HYPERTENSION BUFFY POWELL, DNP, RN, ACNP-BC no disclosures - PowerPoint PPT Presentation

HYPERTENSION BUFFY POWELL, DNP, RN, ACNP-BC no disclosures

HYPERTENSION-HOW DO WE DEFINE IT? BLOOD PRESSURE =CARDIAC OUTPUT X SYSTEMIC VASCULAR RESISTANCE BLOOD PRESSURE IS PRIMARILY AFFECTED BY ¡ ¡ SYMPATHETIC NERVOUS SYSTEM ¡ RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM ¡ PLASMA VOLUME (MEDIATED BY KIDNEYS)

JNC 8 2014 GOAL BLOOD PRESSURE ¡ AGE 60 YRS OR OLDER, NO DIABETES OR CKD, GOAL BP <150/90 mmHg ¡ AGE 18-59 YRS, NO COMORBIDITIES OR 60 YRS OR OLDER WITH DM, CKD OR BOTH, GOAL OF <140/90

AHA 2017 GUIDELINES AND DEFINITIONS ¡ Normal BP <120/<80 ¡ Elevated blood pressure: 120-129/<80 ¡ Hypertension Stage I: 130-139/80-89 ¡ Hypertension Stage II: >140/>90 ¡ Hypertensive Urgency: >180/>120 ¡ Hypertensive Emergency: >180 + Target Organ Damage/ >120 +Target Organ Damage

SPRINT TRIAL 2017 ¡ Systolic blood pressure intervention trial (SPRINT) published ¡ Compared safety and efficacy of lowering systolic <120 versus usual <140 ¡ 9361 participants: >50 yrs old, SBP>130 mmhg, and at least one of the following risk factors: cardiovascular disease other than CVA, CKD, Framigham risk >15%, age >75 yrs ¡ Terminated early due to overwhelming evidence of benefit ¡ Decreased MI, ACS, CHF, CV death in <120 systolic arm of study compared to <140 *** Excluded residents of nursing homes or assisted living

CONSIDERATIONS WITH MEASUREMENT ¡ CUFF SIZE ¡ AMBULATORY BP MONITORING: ¡ MANUAL VS AUTOMATIC ¡ WHITE COAT ¡ DIFFERENCE IN RIGHT VS LEFT ¡ SUSPECTED EPISODIC HTN (EX: READINGS PHEOCHROMOCYTOMA) *** >15 mmHg DIFFERENCE MAY ¡ MONITORING RESPONSE TO INDICATE SUBCLAVIAN STENOSIS MEDICATION AND/OR PVD ¡ AUTONOMIC DYSFUNCTION DIAGNOSIS OF HTN IS MADE WITH THREE DIFFERENT ELEVATED READINGS

AGE REDUCED WEIGHT NEPHRONS PRIMARY GENETICS RACE HTN HIGH SEDENTARY SODIUM LIFESTYLE DIET ETOH

MEDICATION COARTATION ILLICIT DRUGS OF AORTA RENAL THYROID DISEASE DISORDER SECONDARY HTN PRIMARY CUSHINGS ALDOSTERONISM RENALVASCULAR HTN PHEOCHROMOCYTOMA SLEEP APNEA

EFFECTS OF HYPERTENSION ¡ Left Ventricular Hypertrophy (LVH) ¡ For every 20 mmhg systolic and every 10 mmhg diastolic ¡ Congestive Heart Failure over 115/75, the risk of death ¡ Cerebral Vascular Accident from heart disease or CVA ¡ Ischemic Heart Disease doubles ¡ Chronic Kidney Disease

HOW DO WE TREAT HYPERTENSION?

KEY TAKE AWAYS FROM JNC 8 2 nd and 3 rd Line Treatment: ¡ ¡ Higher Doses Or Combos Of Top 4 ¡ First line treatment should be limited ¡ Beta Blockers to 4 classes of medications: ¡ Alpha Blockers ¡ Thiazide Diuretics ¡ Alpha 1/Beta Blockers (Carvedilol) ¡ Calcium Channel Blockers (CCBs) ¡ Vasodilating Beta Blockers (Nebivolol) ¡ Ace Inhibitors ¡ Central Alpha 2/Adrenergic Agonists (Clonidine) ¡ ARBs ¡ Direct Vasodilators (Hydralazine) ¡ Loop Diuretics ¡ Aldosterone Antagonists (Spironolactone)

¡ Do not use ACE and ARB in same ¡ Use of ACE/ARB recommended in all patient patients with CKD ¡ CCBs and Thiazide Diuretics should be ¡ African descent without CKD used instead of ACE/ARB in patients ¡ Use CCB and Thiazide Diuretic >75 yrs of age with impaired renal instead of ACE function

AHA TAKE AWAYS Emphasis on cardiovascular disease ¡ ¡ BP 120-129/<80: Lifestyle changes No more pre-hypertension ¡ Focus on accurate measurement ¡ ¡ BP 130-139/80-89: Assess 10 year Focus on self monitoring ¡ ASCVD risk New targets for comorbidities ¡ ¡ <10%: Lifestyle changes Lifestyle recommendations ¡ ¡ >10% or known CVD, DM, CKD- DASH diet ¡ Lifestyle and 1 BP medication Increased K+ when safe ¡ ¡ >140/>90 Ideal body weight (BP lowered 1 mmHg PER 1 Kg ¡ lost) ¡ Lifestyle Activity 90-150 minutes aerobic activity per week ¡ ¡ 2 meds of different classes Decrease ETOH to 2 or less drinks per day for men ¡ and 1 for women

LIFESTYLE MODIFICATION-FOR EVERY STAGE OF HYPERTENSION TREAT SLEEP APNEA LOW WEIGHT SODIUM LOSS DECREASE ROUTINE ETOH EXERCISE

IF TREATING ISOLATED HYPERTENSION FOUR FIRST LINE CHOICES FOR AFRICAN AMERICAN PATIENTS ¡ Thiazide diuretic (ex: HCTZ, ¡ Thiazide diuretic Chlorthalidone) ¡ Dihydropyridine calcium channel ¡ Dihydropyridine calcium channel blocker blocker (ex: Amlodipine, Nifedipine XL) ¡ ACE (ex: Lisinopril) ¡ ARB (ex: Losartan, Olmesartan, Telmisartan, Valsartan, Irbesartan) Beta blockers not recommended as first line therapy for isolated HTN

SPECIAL POPULATIONS ¡ CHF-ACE/ARB, Beta Blocker, Diuretic, spironolactone ¡ Diabetes-ACE/ARB for renal protection (monitor K+) ¡ CAD-Beta blocker ¡ Angina-Beta Blocker, CCB ¡ Need rate control-beta blockers, non- dihydropyridine CCB ¡ Edema-Diuretic

DIURETICS ¡ Hydrochlorothiazide (HCTZ) 12.5-50mg-Impotence ¡ Chlorthalidone 12.5-25mg-Hypokalemia ¡ Spironolactone 25-50mg-Hyperkalemia, gynecomastia ¡ Triamterene 50-100mg (or in combo with HCTZ)- Hyperkalemia ¡ Furosemide 20-80mg, Bumex,1-2mg Torsemide 10-40mg-Not best BP agents

ACE/ARB ACE ARB Olmesartan Lisinopril ¡ ¡ Telmisartan Benazapril ¡ ¡ Irbesartan Fosinopril ¡ ¡ Valsartan Quinapril ¡ ¡ Losartan Ramipril ¡ ¡ Candesartan Trandolapril ¡ ¡ Edarbi* ¡ Ø Hyperkalemia Ø Angioedema Ø ACE cough in 15-20% Ø Hyperkalemia Monitor Renal Function

CALCIUM CHANNEL BLOCKERS Dihydropyridines Non-Dihydropyridines ¡ Amlodipine ¡ Diltiazem ¡ Nifedipine ER ¡ Verapamil Ø Reduce heart rate BOTH CAN CAUSE EDEMA

BETA BLOCKERS BETTER FOR BP BETTER FOR RATE CONTROL ¡ Carvedilol ¡ Metoprolol Tartrate and Succinate* ¡ Nebivolol ¡ Atenolol ¡ Labetalol ¡ Propranolol ¡ Bisoprolol* CAUTION IN DIABETICS FATIGUE BRADYCARDIA COPD*

VASODILATORS Alpha Blockers ¡ Terazosin ¡ Hydralazine (reflex tachycardia) ¡ Doxazosin ¡ Minoxidil (edema, facial hair) Ø May cause orthostatic hypotension

CENTRALLY ACTING AGENTS ¡ Clonidine (pill and patch)- dry mouth ¡ Methyldopa

CASE 1 ¡ 51 year old Caucasian male ¡ Blood pressure in clinic 164/92 ¡ BMI 40 ¡ HgbA1c 6.5 ¡ T otal Cholesterol 281, LDL 140, TRG 302 ¡ Accountant ¡ On no medications ¡ States “I really do not think I have that high of blood pressure. I do not want any medications because I am planning to lose 50 pounds and start exercising.”

Medication Lifestyle Negotiate Choice • Weight loss, • ACE • Start a diet, • HCTZ? medication exercise, on a “temp • CCB? sleep apnea basis” test

CASE 2 ¡ 34 year old African American male ¡ Blood pressure 152/90 in clinic (home readings range 130-160/80-98) ¡ BMI 20 ¡ Works out everyday, mostly weights ¡ Family history-”everyone has high blood pressure, mom died of a stroke”

• Scare him a little • Thiazide • Less Medication Close follow Education Follow UP Diuretic? weights- Choice up for awhile more cardio • CCB • Low sodium diet

CASE 3 ¡ 78 year old Caucasian female ¡ Blood pressure 180/70 heart rate 51 bpm in clinic ¡ Medications: Clonidine .1mg BID, losartan 100mg QD, Metoprolol succinate 50mg QD ¡ Home log for day before shows BP readings at 0230, 0235, 0700, 0703, 0705, 1023, 1026, 1030, 1900, 1903, 1915 ¡ 120 lbs ¡ Allergy list is two pages long ¡ History of CAD ¡ Lives at an independent senior living facility ¡ Carvedilol made her “bones to hurt”, Lisinopril caused a headache, Valsartan caused “bones to hurt”, Had ankle edema on amlodipine ¡ C/O fatigue, dizziness with standing, has fallen twice in past few months

Examine Her Regimen Bradycardic Stop Clonidine slowly , decease Metoprolol Medication Choices Possibly Nifedipine XL Hydralazine, HCTZ not good choice Change Losartan to Olmesartan? Last ditch effort-Methyldopa Sell It!!!! Encourage exercise Talk up new drug choice-”best drug ever!” Only check BP twice a day

BUFFY ’ S PEARLS ¡ Bring BP down slowly when you can ¡ Edema from CCB is less is a combo pill with HCTZ (ex: Tribenzor) ¡ Less pills is better for adherence ¡ Not a Clonidine fan ¡ Lifestyle change really helps-especially in younger people-encourage it and give ¡ Avoid HCTZ in elderly them tools/ideas that fit their life. ¡ For stubborn HTN, especially in older ¡ Treat sleep apnea women, Methyldopa seems to work ¡ Salesmanship is EVERYTHING

REFERENCES Cartoon Stock. (n.d.). [Cartoon]. Retrieved from www.CartoonStock.com American Heart Association Task Force on Clinical Practice Guidelines. (2017). Highlights from the 2017 guideline for the prevention, detection, evaluation and management of high blood pressure in adults. Hypertension . http://dx.doi.org/10.1161/HYP .0000000000000065 James, P ., Ortiz, E., & et al (2014). Evidence-based guideline for the management of high blood pressure in adults (JNC8). Journal of the American Medical Association , 311 (5), 507-520. Kovell, L., Ahmed, H., Misra, S., Whelton, S., Prokopowicz, G., Blumenthal, R., & McEvoy, J. (2015). US hypertension management guidelines: A review of the recent past and recommendations for the future. Journal of the American Heart Association . http://dx.doi.org/10.1161/JAHA.115.002315 Mann, J. (2020). Choice of drug therapy in primary (essential) hypertension. Retrieved April 16, 2020, from https//www.uptodate.com Page, M. (2014). The JNC 8 hypertension guidelines: An in-depth guide. American Journal of Managed Care . Retrieved from https//www.ajmc.com