Blood pressure goals:
- Pre: < 140 and <90 (lifestyle modifications)
- Stage 1 HTN 140-159 or 90-99 (lifestyle and medications)
- Stage 2 HTN > 160 or >100 (lifestyle and 2 meds)
| JNC 8 | When to start treatment | Goal |
| >=60 years old | >=150/90 | <150/90 |
| <60 years old | >=140/90 | <140/90 |
| >=18 years old + DM or CKD | >=140/90 | <140/90 |
*If urine albumin excretion >= 30 mg, some guidelines suggest 130/80*
| Patient Group | Initial Therapy |
| non-black +/- diabetes | thiazide, CCB or ACEI/ARB |
| black +/- diabetes | CCB or thiazide |
| >= 18 + CKD + HTN | ACEI or ARB |
| Stroke or TIA | ACEI or ARB |
| Coronary disease | Beta-blocker, ACEI or ARB |
| HFrEF | ACEI or ARB, Beta blocker, AA or diuretic |
| HFpEF | ACEI or ARB, beta blocker or diuretic |
Common Adverse Effects:
- Beta-blockers: caution in asthma or COPD. Greater risk of developing diabetes also can mask signs of hypoglycemia. A decrease in HR can cause reflex tachycardia.
- Thiazides: May worsen gout, not for patients with <30 CrCl, greater risk of developing diabetes. Decreases sodium and potassium, increases calcium.
- ACE or ARB: Do not use in pregnancy. Monitor K. Do not use in bilateral renal stenosis. Angioedema. Lisinopril can cause pancreatitis.
- icatibant: protein used for angioedema attack. Usually, use epi. Antihistamine or corticosteroids can also be used.
- Direct renin antagonist: Do not use in pregnancy, d0 not use in combo with ACEI in diabetes, avoid use with cyclosporin or itraconazole.
- Non-DHP CCBs (diltiazem or verapamil): no direct increase in HR, can have reflex tachycardia, decrease vasodilation, do not use in Wolfe-Parkinson White, can cause heart block.
- DHP CCBs: Decrease HR, decrease AV node conduction, decrease ionotropy, decrease vasodilation.
- Loop Diuretics: no effect on HR, decrease potassium
- Metolazone before a loop diuretic: quinazoline diuretics work by inhibiting sodium transport across the epithelium of the renal tubules (mostly in the distal tubules), resulting in a decrease in sodium reabsorption and an increase in sodium, chloride, and water excretion. Loop diuretics bind reversibly to a chloride channel receptor site in the ascending limb of the loop of Henle, inhibiting the reabsorption of filtered sodium and chloride. If you give metolazone 30 minutes before a loop diuretic, it ensures the distal Na-Cl channel is already blocked when the increased sodium reaches the distal convoluted tubule, making the loop work better.
- Clonidine: decreases heart rate, causes reflex tachycardia, alcohol withdrawal, decrease sex drive, sedation, dry mouth, orthostasis
- Methyldopa: anemia, Coombs
- Doxazosin: also used for BPH, orthostasis, especially with diuretics, non-DHPs or Beta-blockers
- Hydralazine: reflex tachycardia, vasodilation, causes lupus.
- Minodoxil: vasodilation
- Fendolopam: vasodilation (dopamine agonist), use only in HTN crisis.
- Nitropress: Decrease pre-load, majorly decrease afterload (vasodilation), cyanide
- Nitroglycerin: decrease preload, afterload (vasodilation) [more pre-load decrease, less afterload decrease than nitropress]