism (BPH):  Alpha-blockers

Medications for Hypertension

* Remember to emphasize lifestyle modification (e.g., low-salt diet, regular physical activity, weight control, off smoking, etc.) and medication adherence.
Diuretics
  • Hydrochlorothiazide/Esidrix 12.5,  25, 50 mg tab/day      
  • Maxzide-25 (HCTZ 25 mg/ triamterene 37.5 mg) once/day
  • Dyazide (HCTX 25 mg/ triamterene 50 mg) once/day
  • Triamterene/Dyrenium 25-100 mg
  • Ethacrynic acid  (Edecrin)- Initial dose: 25 mg/day PO; range: 25–100 mg/day PO; 0.5-1 mg/kg IV (max 50 mg IV) for edema.
    Only non–sulfa-based diuretic, an alternate diuretic in renal insufficiency or sulfa-based diuretic allergy
  • Aldactone (Spironolactone) 25, 50, 100 mg tab 2-3x/day; Potassium sparing, watch for hyperkalemia, gynecomastia.
  • Modurectic (amiloride 5 mg/ HCTZ 50 mg) once/day
  • Amiloride HCl/Midamor 5-10 mg
  • Lasix (Furosemide) 20, 40, 80 mg tab 1-2x/day PO or IV
  • Bumex (Bumetanide) 0.5, 1, 2 mg tablets; 0.5-2 mg once/day PO;  IV or IM 0.5- 1 mg initially (max=10 mg/d) ;  2-10 ml vials(0.25 mg/ml)
  • Zaroxolyn (metolazone) 1.25-2.5-5 mg 1x/d  
  • Lozol (Indapamide) 1.25 - 2.5 mg tablet 1x/d  

Top

ACE INHIBITORS - Angiotensin Converting Enzyme Inhibitor
Indications: Patients with Hypertension, CHF, Kidney disease, Diabetes, Cardiovascular disease, Heart Attack, Diabetes prevention, ? stroke.
  • Lisinopril (Zestril/Prinivil) 5, 10, 20, 40 mg tablets Start 10 mg/d; usual dose 10-40 mg/d once daily    
  • Prinzide (Lisinopril/HCTZ) 10-12.5, 10-25, 20-12.5, 20-25 tab - 1-2 tab daily. 
  • Captopril (Capoten) 12.5, 25, 50, 100 mg tab 12.5-50 mg 2-3x/day; Max:100-150 mg 2-3x/d
  • Benazepril (Lotensin) 5, 10, 20, 40 mg tablets Start 10 mg/d; usual dose 20-40 mg/d once daily
  • Cilazapril ( Inhibase) 1, 2.5, 5 mg tab  Initial dose 1.25-2.5 mg PO qd, usual dose 2.5-5 mg qd, Max 10 mg qd 
  • Enalapril (Vasotec) 2.5, 5, 10, 20 mg tablets 2.5-20 mg/d once daily.
  • Fosinopril (Monopril) 10 mg tablet Start 10 mg once/d; usual 20-40 mg/d once daily
  • Moexipril  (Univasc) 7.5, 15 mg tab. Start 7.5 mg qd PO, usual dose 7.5 - 30 mg/day   (max 30 mg/d)
  • Perindopril erbumine (Acceon) 4-8 mg once daily
  • Quinapril (Accupril) 5,10, 20, 40 mg tab -  Start 10 mg qd, usually 20-80 mg qd or in divided bid dose.  Max 80 mg/d
  • Ramipril (Altace) 1.25, 2.5, 5, 10 mg cap - Start with 2.5 mg once daily up to 20 mg/d (once or in 10 mg bid)
  • Trandolapril (Mavik) 1, 2, 4 mg table once daily.

ARB - Angiotensin II Receptor Blockers

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BETA BLOCKERS  
  • Blocadren (Timolol) 5 10 20 mg tab usual dose 10 20 mg bid; max: 60 mg/d
  • Brevibloc (Esmolol) 80 mg bolus over 30 sec, then 12 mg/min IV infusion (150 ug/kg/min) for perioperative stress related tachycardia or hypertension.
  • Coreg (Carvedilol) 3.125,  6.25,  12.5,  25 mg PO bid for CHF or HTN.
  • Corgard (Nadolol) 20 40 80 120 160 mg tab Start 40 mg once daily, usual dose 40-80 mg/d upto 160-240 mg/d
  • Inderal (Propanolol) 10 20 40 60 80 mg tab, 60 80 120 160 mg LA cap 20 80 mg 2 3x/d
  • Lopressor (Metoprolol) 50 100 mg tab; 5 ml (=5 mg) amp Initial dose 100 mg/d once or in divided doses; Max<450 mg/d In early MI Rx, may give 5 mg IV bolus x3, then PO 50 mg q6h x2d, then 100 mg bid PO as tolerated.
  • Toprol XL (Metoprolol) 50 100 200 mg tab Initial dose: 50 100 mg/d; max:<400 mg/d
  • Normodyne (Labetalol) 100, 200, 300 mg tab.  Start 100 mg bid, usual dose 200-400 mg bid PO.
    IV bolus 20 mg slowlyu over 2 min, additional 40 or 80 mg can be given at 10 min interval until desired BP achieved.  Max. effect usually occurs within 5 min of each injection.  Max. dose 300 mg total IV.  Half life is 5-8 hours.
    IV infusion 200 mg in 200 mL fluid at the rate of 2 mg=2mL/min, rate to be adjusted to control BP, then stop IV infusion, & change to PO Labetalol 200-1200 mg bid
  • Sectral (Acebutolol) 200 400 mg cap Start with 200 mg bid; optimal PVC response 600 1200 mg/d. Use in elderly: doses >800 mg/d should be avoided.
  • Tenormin (Atenolol) 25 50 100 mg tablets .  50- 100 mg once/d
  • Visken (Pindolol) 5, 10 mg tab.  Start 5 mg bid, max. 60 mg/day
  • Ziac (Bisoprolol) 2.5,  5,  10 mg with HCTZ 6.25 mg once daily for BP

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CA- BLOCKERS

Nondihydropytidines:

  • Calan/Isoptin (verapamil) 80-120 mg tablets usual dose 80-120 mg tid
    Calan SR/Isoptin SR (verapamil) 120-180-240 mg tablets usual dose 120-360 mg daily
  • Cardizem (diltiazem) 30-60-90-120 mg tablets tid PO or
    Injectable IV bolus for control of heart rate in atrial fibrillation or flutter.
    Start with 0.25 mg/kg (ave=20 mg), may repeat in 15 min with 0.35 mg/kg (ave=25 mg), then infusion 5-15 mg/hr up to 24 hr.   Onset: 3 min Duration 1-3 hr.  
    (*** Not to be used in WPW or short PR syndrome. Caution should be used in CHF pts.)
    Cardizem CD (diltiazem) 180- 240- 300 mg cap 1 cap daily
    Cardizem SR (diltiazem) 60- 90- 120 mg cap
    Dilacor XR (diltiazem) 180- 240 mg cap 1 cap daily
    Tiazac (Diltiazem) 120, 180, 240, 300, 360 mg extended release cap for BP
  • Posicor/mibefradil (T-channel Ca antagonist)  50-100 mg

Dihydropyridines:

  • Cardene (nicardipine) 20 -30 mg capsules 20- 30 mg tid
    Cardene SR (nicardipine) 30- 45- 60 mg capsules 30- 45 -60 mg 1 cap bid
  • DynaCirc (isradipine) 2.5- 5 mg capsules 2.5 5 mg bid
  • Nimotop (nimodipine) 30 mg cap 60 mg q4h PO for 21 days, preferably >1h before or 2h after meal.
  • Norvasc (Amlodipine)  2.5,  5,  10 mg tab.  Usually 5-10 mg/day
  • Plendil (felodipine) 5- 10 mg tablets Start 5 mg/d once a day; usual dose 5 10 mg/d; max 20 mg/d
  • Procardia (nifidipine) 10 -20 mg cap 10 -20 mg tid, up to 20- 30 mg 3 4x/d.
    Procardia XL (nifidipine)
    30- 60- 90 mg tablets. usual dose 30- 90 mg once daily
  • Sular (Nisoldipine) 10, 20, 30, 40 mg tab once/day.

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ALPHA ADRENERGIC BLOCKERS  
  • Cardura (Doxazosin mesylate) 1 2 4 8 mg tab Start with 1 mg, dose:1 16 ng once daily
  • Hytrin (Terazosin) 1- 2- 5 mg tab Start 1 mg/d, usual dose 1- 5 mg once a day; max: 20 mg/d
  • Minipress (Prazosin) 1- 2- 5 mg cap Start 1 mg 2- 3x/d, usual dose up to 20 mg/d in divided doses.

Combined alpha- & Beta-blockers:

Central alpha-agonist

  • Clonidine/Catapres 0.2-1.2 mg/day; or Catapres-TTS-1, -2, -3 patch weekly
  • Methyldoma/Aldomet 500-3,000 mg/day
  • Guanabenz/Wytensin 8-32 mg/day
  • Guanfacine/Tenex 1-3 mg/day

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Direct Vasodilators  
  • Hydralazine/Apresoline 50-300 mg/day
  • Minoxidil/Loniten  5 - 100 mg/day
  • Nitroglycerin 2.5, 6.5, 9 mg cap  bid

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Peripheral agents
  • Reserpine/Serpasil 0.1,0.25,1.0 mg tab. Usual dose 0.1-0.5 1-2x/d;
  • Hydropress-25 (reserpine 0.125 mg + Hctz 25 mg ); 
  • Guanadrel/Hylorel 10-75 mg/day
  • Guanethidine/Ismelin 10-150 mg/day

Hypertension Crisis

Definition

  • Severe elevation in blood pressure, with diastolic blood pressure (DBP) > 120-130 mmHg.
  • Hypertensive Emergency is defined as a clinical setting where BP must be reduced effectively within minutes to <1hour, such as
    accelerated & malignant hypertension, hypertensive encephalopathy, & severe diastolic hypertension (120-160 mmHg) that is associated with acute pulmonary edema, ischemic chest pain, dissecting aortic aneurysm, or intracerebral hemorrhage,  papilledema (+/ ), evidence of renal function deterioration, or evidence of neurologic dysfunction, etc.
  • Hypertensive Urgency is defined as a clinical setting of severe hypertension  with minimal or no symptoms, where severe elevation of BP are not causing immediate end-organ damage but should be effectively lowered within 24 hours to reduce potential risk to the patient.

Symptoms as:

  • Headache, Visual Changes, Papilledema
  • Chest Pain (MI), Pain to Back (Dissection)
  • Abdominal Pain - abdominal aneurysmal dissection
  • Flank Pain - renal disease
  • Mental Status Changes - stroke, leukoencephalopathy

ACP PIER 2006                                                                      

Approach to Hypertensive Emergency/Crisis          

Distinguish between a hypertensive emergency and a pseudocrisis in patients with markedly elevated BP.

  • Do not use parenteral or sublingual drugs to treat markedly elevated BP (>180/110 mm Hg to 220/120 mm Hg) in the absence of symptoms or progressive target organ damage.
  • Use the following treatment approaches:
    • Administer one or more rapid-onset oral antihypertensive drugs (e.g., furosemide, propranolol, captopril, clonidine, or nicardipine);
      once BP is less than 180/110 mm Hg
      , administer a longer-acting formulation and recheck the BP within 48 hours.
    • Administer a longer-acting oral formulation from the start and recheck BP in 48 hours.

Identify when a hypertensive BP reading may constitute an emergency.

  • Measure BP repeatedly and assess the possibility of ongoing or imminent target organ damage.
  • Consider hospitalizing a patient with hypertensive emergency for parenteral antihypertensive medication when BP is sufficiently elevated to cause target organ damage (imminent) or is judged to have caused or played a role in present (ongoing) target organ damage.
    Specifically, considering hospitalizing hypertensive patients with:
    • Coronary disease and crescendo angina
    • Heart failure with increasing shortness of breath
    • Abrupt worsening of renal function
    • Headache, blurred vision, and increasing disorientation or confusion
    • Past hypertensive end-organ damage
    • Recent vascular surgery
    • Organ transplantation
    • Known aortic aneurysm or a tearing sensation between the scapulae
  • A child with previously normal BP may have a hypertensive emergency at a BP not considered particularly worrisome in an adult. Use clinical judgment to determine need for hospitalization.
  • A pregnant woman with previously normal or low BP may have a hypertensive emergency at a BP not considered particularly worrisome in a nonpregnant adult. Use clinical judgment to determine need for hospitalization.
  • Measure the BP more than once or twice and carefully track it before declaring an “emergency.” The duration of this tracking will vary according to clinical presentation.
  • Monitor the BP in a setting where intravenous antihypertensive drugs can be given rapidly.

Quick Exam in Severe Hypertension   Yes or  No

  • Are pressures equal in the arms?
  • Are femoral pulses present?
  • Is grade III or IV retinopathy present?
  • Is the patient oriented?
  • Are pupils equally dilated?
  • Is the neck stiff?
  • Are rales or an S3 present?
  • Are abdominal bruits present?
  • Are there overt neurologic deficits?

Quick History in Severe Hypertension     Yes or No

  • Was antihypertensive therapy recently interrupted?
  • Are neurologic symptoms present?
  • Were they sudden in onset: i.e., over minutes to hours?
  • Did they occur gradually over days?
  • Is severe headache present?
  • Have visual disturbances occurred?
  • Has nausea or vomiting occurred?
  • Is severe dyspnea present?
  • Is the patient pregnant?
  • Does the patient have worsening angina?
  • Is the patient post- vascular surgery (including CABG)?
  • Has the patient taken sympathomimetics or cocaine?
  • Is the patient taking a MAOI antidepressant ?

Situations In Which Severe Hypertension Constitutes a Crisis

  • Heart/Vascular
    • Left ventricular failure
    • MI
    • Unstable angina
    • After vascular surgery or CABG
    • Aortic dissection
  • Brain
    • Hypertensive encephalopathy
    • Subarachnoid hemorrhage
    • Intracranial hemorrhage
    • Thrombotic stroke with severe hypertension
  • Miscellaneous
    • Severe catecholamine excess:
      • Pheochromocytoma
      • Clonidine withdrawal
      • Tyramine/MAOI interaction
      • LSD/cocaine/phencyclidine/phenylpropanolamine use
    • Eclampsia in pregnancy

Antihypertensive Agents That Are Useful in Hypertensive Crises to guide treatment of patients with:

  • Markedly elevated BP and high intracranial pressure
  • Progressive azotemia
  • Coronary ischemia
  • Acute left ventricular failure
  • Eclampsia
  • Suspected aortic dissection
  • Catecholamine excess
  • Suspected aortic dissection, and in the perioperative setting

   

EMERGENCY TREATMENT OF HYPERTENSIVE CRISIS                              
Antihypertensive Agents That Are Useful in Hypertensive Crises
  • Nitroprusside (Nipride)  IV 
    Initial dose 0.3 µg/kg/min (Max dose 10µg/kg/min) Onset of action <1 minute, duration <2 minutes
    Best use for  Encephalopathy, left ventricular failure, aortic dissection (with ?-blocker)
    Major side effects: Cyanide/thiocyanate toxicity (thiocyanate level>10 mg/dl is toxic; >20 mg/dl may be fatal) ; hypotension, N&V, apprehension, convulsion, twitching, psychosis, dizziness, etc.   It has decreased efficacy in renal failure
  • Nitroglycerin IV
    Initial dose 5 µg/min (Max dose 100 µg/min) Onset of action <5 minutes, duration <5 minutes
    For use for Unstable angina, MI.  Excellent for titrating blood pressure in setting of coronary ischemia
    Major side effect: headache, tachycardia, vomiting, methemoglobinemia
  • Labetalol (Trandate) IV
    Mixed alpha/beta blocker, excellent for most hypertensive emergencies.
    First or second line for eclampsia; excellent in catecholamine surges
    Initial dose :20 mg IV bolus over 2 minutes, then 20- 80 mg q10 min prn, or Continuous infusion at 0.5-2.0 mg/min (Max dose 300 mg),
    Onset of action <5 minutes, duration 1-4 hours, but variable
    Best use for Stroke, intracranial hemorrhage
    Side effects: Nausea Fatigue, dizziness, scalp tingling
    Contraindication: Asthma or bronchospasm, overt cardiac failure, >first-degree heart block, severe bradycardia
  • Diazoxide (Hyperstat) IV
    Initial dose: 1-3 mg/kg (up to 150 mg) IV bolus q5-15 min over 5 minutes until BP is controlled (Max dose 600 mg),
    Onset of action <2 minutes, duration 6-12 hours
    Side effects: — Profound hypotension Elevated heart rate, elevated glucose, sodium retention
    Contraindication: Thiazide allergy
  • Nicardipine (Cardene) IV
    Initial dose: 5 mg/h (Max dose 15 mg/h), Onset of action <1 hour, duration <1 hour
    Best use for Vascular surgery, subarachnoid hemorrhage  
    Side effects: Headache ,Elevated heart rate
    Contraindication: Severe aortic stenosis
  • Enalapril (Vasotec) IV
    Highly variable response; precipitous BP drop in high-renin states, rarely angioedema, hyperkalemia, or acute renal failure.
    Initial dose: 1.25 -5mg IV over 5 min q6h if needed, duration 6 hours
    Best use for Left ventricular failure
    Contraindication: Angioedema
  • Diltiazem (Cardizem) IV
    Initial dose 0.25 mg/kg over 2 min, followed by infusion of 0.35 mg/kg at an initial rate of 10 mg/hour
    Onset:  3-30 min
    Adverse effects: excessive hypotension, flushing
  • Trimethaphan
    Initial dose: 1 mg/min (Max dose 4 mg/min), Onset of action <5 minutes, duration <10 minutes
    Best use for Aortic dissection (with ?-blocker)
    Side effect: Orthostatic hypotension
    Contraindication: Severe volume depletion
  • Hydralazine (Apresoline) IV
    Indicated primarily for eclampsia
    Dose is 10-50 mg IV or IM titrate to effect (onset <20 minutes, duration 3-8 hours)
    Can be given IM as well, 10-50mg (onset 20-30 minutes)
    Onset: 10- 20 min ;  Duration: 3 -8 h
    Adverse effects: tachycardia, flushing, contraindicated in angina or aortic dissection
  • Phentolamine
    Mainly for catecholamine surges as in pheochromocytoma hypertension (pure alpha-adrenergic blockade)
    Dose is 5-15mg IV; onset 1-2 minutes; duration 3-10 minutes
    Side effects: Tachycardia, flushing and headache may occur
  • Esmololol (Breviblock®)
    Mainly for acute aortic dissection, perioperatively, acute coronary ischemia

    May be used with caution in acute MI with depressed LV to modulate heart rate
    Very short half life (2-4 minutes) non-selective ß-blockade
    Dose is 250-500µg/kg/min for 1 minute, then 50-100µg/kg for 4 minutes
    Sequence may be repeated, and continuous drip may be maintained
    Onset of action is 1-2 minutes; 10-20 minute duration
    Very close monitoring is required, and fluid load is large with this agent

Oral Medications for Hypertensive Urgency:

  • Clonidine (Catapres)
    0.2 mg PO, followed by 0.1 mg/hr to total of 0.8 mg until the diastolic BP is <110 mmHg, or reduction in diastolic BP of 20 mmHg or more.
    Onset 30-120 min;  Duration 8-12 h
    Adverse effects: sedation, dry mouth, dizziness, orthostasis, bradycardia
    Contraindicated in pts with sinus bradycardia, sick sinus synd., or heart block.
  • Labetalol (Trandate)
    200-300 mg PO, followed by 100-200 mg q8h
    Onset 1-2h;  Duration 12-24 h
    Adverse effects: bradycardia
  • Furosemide (Lasix)
    20-40 mg PO or IV
  • Nicardipine (Cardene)
    20-40 mg PO tid (Max 120 mg/day) or IV 5 mg/h, increase by 2.5 mg/h q5-15 min to max 15 mg/h.
  • Captopril (Capoten)
    12.5-25 mg PO ,may repeat at intervals of = or > 30-60 min (Typical dose <150mg/d; Max 450 mg/d)

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Distinguish between a hypertensive emergency and a pseudocrisis in patients with markedly elevated BP.

  • Do not use parenteral or sublingual drugs to treat markedly elevated BP (>180/110 mm Hg to 220/120 mm Hg) in the absence of symptoms or progressive target organ damage.
  • Use the following treatment approaches:
    • Administer one or more rapid-onset oral antihypertensive drugs (e.g., furosemide, propranolol, captopril, clonidine, or nicardipine);
      once BP is less than 180/110 mm Hg
      , administer a longer-acting formulation and recheck the BP within 48 hours.
    • Administer a longer-acting oral formulation from the start and recheck BP in 48 hours.

In less than hypertensive crises, but  in hypertension urgency:
one or more rapid-onset oral antihypertensive drugs, as:

  • Furosemide (Lasix) 20-40 mg PO or IV
  • Clonidine 01.-0.2 mg PO
  • Nicardipine (Cardene) 20-40 mg PO tid (Max 120 mg/day) or IV 5 mg/h, increase by 2.5 mg/h q5-15 min to max 15 mg/h.
  • Captopril 12.5-25 mg PO ,may repeat at intervals of = or > 30-60 min (Typical dose <150mg/d; Max 450 mg/d)

 

Causes of Hypertensive Crisis 
  • Chronic hypertension with acute exacerbation (most common)
  • Renovascular hypertension
  • Parenchymal Renal Disease
    • Acute glomerulonephritis
    • Renal Infarction
    • Vasculitis
  • Scleroderma Renal Crisis
  • Drug Ingestion
    • Tricyclic anti-depressants
    • Monoamine Oxidase (MAO) Inhibitors
    • Cocaine
    • Amphetamines
  • Anti-hypertensive drug withdrawal or failed compliance
    • Centrally acting anti-hypertensives (eg. clonidine)
    • Peripheral alpha blockers (eg. prazosin)
    • Beta-Blocker acute withdrawal
  • Pre-eclampsia and Eclampsia
  • Autonomic hyperactivity
    • Guillain-Barre Syndrome
    • Spinal Cord Injury
  • Pheochromocytoma

* Sodium & Potassium in the Pathogenesis of Hypertension 2007  

       2007