Hypertension

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Author / Curator: Justin Berk, MD

Hypertension (HTN), also known as high blood pressure, is a long-term medical condition in which the blood pressure in the arteries is persistently elevated.

The Basics of Hypertension

Learning Objectives

  • Define what hypertension, including what essential and secondary hypertension are.
  • Understand the importance of screening for hypertension and the long and short-term complications that can result from uncontrolled pressures.
  • Understand how to diagnose hypertension, including understanding the JNC-8 and ACC/AHA guidelines.
  • Know how to manage hypertension, including lifestyle and medication management, that best tailored to the patient's demographics and needs.
  • Recognize the difference between hypertensive emergency vs urgency and when to send someone to the emergency department.

Top Teaching Points

  • The #1 cause of resistant hypertension is medication non-adherence.[1]
  • Chlorthalidone is a better at reducing blood pressure than other thiazides such as HCTZ. [2]
  • Switching blood pressure medications to night-time may lead to improvement in pressures.[3] [4] [5]
  • Spironolactone is most likely the best 4th line agent for hypertension when diuretics are also included as one of the other three agents. [6] [WJC:PATHWAY-2]
  • There is conflicting evidence about whether OSA treatment can help with HTN treatment and reduce CV risk. [7] [8] A recent meta-analysis suggested no change in cardiovascular outcomes. [9]
  • Losartan (and calcium-channel blockers) can help prevent gout flairs. [10]
  • High salt diets can void the vasodilatory effects of thiazides, and together, may increase the risk of dizziness, orthostatic hypotension, hyponatremia and hypokalemia.[11]
  • Adding an ACE inhibitor or ARB reduces the likelihood of edema seen with calcium channel blockers. [12] [13]
  • Nifedipine is contraindicated in CHF [14], while amlodipine is safer. [15]
  • Patient titration of anti-hypertensive medication can result in lower systolic blood pressure. [16]
  • Thiazides may help reduce hip and pelvic fractures in older adults. [17]
  • Ace inhibitors and beta blockers appear to work best at lowering blood pressure in Caucasians while diuretics and calcium channel blockers are more effective within the African American Community. [18]
  • Patients who have uncontrolled hypertension should return to clinic ideally in 2 weeks.[19]
  • Patients with white coat hypertension may benefit from ambulatory blood pressure monitoring, which measures a patients blood pressure every 20-30 minutes daily. Hypertension is defined as 135/85 instead of the usual JNC-8 thresholds. The ACC/AHA does not define threshold differences at this time.[20]

Background

Hypertension is defined as blood pressure that is above the systolic or diastolic goal for a patient's given age.[21] The JNC-8 guidelines sets these values at 140 systolic or 90 diastolic while ACA/AHA defines this as 130 systolic or 80 diastolic.[22] [23]

Definitions of Hypertension [24]
Essential Hypertension multifactoral: autonomic nervous system, the renin-angiontensin-aldosterone system, sodium-potassium ratios, and socioeconomic factors including stress.
Secondary Hypertension causes such as chronic kidney disease, pheochromocytoma, hyperaldosteronism, hyperparathyroidism, drug-induced, renal vascular (renal artery stenosis) as well as others.
Hypertensive Emergency elevated blood pressure (SBP > 180, DBP >110) with evidence of end-organ damage (e.g. ACS, encephalopathy, ARF including proteinuria, PRES). This requires immediate treatment in the Emergency Department with the goal of decreasing SBP by 25% within 4- 6 hours.
Hypertensive Urgency SBP > 180 and DBP > 110 without symptoms. Asymptomatic hypertensive urgency does not require ED treatment.

Patients with hypertensive emergency should seek medical care at an emergency department. Hypertensive urgency can be managed in the clinic.

How To Take a Blood Pressure: Measurements of blood pressure outside of a clinic environment are better correlated with long-term outcomes. [25] [26] [27] Confounders that may elevate BP include pain, medications (NSAIDs, SSRIs, OCPs, steroids), caffeine, smoking and stress.

The following are recommended:[28]

  • Make sure the cuff bladder is about 80% the diameter of the patient's arm.
  • Make sure patients have been sitting for a few minutes with their feet flat on the ground.
  • Patients should not be talking
  • Patients should keep their hand relaxed and have their arms supported.
  • The blood pressure cuff should not be over the patient's clothes.

Progression and Complications of Disease

Uncontrolled HTN can lead to: heart failure, coronary artery disease, stroke, aortic aneurysm, peripheral artery disease, and chronic kidney disease. [29]


Rule- 10mmHg = 25%: Every 10mm Hg increase in SBP (or 5mm Hg increase in DBP) is associated with a 28% increase in the risk of death from CAD. [30] A 10mm Hg drop in SBP (or 5mm Hg drop in DBP) is associated with 25% fall in cardiovascular disease, 25% reduction in CHF, and 33% reduction of strokes. [31] [32]

Diagnosis

Initial Work-up of New Hypertension
H&P Important Questions and Tests
ROS Symptoms of OSA, CHF, anxiety
Family Hx Premature heart disease, HTN, DM
Social Hx Use of tobacco, alcohol, cocaine

Diet, exercise, salt intake

Diagnostics CMP, Lipids, urinalysis, CBC, A1c, EKG
Focused exam Eyes, carotids, abdominal bruits, LV heave, CHF (rales, JVP, LEE, S3)
Sources: Harrison's principles of internal medicine, PEAC

JNC 8 guidelines [22]: Goal blood pressure with algorithm found here.

Goal blood pressure of SBP < 140 and DBP < 90 for all age groups and co-morbidities except age > 60. For age > 60, goal blood pressure is SBP < 150 and DBP < 90.

More recent ACC / AHA guidelines: [23]

  • All patients with increased vascular risk are to be treated to < 130/80
  • Low risk patients (non-elderly, no comorbidities, ASCVD risk<10%) with a BP <140/90 can use non-pharmacologic therapy alone. 
  • See Guidelines Made Simple link below.

One older Cochrane review suggested no morbidity or mortality benefit from treating SBP 140-159 / DBP 80-89 [33]. A newer meta-analysis suggests otherwise. [34] [WJC Discussion] Recent evidence from SPRINT trial [35] also supports more intensive therapy goals.

Management

Overall, goal should be for lifestyle management first unless the patient's blood pressure is over 160/110, which is the threshold for needing medication therapy. If a patient has attempted dietary changes for 3 months without success, medication therapy should be initiated. Those with uncontrolled hypertension should be seen back in clinic in at least 2 weeks and possibly earlier if the pressure is very elevated.[19]

Non-Pharmacological Management

The 2004 British Hypertension Society guidelines [36] proposed lifestyle changes consistent with those outlined by the US National High BP Education Program in 2002[37] for the primary prevention of hypertension:

  • maintain normal body weight for adults
  • reduce dietary sodium intake to <6 g of sodium chloride or <2.4 g of sodium per day
  • engage in regular aerobic physical activity such as brisk walking (≥30 min per day, most days of the week)
  • limit alcohol consumption to no more than 3 units/day in men and no more than 2 units/day in women
  • consume a diet rich in fruit and vegetables (e.g. at least five portions per day);

The DASH Diet: fruits, vegetables and low-fat dairy foods can reduce SBP by 11mm Hg and diastolic blood pressure by 5mm Hg. [38] A follow up study added sodium restriction to the DASH diet and further reductions in blood pressure were seen. [39].

Frozen dinners and packaged foods comprise about 75% of daily salt intake, so patients who don't add salt to their food will typically still have a high salt intake. [40] Exercise has shown to coronary heart disease by 6% and increase life expectancy by 0.68 years with a modest reduction in BP (2-4mmHg). [41]

Pharmacological Management

Per a recent Cochrane Review: "Antihypertensive drugs used to treat predominantly healthy adults aged 18 to 59 years with mild to moderate primary hypertension have a small absolute effect to reduce cardiovascular mortality and morbidity primarily due to reduction in cerebrovascular mortality and morbidity. All-cause mortality and coronary heart disease were not reduced." [42]

Per JNC-8 [43], there are 3 strategies of management:

  • Add a second medication before max dose 2) Maximize first med 3) Start with 2 if SBP > 160
  • Starting a second drug offers 5x better BP lowering than doubling dose of current medication [44]
  • JNC 8: Therapy should be given one month to work before advancing regimen.

Treatment Algorithm per JNC8:

  • First line treatment: thiazide, CCB or ACEI/ARB are equivalent unless:
  • If CKD or proteinuria: start ACEI/ARB
  • If black with CKD and NO proteinuria: CAN start ACE/ARB as equivalent to thiazide or CCB
  • In patients with HFrEF: ACE-I / ARB should be replaced with Entresto (secubitril / valsartan.

Trial Summaries

SPRINT: Intensive blood pressure control (SBP < 120) improved CV outcomes and overall survival while modestly increasing the risk of some serious adverse events. [45] [WJC: SPRINT] [NEJM QuickTake Video: SPRINT] [Curbsiders Podcast Discussion]

ALLHAT: Improved CV and stroke outcomes in blacks treated with thiazide diuretics and CCBs Thiazides, ACE-I, and CCBs have equivalent outcomes in non-black populations. [46] [WJC:ALLHAT]

VALUE: Valsartan is inferior for BP control vs. amlodipine but has similar CV event rate. [47]

ACCOMPLISH: In patients with CKD or CVD (including LVH), adding a CCB to ACE-I is potentially better than adding a thiazide to ACE-I for CVD outcomes. [48] WJC:ACCOMPLISH On subanalysis, thiazides may be less effective in obese populations. [49]

ACCORD BP: In patients with T2DM, lower SBP goals did not improve outcomes. [50] [WJC:ACCORD-BP] A sub-analysis of ACCORD-eligible patients in the SPRINT trial showed contrary results. [51]

PREMIER: showed behavioral intervention (weight loss, exercise, limited sodium, and alcohol) reduced SBP by 3.7mmHg with behavior plus DASH decreasing SBP by 3.7mmHg. [52]

Ongoing controversies / New updates

New Guidelines were recently released by the ACC / AHA that re-defined hypertension as SBP < 130. [53]. The American Academy of Family Physicians (AAFP) has declined to endorse these new guidelines and continue to endorse the JNC8 guidelines above.

What is the best goal BP, especially in diabetes and chronic kidney disease?

The ideal blood pressure goal remains unclear in specific demographics such as chronic kidney disease [54]. For patients with diabetes, there are conflicting recommendations from JNC8, ACA/AHA, and the American Academy of Clinical Endocrinologists (AACE).

Is white coat hypertension a thing? Does it still need to be treated?

It remains controversial if “white coat hypertension” is associated with cardiovascular risk and should, therefore, be treated. [55]

External Resources

REFERENCES

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