Management of HTN

1. Management of Hypertension
Kerolus Shehata, MD

2. Educational Objectives
 Understand current definitions of hypertension
 Apply evidence-based approaches to hypertension treatment
 Describe the approach to office-based evaluation and management of markedly elevated
blood pressures.

3. Case No.1
Does Mr. Aldo has HTN?

4. Magnitude of the problem/HTN screening
 More than 360,000 American deaths in 2013 included high blood pressure as a primary or
contributing cause.That is almost 1,000 deaths each day.
 Number of visits to physician offices with essential hypertension as the primary diagnosis:
42.7 million
 Percent of adults aged 20 and over with hypertension (measured high blood pressure
and/or taking antihypertensive medication): 33.5% (2013-2014)…As per JNC-8 guidelines
 7 of every 10 people having their first heart attack have high blood pressure.
 8 of every 10 people having their first stroke have high blood pressure.

5. HTN in the United States

6. HTN in the United States…Cont’d
Based on date gathered
through NHANES
(National Health and
Nutrition Examination
Survey) with a total of
9623 participants (≥20
years of age) between
2011–2014.

7. Is it a true HTN?
 At least two blood-pressure measurements on at least two occasions (2-4 weeks apart) with
the use of a standardized measurement technique and validated equipment, including a cuff
of correct size.
 Measurements should be made with the back supported, legs uncrossed, feet on the floor,
and the measurement arm supported on a table at heart level after the patient has sat quietly
for 5 minutes.
 White coat HTN: 20-35% of patients diagnosed with HTN. Blood pressure elevated in the
office but normal outside. You can use an automated device that take two to six serial
measurements and determine the mean, or use an ambulatory blood-pressure monitoring
device.
 Masked HTN: considered when office blood pressures are controlled but the patient has
elevated home measurements or a greater severity of hypertension-associated target-organ
damage than expected. You can use ambulatory BP monitoring.

8. White coat HTN & Masked HTN

9. Ambulatory Blood Pressure Monitoring
24 hr portable device that patient wears during regular activities
Measures BP every 15-20 min during the day and every 30-60
min during the night.
MediCare and MediCaid pays for only one indication: White coat
HTN
Other potential indications: Evaluate efficacy of drug effect over
24hrs, Nocturnal HTN, Diagnosis of HTN during pregnancy.

10. After you diagnose HTN
Detailed Hx entailing the potential risk factors e.g. family Hx, high
sodium intake, Wight gain, excess alcohol intake, medications
including NSAIDs, OCP, decongestants or illicit drugs.
Coexisting conditions or HTN-associated end organ damage
Exclude secondary HTN…To be discussed later on

11. Threshold for Dx and staging of HTN

12. Why are these two guidelines discrepant and which should we believe?
Before we start our discussion, we should recognize that guidelines are just
recommendations are NOT a substitute for clinical judgment; and decisions must be
carefully considered and incorporate the clinical characteristics of each individual
patient.

13. Controversies around AHA/ACC 2017
Review of the evidence provided by the ACC/AHA 2017 guidelines revealed no reductions in all-cause or CV mortality
for SBP targets <130 mm Hg versus higher targets. Relative reductions across trials in CV disease events (16%) and
stroke (18%) were modest, and absolute risk reductions were small (1.1% and 0.5%, respectively).
SPRINT (Systolic Blood Pressure Intervention Trial) provides the basis for an intensive treatment target in higher-risk
populations, but the lack of consistent benefit across trials underscores the uncertainty about the actual benefit of
aggressive control and highlights the need for targeted application of the SPRINT findings.
Benefits of intensive BP control are often overestimated and harms are often underestimated when trial findings are
applied to broad primary care populations. Trials mostly enrolled patients with hypertension who were tolerating
treatment and used run-in periods to weed out non-adherent persons, including those experiencing harms.
The assumption that data from trials in patients with established hypertension applies to newly diagnosed patients is
flawed. HOPE-3 trial (Heart Outcomes Prevention Evaluation) involving primarily untreated persons with borderline
elevated BP found no reduction in cardiovascular events with treatment
Studies also used time- and resource-intensive BP measurement, follow-up, and adherence protocols. Such protocols
are frequently infeasible in “time- and access-crunched” primary care settings, leading to misdiagnosis and treatment
of less-adherent persons.

14. There is no evidence from randomized controlled trials to support a DBP target <80 mm Hg. The largest trial to examine DBP targets
(Hypertension Optimal Treatment (HOT) found NO improvements in health outcomes associated with a DBP target <80 mm Hg
versus less than 85 or 90 mm Hg.
The ACC/AHA guideline inadequately recognizes and assesses potential harms with restrictive BP targets. Although more intensive
treatment to an SBP near 120 mm Hg has not been shown to increase risk for cognitive decline, fractures, or falls in monitored trial
settings, more intensive treatment increases symptomatic hypotension and syncope risk, and antihypertensive medications have
common, bothersome, and sometimes serious harms.
The treatment burden and risk for adverse events related to polypharmacy may be substantial in older adults with chronic
conditions, to whom multiple disease-specific guidelines apply
In SPRINT, it was necessary to treat 61 patients at the lower systolic target of less than 120 mm Hg (vs. 140 mm Hg) to prevent one
additional cardiovascular event; and to treat 90 patients to prevent one additional death over a period of 3.26 years.
Controversies around AHA/ACC 2017..Cont’d

15. Controversies around JNC-8
Increasing the systolic BP target in those 60 years or older will have the effect of reducing the intensity of antihypertensive treatment
among patients already being treated, among them a large population with established CVD or at high risk for CVD (including African
Americans and patients with multiple CVD risk factors other CKD).
The evidence supporting upping the target from 140-150 mm Hg in people 60 or older was insufficient and inconsistent with the
evidence supporting the decision considered by the panel to use the target of 140 in younger patients.
Raising the target may have the unintended effect of reversing decades of declining CVD rates, especially stroke mortality.
Evidence from trials and observational studies that the panel did not use as part of its review supports the lower goal, especially in high-
risk patients.
A well-known disadvantage of restricting evidence is that exclusion of non-RCT data (Which was implemented in JNC-8 risks application
of an “all-or-none” approach to literature assessment and potentially disregards the totality of the available evidence.
Although the JNC 8 writing panel retained the “JNC” title, its recommendations are not endorsed by the NHLBI (National Heart, Lung,
and Blood Institute) as were the previous JNC reports.

16. You decide that Mr. Aldo has Stage 2 hypertension according to the ACC/AHA guidelines.
What are the next steps in his evaluation?

17. According to the ACC/AHA guidelines, Mr. Aldo should be treated with non-pharmacologic therapy and medications.

18. Non-Pharmacological interventions

19. Threshold and goals of treatment
What medication(s) would you
consider starting for Mr. Aldo?

20. 2017 AHA/ACC takeaways

21. Antihypertensive medications

22. Diuretics • Most effective when combined with ACE-I
• Stronger clinical evidence with Chlorthalidone
• Spironolactone causes gynecomastia and Hyperkalemia
• Loop diuretics may be needed when GFR<30-40
ACE-I & ARB  Angioedema is more with ACE-I
 May cause/exacerbate hyperkalemia
 Losartan has uricosuric effect
 Candesartan may prevent migraine headache
BBs  Not first line agent except if post-MI and in HFrEF
 May cause fatigue +/- depression
 Mask hypoglycemic symptoms
CCBs  May cause peripheral edema
 DHBs can be safely combined with BBs if needed
 Non-DHBs may reduce proteinuria
Vasodilators  Hydralazine and Minoxidil cause reflex tachycardia and fluid retention
 Alpha blockers may cause orthostatic hypotension
Centrally acting agents  Clonidine is available in a weekly patch for resistant hypertension
Characteristics of medication groups

24. JNC-8 medications algorithm

25.  GDMT beta blockers for BP control or relief of angina include
carvedilol, metoprolol tartrate, metoprolol succinate, nadolol,
bisoprolol, propranolol, and timolol.
 Avoid beta blockers with intrinsic sympathomimetic activity
(pindolol, penbutolol and acebutolol)
 Atenolol should NOT be used because it is less effective than
placebo in reducing cardiovascular events.
You choose chlorthalidone and scheduled F/U for Mr. Aldo…

26. Should we be concerned about secondary hypertension in this
patient and, if so, what evaluation should Ms. Renin have?

27. Screening & Causes of secondary HTN

29. Diagnosis & Management
of Resistant HTN

30. Hypertensive crises

31. HTN Management in ICH

32. HTN management in
acute ischemic stroke

33. I C-EO
Initiation of antihypertensive drug therapy with 2 first-line agents of different classes, either as
separate agents or in a fixed-dose combination, is recommended in adults with stage 2
hypertension and an average BP more than 20/10 mm Hg above their BP target.
I B-NR
In adults with SIHD with angina and persistent uncontrolled hypertension, the addition of
dihydropyridine CCBs to GDMT beta blockers is recommended.
III: No
Benefit
B-R
Non-dihydropyridine CCBs are NOT recommended in the treatment of hypertension in adults
with HFrEF.
I C-EO
In adults with HFpEF who present with symptoms of volume overload, diuretics should be
prescribed to control hypertension.
Miscellaneous guidelines
IIa B-R
After kidney transplantation, it is reasonable to treat patients with hypertension with a calcium
antagonist on the basis of improved GFR and kidney survival.

34. IIa C-EO
In adults with ICH who present with SBP greater than 220 mm Hg, it is reasonable to use
continuous intravenous drug infusion and close BP monitoring to lower SBP.
III: Harm A
Immediate lowering of SBP to less than 140 mm Hg in adults with spontaneous ICH who present
within 6 hours of the acute event and have an SBP between 150 mm Hg and 220 mm Hg is NOT
of benefit to reduce death or severe disability and can be potentially harmful.
I B-NR
In adults with an acute ischemic stroke, BP should be less than 185/110 mm Hg before
administration of intravenous tPA and should be maintained below 180/105 mm Hg for at least
the first 24 hours after initiating drug therapy.
IIb C-EO
In patients with BP of 220/120 mm Hg or higher who did not receive intravenous alteplase or
endovascular treatment and have no comorbid conditions requiring acute antihypertensive
treatment, the benefit of initiating or reinitiating treatment of hypertension within the first 48 to
72 hours is uncertain. It might be reasonable to lower BP by 15% during the first 24 hours after
onset of stroke.

35. I ASR In adults with DM and hypertension, ALL first-line classes of antihypertensive agents (i.e.,
diuretics, ACE inhibitors, ARBs, and CCBs) are useful and effective.
IIb B-NR
In adults with DM and hypertension, ACE inhibitors or ARBs may be considered in the presence
of albuminuria.
IIa B-R
Treatment of hypertension with an ARB can be useful for prevention of recurrence of AF.
IIa C-LD
In patients with chronic aortic insufficiency, treatment of systolic hypertension with agents that
do NOT slow the heart rate (i.e., avoid beta blockers) is reasonable.
I C-EO
Beta blockers are recommended as the preferred antihypertensive agents in patients with
hypertension and thoracic aortic disease.
I B-R
In black adults with hypertension but without HF or CKD, including those with DM, initial
antihypertensive treatment should include a thiazide-type diuretic or CCB.

36. I C-LD
Women with hypertension who become pregnant, or are planning to become pregnant,
should be transitioned to methyldopa, nifedipine, and/or labetalol during pregnancy.
I A
Treatment of hypertension with a SBP treatment goal of less than 130 mm Hg is
recommended for non-institutionalized ambulatory community-dwelling adults (≥65 years of
age) with an average SBP of 130 mm Hg or higher.
IIa C-EO
For older adults (≥65 years of age) with hypertension and a high burden of comorbidity and
limited life expectancy, clinical judgment, patient preference, and a team-based approach to
assess risk/benefit is reasonable for decisions regarding intensity of BP lowering and choice of
antihypertensive drugs.
IIa B-R
In adults with hypertension, BP lowering is reasonable to prevent cognitive decline and
dementia.
I B-NR
In patients with hypertension undergoing major surgery who have been on beta blockers
chronically, beta blockers should be continued.

37. Mr. H is a 67-year-old man with a history of hypertension, hyperlipidemia (TC 202,
HDL 36, LDL 138) and current tobacco use. His blood pressure at his clinic visit today
is 136/89, with several home readings in the range of 130-140/80-90. He is currently
taking amlodipine 10 mg daily and lisinopril 40 mg daily. Recent electrolytes and
renal function are normal. According to ACC/AHA guidelines, what would be the next
most appropriate step?
A. Continue to monitor blood pressure at home and reevaluate in six weeks.
B. Add chlorthalidone 25 mg daily and have patient follow up in two to four weeks after
continuing to monitor blood pressure at home.
C. Add chlorthalidone 25 mg daily and check renin/aldosterone levels.
D. Add metoprolol tartrate 25 mg BID and have patient follow up after two to four weeks after
continuing to monitor blood pressure at home.

38. Ms. G is an 80-year-old woman with a history of hypertension and osteoarthritis. She
lives alone in a senior living community not far from your clinic. She walks with a
cane, as her arthritis has caused pain and stiffness in her knees. On exam, her blood
pressure is 149/85. She takes only amlodipine 10 mg daily. Which statement is
correct?
A. SPRINT demonstrated that the mortality and cardiovascular benefits of intensive blood
pressure management were seen in younger adults, as well as those over 75.
B. No studies have evaluated blood pressure targets in patients over 75
C. Thiazide diuretics are a good choice in this patient, as they are less likely to cause
electrolyte abnormalities than in a younger patient.

39. Mr. B is a 35-year-old man with a history of hypertension since his 20s. He has been out
of care for at least 5 years but has come in today because he has noticed he has been
feeling short of breath and chest tightness with exertion over the last week. He denies
recent drug or alcohol use. He does not take any medications. On exam, his blood
pressure is 189/105, HR 85, oxygen saturation 97% on room air, with a respiratory rate
of 14 breaths per minute. What should you do next?
A. Initiate an evaluation for secondary hypertension including a full history and physical exam,
evaluation of renal function, renin/aldosterone levels, and screening for symptoms of
obstructive sleep apnea.
B. Initiate two-drug treatment with lisinopril 40 mg daily and chlorthalidone 25 mg daily and
prescribe a blood pressure cuff for home monitoring.
C. Refer the patient to the nearest emergency department for urgent evaluation.
D. Treat patient with one dose of amlodipine in the office, ensure blood pressure has decreased
below 180/100, prescribe amlodipine 10 and chlorthalidone 25, and arrange close follow up.

40. References
 Taler SJ. Initial treatment of hypertension. N Engl J Med. 2018;378(7):636-44.
https://doi.org/10.1056/NEJMcp1613481
 Wilt TJ, Kansagara D, Qaseem A for the Clinical Guidelines Committee of the American
College of Physicians. Hypertension limbo: Balancing benefits, harms, and patient
preferences before we lower the bar on blood pressure. Ann Intern Med. 2018;168(5):369-
70. Whelton PK, Carey RM, Aronow WS, et al. 2017
 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the
Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults:
Executive Summary: A Report of the American College of Cardiology/American Heart
Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017.
 A randomized trial of intensive versus standard blood-pressure control. N Engl J Med.
2017;377:2506.
 The SPRINT Research Group. A randomized trial of intensive versus standard blood
pressure control. N Engl J Med. 2015; 373:2103-16.

41. THANK YOU