• HTN HTN DRUG THERAPY CLASSIFICATION

1/ THIAZIDE DIURETICS:LOW DOSE

• AFRICAN AMERICANS
• ELDERLY
• SMOKERS

• EFFECTS THIAZIDES ON POTASSIUM: DECREASE IN SERUM POTASSIUM WITH CHRONIC THERAPY.

• DIURETICS	THIAZIDE/K SPARING DIURETICS COMBINATION
  HYDROCHLOROTHIAZIDE =HCTZ, HYDRODIURIL 12.5mg	maxzide= TRIAMTERENE/HYDROCHLOROTHIAZIDE 37.5/25MG
  chlorothiazide [diuril] 250-500mg	MODURETIC [AMILORIDE 5MG/HYDROCHLOROTHIAZIDE 50MG
  chlorthalidone [hygroton] 15-100mg	DYAZIDE = TRIAMTERENE/HYDROCHLOROTHIAZIDE
  indapamide [lozol] 1.25-5mg

• THIAZIDE LOOP DIURETICS POTASSIUM SPARING HYDROCHLOROTHIAZIDE FUROSEMIDE SPIROLACTONE CHLORTHALIDONE BUMETANIDE AMILORIDE METOLAZONE TORSEMIDE TRIAMTERENE INDAPAMIDE

• SPIROLACTONE= GYNECOMASTIA SIDE EFFECTS
• TRIAMTERENE:DON'T GIVE WITH INDOMETHACIN ==> ACUTE RENAL FAILURE
• SPECIFIC INDICATIONS:

1. CONGESTIVE HEART FAILURE
2. EDEMATOUS STATES
3. BLACK PATIENTS.
4. LEAST EXPENSIVE

• MAJOR SIDE EFFECTS:

1. DECREASES IN POTASSIUM AND MAGNESIUM
2. INCREASES IN CALCIUM , URIC ACID , GLUCOSE, LDH CHOLESTEROL.
3. GYNECOMASTIA [SPINOLACTONE]
   
   
   
   2/BETA BLOCKERS

• FOR WHITES
• NONSMOKERS
• YOUNGER PATIENT
• THOSE WITH CHD
• BETA ADRENERGIC BLOCKERS
• ALL BETA ADRENERGIC BLOCKERS ARE EQUALLY EFFECTIVE IN THE TREATMENT OF HYPERTENSION.
  
  
• CARDIOSELECTIVE BETA BLOCKERS BECOME LESS SELECTIVE AS THE DOSE INCREASED.
  
  
• ADVANTAGES IN PATIENT WITH DIABETES OR CHRONIC LUNG DISEASE.
  
  
• AFRICAN ARE MORE RESPONSIVE TO DIURETICS AND CALCIUM ENTRY BLOCKERS THAN BETA BLOCKERS AND ACE INHIBITORS.
  
  
• BETA BLOCKERS ARE MORE EFFECTIVE IN WHITE THAN BLACKS.
  
  
• CARDIOPROTECTIVE EFFECT
  
  
• REDUCE MORTALITY WITH CORONARY HEART DISEASE.
  
  
• DECREASED HDL CHOLESTEROL, INCREASED LDL CHOLESTEROL. [AVOIDED IN PATIENT WITH ELEVATED LDL CHOLESTEROL LEVEL].
  
  
• BETA BLOCKERS SHOULD BE AVOIDED IN DIABETES [MASL HYPOGLYCEMIA SYMPTOMS]
  
  
• LIPOPHILIC BETA BLOCKERS: PROPANOLOL

TIMOLOL

METOPROLOL

PINDOLOL

CARDIOSELECTIVE BETA BLOCKERS	NON CARDIOSELECTIVE BETA BLOCKERS
METOPROLOL = LOPRESSOR	PROPANOLOL LA =INDERAL LA
ATENOLOL = TENORMIN	TIMOLOL=BLOCADREN
	NADOLOL=CORGARD
	PINDOLOL=VISKEN
	CARTEOLOL=CARTROL

LABETALOL [COMBINED ALPHA/BETA BLOCKER].

SPECIFIC INDICATION:

1. MYOCARDIAL INFARCTION
2. SUPRAVENTRICULAR ARRHYTHMIAS
3. MIGRAINE HEADACHE
4. GLAUCOMA
5. ANXIETY
6. RESTING TACHYCARDIA
8. MAJOR SIDE EFFECTS:

• BRONCHOSPASM
• HEART BLOCK
• BRADYCARDIA
• RAYNAUD'S PHENOMENON
• DEPRESSION
• IMPOTENCE
• FATIGUE
• DECREASES HDL
• INCREASES TRIGLYCERIDE
• HYPERGLYCEMIA
• RELATIVE CONTRAINDICATION:

1. ASTHMA
2. COPD
3. ATRIOVENTRICULAR CONDUCTION DEFECTS
4. CONGESTIVE HEART FAILURE FROM SYSTOLIC DYSFUNCTION
5. DIABETES BECAUSE MASKING HYPOGLYCEMIA.

3/Angiotensine Converting Enzyme Inhibitors [ACE]

• WHITE
• YOUNGER
• WITH TOTAL CHOLESTEROL > 240 MG/DL
• DIABETES
• ANGIOTENSINE - CONVERTING ENZYME [ACE] IHNIBITORS

• AGENT OF CHOICE FOR DIABETICS [SLOW PROGRESSION OF RENAL FAILURE].
  
  
• RISK IN DIABETICS = HYPERKALEMIA
  
  
• BENEFICIAL IN REVERSING HEART FAILURE IN PATIENT WITH HYPERTENSION.
  
  
• NORMALIZE INTRAGLOMERULAR FILTRATION PRESSURE, DECREASING THE RATE OF THE NEPHRON LOSS DUE TO THE CONSEQUENCES OF GLOMERULAR HYPERFILTRATION.
  
  
• ADVERSE EFFECT :CHRONIC COUGH++++++[CAPTOPRIL -ENAPRIL]

• ACE INHIBITOR

  RAMIPRIL = ALTACE

  QUINAPRIL = ACCUPRIL

  LISINOPRIL =ZESTRIL -PRINIVIL

  BENAZEPRIL = LOTENSIN

  FOSINOPRIL =MONOPRIL

  ENALAPRIL=VASOTEC [ONLY IV FORM]

  MOEXIPRIL =UNIVASC

  CAPTOPRIL =CAPOTEN

• 4/CALCIUM CHANNEL BLOCKERS
• ELDERLY
• SYMPTOMATIC CHD
• AFRICAN AMERICANS
• HYPERCHOLESTEROLEMIA
• CALCIUM ENTRY BLOCKERS=CALCIUM CHANNEL BLOCKERS
• 
  EFFECTIVE FIRST LINE DRUG IN HTN TREATMENT

• NO ADVERSE EFFECT ON LIPIDS
  
  
• CAUTION IN HEART FAILURE ===> NEGATIVE INOTROPIC EFFECTS.
  
  
• NO CARDIOPROTECTIVE BENEFIT FOLLOWING MYOCARDIAL INFARCTION.
  
  
• WORK EQUALLY WELL IN AFRICANS AND WHITES.
  
  
• DIHYDROPYRIDINE= NIFEDIPINE,NICARDIPINE,ISRAPIDINE,FELODIPINE
  
  
• DIHYDROPIRIDINE,VERAPAMIL,DILTIAZIEM, BEPRIDIL ARE EQUALLY EFFECTIVE IN THE HTN TREATMENT., WITH DIFFERENT CARDIAC CONDUCTION EFFECTS AND PERIPHERAL VASODILATATION.
  
  
• VERAPAMIL EXACERBATE GLUCOSE INTOLERENCE BY REDUCING INSULIN RELEASE [AT VERY HIGH DOSE >TO CLINICAL USE]
  
  

CALCIUM ENTRY BLOCKERS

DILTIAZEM SR =CARDIZEM SR

NIFEDIPINE XL =PROCARDIA XL - ADALAT CC

VERAPAMIL = CALAN -COVERA

AMLODIPINE=NORVASC

FELODIPINE = PLENDIL

ISRADIPINE =DYNACIRC

NICARDIPINE =CARDENE

5/ALPHA 1 BLOCKERS

• MEN WITH SYMPTOMATIC PROSTATIC HYPERPLASIA

• NO ADVANTAGE OVER THE OTHER HTN MEDICATION
• REDUCE PROSTATIC HYPERPLASIA
• LOWER TOTAL AND LDL CHOLESTEROL

COMBINATION AGENTS

LOTREL = AMLODIPINE / BENAZEPRIL

LOTENSIN=BENAZEPRIL/HCTZ

HYZAAR =LOSARTAN/HCTZ

VASERETIC = ENALPRIL /HCTZ

6/COMBINED ALPHA1-BETA BLOCKERS

FROM PUBLIC POLICY, GENERIC DIURETICS AND BETA BLOCKERS ARE PREFFERED

THE CEI OFFER A LOW SIDE EFFECTS PROFILE, MAY PREVENT NEPHROPATHY IN DIABETICS.

BETA BLOCKERS	DECREASE CAD MORTALITY IN NON SMOKERS DECREASE INCIDENCE OR PROGRESION OF CAD DECREASE MORTALITY AFTER MYOCARDIAL INFARCTION MORE EFFECTIVE IN WHITE AND YOUNGER PATIENT PROPANOLOL IS THE LEAST EXPENSIVE MAY LOWER HDL CHOLESTEROL CAN PRECIPITATE GLUCOSE INTOLERENCE SEXUAL DYSFUNCTION IN MEN
THIAZIDE TYPE DIURETICS	PROTECT AGAINST STROKE IN SMOKERS AND NON SMOKERS MORE EFFECTIVE IN AFRICAN AMERICAN AND ELDERLY MAY RAISE LDL AND TOTAL CHOLESTEROL FOR <1 YEAR HYPOKALIEMIA IMPOTENCE - FATIGUE PROTECT ELDERLY PERSONS FROM HIP FRACTURE INCREASE MORTALITY WHEN USED IN DIABETICS, ABNORMAL ECG
CALCIUM CHANNEL BLOCKERS	MORE EFFECTIVE IN AFRICAN AMERICAN AND ELDERLY PATIENT EFFECTIVE FOR CAD BUT LITTLE BENEFIT FOR POST -MI NO ADVERSE EFFECT ON LIPID OR GLUCOSE TOLERANCE PREVENT PROGRESSION OF ATHEROSCLEROSIS EXPENSIVE
CONVERTING ENZYME IHIBITOR [CEI]	MORE EFFECTIVE IN WHITE AND YOUNGER PATIENT NO ADVERSE EFFECT ON LIPID OR GLUCOSE TOLERENCE MAY RAISE K+ AND CAUSE RENAL INSUFFICIENCY COUGH AS SIDE EFFECT BEST QUALITY LIFE MAY HELP TO PREVENT PROGRESSION OF NEPHROPATHY IN DIABETES EXPENSIVE
	

CATEGORY	SYSTOLIC	DIASTOLIC	RECOMMENDED FOLLOW UP
NORMAL	<130 mmHg	<85mmHg	RECHECK IN 2 YEARS
HIGH NORMAL	130-139	85-89	RECHECK IN 1 YEAR
STAGE I HTN	140-159	90-99	REEVALUATE WITHIN 2 MONTHS
STAGE II HTN	160-179	100-109	EVALUATE AND TREAT WITHIN 1 MONTH
STAGE III HTN	180-209	110-119	EVALUATE AND TREAT WITHIN 1 WEEK
STAGE IV HTN	>210	>120	EVALUATE AND TREAT IMMEDIATLY
			

• What are the indications for specif hypertension group:

1. Diabetics: should be treated with ACE INHIBITORS: they prevent the development of nephropathy.
2. Post myocardial infarction :ischemic heart disease should be treated with beta blockers.
3. Diminished left ventricular systolic function [ congestive heart failure or post myocardial infarction ] should be treated with ACE INHIBITORS.
4. BLACK PATIENT: EFFECTIVE TO DIURETICS OR CALCIUM CHANNEL BLOCKERS, LEAST EFFECTIVELY TREATED WITH ACE INHIBITORS.
5. PREGNANT PATIENT:BEST TREATED WITH LABETOLOL [BETA BLOCKERS] OR HYDRALAZYNE [VASODILATATORS]
   • .HYPERTENSIVE EMERGENCIES:
     • END ORGAN DAMAGE:
     • DIASTOLIC >120-130 mmHG
     • 1% OF HYPERTENSIVE PATIENT.
     • PRESENTATION:
       • NEUROLOGIC:
       • Encephalopathy
       • headache
       • Confusion
       • Seizures
       • Subarachnoid or intracerebral hemorrhage.
       • CARDIAC
       • Chest pain
       • myocardial infarction
       • palpitation
       • dyspnea
       • pulmonary edema
       • jugular distension and gallops
       • NEPHROPATHY:
       • ACUTELY PROGRESSIVE HEMATURIA
       • PROTEINURIA
       • RENAL DYSFUNCTION
       • RETINOPATHY
       • PAPILLEDEMA
       • HEMORRHAGES
       • BLURRED EYES
   • TREATMENT OF EMERGENCY HTN:
     • IV[INTRA VENOUS] NITROPRUSSIDE [VASODILATATOR] AND LABETOLOL
     • NITROGLYCERIN IS PREFERABLE IN THOSE WHO HAVE MYOCARDIAL ISCHEMIA.
     • IV ENALAPRILAT
     • LESS USED: ESMOLOL . DIAZOXIDE, TRIMETHAPHAN
     • 
       

• Urgent hypertensive crisis (no end organ damage) should be initially handled as outpatient rather than in-patient treatment. If after 6 hrs BP fails to fall, patient should be hospitalized.
• The goal of treatment is to reduce BP by 20% of mean arterial pressure or to a diastolic BP less than 120 mm Hg. Drugs of choice include nifedipine (bite and swallow or sublingual) or clonidine (effective in rapidly lowering BP.)
• Special situations for patients with urgent hypertensive crisis include: history of CVA, MI, or elderly. These patients require more careful observation and generally modification of drug dosages.

• Approach to the Patient with a Hypertensive Crisis
• Joel Gordon, M.D., John Trapp, M.D., Dave Ringold, B.S.S.
  Peer Review Status: Internally Peer Reviewed
• Distinguish between hypertensive emergency (end organ damage is present) and hypertensive urgency (no end organ damage.)
• History: asses for the following
  • Pre-existing hypertension
  • Knowledge of pre-existing renal disease
  • History of cardiac (peripheral edema, orthopnea, shortness of breath) or neurologic symptoms (slurred speech, abnormal motor or sensory changes)
  • Medication history
    • Prescription and nonprescription
    • Illegal substance abuse: amphetamines, cocaine, LSD, other sympathetic CNS stimulants
    • Recent withdrawal from prescription antihypertensive drugs (particular attention should be given to clonidine and beta blockers)
• Physical Exam:
  • Supine and upright BP's: many patients with severe hypertension undergo pressure diuresis. This is because the kidney has seen increased pressure for an extended period of time and the body has undergone natriuresis (excretion of sodium) resulting in decreased volume. These patients may be orthostatic.
  • Left upper extremity and right upper extremity BP's: look for a difference in the two arms to asses for aortic disease.
  • Assess end organ involvement
    • Funduscopic exam: dilate eyes if needed. Funduscopy helps to distinguish between hypertensive urgency (look for good vessels, no spasm, no exudates) and emergency (look for papilla edema, and hard exudates)
    • Cardiovascular exam: examine the heart and aorta. Use ECG, point of maximum impulse, cardiomegaly, and presence of aortic insufficiency murmur, S₃ or S₄ to determine if there is myocardial damage. Check for an abdominal pulsatile mass to assess the possibility of abdominal aortic aneurysm which by itself would not cause urgent hypertension, but may be a result of advanced atherosclerosis.
    • Neurological exam: define any deficits.
• Laboratory tests should include:
  • Urinalysis with a dipstick testing for proteinuria and hematuria.
  • Peripheral blood smear: examine for the presence of schistocytes (suggests hemolysis).
  • Electrolyte panel (with BUN and creatinine) looking for azotemia or renal insufficiency.
  • Chest x-ray looking for cardiomegaly and/or pulmonary edema.
  • EKG looking for left ventricular hypertrophy, strain, ischemia-injury, or infarction.
  • CBC

Emergency Medicine: Hypertensive Emergencies

Myocardial Ischemia / Infarction

The goal of treatment is to reduce systemic vascular resistance and improve coronary perfusion. You don't want to decrease coronary perfusion and cause the conversion of ischemia to infarction. Likewise, you don't want to decrease coronary perfusion in an infarcted patient and cause further damage.

The target diastolic BP is 100 mm HG. This should be reached by using IV nitroglycerin. Nitroglycerin is the drug of choice because it is a good coronary vasodilator, and it also works on the capacitance vessels on the venous side which lowers BP. IV labetalol is a reasonable alternative choice. It has both alpha and beta blocking capacity. Avoid hydralazine and diazoxide because they increase myocardial oxygen consumption.

SECONDARY HYPERTENSION: Renal Artery stenosis is the most common cause of secondary HTN.

I/ RENAL ARTERY STENOSIS: CAUSES: ***ARTHROSCLEROSIS DISEASE IN THE ELDERLY. ***FIBROMUSCULAR DYSPLASIA IN YOUNG WOMEN. SIGNS: ***UPPER ABDOMINAL BRUIT RADIATING LATERALLY [50-70%] DIAG: ***BEST INITIAL SCREENING TESTS ARE THE ABDOMINAL ULTRASOUND ***CAPTOPRIL RENOGRAM.= THE BEST NON INVASIVE METHOD TO CONFIRMING THE DIAG OF RENAL ARTERY STENOSIS. ARTERIOGRAM = STILL THE BEST METHOD OF CONFIRMING THE DIAGNOSIS. ***INTRAVENOUS PYELOGRAPHY ***DUPLEX DOPPLER ULTRASONOGRAPHY ***SELECTIVE RENAL VEIN RENIN DETERMINATION. TREATMENT: BEST INITIAL TREATMENT IS PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY. SURGICAL RESECTION IF ANGIOPLASTY FAILED. ACE TREATMENT FOR THOSE WHOM ANGIOPLASTY AND SURGERY FAILED OR CONTRINDICATED.

II/PRIMARY HYPERALDOSTERONISM [CONN'S SYNDROME] MOST COMMONLY DUE TO A UNILATERAL ADENOMA BILATERAL HYPERPLASIA CANCER RARE. SIGNS: Hypertension in association with hypokaliemia hypokaliemia symptomes [muscular weakness and polyuria , polydipsia from nephrogenic diabetes insipidus. DIAG: ELEVATED ALDOSTERONE LEVELS IN URINE AND BLOOD. TRT: SURGICAL RESECTION POTASSIUM SPARING DIURETICS ===> SPIROLACTONE IN THOSE WITH HYPERPLASIA.

III/ PHEOCHROMOCYTOMA:

10% BILATERAL

10% MALIGNANT

10% EXTRA ADRENAL

SIGNS:

EPISODIC HYPERTENSION

HEADACHE

SWEATING

PALPITATION AND TACHYCARDIA

PALLOR, FLUSHING

DIAG:

BEST INITIAL TEST = URINARY VANILLYLMANDELIC ACID[ VMA ]

METANEPHINE

FREE URINARY CATECHOLAMINES

CT + MRI

TRT:

ALPHA ADRENERGIC BLOCKADE FOLLOWED BY SURGICAL REMOVAL

IV/CUSHING SYNDROME

V/ COARTATION OF THE AORTA

VI/ORAL CONTRACEPTIVE

VII/ACROMEGALY

VIII/ CONGENITAL ADRENAL ENZYME DEFICIENCIES

IX/CHRONIC RENAL DISEASE [GLOMERULONEPHRITIS-POLYCYSTIC DISEASE-DIABETIC NEPHROPATHY-CHRONIC PYELONEPHRITIS].