10-Fritz-Hypertension Management for Advanced Practice …...– Screen for secondary hypertension • 8. Treatment of High BP – Pharmacological treatment in context of CVD risk

1

Hypertension Management for

Advanced Practice Nurses

Ruth Ann Fritz APRN-CNS BC

April 13, 2019

1

Objectives

Participant will be able to:

• Discuss new Hypertension guideline recommendations

• List 2 secondary causes of hypertension and recommended evaluation and treatment

• Review action and precautions of medications for hypertension

2

1

2

2

UpToDate 2019

• NHANES (National health and nutrition examination survey) 2011-2014 - adjusted to new guidelines

– 46% adults in USA have HTN

– 103 million adults

• Will increase as population ages and with the rising incidence of obesity

3

Causes of Hypertension

• Essential hypertension

– Genetic

– Decline in healthy life style

• Secondary causes

– Kidney disease

– Malfunction of certain glands

– Substance/medication intake-ETOH/steroids

– Rare tumor – pheochromocytoma

– Sleep apnea

4

3

4

3

Hypertensive Crisis

• Hypertensive Emergency- elevation of DBP accompanied by acute target organ damage

– Encephalopathy

– Intracranial hemorrhage

– Acute left ventricular failure with Pulmonary edema

– Dissecting aortic aneurysm

– Unstable angina

• Hypertensive Urgency – severe hypertension without organ damage

5

Classifications of Blood Pressure

JNC 7• Normal -

– SBP < 120 and DBP <80

• Prehypertension

– SBP 121-139 or DBP 80-89

• Hypertension stage 1

– SBP139-159 or DBP 90-99

• Hypertension stage 2

– SBP >/= 160 or DBP >/=100

Treatment to <140/90 but <130/80 DM, CKD

6

5

6

4

Compelling Indications – JNC7

• Compelling indications for Individual Drug Classes

– Heart failure THIAZ, BB, ACEI, ARB, ALDO ANT

– Post myocardial infarction BB, ACEI, ALDO ANT

– High CVD risk THIAZ, BB, ACEI, CCB

– Diabetes THIAZ, BB, ACEI, ARB, CCB

– Chronic kidney disease ACEI, ARB

– Recurrent stroke prevention THIAZ, ACEI

• Key: THIAZ = thiazide diuretic, ACEI= angiotensin converting enzyme inhibitor, ARB = angiotensin receptor blocker, BB = beta blocker, CCB = calcium channel blocker, ALDO ANT = aldosteroneantagonist

7

JNC 8

• In general population < 60 years initiate pharmacological therapy at DBP >/= 90 and SBP at >/= 140, and treat to goal <140

• In general population >/= 60 years initiate pharmacologic therapy at SBP>/=150 or DBP>/=90 - treat to goal <150/90

• Recommended starting meds and guidelines listing recommended medications in several co-morbid conditions

8

7

8

5

Comparison JNC 7 and JNC 8

JNC 7

• Recommended 5

classes for initial

therapy but

recommended

thiazide-type diuretic

unless compelling

indication (DM, CKD,

CHF, MI, CVA, high

CVD risk) and included

comprehensive table

drugs /doses

JNC 8

• Recommended 4 specific

classes (ACEI or ARB,

CCB or diuretics) doses

based on RCT evidence,

recommended specific

classes for racial, CKD,

and diabetic subgroups,

included table of

drugs/doses used in the

outcome trials

9

Comparison JNC 7 and JNC 8

JNC 7

• Addressed multiple

issues – measurement,

evaluation of HTN,

secondary causes,

adherence, resistant

HTN, and special

populations) based on

literature review and

expert opinion

• Reviewed by National

High BP Education

Program Coordinating

Committee

JNC 8

• Review of RCT addressed

3 questions deemed to be

of highest priority

• Reviewed by experts

including ones in

professional, public , and

Federal organizations

10

9

10

6

Lifestyle Work Group –

AHA BP Recommendations

• 1. Diet

– Vegetables, fruits, whole grain, include low fat dairy,

poultry, fish, legumes, non-tropical vegetable oils, and

limit sweets, sugar sweeten beverages, and red meat.

– Adapt to appropriate calorie, personal, cultural,

nutritional therapies – DM.

– DASH – (Dietary Approaches to Stop Hypertension),

USDA food pattern, or AHA diet

11

Lifestyle Work Group

• 2. Low sodium diet lowers BP

• 3. Consume

– not more than 2400mg sodium,

– 1500 mg better,

– but even 1000mg lower - even if desired goal not

reached- decreases CV events by 30%

• 4. Combine DASH and low sodium even better than low sodium alone

12

11

12

7


• Adults to engage aerobic physical activity to lower BP

– 3-4 sessions/week

– Average 40 min of mod-vigorous intensity

physical activity

• Healthy weight- maintain healthy weight (BMI 18.5-24.9)

• Decrease ETOH use

13


• Found no evidence

– That high K diet helps lower BP or

– That high K, Ca, Mag, low sodium diet any better than

low sodium

– That low or high glycemic foods have effect on lipids

or BP in non DM pt

• Studied Mediterranean diet – if adhered to did lower BP – evidence low

• Stopping smoking and decreasing stress helpful

14

13

14

8

Recent Practice Guidelines

• March 2017 Pharmacologic Treatment of Hypertension in

Adults Aged 60 Years or Older to Higher vs Lower Blood

Pressure Targets: A Clinical Practice Guideline from the

ACP and AAFP

• Sept 2017 DM and HTN: Position statement ADA

• Nov 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/

APhA/ASH/ASPC/NMA/PCNA

Guideline for the Prevention, Detection, Evaluation, and

Management of High Blood Pressure in Adults

• 2018 ESC/ESH Guidelines for Management of Arterial

Hypertension

15

2017 Pharmacologic Treatment of

Hypertension in Adults Aged 60 Years or

Older to Higher vs Lower Blood Pressure

Targets: A Clinical Practice Guideline from the

ACP and AAFP

• 1. Start treatment in adults age 60 or older with systolic BP

persistently => 150 to goal <150 to reduce risk of stoke,

cardiac events, and possibly morality (strong/high)

• 2. Consider starting or increasing meds in adults 60 or

older with hx CVA or TIA to target SBP <140 to prevent

recurrent CVA (weak/mod)

• 3.Consider starting or increasing meds in some adults age

60 or older at high CV risk, based on individualized

assessment to target SBP<140 (weak/low)

Select goals based on a periodic discussion of benefits and

harms of specific BP targets with the patient

16

15

16

9

2017 DM and HTN:

Position statement ADA

• Position statement

– BP check q visit, r/o white coat/ orthostatic hypotension

– Goals for diabetic pts

• <140/90 adults

• <130/80 younger adults and adults with high risk CVD

• 120-160/80-105 pregnant pts with HTN who are being treated

– SBP>120/80 –wt loss, DASH, less Na, more K, fruit/veg,

moderation alcohol, increased physical activity

– SBP >140/90 lifestyle, and timely titration medication

– SBP>160/100 lifestyle and timely titration 2 meds

– Include classes drugs reduce CV - ACE,ARB, Thiazide

diuretics, dihydropyridine CCB

– Proteinuria – ACE or ARB first line –monitor lab

17

Questions guiding review

2017 High BP Guidelines

• In adults with HTN

1. Is self BP monitoring /ambulatory BP superior to BP healthcare worker for preventing adverse outcomes, and achieving better BP control?

2. What is optimal target when treating?

3. Do various drugs/classes differ in comparative benefits/harms?

4. Does initiating 1 drug vs 2 drugs, either of which followed by more, differ in comparative benefits/harm on specific health outcomes

18

17

18

10

2017 ACC/AHA/AAPA/ABC/ACPM/AGS/




• 1. Scope of guideline- update of JNC 7

• 2. Research has established a relationship between HTN

and CV risk

– In USA HTN cause of more CV deaths than other modifiable risk factors

• 2.4 Need screen for risk factors

– Modifiable – smoking, DM, high lipids, overweight, physical inactivity, unhealthy diet

– Relatively fixed – CKD, family hx, advanced age, low socioeconomic, low educational level, obstructive sleep apnea, psychosocial stress

19





• 3. Classification of BP – definition

– Normal – SBP <120 and DBP <80

– Elevated – SBP 120-129 and DBP<80

– Hypertension

– Stage 1 – SBP130-139 or DBP 80-89

– Stage 2 - SBP =>140 or DBP =>90

• 4. Measurement of BP

– In office and out office/home monitoring

– Masked and white coat hypertension

– Accurate BP techniques

20

19

20

11





• 5. Causes of Hypertension

– New onset or uncontrolled

– Screen for secondary hypertension

• 6. Nonpharmacological Interventions

– Wt loss

– Heart healthy diet (DASH)

– Na reduction

– Potassium supplementation unless CKD or K conserving meds

– Increase physical activity

– If consume alcohol – no more than 2 drinks for man and 1 female

21





• 7. Patient Evaluation

– Basic – FBG, CBC, lipids, Creatinine with GFR, TSH, UA, EKG

– Optional – Echo, Uric Acid, Urinary alb to creatinine ratio

– Screen for secondary hypertension

• 8. Treatment of High BP

– Pharmacological treatment in context of CVD risk

– Secondary prevention of recurrent CVD events pt average 130/80 and primary prevention in adults with 10 year ASCVD risk 10% or higher

– Primary prevention of CVD no history and ASCVD risk <10%

– Goal – Less than 130/80

– Initiation – first line – thiazide diuretics, CCBs, and ACE or ARB

– Do not use ACE, ARB and/or renin inhibitor together - harmful

22

21

22

12





• 9. Hypertension in patients with comorbidities

– Stable Ischemic Heart Disease (SIHD)• GDMT (guideline determined medical therapy) Beta blockers (carvedilol, metoprolol,

nadolol, bisoprolol, propranolol and timolol), ACE or ARB first line

• Addition of dihydropyridine CCB, thiazide diuretics and /or mineralocorticoidreceptor antagonist as needed

• SIHD with angina and persistent HTN – addition of dihydropyridine CCB to GDMT BB

– Heart Failure• HFrEF – GDMT (ACE/ARB, BB, ARA -Aldosterone receptor antagonist,

hydralazine/nitrates) titrated to <130/80 – do not use nondihydropyridine CCB

• HFpEF – if fluid overload – diuretics, persistent – ACE or ARB and BB to <130/80

• (r=reduced, p=preserved)

– Chronic Kidney Disease• Treat to <130/80

• CKD 3 or more – with albuminuria >=300mg/g or alb/creat ratio>=300 – treatment with ACE or ARB if ACE not tolerated

• Renal Transplant - treat with Calcium antagonist

23



Guideline for the Prevention, Detection, Evaluation,

and Management of High Blood Pressure in Adults

• 9. Hypertension in patients with comorbidities cont.

– Cerebrovascular disease• Acute cerebral Hemorrhage (ICH) >220/s – IV med and monitoring to lower, but

if BP 150-220 immediate lowering to <140/s - not benefit could be harmful

• Acute ischemic Stroke – if eligible for TPA BP slowly lowered to <185/110 before TPA, then maintain below 180/105 for at least 24hr, may start or restart meds on patients with BP >140/90 if neurologically stable, If no TPA –>220/s benefit uncertain, but reasonable to lower BP by 15% first 24 hrs

• Secondary Stroke prevention – TIA or CVA – restart meds after few days of event – treat with thiazide diuretic, ACE or ARB or combination – reasonable goal <130/80, if been untreated and BP <140/90 – usefulness of starting med not well established

• Peripheral Artery Disease- Treat same as pt without PAD

24

23

24

13





• 9. Hypertension in patients with co-morbidities cont.

– Diabetes• Goal to <130/80

• All first line medications (thiazide diuretics, ACE, ARB, CCB) good to use

• If albuminuria ACE or ARB preferred

– Metabolic Syndrome – lifestyle, medications not established

– Atrial Fib – treatment with ARB can be useful prevention of recurrence of Atrial fib

– Valvular Heart Disease• Asymptomatic Aortic Stenosis – treat start low dose and titrate

• Chronic aortic insufficiency – avoid BB as slow heart

25





• 10. Special patient groups

– Racial and Ethnic differences –• In Black adults without HF or CKD initial tx with thiazide diuretic or CCB

• 2 or more meds are recommended to goal <130/80 in most adults esp. Black adults

– Sex• Pregnancy – methyldopa, nifedipine, and/or labetalol

• Do not treat with ACE, ARB or direct renin inhibitor

– Age related• Older persons - goal <130/80 for noninstutionalized ambulatory community-dwelling

adults >= 65,

• But if high burden comorbitity and limited life expectancy, clinical judgment, pt preference, and team-based approach to assess risk/benefit if reasonable regarding intensity of BP lowering and choice of medications

26

25

26

14





• 11. Other considerations

– Resistant hypertension • Confirm resistance – BP>130/80 on 3 meds or <130/80 but on 4 meds

• exclude pseudoresistance – accurate BPs, check nonadherence

• Indentify and reverse lifestyle factors

• Dc or minimize interfering substances –drugs, licorice

• Screen for secondary causes

• Pharmacological treatment

• Refer to specialist

– Hypertensive Crisis - Emergency/Urgencies• ICU monitoring - BP and target organ damage and IV meds

• Compelling condition – aortic dissection, sever preeclampsia or eclampia or pheochromocytoma crisis – SBP to <140 first hour or <120 if aortic dissection

• No compelling – SBP reduce no more than 25% first hour, then if stable to 160/100 in 2-6 hrs then cautiously to normal in 24-48hrs

27





• 11. Other considerations continued

– Cognitive Decline and Dementia – BP lowering is reasonable to prevent cognitive decline and dementia – Class IIa

– Patients undergoing surgery • If major surgery and been on BB keep on BB, but pre-op dc of ACE or ARB may be

considered

• Planned elective OR – reasonable to keep on meds until surgery, but if BP>= 180/110 deferring surgery may be considered

• Harmful – to abruptly dc BB or clonidine pre op

• Harmful to start BB on day of surgery in BB naïve pts

28

27

28

15





• 12. Strategies to Improve HTN treatment and control

– Adherence strategies • Medications -Once daily, and Combination pills are useful

• Promote lifestyle modifications – behavioral and motivational ( stop smoking, wt loss, mod alcohol intake, more physical activity, less Na, healthy diet)

– Structured, Team-based, care interventions

– Heath information technology – EHR and Telemedicine

– Improving quality of care – performance measures

– Financial Incentives • Paid to providers useful in achieving improvements

• Heath system financing strategies ( insurance coverage and co-pay benefit)

29

Response to 2017 Guidelines

• AAFP declined to endorse guideline

– Did not look at harm with treating to lower BP

– Questions about the evidence used

– Use of ASCVD tool –no evidence it helps outcomes

– Conflict of interest

• AHA – developing tools for providers and patients based on

guidelines

– HTN guideline toolkit

– Education for patients

• Cleveland Clinic Journal of Medicine Jan 2019

– “Treat patients, not numbers” as some at risk of adverse events

– Good review of history of guidelines and research used

30

29

30

16

2018 ESC/ESH Guidelines for Management of

Arterial Hypertension

• Evidence – RCTs and meta-analysis – more conservative

• Diagnosis – office BPs, home BPs

– Range

– Normal <120/80 – to Grade 3 180/110

• Treatment thresholds

– High normal (130-139/85-89) – Meds if CV risk very high

– Grade 1 HTN (SBP 140/159)- low/mod risk, med if high after lifestyle, >65 <80 age lifestyle/ medications if tolerated

• BP Targets - compliance, discussions with pt

– First objective is all to <140/90 and if tolerated to 130/80 most pts

– <65 age – SBP 120-129, =>65 age- SBP 130-139

31

Diagnosis of HTN

• Not on one reading – white coat

• Measure correctly

– Sprint trial – used auto BP cuff set to do more than 1 reading without person in room

– Correct cuff size, position

– Average

• Evaluation

• Assess risk factors

• Look for causes of hypertension

• Assess for organ damage signs

• H/P, lab tests, EKG, echo

32

31

32

17

Secondary causes of HTN

• Renal disease

– UTI, obstruction, hematuria, analgesic abuse,

– Glomerular, vascular, family hx PKD

– Acute /CKD

– Treatment – Renal US, treat cause if possible, manage

fluid, if ESRD dialysis and BP med as needed

• Renovascular Dx - renal artery stenosis

– Renal US and stents if needed in renal arteries

– Creatinine significant increase after add ACEI

33

Secondary HTN

• Drug Induced –

– NSAIDS, antidepressants, drug and ETOH abuse

– Decongestants, caffeine, nicotine, cyclosporine or

tacrolimus, neuropsychiatric, ESA, Clonidine withdrawal

– Management – limit or avoid, alternatives

• Oral contraceptives/hormone therapy

– Rises BP in normal range but can cause HTN

– Avoid, or low dose agents, or alternate birth control

34

33

34

18

Secondary HTN

• Phenochromocytoma – rare neuroendocrinetumor, catecholamine producting

– Meds vs surgery

– Need for perioperative management

• Primary Aldosteronism

– Triad – HTN, low K, and metabolic acidosis

– Receptor blocker – Spirolactone

– Surgery if adenoma

35

Secondary HTN

• Cushing’s syndrome

– major cause of morbidity and death

– Excess cortisol – steroid meds or adrenal disease

– Treatment – surgery radiation, chemo, cortisol

inhibiting drugs, or withdraw steroids slowly

• Other endocrine dx - low/high thyroid – treat cause

• Primary hyperparathyroidism – treatment cause

36

35

36

19

Secondary HTN

• Obstructive Sleep Apnea

– Resistant HTN, fitful sleep, daytime sleepiness

– Obesity

– Sleep study

– CPAP

• Coarctation of aorta - cause of hypertension in <30 years of age

– BP in legs weaker than arms

– Echo, CT, angiogram

– Surgery

37

Medications - Diuretics

• Action- increase kidneys excretion of sodium and water- decreased volume and decreased BP

– 2017 recommendation for initial therapy is Thiazide

type diuretics, not loop or potassium sparing

– Thiazide type diuretics

• Distal renal tubule inhibit NA reabsorbtion/Vasodilator

• HCTZ- 25-50mg

• Chlorthalidone – initial 12.5mg to goal 12.5-25mg

• Indapamide – initial 1.25 to goal 1.25-2.5

• Metolazone – if on HD/PD may give but no supplement

38

37

38

20

Medications - Diuretics

• Thiazide type diuretics

– Adverse reactions

• low Na, K, Ca, Mag,

• high Uric acid, BS, lipids,

• sexual dysfunction

• Avoid <30GFR except metolazone,

• anuria contraindicated

• Caution sulfa allergy

39

Medications - Diuretics– Potassium sparing –Triamterene, Amiloride

• Inhibit excretion of K, use with other diuretics

• Avoid renal disease <45 GFR, ACE/ARB, or on potassium supplements

– Aldosterone antagonists- Spirolactone

• Spirolactone can cause gynecomastia

• Beers list avoid in elderly

• Avoid with K supplements, other K sparing or renal dx

– Monitor

• Volume Depletion - hypotension / decreased GFR

• Hypokalemia and other electrolyte abnormalities

– Combinations may improve adherence

40

39

40

21

Medications - Diuretics• Action- Cont.

– Loop diuretics- Lasix, Demadex, Bumex

• Secondary agent

• Inhibit Na reabsorbtion in loop of Henle

• Adverse reactions – as with Thiazide type diuretics, but less high lipids/glucose

• Preferred in symptomatic HF

• Recommended for <30 GFR

• May use loop with Thiazide if pt ECF volume expansion and edema (KDIGO Hypertension/CKD guideline)

41

A& P Review

• Humoral Mechanisms

– Renin Angiotension

System

• Renin production

• ACE – Angiotension-converting enzyme

• Angiotension II –most potent vasoconstrictor

• Adrenal gland stimulated to produce aldosterone cause kidney to reabsorb sodium

– Black box – fetal/neonatal

morbidity/mortality -with

drugs with direct effect on

RAS in pregnancy

42

41

42

22

ACE Inhibitors

• Action- Blocks conversion of Angiotension I to Angiotension II - blocks breakdown of bradykinin

– Captopril (Capoten) initial 50 to target 150-200 mg

– Enalapril (Vasotec) initial 5mg to target 20mg

– Lisinopril (Zestril/Prinavil) initial 10mg to target 40mg

– Benazepril (Lotensin)-Fosinopril (Monopril)

– Quinapril (Accupril) -Ramipril (Altace)

• Risk AKI if pt has severe bil renal stenosis

43

ACE Inhibitors

• Adverse Effects – Cough-10%, hyperkalemia, renal insufficiency, and rarely angioedema

• Indications – Consider for initial therapy

– CKD – first line renal protective effect for diabetics to

reduce proteinuria and preserve function

– May have 15% drop in GFR in week 1 - usually returns

to baseline in 4-6 weeks

• Caution

– Stop ACEI/ARB if K 5.6 or greater/Pregnancy

– GFR decline >30% in 4 months without explanation

– If patient hypotensive and on ACE - reduced GFR,

– pt on potassium supplements or in Elderly

44

43

44

23

Angiotensin-Receptor Blockers

• Action – Directly blocks the AT1 receptor to block effects of Angiotensin II, does not affect bradykinin

– Irbesartan – Avapro 150mg-300mg

– Losartan – Cozaar 50mg-100mg ** combo with HTTZ

recalled

– Valsartan – Diovan 80mg-320mg

– Candesartan - Atacand

– Telmisartin – Micardis

• Indications

– Consider for initial therapy

– Diabetic – reduce proteinuria

45

Angiotensin-Receptor Blockers

• Adverse reactions

– Renal Insufficiency, AKI risk - RAS

– Hyperkalemia – monitor labs

– Less incidence of cough and angioedema

• Caution

– Not use ACE inhibitor, ARB, or renin inhibitor at same

time in patient

– CKD patient over 75 not recommended as raise

creatinine and risk of hyperkalemia

– Contraindicated in pregnancy

– If angioedema with ACE – wait 6 weeks, can try

46

45

46

24

Renin Inhibitor

• Action – targets RAS inhibits Renin production of Renin

– Aliskiren – Tekturna USA /Rasilez Europe

• Indications –

– Secondary agent

– potent dose dependent blood pressure reduction –

used with other agents

– Very long acting, not with ACE or ARB

• Adverse effects – Diarrhea, hyperkalemia, angioedema, AKI, contraindicated pregnancy

47

Calcium Channel Blockers

• Action – Blocks influx of calcium which inhibits the contraction of cardiac and arterial smooth muscle cells (Ca antagonist)

• 2 types of calcium channels – 2 types of meds

– Dihyropyridines – usually avoid in HFrEF

• Amlodipine 2.5 mg-10mg (ok HFrEF if needed)

• Felodipine 2.5mg-10 (ok HFrEF if needed)

• Nifedipine LA 30mg-90mg

– Non-Dihyropyridines – reduce HR, CO

• Avoid with BB and patients with HFrEF

• Diltiazem ER 120mg-360mg

• Verapamil 120mg-360

48

47

48

25


• Adverse Reactions – Dihydropyridines

• Dose related pedal edema, headache,

• Lightheadedness, reflux tachycardia,

• Avoid immediate release Nifedipine elderly Beers

list 2019

• Adverse Reactions -Non-Dihydropyridines

• Bradycardia, AV block,

• Constipation, edema, headache,

• Do not use if patient has HFrEF

• Avoid with BB

• Beers list 2019 if hx HFrEF

• Drug interactions with meds (CYP3A4)

49


• Indications –consider for initial therapy

• Newer, longer acting agents may be safer than old ones

• Combos

– Caduet – Amlodipine/Atorvastatin

– Lotrel – Amlodipine/Benazepril

– Exforge – Amlodipine/valsartan – recalled due to

impurities in it

• Caution Grapefruit juice

50

49

50

26

Beta (Adrenoceptor)Blockers

• Action – negative chronotropic (reduce HR) and negative inotropic (reduce pump –reduce CO) by action on beta 1 and beta 2 receptors

• Beta 1 selective (but may have beta 2 at high doses) - Cardioselective

– Atenolol (Tenormin) initial 25-50mg goal 100

– Metroprolol (Lopressor/Toprol) initial 50/goal 100-200mg

– HFrEF

– Bisoprolol (Zebeta)2.5-10mg – HFrEF

– Not first line unless Ischemic HD or HF

– Preferred if bronchiospastic dx

51


• Cardioselective and vasodilatory

– Nebivolol - Bystolic - less side effects

– Nitric oxide-induced dilation

• Beta noncardioselective

– Propanolol (Inderal)

– Nadolol (Corgard)

– Avoid in reactive airway dx

• Beta and Alpha 1 blockade (dilate arteries)

– Carvedilol (Coreg) – preferred in HFrEF

– Labetolol (Normodyne/Trandate) – ok in pregnacy

52

51

52

27


• Intrinsic sympathomimetic activity – avoid CHF

– Acebutolol

– Pindolol

• Adverse Effects –

– Bradycardia, AV blocks, CHF, bronchospasm in

asthma/COPD pts, may aggravate intermittent

claudication or Raynaud’s, increase triglycerides,

decrease HDL, depression, and impotence, rarely

contribute to confusion

– Need to taper drug off over 14 days

– Caution in diabetics – may mask signs of hypoglycemia

except for diaphoresis

– Avoid Clonidine with Beta Blocker – or withdraw Beta

blocker first

53

Alpha 1 Blockers

• RCT – Alpha Blockers resulted in inferior CV outcomes compare with use of a diuretic so not for initial therapy

• Action – “Peripheral alpha-1 receptor blockers” selectively block the alpha-1 receptors in the arterioles and venules, (bladder neck and prostate)

– Doxazosin – Cardura 1mg-16mg

– Terazosin – Hytrin 1mg-20mg

– Prazosin – Minipress 1mg-20mg

– (Tamsulosin – Flomax)

– (Phentolamine – Regitine) (alpha 1 and 2 – has

limited use)

54

53

54

28

Alpha 1 Blockers

• Indications – Not for initial therapy, but may be second line for patients with BPH

• Adverse Effects – “first dose phenomenon” transient dizziness/faintness, palpitations, and possible syncope with orthostatic hypotension

• Contraindicated in presence of volume depletion and CHF - decreases venous return and cause significant heart failure

• Beers list 2019 avoid in the elderly

55

Alpha 1 Blockers

• Adverse Effects cont: may cross blood/brain barrier and CNS effects – lassitude, vivid dreams, depression, rare priapism, and at larger doses may cause Na and fluid retention

• Have pt take initial / increased dose at bedtime to assist with orthostatic hypotension

• Warn if get up during night to sit on bed a while, then get up slowly

• Beneficial effects of lipid profile

56

55

56

29

Centrally acting agents

• Action – “Central alpha 2 receptor agonist” – acts as an agonist at the presynaptic alpha-2 receptor to decrease sympathetic outflow and an increase in vagal tone – HR, CO, and TPR are lowered, renin activity reduced – (CNS/brain effects)

– Clonidine – Catapres oral .1mg-.8mg

– Methyldopa – Aldomet 250mg-1000mg

• Indications - reserved last line as CNS SE, Methyldopa used in pregnancy

• Adverse reactions – dry mouth, drowsiness, depression, retention of Na and fluid

57

Centrally acting agents

• Caution – do not stop Clonidine abruptly as can cause rebound hypertension – sudden increase in BP often in excess of pretreatment BP – wean gradually

• Methyldopa rarely can cause hepatitis or hemolytic anemia

• Clonidine comes as patch which has fewer side effects and improved compliance – but cost issue and 2-3 day delay of onset

• Beers list 2019 avoid in elderly

58

57

58

30

Direct Vasodilators

• Action – Increase intracellular concentrations of cGMP which cause direct arteriolar smooth muscle relaxation – little effect on venous side

– Minoxidil – Loniten – 5mg-40mg - max 100mg

– Hydralazine 100mg-200mg

– Nipride (dilute D5, cyanide toxicity, not in pregnancy)

• Indications – resistant hypertension

• Adverse Effects –

– Activates the baroreceptor reflexes - increases SNS –

elevated HR, CO, renin, and retention Na and fluid -

edema (precipitate angina) so needs BB or other SNS

inhibitor and diuretic if needed.

59

Direct Vasodilators

• Adverse Effects cont:

– Hydralazine – headache, nausea, angina, Lupus like

syndrome (reversible), drug fever, dermatitis

– Minoxidil – hirsutism– hair growth on face, arms, back

and chest (reverses when drug stopped), pericardial

effusion, non-spec T wave changes on EKG, need

loop diuretic

60

59

60

31

Postganglionic Blockers

• Action – Act indirectly on adrenergic neurons by inhibiting release of norepinephrine from synaptic nerve endings – depletes CNS of catecholamines and serotonin

– Reserpine – Serpasil

– Guanadrel – Hylorel

– Guanethidine - Ismelin

• Indications – used as sympathetic inhibitor -used in trials

• Adverse reactions – mental depression, bradycardia, impotence, diarrhea, weight gain, nasal congestion

61

HTN in the Elderly

• Caution

– Prescribe safely

• Start low – go slow

• Careful monitoring for SE

– Polypharmacy/Compliance issues

• Multiple meds, times/day, providers, pharmacies

• Generic vs name brand/Use other person meds

• OTC /Herbals –drug interactions

• Cost concerns – make meds last, compliance

• Simplify dosage, 1 pharmacy, accurate med list

with all OTC and generic and name brand

• Educate and involve family

62

61

62

32

Questions ?

63

63

Documents

10-Fritz-Hypertension Management for Advanced Practice …...– Screen for secondary hypertension • 8. Treatment of High BP – Pharmacological treatment in context of CVD risk