TREATMENT OF HYPERTENSION
Treatment of Chronic HTN
- When to Treat?
- See new WHO guidelines for Prevention of Cardiovascular Disease!
- In general, any patient with severe (Grade 3) HTN and/or signs of complications (stroke, CKD, CAD, CCF, retinopathy etc) should be started on antihypertensive treatment immediately
- Patients with mild to moderate (Grade 1-2) HTN should be given 3 months to see if they respond to behavioral modification first. If BP remains >140/90 they should then be started on antihypertensives.
- Counseling
- All patients with hypertensive should be told to:
- lose weight (>5kg) if overweight by BMI > 25
- reduce salt intake – no added salt in cooking or at table
- increase physical activity
- smoking cessation!
- Reduce alcohol intake (<3 units/day)
- Patient should also be counseled that, if they start antihypertensives, they will likely need to take medications every day for life to prevent complications. They need to take the medication even if they feel well. If they have side effects they should come directly to see the doctor and not stop the medications until they are seen.
- Which drug to start with?
- For most patient, bendrofluazide 5mg PO OD is the best first drug as it is cheap, easy to take and very effective in Africans.
- Use with caution in patients with DM and gout as bendrofluazide can cause hyperglycemia and hyperuricemia.
- CCBs (like Nifedipine or amlodipine) are all very effective in Africans and is a good first antihypertensive if you want to lower the BP rapidly (as in hypertensive urgency)
- For patients with DM or CCF and a normal or stable creatinine, ACE inhibitors (like captropril or lisinopril) are the best first antihypertensive.
- In patient with CAD, beta blockers are the best first antihypertensive as they reduce the risk of death from CAD
- Of note, most antihypertensives take 2-4 weeks to reach maximal effect so it is good to wait 1 month before increasing the dose of a medicine or adding another one.
- What to do if the first drug doesn’t work?
- 2/3 of patient with hypertension will require at least 2 drugs to control their hypertension and 1/3 will require 3 drugs
- Always titrate your first drug to its maximum dose first before adding another drug.
- Monitor for side effects
- ACE inhibitors – monitor creatinine
- Thiazide diuretics – monitor electrolytes
- Beta blockers – monitor heart rate
- If the BP remains elevated despite maximal dose of a first drug, add another drug and then titrate this to its maximal dose. Whatever you start with, either thiazides or CCB are good second drugs in most African patients.
- What is the goal BP?
- In most patients the goal BP is < 140/90
- In patients with DM or CKD we use a goal BP of < 130/85
Treatment of Hypertensive Urgency and Emergency
- In any patient with BP > 220/120 (“Very Severe Hypertension”), assess for signs of end organ damage and consider admission to the hospital.
- Hypertensive emergency usually does not occur unless DBP > 130
- Keep in mind that urgency is much more common than emergency
- Signs of End Organ Damage
- Hypertensive Encephalopathy (confusion, headache)
- Acute retinal hemorrhage (sudden onset of blurry vision, massive hemorrhage on opthalmoscopy)
- Myocardial ischemia or infarction (chest pain, ECG changes)
- Pulmonary Edema (shortness of breath, CXR with pulmonary edema)
- Acute Kidney Injury (recent onset of oliguria or anuria, elevated creatinine, blood on UA)
- If Hypertensive Urgency (no signs of end organ damage)
- Aim to lower MAP by 25% over 2-3 days using oral medications
- Start with Nifedipine 20mg BD and add other meds as necessary
- If Hypertensive Emergency (+ signs of end organ damage)
- Aim to lower MAP by 25% over 1-2 hours using IV medications
- Currently we are using IV Hydralazine drips titrated to goal BP
- Labetalol drips (+ other meds) are better when available
- Once the BP improves, patients can be transitioned to oral medications
Case 1
A 65 yo male patient comes to the MOPD with a complaint to blurry vision that has slowly been getting worse of the last 3 years. The nurse has already taken the blood pressure and it is 170/95 in both arms.
1) What grade of hypertension does the patient have?
-moderate (Grade 2)
2) What complication of hypertension might the patient have?
-hypertensive retinopathy
The rest of the history is unremarkable except that the patient smokes 5-6 cigarettes per day and drink 2-3 bottles of beer per night. Physical examination is unremarkable. You ask the resident to perform ophthalmoscopy.
3) What do you expect that she will see if this is hypertensive retinopathy?
-flame (splinter) hemorrhages, cotton wool spots, copper wiring, AV nicking, arteriolar narrowing. Review also findings in diabetic retinopathy with neovascularization.
The resident sees copper wiring of the vessels with a few areas of flame hemorrhage but no papilledema.
4) What investigations would you like to perform?
-creatinine, urinalysis, cholesterol, RBG, ECG
5) What advice will you give the patient (behavioral modification)?
-low salt diet, weight loss, regular exercise, smoking cessation, limiting alcohol intake
6) Will you start treatment for the hypertension today?
-yes since this patient already has signs of end organ damage
7) What treatment will you start?
-bendrofluazide 5 mg PO OD
You start the patient on bendrofluazide 5mg PO OD and see the patient again in 1 month. The blood pressure now is 150/90. Creatinine, electrolytes, RBG, ECG all come back as normal.
8) Is the patient’s blood pressure at goal?
-no. Review BP goals in patients with and without DM.
9) What would you like to do next?
-add another medication as the patient is taking the maximum dose of bendrofluazide
10) What medication would you like to add?
-nifedipine 20 mg PO BD (captopril also OK)
11) When would you like to see the patient again?
-the patient should return to clinic in 2 weeks to have BP rechecked
Case 1
A 35 year old female with diabetes (diagnosed 3 years ago, on metformin) comes to see you in the diabetes clinic. The nurse has already taken her blood pressure and it is 200/140. She is complaining of chest pain and shortness of breath.
1) What is the MAP?
-MAP = [SBP + (DBPx2)]/3 = (200 +(140x2))/3 = 160
2) What urgent investigations would you like to order?
-ECG, CXR, creatinine, urine dipstick, RBG
The patient tells you that her chest pain is worse with exertion. She also complains of orthopnea and paroxysmal nocturnal dyspnea over the last several days. Pulmonary examination reveals bilateral crepitations. The rest of the exam is unremarkable. The chest x-ray shows pulmonary edema. The ECG is normal. You are still waiting for other tests.
3) What is your diagnosis?
-hypertensive emergency with pulmonary edema since this patient has end organ damage (CCF)
4) Where do you admit the patient?
-ICU
5) What treatment would you like to begin?
-LMNOP (Lasix, Morphine, Nitrates, Oxygen, cardiac Position) for pulmonary edema and IV Hydralazing (or other IV antihypertensive) for BP
6) What is your goal BP?
-you would like to lower the MAP by 25% (MAP 180 à120). Could also just use DBP and try to reduce this to less than 120.
You admit the patient to the ICU and start lasix, morphine, oxygen, nitroglycerin and put the patient in cardiac posture. The blood pressure is still 200/130 so you start an IV hydralazine drip with orders to titrate the drip to a goal MAP of 120. You stay by the bedside and the blood pressure comes down appropriately. After 2 hours the BP is 160/100 (MAP 120). You leave the patient on the hydralazine drip overnight and see the patient the following day. Her chest pain and shortness of breath have now resolved. The patient’s creatinine has come back normal.
7) What do you do now?
Start oral medication. In this case would start with at least 2 like nifedipine 20mg BD and captopril 25mg BD. Will need to transition slowly from IV drip to oral meds to prevent BP from rising again.
You start the patient on nifedipine 40mg PO BD and captopril 25mg PO BD and slowly titrate off the hydralazine drip. The MAP remains around 120. You decide to transfer the patient to the floor the following day. One day later, on MWR, the BP is 160/100 (MAP 120) remains around 120. The patient feels fine. You decide to discharge the patient.
8) What is your long term goal for the patients BP?
-goal of BP <140/90
9) When will you see the patient in clinic?
-patient should return to clinic in 2 weeks
The patient returns to clinic in 2 weeks. BP remains 160/100.
10) What do you do next?
Continue Nifedipine 40mg PO BD and increase captopril to 50mg PO BD. Have the patient return to clnic in 1 month.
