HTN

• In African American adults with hypertension but without HF or CKD, including those with DM, initial antihypertensive treatment should include a thiazide diuretic or CCB
• Pregnancy - Recommended antihypertensive treatments (HLMN)

  • Methyldopa
  • Nifedipine
  • Labetalol
  • Hydralazine
• Avoid ACEI, ARB, DRI during pregnancy
• Adults with HF

  • Should be prescribed ACE inhibitors or ARBs and beta blockers
  • Titrated to attain SBP of less than 130 mmHg
  • Nondihydropyridine CCBs are not recommended for the treatment of hypertension in adults with HFREF
• First line treatment options for general Non-black population with HTN, including the ones with DM but no albuminuria

  • Thiazides
  • CCB
  • ACEI
  • ARB
• General black population, including the ones with DM, but no albuminuria

  Can start with thiazides or CCB
• General black population, including the ones with DM, but no albuminuria Can start with thiazides or CCB. But If CKD present

  Use ACEI or ARB as 1st line
• Do not give ACEI & ARB together (risk of ↑ K*)
• Patients with CKD & HTN, regardless of ethnicity

  Should receive an ACEI or ARB to help preserve remaining kidney function
• ACEI/ARBs Not recommended if the patient is ESRD/dialysis dependent (risk of ↑ K+ and also no kidney function left to preserve)
• Use CCB or thiazides instead (for ESRD/dialysis dependent patients)
• Medications to avoid as initial agents in general population with HTN

  • Beta blockers
  • Alpha blockers
  • Loop diuretics
  • Alpha1/beta-blockers
  • Central alpha2-adrenergic agonists
  • Direct vasodilators
  • Aldosterone antagonists
  • Peripherally acting adrenergic antagonists
• Systolic DICC pressure


  Systolic blood pressure
• Mean Arterial Pressure


  MAP = [SBP + 2 (DBP)]/3
• Diastolic Pressure


  Baseline pressure inside the systemic arteries during diastole when the heart is not pumping, but instead is filling up
• Diastolic Pressure


  • TPR (Total Peripheral Resistance: how constricted arteries are) determines it
  • Blood volume determines it
• Mean Arterial Pressure (MAP)

  MAP = [SBP + 2(DBP)] / 3
• Cardiovascular Risk Factors


  • HTN
  • Smoking
  • Dyslipidemia
  • DM
  • Microalbuminuria or GFR< 60mL/min
  • Age (>55 males, > 65 females)
  • Family history (Women <65 or Men < 55)
  • Obesity (Body Mass Index > 30 kg/m)
  • Physical inactivity
• How to reduce BP

  1. Reduce volume of fluid

  2. Dilate the vessels
• Essential HTN


  Over 90% of cases; Not secondary to a known cause
• Causes of Secondary HTN

  • Endocrine: Cushing's syndrome (⬆️cortisol)
  • Pheochromocytoma (⬆️ Epinephrine)
  • Thyroid disease
  • Hyper-aldosteronism
  • Vascular diseases
  • Renal diseases
  • Sleep Apnea
  • Medications
• HTN Treatment Principles


  1. Volume of fluid reduction

  2. Vessel dilation
• Smooth muscle surrounding vessels

  1. Contraction -> Vasoconstriction

  2. Relaxation -> Vasodilation
• Volume regulation


  1. Decrease volume via kidneys

  2. Increase volume via Na+ excretion (salt retains water)
• Diuretics


  Cause Na+ excretion
• Electrolyte disturbances


  • ⬇️Na+
  • ⬇️Cl-
  • ⬆️Uric acid
  • ⬆️Ca2+ with Thiazides (T-Top) & ⬇️ when taking Loops (Loose Ca)
  • ⬇️K+
  • ⬇️Mg2+
• Thiazides and Loop Diuretics Decrease volume by Na excretion (Salt retains water)
• when taking Thiazide and Loop diuretics 


  Expect electrolyte disturbances:
• Antihypertensive drug classes that results Arterial Dilation (⬇️ After Load)

  • CCBs
  • Adrenergic blockers: Beta blockers , a1 blockers , a2 agonists , Peripheral adrenergic antagonists
• Arterial Dilators (CCBs & Adrenergic Blockers) have Possible cardiac effects which are

  • Neg Chronotropic [Heart Rate]
  • Neg Inotropic [Contractility]
  • There is NO Electrolyte Disturbance like ACE and ARBs.
• Vasopressin Antagonist that works at the collecting duct is


  Conivaptan (Vaprisol)
• RAAS antagonists

  • ACEI
  • ARB
  • DRI
• RAAS (Renin-Angiotensin-Aldosterone System) antagonists

  1. ⬇️Volume by ⬇️aldosterone effect: → Na+ excretion

  2. Vasodilate by ⬇️angiotensin effect: Vasodilation
• Drugs that works on Proximal Convoluted Tubule (PCT) is

  1. Acetozolamide (Diamox)Drug Class: Carbonic Anhydrase

  2. Mannitol
• What are the drugs works on Distal Convoluted Tubule (DCT)

  1. Chlorthalidone
  2. HCTZ
• What drugs works on Ascending loop of Henle ?

  Loop Diuretics
• What drug works on both DCT and Collecting duct ?

  Potassium sparing Diuretics
• What is the closest tubule near Gloremuli ?

  PCT
• How does the RAAS system work ?

  Liver Produces Angiotensinogen

  Kidney Produces Renin that converts Angiotensinogen to Angiotensin I

  Lungs Produce ACE to convert Angiotensin I to Angiotensin II
• How does Angiotensin II maintain BP ?

  1. Increase Sympathetic activity [Producing Pressure]
  2. Using Adrenal gland secretes Aldosterone that Retain H2O & Na+ while Excreting K+
  3. By direct Vasocontriction Arterioles
  4. By letting Pitutary secrete ADH (AntiDiuretic hormone) Collecting H2O