NCMA 216

• Blood pressure classification


  • Normal
  • Pre-hypertension
  • Hypertension stage 1
  • Hypertension stage 2

  
• Systolic blood pressure


  • Normal: <120
  • Pre-hypertension: 120-139
  • Hypertension stage 1: 139-159
  • Hypertension stage 2: >160

  
• Diastolic blood pressure


  • Normal: <80
  • Pre-hypertension: 80-90
  • Hypertension stage 1: 90-100
  • Hypertension stage 2: >100

  
• Lifestyle modification recommended for

  • Pre-hypertension
  • Hypertension stage 1
  • Hypertension stage 2

  
• Recommended follow-up schedule after initial blood pressure measurement

  • Systolic <130 and diastolic <85: Recheck in two years
  • Systolic 130-139 and diastolic 85-89: Recheck in one year
  • Systolic 140-159 and diastolic 90-99: Confirm within two months
  • Systolic 160-179 and diastolic 100-109: Evaluate or refer to source of care within 1 month
  • Systolic >180 and diastolic >110: Evaluate or refer to source of care immediately or within 1 week, depending on clinical situation

  
• Lifestyle modifications to manage hypertension

  • Weight reduction: Maintain normal body weight (BMI 18.5-24.9 kg/m2)
  • Adopt DASH eating plan: Consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat
  • Dietary sodium reduction: Reduce dietary sodium intake to no more than 100 mmol per day (2.4 g sodium or 6 g sodium chloride)
  • Physical activity: Engage in regular aerobic physical activity such as brisk walking (at least 30 minutes per day, most days of the week)
  • Moderation of alcohol consumption: Limit consumption to no more than two drinks (1 oz 80-proof whiskey) per day in most men and no more than one drink per day in women and lighter weight persons
• Major risk factors for hypertension

  • Hypertension
  • Cigarette smoking
  • Obesity (BMI ≥ 30 kg/m2)
  • Physical inactivity
  • Dyslipidemia
  • Diabetes mellitus
  • Microalbuminuria or estimated glomerular filtration rate (GFR) <60 mL/min
  • Age (older than 55 for men, 65 for women)
  • Family history of premature cardiovascular disease (men younger than age 55, women age 65)
• Target organ damage


  • Heart: Left ventricular hypertrophy, angina or prior myocardial infarction, prior coronary revascularization, heart failure
  • Brain: Stroke or transient ischemic attack
  • Chronic kidney disease
  • Peripheral arterial disease
  • Retinopathy
  • Glomerular filtration rate (GFR)
  • Components of the metabolic syndrome
• Classes of antihypertensive drugs

  • ACE inhibitors
  • Calcium antagonists
  • Angiotensin II antagonists
  • Diuretics
  • Beta-blockers
• Compelling indications for ACE inhibitors

  Heart failure, left ventricular dysfunction, after myocardial infarct, diabetic nephropathy
• Compelling contraindications for ACE inhibitors

  Hyperkalemia, bilateral renal artery stenosis
• Compelling indications for calcium antagonists

  Angina, elderly patients, systolic hypertension
• Possible indications for calcium antagonists

  Peripheral vascular disease
• Compelling contraindications for calcium antagonists

  Heart block, congestive heart failure
• Compelling indications for angiotensin II antagonists


  ACE inhibitor cough, heart failure
• Compelling contraindications for angiotensin II antagonists


  Pregnancy, bilateral renal artery stenosis, hyperkalemia
• Compelling indications for diuretics

  Heart failure, elderly patients, systolic hypertension
• Possible indications for diuretics

  Diabetes, gout, dyslipidemia, sexually active males
• Compelling indications for beta-blockers

  Angina, after myocardial infarct, tachyarrhythmias, heart failure
• Possible indications for beta-blockers

  Pregnancy, diabetes
• Compelling contraindications for beta-blockers

  Heart block, asthma and COPD
• Possible contraindications for beta-blockers

  Dyslipidemia, athletes and physically active patients, peripheral vascular disease
• Therapeutic agents used to treat malignant hypertension (immediate onset)

  • Nitroprusside (continuous IV)
  • Nitroglycerin (continuous IV)
  • Diazoxide (IV bolus)
  • Fenoldopam (continuous IV)
  • Esmolol (continuous IV)

  
• Therapeutic agents used to treat malignant hypertension (delayed onset)

  • Enalaprilat (IV)
  • Hydralazine (IV, IM)
  • Labetalol (IV)
  • Nicardipine (IV)

  
• Blood pressure


  CO (cardiac output) x SVR (systemic vascular resistance)

  
• Antihypertensive agent categories


  • Adrenergic agents
  • Angiotensin-converting enzyme inhibitors
  • Angiotensin II receptor blockers
  • Calcium channel blockers
  • Diuretics
  • Vasodilators
• Adrenergic agent subcategories


  • Alpha1 blockers
  • Beta blockers (cardioselective and nonselective)
  • Centrally acting alpha blockers
  • Combined alpha-beta blockers
  • Peripheral-acting adrenergic agents
• Mechanism of action of alpha1 blockers

  Block the alpha1-adrenergic receptors, the sympathetic nervous system is not stimulated, resulting in decreased blood pressure
• Examples of alpha1 blockers

  • doxazosin (Cardura)
  • prazosin (Minipress)
  • terazosin (Hytrin)
• Mechanism of action of central-acting adrenergics

  Stimulate alpha2-adrenergic receptors, decreasing sympathetic outflow from the CNS, resulting in decreased blood pressure
• Examples of central-acting adrenergics

  • clonidine (Catapres)
  • methyldopa (Aldomet)
• Mechanism of action of adrenergic neuronal blockers

  Inhibit release of norepinephrine and deplete norepinephrine stores, the peripheral adrenergic nerves are not stimulated, resulting in decreased blood pressure
• Examples of adrenergic neuronal blockers


  • reserpine
  • guanadrel (Hylorel)
  • guanethidine (Ismelin)
• Therapeutic uses of alpha1 blockers

  • Treatment of hypertension
  • Relief of symptoms of BPH
  • Management of severe CHF when used with cardiac glycosides and diuretics
• Therapeutic uses of central-acting adrenergics

  • Treatment of hypertension, either alone or with other agents
  • Management of withdrawal symptoms in opioid- or nicotine-dependent persons
• Therapeutic uses of adrenergic neuronal blockers

  • Treatment of hypertension, either alone or with other agents
• Side effects of adrenergic agents

  • Dry mouth
  • Drowsiness
  • Sedation
  • Constipation
  • Headaches
  • Sleep disturbances
  • Nausea
  • Rash
  • Cardiac disturbances (palpitations)
  • High incidence of orthostatic hypotension
• ACE inhibitors


  Block the angiotensin-converting enzyme, preventing the formation of angiotensin II and breakdown of vasodilating bradykinin, resulting in decreased systemic vascular resistance and blood pressure
• Examples of ACE inhibitors

  • captopril (Capoten)
  • enalapril (Vasotec)
  • lisinopril (Prinivil and Zestril)
  • quinapril (Accupril)
• Therapeutic uses of ACE inhibitors

  • Hypertension
  • CHF (either alone or in combination with diuretics or other agents)
  • Slows progression of left ventricular hypertrophy after an MI
  • Renal protective effects in patients with diabetes