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Informatics in Pharmacy

Hypertension

August 12, 2018 By Dr. G, PharmD

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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 8When to start treatmentGoal
>=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 GroupInitial Therapy
non-black +/- diabetesthiazide, CCB or ACEI/ARB
black +/- diabetesCCB or thiazide
>= 18 + CKD + HTNACEI or ARB
Stroke or TIAACEI or ARB
Coronary diseaseBeta-blocker, ACEI or ARB
HFrEFACEI or ARB, Beta blocker, AA or diuretic
HFpEFACEI 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]

Filed Under: Cardiology Tagged With: blood pressure, hypertension

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acid base acidosis acute coronary syndrome alkalosis analgesics anaphylaxis aortic dissection arrhythmia Beta-Blockers biostatistics blood pressure cardiac markers CHA2DS2-VasC cocaine COVID-19 diabetes diabetes inspidius Guidelines heart failure Heparin hypersensitivity hypertension hypovolemic shock intubation ionotropes journal club lipids LMWH medication safety morphine conversions myocardial infarction needs work NOAC NSTEMI obstructive shock pharmacoeconomics pheochromocytoma pressors reference materials right mi sedation septic shock shock STEMI Updated 2020