Management of hypertension

1. W. P. Rivindu H. Wickramanayake
Group no. 04a
6th Year 2nd Semester – 2020 November
Tbilisi State Medical University, Georgia
Management
of Hypertension

2. ● Hypertension (HTN) is considered one of the leading causes of increased
cardiovascular disease.
● The 2017 American College of Cardiology (ACC) and American Heart
Association (AHA) definition of HTN stages is:
• Normal blood pressure (BP):
- systolic BP is less than 120, and diastolic BP is less than 80.
• Elevated BP:
- systolic BP 120 to 130 and diastolic BP is less than 80.
• Stage 1 HTN:
- systolic BP 130 to 139 or diastolic BP 80 to 89.
• Stage 2 HTN:
- systolic BP at least 140 or diastolic at least 90.
• Hypertensive crises:
- systolic BP over 180 and/or diastolic BP over 120.

3. Abbreviations: BMI, body mass index; DASH, Dietary Approaches to Stop Hypertension (trial).
● In the 2019 ACC/AHA Guideline on the Primary Prevention of
Cardiovascular Disease: all patients with elevated blood pressure are
recommended to have Lifestyle Modifications as the initial treatment.

4. ● Stage 1 HTN + 10-year ASCVD risk of >10% - start antihypertensive medications to
prevent patients from cardiovascular events.
● Stage 1 HTN + 10-year ASCVD risk of <10% - lifestyle modification measures.
● Stage 2 HTN - start antihypertensive medications to lower BP to a target lower than
130/80 even if the 10-year ASCVD risk is less than 10%.
● Patients with chronic kidney disease, the target BP is 130/80
● Patients with type 2 diabetes mellitus (T2DM) - start on antihypertensive medications
● Antihypertensive medication treatment usually starts as monotherapy after failure of
conservative management with lifestyle modification.
● The use of combination therapy is common when patients fail the monotherapy
approach.
● Lowering blood pressure does reduce cardiovascular risks, maintaining systolic blood
pressure less than 130 mm Hg has shown to prevent complications in patients with heart
failure, diabetes, coronary artery disease, stroke, and other cardiovascular diseases.
● The response to initial monotherapy is affected by age and race.

5. Examples of Oral Drugs Used in Treatment of Hypertension

6. Thiazide & thiazide-like diuretics
● In The Eighth Joint National Committee(JNC8) guidelines & The Antihypertensive and
Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) study recommended
thiazide diuretics as the first line of treatment for hypertension unless there are
contraindications.
● Hydrochlorothiazide as a single agent with a dose of 12.5 mg or 25 mg daily showed no
evidence of decreasing morbidity or mortality.
● Thiazide-type diuretics (chlorthalidone and indapamide) have demonstrated to be
superior to prevent cardiovascular disease at a lower cost. More potent & better at
decreasing the risk of cardiovascular disease comparing to hydrochlorothiazide.
● Chlorthalidone – Best monotherapy to control BP and to prevent mortality and morbidity.
- at 12.5 to 25 mg/day
● Chlorthalidone is the first choice for older patients with osteoporosis, as it showed less
incidence of pelvic fractures when compared to amlodipine and lisinopril. Better in
preventing cardiovascular disease including strokes and heart failure incidence, and when
compared with amlodipine was better in preventing heart failure.

7. Loop diuretics
● More effective than thiazides in patients with a low estimated glomerular filtration rate of
less than 30 mL/min.
● Treatment of peripheral edema associated with congestive heart failure and other non-
cardiac causes of edema as in liver and kidney diseases.
● Not first-line agents for HTN treatment.
Potassium Sparing Diuretics: "Mineralocorticoid receptor antagonists"
● Not usually used as first-line treatment.
● Spironolactone and eplerenone are considered good in hypertension treatment when
added to other antihypertensive medications in resistant HTN, this group of medication is
effective when added to triple hypertension medications regimen but should be used
cautiously when added to ACE inhibitors or ARBs due to higher incidence of
hyperkalemia.
● Effective in the treatment of heart failure as they are proven to decrease mortality rates,
and they help to decrease hypokalemia rates.
● Spironolactone is superior to doxazosin and bisoprolol in lowering blood pressure when
added to first-line antihypertensive agents in treating resistant hypertension.

8. Beta-blockers
● Not indicated as primary treatment for hypertension unless there is a specific indication of
heart failure and myocardial infarction.
● Associated with decreased cardiovascular morbidity and mortality when used in younger
patients, but less protective in patients older than 65 and were noted to be associated with
increased risk of strokes.
● Not used in the treatment of hypertension as a first-line agent because they are not as
effective in the prevention of cardiovascular disease when compared with other first-line
agents.
● Clonidine: a central alpha-2 agonist, it is not a first-line therapy, but can be used as an
additional agent when patient fails combination therapy, the transdermal form is preferred.
Alpha-blockers

9. Continued;
● Hydralazine - for tx. of resistant HTB, either alone or in combination with nitrates, in case of heart
failure. Associated with increased sympathetic tone and increases sodium avidity, adding beta-blocker, and loop
diuretics help to decrease these effects.
● Minoxidil - when the patient fails tx. with hydralazine, provides good BP control, but it is associated with fluid
retention, for which adding a loop diuretic is helpful. It increases the sympathetic tone that may require adding a
beta-blocker.

10. ● The best alternative to thiazides when patients do not tolerate thiazides.
● CCBs divide into two groups: dihydropyridines and non-dihydropyridines
● Dihydropyridines are more potent as vasodilators and used more for HTN treatment.
- Less effect on heart contractility and conduction.
- Used more for the management of HTN.
- Nifedipine and Amlodipine are the most used medications in this group.
● Non-dihydropyridines are less potent as vasodilators and
- better effect on cardiac contractility and conduction.
- Used more as antiarrhythmic medications and less for HTN treatment.
● For African descent patients, initial treatment for hypertension (without evidence of heart
failure or chronic kidney disease) should include CCB or a thiazide diuretic.
Calcium Channel Blockers (CCBs)

11. ● Long-acting nifedipine has greater antihypertensive action when compared to amlodipine.
● Dihydropyridines should not be a primary treatment for congestive heart failure (CHF) but
are a safe additional treatment in these patients for better blood pressure control or angina
pectoris.
● Non-dihydropyridines are relatively contraindicated in patients with CHF with reduced
ejection fraction, second and third-degree heart blocks, and in patients with sick sinus
syndrome.
● When compared to valsartan in a study, amlodipine was found to have better control of
24-hour ambulatory blood pressure.
● In the ASCOT(Anglo-Scandinavian Cardiac Outcomes Trial), amlodipine was found to be
better than atenolol in lowering the risk of cardiovascular disease and is associated with
less risk of diabetes development.
● When compared to thiazide diuretics, amlodipine was equally effective in lowering
cardiovascular disease risk regardless of patient's weight, while thiazides are less effective
in normal body mass index (BMI) patients than in patients with obesity.
Continued;

12. Continued;

13. ACE inhibitors and ARBs
● First-line treatment for pts. with HF and CKD with evidence of proteinuria.
● Cardio-protective effect in patients who carry a high risk of CVD.
● Both classes have similar efficacy and share the same indications for treatment, they are
both recommended as first-line treatment for patients with left ventricular dysfunction,
and ST-elevation MI or non-ST elevation MI with the presence of diabetes, systolic
dysfunction or anterior infarct.
● Ramipril has shown to decrease mortality, the incidence of stroke, and MIs when used in
patients with symptomatic HF or asymptomatic patients with low ejection fraction.
● Perindopril decrease cardiovascular events when used in a patient with stable coronary
artery disease and normal systolic dysfunction. When compared with Atenolol, Losartan
was found to be better in decreasing morbidity and mortality and better in lowering blood
pressure.
● Comparing ramipril with telmisartan, they were equivalent in effect in diabetic or heart
failure patients, with telmisartan correlating with less angioedema.

14. ● Thiazide is better than ACE inhibitors in decreasing blood pressure and preventing stroke,
CCBs are better than ACE inhibitors in lowering blood pressure, and in preventing from
stroke and heart failure.
Combination therapy
● When a patient fails a monotherapy for HTN, a combination of two antihypertensive
medications should be a therapeutic option for patients with stage 2 hypertension.
● A reduction in blood pressure when 2 different drugs combined is about x5 greater than
when the dose of one drug dose doubles.
● A combination of ARB-diuretic or ACE inhibitor-CBB is superior to the beta-blocker-
diuretic combination.
● The beta-blocker and diuretic combination is associated with a higher incidence of diabetes.
● Should use beta-blockers in the combination in patients with heart failure, tachycardia, or
post-MI patients.
● Combination of thiazide with a potassium-sparing diuretic is as effective as CCB
monotherapy in HTN management and showed less incidence of hypokalemia when
compared to hydrochlorothiazide monotherapy.

15. ● Combination of CCB and diuretics are less available as ARBs or ACE inhibitors based
combinations are preferred when a combination is required, these types of combinations
(ACE inhibitors or ARBs based combinations) should be used in patients with CKD.
● The combination of benazepril-amlodipine is superior to benazepril-hydrochlorothiazide
combination in decreasing the incidence of cardiovascular events in patients with high
risk, and it decreases the progression of nephropathy.
● The ACE inhibitor-ARB combination is not recommended; it showed a higher incidence of
side effects with no added benefits.
● When the combination of 2 medications does not achieve the treatment goal, a third agent
should be added, which is usually done by adding a third agent of the first line group of
medications (thiazide-like diuretics, CCB, ACE inhibitors, and ARBs).
● When the patient fails the three-drug regimen, the clinician should consider treatment for
resistant HTN, adding a fourth antihypertensive agent can be from any of the other classes.
Continued;

18. Preferred Parenteral Drugs for Selected Hypertensive Emergencies
Source: Adapted from DG Vidt, in S Oparil, MA Weber (eds): Hypertension, 2nd ed. Philadelphia, Elsevier Saunders, 2005.

19. ● a Constant blood pressure monitoring is required.
● Start with the lowest dose.
● Subsequent doses and intervals of administration
should be adjusted according to the blood
pressure response and duration of action of the
specific agent.
Usual Intravenous Doses of Antihypertensive Agents
Used in Hypertensive Emergenciesa

21. References;
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