From: Subject: Best Dx/Best Rx: Hypertension Date: Wed, 3 Jun 2009 21:23:03 -0700 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_019B_01C9E491.7A9D9BB0" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.5579 This is a multi-part message in MIME format. ------=_NextPart_000_019B_01C9E491.7A9D9BB0 Content-Type: text/html; charset="Windows-1252" Content-Transfer-Encoding: quoted-printable Content-Location: http://www.acpmedicine.com/acp/newrxdx/rxdx/dxrx0103.htm Best Dx/Best Rx: Hypertension



Hypertension

Gary L. Schwartz, M.D.
Mayo Medical=20 School

Sheldon G. Sheps, M.D.
Mayo = Clinic

Defin= ition/Key=20 Clinical Features
Diffe= rential=20 Diagnosis
Best = Tests
Best = Therapy
Best = References

Definition/Key Clinical=20 Features

Prehypertension

  • SBP: 120=96139 mm Hg=20
  • DBP: 80=9689 mm Hg

Essential Hypertension

  • Stage 1=20
    • SBP: 140=96159 mm Hg
    • DBP: 90=9699 mm Hg
  • Stage 2=20
    • SBP: ≥ 160 mm Hg=20
    • DBP: ≥ 100 mm Hg
  • Age at onset: 40=9660 yr
  • Family history of hypertension=20
  • BP at diagnosis: < 180/< 110 mm = Hg=20
  • Asymptomatic=20
  • Normal history, physical exam, and routine = laboratory=20 studies (no target-organ damage) at time of diagnosis=20
  • BP control achieved with lifestyle changes and = 1 or 2=20 drugs=20
  • BP control maintained once achieved in a = compliant=20 patient

Secondary Hypertension

  • Age at onset: < 30 yr or > 50 yr
  • BP: > 180/110 mm Hg at diagnosis=20
  • Significant target-organ damage at = diagnosis=20
  • Hemorrhages and exudates on retinal = examination=20
  • Renal insufficiency=20
  • Left ventricular hypertrophy
  • Poor response to appropriate 3-drug therapy = (which=20 includes a diuretic)=20
  • Accelerated or malignant hypertension
  • Sudden worsening of hypertension at any age=20
3D""=20=20 bac= k to=20 top

Differential = Diagnosis

  • Isolated clinic ("white-coat") = hypertension=20
  • Secondary hypertension
3D""=20=20 bac= k to=20 top

Best=20 Tests

Essential Hypertension

BP Measurement

  • At least two clinic visits 1=962 mo apart = (shorter period=20 if initial BP is severely elevated) with two standardized readings at = each=20 visit averaging ≥ 140/90 mm Hg=20
  • Patient self-measured BP ≥ 135/85 mm = Hg=20
    • Elevated office BP with self-measured BP = < 130/80=20 mm Hg identifies isolated clinic (white-coat) hypertension =
  • Ambulatory BP monitoring to distinguish = sustained=20 hypertension from isolated clinic (white-coat) hypertension and to = assess the=20 following:
    • Hypotension=20
    • Episodic hypertension=20
    • Masked hypertension=20
    • Suspected autonomic dysfunction in patients = with=20 postural hypotension

Lab Tests

  • Identify CV risk factors
    • Cholesterol (LDL and HDL)=20
    • Triglycerides=20
    • Fasting blood glucose
  • Identify target-organ injury
    • Chest x-ray=20
    • ECG=20
    • Urinalysis=20
    • Serum creatinine or BUN=20
    • Uric acid
  • Potassium=20
  • Calcium=20
  • Urinalysis
  • If initial assessment suggests renal = dysfunction,=20 evaluate for chronic kidney disease by measuring 24-hour urinary = protein=20 excretion and estimating glomerular filtration rate (GFR):=20
    • GFR =3D (140 =96 age in yr) =D7 (weight in = kg) =D7 0.85 (if=20 patient is female)/72 =D7 serum creatinine (mg/dl) =

Screening Tests for Secondary Hypertension=20 (Sensitivity/Specificity)

Renovascular Hypertension

  • Captopril radionuclide renal scan (75% = sens./85%=20 spec.)=20
    • Advantage: no contrast exposure=20
    • Disadvantages: renal dysfunction impairs=20 interpretation; may miss bilateral, accessory-, or branch-vessel = disease=20
  • Duplex ultrasound (80%=9690% sens./90% = spec.)=20
    • Advantages: no contrast or radiation = exposure; renal=20 dysfunction does not impair interpretation; calculation of resistive = index=20 identifies subset of patients with renal dysfunction likely to = benefit from=20 intervention (RI < 0.80)=20
    • Disadvantages: failure to visualize both = renal=20 arteries (15%=9620% of cases); may miss accessory- or branch-vessel=20 disease
  • Spiral CT angiography=20
    • Advantages: excellent images of renal = arteries; can=20 identify dissection, accessory vessels, and fibromuscular disease =
    • Disadvantages: considerable contrast load = precludes=20 use in presence of renal dysfunction; expensive
  • Magnetic resonance angiography (85%=96100% = sens./79%=9698%=20 spec.)=20
    • Advantages: no contrast or radiation = exposure; renal=20 dysfunction does not impair interpretation=20
    • Disadvantages: cost; may overstate degree of = stenosis;=20 claustrophobic patients may not tolerate test
  • Renal angiography: gold standard=20
    • Advantages: identifies accessory- and = branch-vessel=20 disease; percutaneous interventions can be performed as part of = study=20
    • Disadvantages: cost; contrast exposure; = invasive=20 (atheroemboli)

Primary Aldosteronism

  • Measurement of serum sodium, potassium, plasma = renin=20 activity (PRA), and plasma aldosterone concentration (PAC)=20
  • 24-hr urinary aldosterone, sodium, and PRA = after 3 days=20 of a 200 mEq=96sodium diet
  • Screening: ratio of PAC/PRA > 20
    • Diagnosis confirmed if UNa > = 200 mEq,=20 Ualdo > 12, and PRA < 1.0 after 3 days of = high-sodium=20 diet=20
    • Advantage: 30% of patients with primary = aldosteronism=20 are normokalemic at presentation; ratio is easy to obtain=20
    • Disadvantages: many antihypertensive drugs = can=20 influence values of PRA and PAC; sensitivity and specificity of = ratio not=20 established
Pheochromocytoma=20
  • Plasma-free metanephrines (99% sens./89% = spec.)=20
    • 24-hr fractionated urinary metanephrines = (77%=20 sens./93% spec.)=20
    • Use plasma test if degree of suspicion is = high or=20 familial syndrome is suspected
Cushing Syndrome=20
  • 24-hr urinary free cortisol (95%=96100% = sens./97%=96100%=20 spec.)=20
    • Diagnosis certain if 24-hr urinary free = cortisol level=20 > 3 times normal=20
    • Diagnosis excluded if level normal
    • Use low-dose dexamethasone suppression test = if=20 elevation < 3 times normal
Coarctation of the Aorta=20
  • Chest x-ray; transesophageal = echocardiogram=20
  • CT or MRI of the aorta
  • Diagnostic findings on chest x-ray
    • "3" sign from dilation of aorta above and = below the=20 coarctation
    • Rib notching from collateral vessels=20

Best=20 Therapy

Prehypertension

  • Monitor BP annually=20
  • Lifestyle adjustments to lower BP and CV risk = and=20 prevent progression to hypertension=20
  • In patients with diabetes or renal disease, = treat with=20 lifestyle adjustments and antihypertensive drugs if systolic BP > = 130 mm Hg=20 or diastolic BP > 80 mm Hg

Essential Hypertension: Risk Stratification = and Initial=20 Treatment in Hypertensive Patients by Blood Pressure Stage (mm=20 Hg)

Risk Group A (No CV Risk = Factors, No=20 Target-Organ Disease or Clinical Cardiovascular Disease)

  • Prehypertension (120=96139/80=9689): lifestyle = modification=20
  • Stage 1 (140=96159/90=9699): lifestyle = modification (up to=20 12 mo)=20
  • Stage 2: (≥ 160/≥ 100): lifestyle = modification + drug=20 therapy

Risk Group B (≥ 1 CV Risk Factor, Not = Including=20 Diabetes; No Target-Organ Disease or Clinical Cardiovascular=20 Disease)

  • Prehypertension (120=96139/80=9689): lifestyle = modification=20
  • Stage 1 (140=96159/90=9699): lifestyle = modification (up to 6=20 mo); consider adding drugs initially=20
  • Stage 2: (≥ 160/≥ 100): lifestyle = modification + drug=20 therapy

Risk Group C (Target-Organ Disease or Clinical = Cardiovascular Disease and/or Diabetes =B1 Other CV Risk = Factors)

  • Prehypertension (120=96139/80=9689)
    • Lifestyle modification
    • Drug therapy: use drugs if SBP > 130 or = if DBP >=20 80 and patient has heart failure, chronic kidney disease, or = diabetes=20
  • Stage 1 (140=96159/90=9699): lifestyle = modification + drug=20 therapy
  • Stage 2: (≥ 160/≥ 100): lifestyle = modification + drug=20 therapy
  • Treatment goals
    • Reduce risk of CV morbidity and mortality =
    • Lower BP to < 140/90; lower to < = 130/80 in=20 patients with heart failure, diabetes, renal disease; lower to < = 140 mm=20 Hg in older patients with isolated systolic hypertension =
  • Coexisting CVD risk factors should be = addressed
  • Consider low-dose aspirin once BP is = controlled
  • Encourage self-measurement of BP =

Treatment for Patients with Essential=20 Hypertension

  • Continue lifestyle modifications
  • Start with lowest recommended dose of a = once-daily drug=20
    • Combination drug therapy is appropriate if = BP >=20 20/10 above goal
    • Thiazide diuretic + one of the following as = second=20 agent: beta blocker; ACE inhibitor; angiotensin receptor blocker; = calcium=20 antagonist
    • If no response or significant side effects = at 2=964 wk,=20 substitute another drug from a different class
    • If partial response at 2=964 wk and drug is = well=20 tolerated, increase dose of initial drug or add agent from a = different class=20 (diuretic if not chosen initially)
    • If not at goal BP in 2=964 more wk, continue = titrating=20 doses and adding agents from other classes at regular follow-up = visits=20
    • If patient on three drugs and goal BP not = reached,=20 review considerations for resistant hypertension; consider referral = to=20 hypertension specialist

Lifestyle Modification

  • Weight reduction if overweight
  • Reduce sodium intake to ≤ 100 mmol/day: = 2.4 g sodium, 6=20 g salt
  • Increase aerobic exercise: 30=9645 min/day =
  • Limit alcohol intake to ≤ 1 oz/day =
  • Maintain adequate intake of potassium: 90 = mmol/day=20
  • Eat a diet rich in fruits, vegetables, and = low-fat dairy=20 products but reduced in saturated and total fat
  • Discontinue tobacco use (reduce CVD = risk)=20

Pharmacologic Therapy

  • Thiazide diuretics are initial drugs of choice = for most=20 patients with uncomplicated hypertension
  • Common comorbid conditions may dictate choice =
  • Long-acting agents preferable because = compliance and=20 consistency of BP control are superior with once-a-day dosing
  • When monotherapy is unsuccessful, add second = agent of a=20 different class
  • Initiate treatment with combination therapy = (two drugs)=20 if BP > 20/10 above goal
  • Include a diuretic appropriate for level of = renal=20 function
  • Refractory/resistant hypertension: consider = the=20 following: noncompliance, interfering substances, inappropriate = regimens,=20 office hypertension, secondary hypertension

Diuretics

  • General side effects of diuretics: = hyponatremia;=20 hypokalemia; hypomagnesemia; hyperglycemia; hypercalcemia (decrease in = urinary=20 calcium excretion); hyperuricemia; increase in triglycerides and = cholesterol;=20 decrease in lithium secretion
  • Contraindications: diuretics should be avoided = in=20 pregnancy and in patients with gout
  • Hydrochlorothiazide (HCTZ)=20
    • First choice in uncomplicated hypertension = and=20 isolated systolic hypertension=20
    • Initial dose: 12.5 mg/day; range: 12.5=9650 = mg/day;=20 cost/mo: $9
  • Chlorthalidone
    • First choice in uncomplicated hypertension = and=20 isolated systolic hypertension
    • Initial dose: 12.5 mg/day; range: 12.5=9625 = mg/day;=20 cost/mo: $9
  • Indapamide
    • Use in presence of renal insufficiency =
    • Initial dose: 1.25 mg/day; range: 1.25=965.0 = mg/day;=20 cost/mo: $16
  • Metolazone
    • Use in presence of renal insufficiency =
    • Initial dose: 1.25 mg/day; range: 1.25=965.0 = mg/day;=20 cost/mo: $66
  • Furosemide
    • Alternate diuretic in renal insufficiency =
    • Side effects: same as other diuretics but = increases=20 urinary calcium excretion
    • Initial dose: 20 mg/day; range: 20=96320 = mg/day;=20 cost/mo: $11
  • Bumetanide
    • Alternate diuretic in renal insufficiency =
    • Side effects: same as other diuretics but = increases=20 urinary calcium excretion
    • Initial dose: 0.5 mg/day; range: 0.5=965.0 = mg/day;=20 cost/mo: $37
  • Ethacrynic acid
    • Alternate diuretic in renal insufficiency or = sulfa-based diuretic allergy
    • Only non=96sulfa-based diuretic
    • Side effects: same as other diuretics but = increases=20 urinary calcium excretion
    • Initial dose: 25 mg/day; range: 25=96100 = mg/day;=20 cost/mo: not available
  • Torsemide
    • Alternate diuretic in renal insufficiency =
    • Long-acting loop diuretic
    • Side effects: same as other diuretics but = increases=20 urinary calcium excretion
    • Initial dose: 5 mg/day; range: 5=9620 = mg/day; cost/mo:=20 $23
  • Spironolactone (also available combined with = HCTZ)=20
    • Potassium sparing
    • Aldosterone antagonist
    • Avoid in renal insufficiency
    • Specific side effects: hyperkalemia, = hyponatremia,=20 painful gynecomastia, menstrual irregularities
    • Initial dose: 25 mg/day; range 25=96100 = mg/day; cost/mo:=20 $40
  • Eplerenone
    • Potassium sparing
    • Aldosterone antagonist
    • Fewer antiandrogen side effects than = spironolactone=20
    • Avoid in renal insufficiency
    • Specific side effects: hyperkalemia, = hyponatremia=20
    • Reduce dose by half if patient is on = verapamil
    • Initial dose: 50 mg/day; range: 50=96100 = mg/day;=20 cost/mo: $108
  • Triamterene (also available combined with = HCTZ)
    • Potassium sparing
    • Usually used for prevention of = diuretic-induced=20 hypokalemia
    • Specific side effects: hyperkalemia, = nephrolithiasis=20
    • Initial dose: 50 mg/day; range: 50=96150 = mg/day;=20 cost/mo: $18
  • Amiloride (also available combined with HCTZ) =
    • Potassium sparing
    • Usually used for prevention of = diuretic-induced=20 hypokalemia
    • Specific side effect: hyperkalemia
    • Initial dose: 5 mg/day; range: 5=9610 = mg/day; cost/mo:=20 $36
Calcium = Antagonists=20 (Alternative First-Line Drugs)

  • General side effects of calcium antagonists: = headache,=20 edema, gingival hyperplasia
  • Diltiazem extended-release (many versions = available)=20
    • Additional side effects: constipation, AV = block,=20 bradycardia, heart failure
    • Initial dose: 120 mg/day; range: 120=96480 = mg/day;=20 cost/mo: $34
  • Verapamil extended-release (many versions = available)=20
    • Additional side effects: constipation, AV = block,=20 bradycardia, heart failure
    • Initial dose: 120 mg/day; range: 120=96480 = mg/day;=20 cost/mo: $26
  • Nifedipine extended-release
    • Additional side effects: flushing, = tachycardia
    • Initial dose: 30 mg/day; range: 30=96120 = mg/day;=20 cost/mo: $66
  • Amlodipine
    • Additional side effects: flushing, = tachycardia
    • Initial dose: 2.5 mg/day; range: 2.5=9610 = mg/day;=20 cost/mo: $61
  • Nicardipine extended-release
    • Additional side effects: flushing, = tachycardia
    • Initial dose: 60 mg/day; range: 60=96120 = mg/day;=20 cost/mo: $98
  • Felodipine
    • Additional side effects: flushing, = tachycardia
    • Initial dose: 2.5 mg/day; range: 2.5=9610 = mg/day;=20 cost/mo: $60
  • Isradipine extended-release
    • Additional side effects: flushing, = tachycardia
    • Initial dose: 5 mg/day; range: 5=9610 = mg/day; cost/mo:=20 $67
  • Nisoldipine
    • Additional side effects: flushing, = tachycardia
    • Initial dose: 10 mg/day; range: 10=9660 = mg/day; cost/mo:=20 $96
Beta Blockers = (Alternative=20 First-Line Drugs)

  • General side effects of beta blockers: = fatigue;=20 bradycardia; reduced exercise tolerance; bronchospasm; vivid dreams; = reduction=20 in HDL cholesterol; increase in triglycerides; insomnia; mask symptoms = and=20 delay recovery from hypoglycemia in diabetics
  • Propranolol
    • Initial dose: 40 mg/day; range: 40=96240 = mg/day;=20 cost/mo: $19
  • Propranolol extended release
    • Initial dose: 60 mg/day; range: 60=96240 = mg/day;=20 cost/mo: $112
  • Metoprolol (fumarate)
    • Initial dose: 50 mg/day; range: 50=96200 = mg/day;=20 cost/mo: $14
  • Metoprolol (succinate)
    • Initial dose: 50 mg/day; range: 50=96400 = mg/day;=20 cost/mo: $118
  • Atenolol
    • Initial dose: 25 mg/day; range: 25=96100 = mg/day;=20 cost/mo: $11
  • Bisoprolol
    • Initial dose: 5 mg/day; range: 5=9620 = mg/day; cost/mo:=20 $68
  • Nadolol
    • Initial dose: 20 mg/day; range: 20=96320 = mg/day;=20 cost/mo: $55
  • Timolol
    • Initial dose: 10 mg/day; range: 10=9640 = mg/day; cost/mo:=20 $32
  • Acebutolol
    • Additional side effects: intrinsic = sympathomimetic=20 activity, resulting in less bradycardia and lipid changes
    • Associated with positive ANA and = drug-induced lupus=20
    • Initial dose: 200 mg/day; range: 200=961,200 = mg/day;=20 cost/mo: $58
  • Pindolol
    • Additional side effects: intrinsic = sympathomimetic=20 activity, resulting in less bradycardia and lipid changes
    • Initial dose: 10 mg/day; range: 10=9660 = mg/day; cost/mo:=20 $38
  • Labetalol
    • Alpha1-blocking activity
    • Additional side effects: orthostatic = hypotension,=20 hepatotoxicity
    • Initial dose: 200 mg/day; range: 200=961,200 = mg/day;=20 cost/mo: $78
  • Carvedilol
    • Alpha1-blocking activity
    • Additional side effects: orthostatic = hypotension,=20 hepatotoxicity
    • Initial dose: 12.5 mg/day; range: 12.5=9650 = mg/day;=20 cost/mo: $95
ACE = Inhibitors=20 (Alternative First-Line Drugs)
  • General side effects of ACE inhibitors: cough; = angioedema; hyperkalemia; acute renal failure if there is bilateral = renal=20 artery stenosis
  • Contraindicated in pregnancy
  • Captopril
    • Additional side effects: taste disturbance;=20 leukopenia; proteinuria with membranous glomerular lesion secondary = to=20 sulfhydryl group
    • Only sulfa-based ACE inhibitor
    • Initial dose: 12.5 mg/day; range: 12.5=96100 = mg/day;=20 cost/mo: $9
  • Enalapril
    • Initial dose: 2.5 mg/day; range: 2.5=9640 = mg/day;=20 cost/mo: $22
  • Lisinopril
    • Initial dose: 5 mg/day; range: 5=9640 = mg/day; cost/mo:=20 $25
  • Benazepril
    • Initial dose: 10 mg/day; range: 10=9680 = mg/day; cost/mo:=20 $24
  • Fosinopril
    • Initial dose: 10 mg/day; range: 10=9640 = mg/day; cost/mo:=20 $30
  • Moexipril
    • Initial dose: 7.5 mg/day; range: 7.5=9630 = mg/day;=20 cost/mo: $46
  • Perindopril
    • Initial dose: 4 mg/day; range: 4=968 mg/day; = cost/mo:=20 $49
  • Quinapril
    • Initial dose: 5 mg/day; range: 5=9680 = mg/day; cost/mo:=20 $72
  • Ramipril
    • Initial dose: 1.25 mg/day; range: 1.25=9620 = mg/day;=20 cost/mo: $93
  • Trandolapril
    • Initial dose: 1 mg/day; range: 1=964 mg/day; = cost/mo:=20 $30
Angiotensin II = Receptor=20 Antagonists (Alternative First-Line Drug; Alternatives to ACE = Inhibitors)=20
  • General side effects of angiotensin II = receptor=20 antagonists: renal dysfunction (particularly in heart failure); = angioedema=20 (rare)
  • These drugs do not cause cough
  • Losartan
    • Initial dose: 25 mg/day; range: 25=96100 = mg/day;=20 cost/mo: $58
  • Valsartan
    • Initial dose: 80 mg/day; range: 80=96320 = mg/day;=20 cost/mo: $63
  • Irbesartan
    • Initial dose: 150 mg/day; range: 150=96300 = mg/day;=20 cost/mo: $53
  • Candesartan
    • Initial dose: 8 mg/day; range: 8=9632 = mg/day; cost/mo:=20 $56
  • Eprosartan
    • Initial dose: 400 mg/day; range: 400=96800 = mg/day;=20 cost/mo: $61
  • Telmisartan
    • Initial dose: 40 mg/day; range: 40=9680 = mg/day; cost/mo:=20 $46
  • Olmesartan
    • Initial dose: 20 mg/day; range: 20=9640 = mg/day; cost/mo:=20 $43
Alpha1=20 Blockers (Add-On Therapy; Not First-Line Drugs as Monotherapy) =
  • General side effects of alpha1 = blockers:=20 orthostatic hypotension; edema; syncope with first dose (take at = bedtime)=20
  • Prazosin
    • Initial dose: 1 mg/day; range: 1=9620 = mg/day; cost/mo:=20 $52
  • Doxazosin
    • Initial dose: 1 mg/day; range: 1=9616 = mg/day; cost/mo:=20 $48
  • Terazosin
    • Initial dose: 1 mg/day; range: 1=9620 = mg/day; cost/mo:=20 $28
Central = Alpha-adrenergic=20 Agonists (Add-On Therapy; Use as Second Drug with Diuretic)
  • General side effects of central = alpha-adrenergic=20 agonists: sedation, fatigue, dry mouth, bradycardia, heart block, = fluid=20 retention, rebound hypertension with sudden discontinuance
  • Clonidine
    • Initial dose: 0.1 mg/day; range: 0.1=960.6 = mg/day;=20 cost/mo: $12
  • Clonidine transdermal patch
    • Rebound HTN less likely than with oral form =
    • Additional side effect: contact dermatitis = from patch=20
    • Initial dose: 0.1 mg/day; range, 0.1=960.3 = mg/day;=20 cost/mo: $121
  • Methyldopa
    • Additional side effects: can cause = hepatitis,=20 Coombs-positive hemolytic anemia, lupuslike syndrome, blood = dyscrasias=20
    • Initial dose: 250 mg/day; range: 250=962,000 = mg/day;=20 cost/mo: $25
  • Guanfacine
    • When taken at bedtime, lessens sedation side = effect;=20 cost/mo: $61
  • Guanabenz
    • Initial dose: 4 mg/day; range: 4=9664 = mg/day; cost/mo:=20 $362
Direct = Vasodilators (Add-On=20 Therapy; Use as Third Drug in Combination with Diuretic and Adrenergic=20 Inhibitor)
  • General side effects of direct vasodilators: = headache,=20 fluid retention
  • Hydralazine
    • Additional side effects: flushing, = tachycardia, nasal=20 congestion, hepatitis, lupuslike syndrome
    • Initial dose: 40 mg/day; range: 40=96200 = mg/day;=20 cost/mo: $11
  • Minoxidil
    • Use for resistant HTN
    • Additional side effects: tachycardia; = significant=20 fluid retention requiring loop diuretic for control; pericardial = effusion;=20 hair growth
    • Initial dose: 2.5 mg/day; range: 2.5=9640 = mg/day;=20 cost/mo: $72
Patient Condition=20 and Choice of Antihypertensive Drugs

  • No comorbid conditions: thiazide = diuretics=20
  • Isolated systolic hypertension (elderly = patients):=20 thiazide diuretics (preferred) (compelling indication [CI]); calcium=20 antagonists (dihydropyridine [DHP]) (CI)=20
  • Angina: beta blockers (CI); calcium = antagonists=20 (non=96short-acting DHP) (specific indication [SI])=20
  • Angina with diabetes or LV dysfunction: ACE = inhibitors=20 (SI) (in addition to beta blockers and calcium antagonists)=20
  • Atrial fibrillation: beta blockers (CI); = calcium=20 antagonists (diltiazem, verapamil) (CI, SI)=20
  • Cough with ACE inhibitors: ARBs (CI)=20
  • Type 1 diabetes mellitus with proteinuria: ACE = inhibitors (CI); calcium antagonists (non-DHP); diuretics; beta = blockers (SI)=20
  • Type 2 diabetes mellitus with proteinuria: = angiotensin=20 II receptor blockers (ARBs) (CI, SI); calcium antagonists (non-DHP) = (SI);=20 diuretics (SI); beta blockers (SI)
  • Essential tremor: noncardioselective beta = blockers (SI)=20
  • Heart failure, LV dysfunction: ACE inhibitors; = beta=20 blockers; diuretics; aldosterone antagonists (CI); ARBs (SI)=20
    • Generally, an ACE inhibitor is first choice, = =B1 a beta=20 blocker in asymptomatic patients=20
    • Diuretic used to treat congestion=20
    • Aldosterone antagonist used only in advanced = disease=20 in combination with other agents (creatinine < 2.5 mg/dl and = serum=20 potassium < 5.0 mg/dl)=20
    • ARB should not be used in patients on ACE = inhibitor=20 and beta blocker
  • Patient at high risk for CV disease or type 2 = diabetes:=20 ACE inhibitor (SI)=20
  • Hyperlipidemia: alpha blockers (not considered = first-line therapy) (SI)=20
  • Intolerance to other antihypertensive drugs: = ARBs=20 (SI)=20
  • Left ventricular hypertrophy (by ECG): ARBs = (SI)=20
  • Migraine: noncardioselective beta blockers = (SI); calcium=20 antagonists (verapamil) (SI)=20
  • Myocardial infarction: beta blocker (without = intrinsic=20 sympathomimetic activity) most often drug of choice, with ACE = inhibitor added=20 if LV function impaired (CI); aldosterone antagonist can be added to = standard=20 therapy in patients with LV dysfunction (CI); diltiazem (non=96Q wave=20 infarction; avoid if heart failure) (SI); verapamil (avoid if heart = failure)=20 (SI)
  • Osteoporosis: thiazide diuretics (SI)=20
  • Peripheral vascular disease: calcium = antagonists=20 (SI)=20
  • Preoperative hypertension if at increased CV = risk: beta=20 blockers (SI)=20
  • Previous stroke: diuretic + ACE inhibitor = (CI)=20
    • ACE inhibitor as monotherapy had no effect = on BP or=20 outcome; benefit noted only with combination that lowered BP =
  • Prostatism: alpha blockers (not considered = first-line=20 therapy) (SI)=20
  • Renal insufficiency with proteinuria from any = cause: ACE=20 inhibitors; ARBs; calcium antagonists (non-DHP) (SI)
    Hypertensive Crisis: Key Clinical=20 Features=20
    • Acute, severe elevation in BP, with DBP often = > 130=20 mm Hg=20
    • Retinal hemorrhages, exudates, and = papilledema=20
    • Encephalopathy (headache, confusion, = somnolence, stupor,=20 visual loss, focal neurologic deficits, seizure, or coma)=20
    • Oliguria and azotemia=20
    • Nausea, vomiting, dyspnea=20
    • Physical findings of heart = failure
    Hypertensive Crisis: Emergency Therapy=20
    • Hospitalize patient in ICU=20
    • Begin parenteral therapy to lower mean BP by = 20% in the=20 first hour (DPB should be reduced to 100=96110 mm Hg)=20
    • If patient stable, reduce BP further over the = next 24=20 hr; oral therapy can be started, and parenteral therapy gradually=20 discontinued=20
    • Monitor patient for evidence of worsening = cerebral,=20 renal, or cardiac function=20
    • Once the patient is stabilized, evaluate for = causes of=20 secondary hypertension
    Parenteral Therapy=20 for Hypertensive Crisis=20
    • Sodium nitroprusside=20
      • General drug of choice=20
      • Produces direct arteriolar and venous = dilation=20
      • Immediate onset and offset=20
      • Side effects: metabolic acidosis, nausea, = vomiting,=20 agitation, psychosis, tremor (monitor thiocyanate levels)=20
      • Dose: 0.25=9610.0 =B5g/kg/min I.V. = infusion
    • Labetalol=20
      • Combination alpha/beta blocker=20
      • Onset 5=9610 min, offset 3=966 hr=20
      • Useful in most settings, especially = postoperative=20 state, hypertensive crisis of pregnancy=20
      • Avoid in acute heart failure=20
      • Take beta-blocker precautions=20
      • Side effects: scalp tingling, vomiting, = heart block,=20 orthostatic hypotension
      • Dose: repetitive I.V. boluses of 20=9680 mg = q. 10 min or=20 constant infusion of 0.5=962.0 mg/min
    • Glyceryl trinitrate=20
      • Produces direct arteriolar and venous = dilation=20
      • Onset 5=9610 min, offset 3=965 min=20
      • Especially useful in acute coronary = ischemia,=20 CHF=20
      • Tolerance with prolonged infusion=20
      • Side effects: headache, flushing, nausea,=20 methemoglobinemia=20
      • Dose: 5=96100 =B5g/min I.V. = infusion
    • Esmolol=20
      • Cardioselective beta blocker=20
      • Onset 1=962 min, offset 10=9620 min=20
      • Especially useful in postoperative state, = aortic=20 dissection, ischemic heart disease=20
      • Take beta-blocker precautions=20
      • Side effects: bradycardia, nausea=20
      • Dose: 50=96300 =B5g/kg/min = I.V.
    • Hydralazine=20
      • Causes direct arteriolar vasodilation =
      • Onset 10=9620 min, offset 3=968 hr=20
      • Used primarily for hypertensive crisis of=20 pregnancy=20
      • Avoid in acute MI, angina, aortic = dissection=20
      • Side effects: headache, flushing, nausea, = vomiting,=20 tachycardia, angina
      • Dose: 10=9620 mg I.V. bolus =
    • Enalapril=20
      • ACE inhibitor=20
      • Onset 15 min, offset 6 hr=20
      • Especially useful in acute heart failure in=20 postoperative state=20
      • Lower doses in renal disease=20
      • Side effects: precipitous decline in BP = (high-renin=20 states), acute renal failure (presence of renal vascular = disease)=20
      • Dose: 1.25=965 mg I.V. bolus, q. 6 = hr
    • Nicardipine=20
      • Dihydropyridine calcium antagonist=20
      • Onset 5=9610 min, offset 1=964 hr=20
      • Especially useful in postoperative = state=20
      • Avoid in acute heart failure=20
      • Side effects: headache, nausea, flushing,=20 phlebitis=20
      • Dose: 5=9615 mg/hr I.V. = infusion
    • Fenoldopam=20
      • Dopamine (DA1) agonist=20
      • Onset 5 min, offset 30=9660 min=20
      • Especially useful in patients with impaired = renal=20 function=20
      • Side effects: nausea, vomiting, headache,=20 flushing=20
      • Dose: 0.1=961.6 =B5g/kg/min I.V. = infusion
    • Phentolamine=20
      • Alpha blocker=20
      • Onset instantaneous, offset 3=9610 = min=20
      • Drug of choice for pheochromocytoma = crisis=20
      • Side effects: flushing, tachycardia=20
      • Dose: 5=9615 mg I.V. bolus
    • Trimethaphan=20
      • Ganglionic blocker=20
      • Onset 1=965 min, offset 10 min=20
      • Tachyphylaxis common with prolonged = infusion=20
      • Side effects: urinary retention, paralytic = ileus, dry=20 mouth, blurred vision, orthostatic hypotension=20
      • Dose: 0.5=9615 mg/min I.V. infusion=20

    Best References

    Chobanian A, et al: Hypertension 42:1206, 2003 = [PMID=20 14656957]

    European Society of Hypertension =96 European = Society of=20 Cardiology Guidelines Committee: J Hypertens 21:1011, 2003 [PMID=20 12777938]

    Williams B, et al: J Hum Hypertens 18:139, 2004 = [PMID=20 14973512]

    July=20 2006

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