Hypertension Management

Aka: Hypertension Management

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II. Management: General Guidelines

  1. See patients back at one month after starting agent
    1. Significantly improves compliance
    2. BP requires 1 month on agent to equilibrate
  2. Maximize compliance
    1. Work with patients to reduce adverse effects
    2. Switch to other agents if adverse effects significant
  3. Do not be overzealous
    1. Risk of overcorrection of Blood Pressure
    2. Avoid lowering diastolic pressure <70 mmHg
    3. Greater tolerance for elevated BP with increased age
      1. Study of 484 Swedish men over 70 from 1982-1992
      2. Risk if Diastolic Blood Pressure lowered below 90
        1. Increased cardiac event risk 3.9x
        2. Controlled for confounding factors
      3. Reference
        1. Merlo (1996) BMJ 313:457-61 [PubMed]
  4. Consider nighttime dosing
    1. Advantages
      1. Associated with decreased cardiovascular events and improve Blood Pressure control
        1. Hermida (2019) Eur Heart J +PMID:31641769 [PubMed]
      2. Benefit may best in patients who do not dip their Blood Pressure overnight
        1. Non-dippers: Older, Diabetes Mellitus, Chronic Kidney Disease, Resistant Hypertension
        2. Consider 24 hour ambulatory monitoring to define unclear cases
    2. Disadvantages
      1. Risk of non-compliance
        1. Do not switch to nighttime dose if patient can not remember that dose
      2. Risk of Orthostatic Hypotension and Fall Risk at night
    3. Indications to switch at least one medication to nighttime dosing
      1. Three or more antihypertensives used
      2. Best medications for nighttime dosing
        1. Angiotensin Converting Enzyme Inhibitors (ACE Inhibitors)
        2. Angiotensin Receptor Blockers
        3. Calcium Channel Blockers
        4. Alpha Blockers
        5. Beta Blockers
        6. Avoid Diuretics over night
    4. References
      1. (2012) Prescr Lett 19(1): 4
      2. Hermida (2011) J Am Soc Nephrol 22: 2313-21 [PubMed]

III. Management: Choose agents with best outcome data

  1. Medications that prevent Hypertension vascular sequelae
    1. Diuretics
    2. ACE Inhibitors
    3. Calcium Channel Blockers
    4. Beta-Blockers
      1. Indicated in patients with known Coronary Artery Disease or chronic, stable Systolic Dysfunction
  2. Medications that prevent Left Ventricular Hypertrophy
    1. Most effective at reducing LVH risk
      1. ACE Inhibitors (e.g. Lisinopril)
      2. Diuretics (e.g. Chlorthalidone)
      3. Beta-Blockers (e.g. Metoprolol)
    2. Least effective at reduced LVH risk
      1. Prazosin
      2. Clonidine
      3. Diltiazem
    3. Reference
      1. Gottdiener (1997) Circulation 95:2007-14 [PubMed]

IV. Management: Protocol

  1. See Hypertension Risk Stratification
  2. See Hypertension Reduction Goal

V. Management: Strategies

  1. Hypertension General Measures
  2. Antihypertensive Selection
  3. Hypertension Combination Therapy
  4. Hypertension Management for Specific Comorbid Diseases
  5. Hypertension Management for Specific Populations
  6. Hypertension Management for Specific Emergencies

VI. References

  1. (2000) Lancet 356:1955-64 [PubMed]

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