Hypertension: Monitoring Parameters and Non-Pharmacologic Recommendations

HYPERTENSION
Hypertension affects 78 million Americans (Approximately 1 in 3 adults) making it the most common chronic disease in the United States. Hypertension is a major modifiable risk factor for development of heart disease, stroke, heart failure and renal disease; complications of uncontrolled or inadequately controlled hypertension include consequences at target organs.
The good thing about this disease is it is very well diagnosed – almost 80% of patients that have hypertension know they do. The bad thing is less than half of those patients have adequately controlled blood pressure (≈ 48.5%).
The exact cause of hypertension can be identified in less 10-15% of those diagnosed (essential hypertension). There are however many secondary causes including comorbidities and drugs (prescription, non-prescription and illicit).
Although an asymptomatic disease, detection is essential. Starting at ≈115/75 mmHg, the risk for cardiovascular disease doubles with each increment of 20/10 mmHg throughout the blood pressure range. So what then is "normal" and what are the "goal" blood pressures in those with hypertension?
Classification of Blood Pressure and Targets
Initiating Anti-hypertensive Therapies
JNC8
• ≥
60 years
Initiate pharmacologic treatment to lower BP at SBP 150 mmHg or DBP 90mmHg and treat to a goal SBP <150 mm Hg and goal DBP <90 mm Hg.
If pharmacologic treatment for high BP results in lower achieved SBP (eg, <140mmHg) and treatment is well tolerated and without adverse effects on health or quality of life, treatment does not need to be adjusted.
•<60 years, > 18 years of age with CKD or DM
initiate pharmacologic treatment to lower BP at DBP 90mmHg and treat to a goal DBP < 90mmHg
Pharmacologic treatment in this population may also be initiated at SBP ³ 140mmHg and treat to a goal SBP < 140mmHg; however the focus is on DBP
ACC / AHA 2017
Initiate pharmacologic treatment to lower BP if
≥130-140 or DBP ≥80-90 mm Hg PLUS any of the following:
–History of CAD, DM, or CKD
–10 yr risk of CVD ≥ 10% using the Pooled Cohort equations
–Age ≥65 years and SBP ≥130
SBP ≥140 or DBP ≥ 90, mm Hg
Treatment
1 Allow 2 weeks to reach full effect of each drug. Proceed through steps until target blood pressure is attained.
2 Beta-blockers can be used at any stage if specifically indicated, eg, heart failure or angina.
3 The European guidelines recommend starting with low-dose combination of two antihypertensive drugs. American guidelines suggest initiation with dual therapy for stage 2 hypertension, > 160/100 mm Hg.
4 Thiazide or calcium channel blocker is more effective initial therapy in older people and blacks.
5 If required, add a calcium channel blocker rather than diuretic in younger patients to avoid long-term exposure to metabolic side effects of diuretics.
6 Alternatives to spironolactone include eplerenone, amiloride, or triamterene. Watch for hyperkalemia, especially if also receiving ACE inhibitor/ARB. Avoid potassium-sparing diuretics in advanced CKD. If more than three drugs are required at maximum dose, consider specialist referral.
1 Compelling indications may alter the selection of an antihypertensive drug.
2 Start with full dose of one agent, or lower doses of combination therapy. In stage 2 hypertension, consider initiating therapy with a fixed dose combination.
3 Women of childbearing age should avoid ACE inhibitors and ARBs or discontinue as soon as pregnancy is diagnosed.
4 The adverse metabolic effects of thiazide diuretics and beta-blockers should be considered in younger patients but may be less important in the older patient.
5 For patients with significant kidney dysfunction, use loop diuretic instead of thiazide.
6 There are theoretical advantages in the use of vasodilating beta-blockers such as carvedilol and nebivolol.
7 Alpha-antagonists may precipitate or exacerbate orthostatic hypotension in older adults.
The antihypertensives that are available ultimately act one or more physiologic sites, including vasculature, heart and kidneys. The ultimate choice of appropriate agent(s) requires a thorough understanding of mechanism of action, side effects, comorbidities (compelling indications), contraindications, guidelines and then follow up and monitoring.
HEART FAILURE
Heart failure is a structural or functional change that impairs the hearts’ ability to provide enough CO to support metabolic function. The condition may be the result of impaired systolic function, diastolic dysfunction or both. Approximately 5 million patients have HF and over ½ million cases diagnosed each year and is often the endpoint of other cardiac disorders (e.g., longstanding hypertension).
Heart failure is classified differently in various clinical venues including functional (New York Heart Association Functional Classification), staging (ACC/AHA Stages of Heart Failure) and hemodynamic subsets, each having their own advantages.
The goals of therapy are modeled after the ACC/AHA Stages of Heart Failure, beginning at stage A where the emphasis is on identification and modification of risk factors to prevent development of structural heart disease. Additional goals include removing or mitigating underlying causes, relieving symptoms, including managing episodes of acute decompensation, improving quality of life, preventing hospitalization and prolonging life.
Pharmacotherapy essentially includes "The Heart Failure Five" -
ACE/ARB /ARNI
Beta blocker
Diuretics
Aldosterone antagonist
Digoxin
Newer therapies are emerging, however their place in therapy has not yet been completely defined (ie addressed by current guidelines).
Proper utilization involves recognition of the Stage of heart failure, mechanism of action, dosing (target doses for some agents), side effects, comorbidities, contraindications, guidelines and then follow up and monitoring. It is also important to note that some interventions are associated with improving morbidity, while other have clear mortality benefits.
Objectives
HYPERTENSION
See "Learning Objectives" outlined in chapter 5 of Pharmacotherapy: Principles and Practices; page 45
List the major applications and toxicities of thiazides, loop diuretics and potassium sparing diuretics
List the major types of antihypertensive drugs and examples. Describe the compensatory physiological responses, if any
What are 2 drugs, other than potassium supplementation, that reduce potassium loss during diuresis
What are the toxicities associated with the antihypertensive drugs
What are the types of diuretics and relate them to their site of action
What is the difference between the 3 types of drug that interfere with the RAAS cascade
What is the MOA of the vasodilator drugs, and describe their effects
Provide a recommendation for antihypertensive therapy given a patient case, based on ACC/AHA 2017 guidelines
HEART FAILURE
See "Learning Objectives" outlined in chapter 6 of Pharmacotherapy: Principles and Practices
Define the role of beta-blockers in heart failure despite the seemingly paradoxical contraindication to use
Describe the current guidelines with regard to the management of systolic heart failure. Where each medication fits in therapy and the impact on mortality
Describe the MOA of digoxin and its major effects (including toxicities). Why is digoxin no longer considered first line therapy in chronic HF
Describe the strategies and major drugs used in the treatment of acute and chronic heart failure
Explain the beneficial effects of diuretics, vasodilators, ACEIs and other drugs that lack positive inotropic effects in HF
List some positive inotropic drugs used in HF other than digoxin
Recommend patient-specific pharmacologic therapy for the management of chronic heart failure, with an emphasis on mortality-reducing agents and their target doses
Forward
HYPERTENSION
You are expected to thoroughly understand the material as presented in chapter 5 of the assigned textbook. You should understand the recommendations and changes set forth in ACC/AHA 2017 and apply the current standards of practice to a given case or patient.
HEART FAILURE
You are expected to thoroughly understand the material as presented in chapter 6 of the assigned textbook. You should understand the recommendations and changes set forth by 2013 ACCF / AHA Guidelines and apply the current standards of practice to a given case or patient.
→ Available through Dynamed
Readings
Text
Pharmacotherapy: Principles and Practices. Chisholm-Burns et. al., eds. 5th edition. Chapter 5
Pharmacotherapy: Principles and Practices. Chisholm-Burns et. al., eds. 5th edition. Chapter 6
Evidence-Based Medicine Resources
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). James PA, Oparil, S, et al. JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427
2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. J Am Coll Cardiol. Sep 2017, 23976; DOI: 10.1016/j.jacc.2017.07.745
2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
Dynamed permalinks:
Hypertension
https://wilkes(dot)idm(dot)oclc(dot)org/login?url=http://www(dot)dynamed(dot)com/topics/dmp~AN~T115345/
Heart failure
https://wilkes(dot)idm(dot)oclc(dot)org/login?url=http://www(dot)dynamed(dot)com/topics/dmp~AN~T114099/
Websites
Your Guide to Lowering Blood Pressure (The DASH Diet)
Videos
JNC-8 Evidence-Based Guidelines
https://youtu(dot)be/ZoOqpSlwC8Q
Transcript of Hypertension Today: JNC-8 Evidence-Based Guidelines video
ACC/AHA - 2017 Hypertension Guidelines
Part I: https://youtu(dot)be/TEXY5rpj-MY
Part II: https://youtu(dot)be/nFkLMp2Q-hw
Heart failure Pathophysiology Review
https://youtu(dot)be/okTQ6xmwWyw
Transcript of Pathophysiology of Heart Failure Part 1 video
https://youtu(dot)be/XZ1PQ2izmAk
Transcript of Pathophysiology of Heart Failure Part 2 video
Module X Discussions & Assignments
Discussion 1
A 50yo African American woman presents to clinic feeling tired for the last 3 months. She also has trouble breathing when walking 2-3 blocks. She sleeps on 2 pillows at night to help with her breathing. PMH: HTN, arthritis. Physical exam: edema present in both feet. Medications: HCTZ 12.5mg daily, verapamil SA 120 mg daily, ibuprofen 200 mg BID for arthritis in knee. Vitals: height 5'2", 63kg, BP 134/84, HR 78, EF 30% per echocardiogram. Her labs are normal including a creatinine of 1.1. She denies chest pain or palpitations. Her EKG reveals normal sinus rhythm with no evidence of ischemia or recent acute coronary syndrome.
How would you classify her heart failure?
What changes (modifications, additions, deletions) to her medications do you recommend that will:
Improve her symptoms?
Impact long term outcomes?
What monitoring parameters do you recommend?
What non-pharmacologic recommendations do you have?
Module X: Hypertension/Heart Failure Discussion
Assignments
None
Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight. Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced. A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section.
Special Guidance on APA formatting in Discussion Posts
APA formatting is required in discussion posts with the following two exceptions (due to limitations with the text editor in LIVE): double line space and indent 1/2 inch from the left margin. Discussion posts will NOT be evaluated on those two formatting requirements. All other APA formatting guidelines should be followed. For example, in-text citations must be formatted with the appropriate information and in the correct sequence (Author, year), reference list entries must include all appropriate information following guidelines for capitalization, italics, and be in the correct sequence. Refer to the APA Publication Manual 7th ed. for each source type's specific requirements. Please let your instructor know if you have any questions.
Hello Chapters in the text book may not necessarily be 5&6 but you can look up the chapters with heart failure, I will also do so and communicate them to you