Management of Chronic Hypertension

Table of Contents

Table of Contents

Published September 2021

Brandon Fainstad, MD1 Kathryn Guinn, MD2 Meara Melton, MD3 Ben Trefilek, MD4 Molly Brett, MD5
1 Assistant Professor, Department of Medicine, University of Colorado 2 Cheif Resident, University of Colorado Internal Medicine Residency Program 3 Fellow in Geriatric Medicine, University of Colorado 4 Clinical Instructor, Department of Medicine, University of Colorado 5 Assistant Professor, Department of Medicine, University of Colorado

Objective(s)

  1. Identify patients for whom the initiation of antihypertensive therapy will have a clinically significant reduction in cardiovascular outcomes and death.
  2. Based on underlying comorbidities, determine the target blood pressure and demonstrate an appropriate selection of a first-line antihypertensive agent.
  3. Identify patients whose clinical presentation is concerning for a secondary cause of hypertension.

Teaching Instructions

Plan to spend at least 20 minutes preparing for this talk by using the interactive board for learning/preparing, clicking through the graphic, and becoming familiar with the order of the content that appears on the graphic. The teaching script below details how to walk through the talk. Every interactive or “clickable” element is denoted with a rounded box and cursor icon.

Anticipated time to deliver the talk with and without cases or other features: without cases 15-20 minutes. The cases may take an additional 10-15 min.

The talk can be presented in two ways:
1. Project the “interactive Board for Presentation” OR
2. Reproduce your own drawing of the presentation on a whiteboard.
With either method, print out copies of the Learner’s Summary Handout so they may have this for reference after the discussion. Begin with reviewing the objectives for the session.

Objective 1: Identify patients for whom the initiation of antihypertensive therapy will have a clinically significant reduction in cardiovascular outcomes and death

  • Click through slide 2, asking learners along the way about the prevalence of HTN as well as its consequences (CV disease, stroke, CKD).
  • Click on “benefits of treatment” to estimate NNT for a sample patient. Of note – this NNT is substantially lower than treatment with statins, aspirin, or anti-diabetic agents.

Objective 2: Based on underlying comorbidities, determine the target BP and demonstrate an appropriate selection of a first-line antihypertensive agent.

  • Explain that the ideal BP (for CV/mortality benefit) is likely <120/80, but the use of medications to achieve that target entails risks.

    BONUS: In the SPRINT trial, which seemed to suggest lower BP is better in high-risk patients, patients required an average of 2.7 BP meds to achieve tight control, and there were higher rates of adverse events like syncope and electrolyte abnormalities in the intensive treatment group.

BONUS: “White coat hypertension” (elevated in-office readings with normal home readings in a patient who is not on treatment for hypertension) indicates a substantially increased risk of going on to develop “true” hypertension, and it may also indicate increased cardiovascular risk. Think of white coat hypertension as a pre-hypertensive state and a CV risk factor. Over 35% of patients with white coat hypertension develop true hypertension within 15 years (compared to 10% in normotensive patients). Still, most guidelines do not recommend treating white coat hypertension at this time

  • Click through the tabs to explain which high-risk patients will derive the most benefit from tight control (it is reasonable to allow less strict control for patients at lower CV risk)
  • On slide 4, ask learners to talk through the risks/benefits of the four first-line agents for HTN treatment.

BONUS: ACEi’s appear to be less effective at lowering BP in Black patients (but should still be used if there is any secondary indication for an ACE, like diabetic nephropathy)

BONUS: ARBs are generally considered a first-line option, but some studies show less CV risk reduction with ARBs compared to ACEi’s or diuretics

BONUS: Chlorthalidone is more potent than hctz – it has a longer half-life, and likely has more CV risk reduction as well. (This comes at the expense of more adverse effects, like hypokalemia, however).o BONUS: A word on SGLT2 inhibitors: they reduce systolic blood pressure by ~5 mmHg. Not FDA approved for blood pressure reduction in absence of another indication.

Objective 3: Identify patients whose clinical presentation is concerning for a secondary cause of hypertension.

  • Guide learners through indications for evaluation of secondary hypertension. Then, click on “common differential” to work through the evaluation of secondary HTN.
  • Of note, 20-30% of hypertension is due to hyperaldosteronism state. There should be a low threshold for testing renin-aldosterone levels when treating hypertension with atypical features.

Lifestyle
ACC/AHA 2019: Proven Lifestyle Modifications to Prevent CV Disease

1. DASH/USDA type diet: vegetables, fruits, whole grains, low-fat dairy, poultry, fish, legumes, vegetable oils, nuts. Limit sweets, sugar-sweetened beverages, and red meat.
2. Weight loss.
3. Lower sodium intake.
4. High potassium diet (if no CKD or drug contraindication).
5. Moderate to vigorous aerobic physical activity 90-150 minutes per week (resistance exercise also beneficial).
6. If drinking alcohol, moderate intake.

Handouts

Learner Handout  – Recommend printing out ahead of time and distributing to learners when you are ready to do pair-shares for the cases.

Tutorial on delivering the talk

Presentation Board

Take Home Point

  1. Pharmacologic treatment target for low-risk patients is BP <140/90, for high-risk patients, is <130/80.
  2. There are four first-line agents for the treatment of hypertension: ACEi (lisinopril), ARB (losartan), Dihydro CCB (amlodipine), & Thiazide (chlorthalidone).
  3. Consider secondary cause for hypertension if:
    1. Severe or resistant.
    2. Acute rise and increased lability of BP.
    3. Less than 30 years of age.
    4. Associated with electrolyte abnormalities.
  4.  

References

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Dennison Himmelfarb, C., … & Wright, J. T. (2018). 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: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology, 71(19), e127-e248.

Prevalence of HTN using NHANES data with ACC/AHA definition
Hypertension is a major risk factor for cardiovascular disease. Lowering blood pressure has been shown to decrease the incidences of stroke, heart attack, and heart failure (1,2). This report provides 2017-2018 U.S. hypertension prevalence estimates using the 2017 American College of Cardiology and American Heart Association definition of hypertension (3) and new guidelines, which redefine hypertension by lowering the previous threshold levels of 140/90 mmHg to 130/80 mmHg (4). This change categorizes a greater percentage of people as having hypertension.

Ogden, L. G., He, J., Lydick, E., & Whelton, P. K. (2000). Long-term absolute benefit of lowering blood pressure in hypertensive patients according to the JNC VI risk stratification. Hypertension, 35(2), 539-543.

Krist, A. H., Davidson, K. W., Mangione, C. M., Cabana, M., Caughey, A. B., Davis, E. M., … & US Preventive Services Task Force. (2021). Screening for hypertension in adults: US Preventive Services Task Force reaffirmation recommendation statement. JAMA, 325(16), 1650-1656. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hypertension-in-adults-screening

James, P. A., Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J., … & Ortiz, E. (2014). 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). Jama, 311(5), 507-520.

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