Disclaimer: new guidelines as of late 2017
Unlikely to be reflected on PANCE yet.
New BP Guidelines:
Elevated: 120-129/< 80
Stage 1: 130-139/80-89
Stage 2: 140+/90+
Hypertensive crisis: 180+/120+ with patients needing prompt changes in medication if there are no other indications of problems, or immediate hospitalization if there are signs of organ damage.
Medication for Stage 1 only if high ASCVD risk (same calculator used in prescribing statins)
Now Back to the PANCE:
Hypertension
Definition
Prehypertension 120-139/80-89
Stage 1 140-159/90-99
Stage 2 160+/100+
Urgency 180+/120+ & NO end organ damage
Emergency 180+/120+ & end organ damage (HERB)
ON 2 DIFFERENT READINGS
Symptoms
Primary Hypertension is typically asymptomatic
Hypertensive emergency
Encephalopathy
Intracranial hemorrhage
Nephropathy
Unstable angina/MI
Papilledema=malignant hypertension
Treatment (non-urgent/emergent)
Lifestyle Modifications 1stALWAYS (Including those with Pre-HTN)
DASH Diet
Lower Sodium
Exercise
Healthy weight
Smoking Cessation
Medication Therapy
Begin at 140/90 (this is also BP goal)
Unless
Over age 60
Normal Kidneys
No Diabetes
Then 150/90
Which med?
4 Main Classes to Choose From
ACE Inhibitor
Angiotensin converting Enzyme
-“pril”
Side Effects:
Cough
Hyperkalemia
Angioedema
Contraindications:
Renal artery stenosis
Pregnancy
ARB
Angiotensin II Receptor Blocker
-“sartan”
Side Effects:
Hyperkalemia
Angioedema
Contraindications:
Renal Artery Stenosis
Pregnancy
Calcium Channel Blocker
-“dipine”
More effective as vasodilators than verapamil and diltiazem
Side Effects:
Cardiac depression
Still have some cardiac effects
Thiazide Diuretic (HCTZ)
Side Effects:
Hypokalemia
Gout
Dyslipidemia
Contraindication:
Sulfa Allergy
How to choose?
If they have CKD or DM
ACE/ARB (Renal Protective)
African American
TZD or CCB
None of the above?
Then just pick one!
You can max out the dose before adding a 2ndor add a 2ndif goal isn’t met, doesn’t matter
NEVER MIX AN ACE AND AN ARB
Both inhibit the RAAS
Renin angiotensin aldosterone system
So at most, they’ll be on ACT
Other possible additions
Beta blockers “olols”
fib
Post MI
Stable Angina
Heart failure
Alpha blockers “zosin”
Pts with BPH
Pregnant? Use Methyldopa
Resistant to medication? Consider secondary hypertension
Renal artery stenosis
Coarctation of the Aorta (think Peds)
Sleep Apnea
Pheochromocytoma
Primary Hyperaldosteronism
Thyroid disease
Treatment
Urgency
Decrease by 25% over 24-48 hours
Rest in a quiet room