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Hypertension
 Classification
 BP
of hypertension
targets
 Basic evaluation
 When to evaluate for secondary
causes
 Which drug(s) you should use
 Classes of antihypertensives
Classification of blood pressure in adults
BP classification
SBP (mmHg)
DBP (mmHg)
< 120
and < 80
Prehypertension
120-139
or 80-89
Stage 1
hypertension
140-159
or 90-99
Stage 2
hypertension
>=160
or >= 100
Normal
Target BP
 Patients
with diabetes and CKD –
130/80
 Everybody else – 140/90
Basic evaluation

History
– HPI – onset of hypertension, antihypertensives (which
ones used, side effects), severity of hypertension
– PMH – all drugs used including OTC meds, herbals;
other medical conditions
– FH – specifically hypertension, renal disease
– SH – EtOH, salt intake, increase in weight
– ROS – HA, palpitations, sweating, thyroid sxs

Physical
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BP in both arms
fundoscopic exam
thyroid exam
heart, lungs
abd – specifically listen for bruits
ext – pulses, edema
Initial labs
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BUN, creat(eGFR), urinalysis
Calcium
K
TSH
When to eval for secondary causes
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When basic eval suggests a secondary cause –
e.g. variable BP, HA, palpitations, sweating –
pheo; severe hypertension in a young female or
sudden worsening of hypertension in an older
person – renovascular hypertension
When history is not consistent with essential
hypertension (positive FH, onset in 20’s, initially
mild)
For resistant hypertension – elevated BP when
patient is reliably taking adequate doses of three
antihypertensives, one of which is a diuretic
First drug with no other medical
problems
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Anything would work (the most important thing is
to control the blood pressure)
Diuretics have been the most thoroughly studied
and are safe, effective and inexpensive
I recommend starting with chlorthlidone 12.5 qd;
if the BP is not controlled I would add lisinopril
Compelling indications
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CHF – ACE, ARB, BB, Aldo ant; also diuretics
Post-MI – BB, ACE
High CAD risk – BB, ACE; also diuretics, CCB
Diabetes – BB, ACE, ARB; also diuretics, CCB
CKD – ACE, ARB
Recurrent stroke prevention – ACE; also diuretics
BPH (not in JNC VII) – α-blocker
Second and third drugs
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If first drug is not a diuretic second one should be
(almost all non-diuretic antihypertensives result
in sodium retention which limits their efficacy)
Best 3 drug combo is appropriate dose of a
diuretic, an ACE inhibitor and a calcium channel
blocker
Diuretics

Thiazides
– qd for BP; chlorthalidone making a comeback
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Loop
– GFR < 30 - 50
– bid for BP (except for torsemide which is qd)

Aldo antagonists
– primary aldo and aldo mediated hypertension more
common than previously thought so consider these
drugs in resistant BP
– spironolactone – 25 qd is usually sufficient
– eplerenone has few hormonal side effects but is very
expensive (is half as potent as spironolactone)
Calcium channel blockers
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Decrease tone of LES/dose-dependent
edema/can be used together
Dihydropyridines
–  glomerular pressure in CKD so don’t use as first BP
drug; OK if patient already on ACE or ARB
– amlodipine is generic and has long half life without
delivery system
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Diltiazem
–  glomerular pressure in CKD
– neg inotrope and chronotrope
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Verapamil
–  glomerular pressure in CKD
– neg inotrope and chronotrope
– all older patients get constipated
ACE inhibitors
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16% get dry cough, can start > 1 year after
starting ACE
Angioedema
Captopril is short acting
Work great with diuretic
Angiotensin receptor blockers
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No cough
8% of patients who get angioedema with ACE get
it with ARB
Probably like an ACE without the cough
ONTARGET trial (25,000 patients with vascular
disease or DM with end-organ damage) –
proteinuria was decreased but CV outcomes and
renal function were worse in patient treated with
combo ACE/ARB as opposed to either drug alone
Renin antagonists (aliskiren)
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Very few clinical trials
Very expensive
No cough
Can cause angioedema
ß-blockers
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Use metoprolol, not atenolol
Metoprolol XL is now generic so is probably the
preferred ß-blocker
Lower BP by decreasing renin levels so add little
BP lowering to ACEs or ARBs
α-blockers
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Some risk of precipitating CHF
Only indication is BPH
First dose syncope can occur after
stopping/restarting med or increasing dose
Tamsulosin is much better than doxazosin or
terazosin for BPH so often times I am switching
metoprolol to carvedilol instead of using
doxazosin or terazosin
Direct vasodilators
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Hydralazine rarely indicated
– frequent dosing
– drug induced lupus
– possibly indicated in patient with CHF who gets
angioedema on ACE/ARB
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Minoxidil
– Extremely potent and effective
– Hirsutism is a problem in females
– Can cause severe fluid retention, tachycardia and
pericarditis so should probably only be used by
hypertension specialists
Centrally acting agents
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Clonidine
– short acting so good for EtOH withdrawal or
hypertensive urgencies
– bedtime dose can be used for patients with PTSD
– clonidine withdrawal can be severe – it is caused by
rebound increase in centrally mediated α and β
adrenergic stimulation; when patients are also on a βblocker unopposed α stimulation can increase the BP
– rash frequent with patch
Rules of thumb
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Never use ß-blocker and clonidine together
Never use ß-blocker and verapamil together
Be careful when using a ß-blocker and dilt
together
Never use 10 mg of furosemide
A 25% increase in creat after starting an ACE is
good, not bad
Don’t increase doses of long acting BP meds daily
Never use tid antihypertensives