​Kembara Xtra - Medicine - Essential Hypertension

​Kembara Xtra - Medicine - Essential Hypertension 
Essential hypertension (HTN), commonly referred to as primary HTN and (inappropriately) as benign HTN, is HTN without a clearly defined cause. Although its significance as a risk factor for cardiovascular disease and other morbidities and deaths is well established, there is ongoing debate over the ideal cutoff points for diagnosis and treatment.

According to the Joint National Committee [JNC] and the International Society of Hypertension, HTN is defined as the following (all pressures in mm Hg):
Age 60: systolic blood pressure (SBP) >140 and/or diastolic blood pressure (DBP) >90 at 2 visits
Age 60: SBP 150 and/or DBP 90 at 2 visits
SBP 130 and/or DBP 80 is considered "stage 1 hypertension" by the American College of Cardiology (ACC)/American Heart Association (AHA), which should be treated with exercise and lifestyle changes. Medication should only be used when necessary for patients who are at "higher risk," which is defined as age 65, CKD, diabetes, or known cardiovascular disease (CVD).
Aspects of Geriatrics
Systolic HTN that is isolated is typical. Although the target SBP for elderly patients is greater than it is for younger people (150 mm Hg systolic), and drug side effects are more common, therapy has been demonstrated to be helpful and effective at preventing stroke, cardiovascular morbidity, and all-cause mortality (2)[A]. For SBP 160, the therapeutic advantage has been unequivocally proven in older individuals. Patients who are very old may be at an especially high risk for side effects from HTN medication. The use of thiazide diuretics has been associated with the strongest evidence of benefit.
Child Safety Considerations
As determined by repeated measurements, SBP or DBP 95th percentile. At the start of routine tests, at age 3, measure blood pressure. SBP or DBP pre-HTN between the 90th and 95th percentile

pregnant women's issues
Elevated blood pressure during pregnancy could be a sign of preeclampsia, pregnancy-induced hypertension, or chronic HTN.
ARBs and ACE inhibitors, which block the production of angiotensin II, are not recommended.
Treatment of severe HTN lowers maternal and fetal mortality (see item "Preeclampsia and Eclampsia (Toxemia of Pregnancy)"); suggested medications include labetalol, nifedipine, methyldopa, or hydralazine.


Prevalence of Epidemiology
32-46% of individuals in the United States have HTN, depending on the definition used; incidence and prevalence are higher in males.

More than 90% of instances of HTN lack a known etiology or pathophysiology. See "Hypertension, Secondary and Resistant" for information on differential diagnosis and causes of secondary HTN.
BP levels have a high familial genetic component. A family history of CVD should be taken into account.

Family history, obesity, alcohol usage, excessive sodium intake, stress, inactivity, tobacco use, insulin resistance, and obstructive sleep apnea (OSA) are risk factors.


Diagnosis Despite more strict guidelines being released by the ACC/AHA in 2017, many specialists believe that JNC 8 (1)'s recommendations should continue to take precedence.
The ACC/AHA recommendations have drawn criticism for a number of methodological issues. Millions more persons would be diagnosed with and treated for HTN under thresholds of 130/80 (as recommended by the ACC/AHA) as opposed to JNC 8, with uncertain benefits and perhaps unavoidable downsides.
Although JNC 8 serves as its foundation, the guidelines are applicable regardless of the particular guideline being implemented. We advise evaluating the entire CV risk and working together to make decisions.

Introducing History 

Except in rare circumstances or when associated cardiovascular problems manifest, HTN is asymptomatic. Higher BP might be a sign of a headache, which is frequently occipital in position, evident right after awakening.

clinical assessment 
Waist size and Body Mass Index (BMI). Check the blood pressure in both arms (the proper method is described below; it is crucial for precise diagnosis and therapy). Overdiagnosis is frequently caused by incorrect BP measurement.
Complete cardiac and pulse examination: Compare the volume and timing of the radial and femoral pulses to check for aortic coarctation (particularly in young people) and subclavian stenosis. Funduscopic examination for papilledema, AV compression, hemorrhages, exudates, and arteriolar constriction


Multiple Diagnoses 
Only take into account a workup for secondary HTN if a history, physical examination, or simple laboratory analysis points to a higher chance. Also take into account patients who display treatment resistance (see "Hypertension, Secondary and Resistant").
White coat HTN: increased BP in the office and normal BP outside the office


Laboratory Results 

 Avoid caffeine, exercise, and smoking for at least 30 minutes before taking your blood pressure. Patient should be sitting for at least five minutes with back supported, feet flat on floor, and arm supported at heart level. Use the proper cuff size. Use an automated device or progressively deflate the cuff. In order to avoid "rounding" results, average two or more measurements. Patient may be left unattended while in-office readings are taken with an automated or patient-activated cuff.
Statement (Grade A) from the United States Preventive Services Taskforce for 2021: Measurements of BP taken outside of a clinical context should be used to confirm an HTN diagnosis. Home blood pressure measurements (HBPM) help to reduce clinic measurement errors and have a stronger correlation with CV outcomes than office readings (3)[A]. It should be encouraged to test your blood pressure at home for monitoring and diagnosis. For HBPM results, a diagnostic threshold of 135/85 and a treatment goal of 135/85 should be employed.
The best method is ambulatory blood pressure monitoring (ABPM), however it is not frequently used in the United States.

Initial examinations (lab, imaging)

 Complete urinalysis (proteinuria, hematuria), potassium, calcium, creatinine, and uric acid; hemoglobin, hematocrit, and complete blood count
Panel of lipids. A1c or fasting blood sugar levels.
With a high BMI, take sleep apnea into consideration.
An ECG to check for potential left ventricular hypertrophy (LVH) or rhythm problems

Tests in the Future & Special Considerations

 ABPM or HBPM if episodic HTN, "white coat" HTN, or autonomic dysfunction is suspected. If autonomic dysfunction is detected, ambulatory measurement may be extremely beneficial.
Perform a CV risk analysis. In particular for elderly patients, the ACC/AHA risk calculator overestimates risk (by 50% or more). Patients having a history of CVD, diabetes mellitus, CKD, familial hypercholesterolemia, or familial premature coronary artery disease are not included in a definition of "low risk".

Management 
The procedure presented adheres to JNC 8 recommendations. Recent systematic reviews and meta-analyses of randomized trials do not support suggestions for average-risk populations to have lower-than-average objectives. Therapy risks must be considered against its potential rewards.
Treatment objectives:
- SBP 140 and DBP 90 for individuals 60 years of age (for HBPM 135/85)
- SBP 150 and DBP 90 (for HBPM 140/90) if under 60 years old.
- SBP 140 and DBP 90 for those 60 years old with diabetes or CKD (for HBPM 135/85)

However, 61 non-diabetic patients would need to be treated (NNT) for 3 years to a goal SBP of 120 mm Hg to prevent one major cardiovascular outcome and 90 such patients would need to be treated over 3 years to prevent one death (NNT 90). More aggressive treatment may be considered in high-risk patients meeting enrollment criteria for SPRINT because aggressive treatment improves outcomes.
● Even in secondary prevention, no definite conclusions on the relative merits of intensive vs ordinary therapy can yet be made.
Following a discussion of the predicted potential benefits and drawbacks, patients should help create their own treatment goals (shared decision-making).

 Suggest dietary changes, regular exercise, and cutting back on or quitting alcohol and tobacco use.
Pharmacologic therapy for low-risk patients with class I HTN (140 to 150/90 to 99) has not been proven to be beneficial, and side effects such syncope, kidney damage, and altered electrolytes have been reported. Personalize your choices.
It does not appear that treating patients with CKD or diabetes to blood pressure goals that are lower than normal, such as 140/90, will further reduce mortality or morbidity. Individualize target blood pressure depending on patient preferences and risk factors.
reducing very high SBP (for example, from 190 to 150, as opposed to the advantage of reducing from 150 to 136) results in the majority of treatment benefits. It is less likely to have clinically useful effects and more likely to have negative consequences to try to obtain tiny incremental dips in BP by adding a fourth or fifth medicine to reach a "target." Lower than average JNC-8 DBP objectives are not linked to a reduction in morbidity or death.

Medication 

Multiple medications at submaximal doses may help reach target blood pressure with fewer adverse effects. These advantages must be weighed against the difficulties in adherence brought on by more difficult dosing schedules and heavier tablet loads.
For a better 24-hour antihypertensive effect, administer nondiuretic drugs at bedtime to individuals on more than one medication.

Because individual reactions vary, sequential monotherapy attempts should be made with several classes.
Many people will need to take several different drugs.

 Choose from one of four drug groups for initial monotherapy: diuretics, thiazide diuretics, or calcium channel blockers (CCBs), which are chosen as first lines in the general black population.
Up until recent meta-analyses, -Blockers like atenolol have come highly recommended. Patients with ischemic heart disease, atrial fibrillation, CHF, migraine, and ST-segment elevation myocardial infarction (STEMI) history, however, may benefit with -blockers.

Patients with diabetes, proteinuria, atrial fibrillation, or heart failure with reduced ejection fraction (HFrEF) should take ACE inhibitors, but not pregnant women.
Adrenergic blockers are a second-line treatment after combination therapy with first-line medications, which may be advantageous for men with benign prostatic hypertrophy (BPH).

CCB has been shown to lower the risk of stroke and may be used in patients with isolated systolic HTN, atherosclerosis, angina, migraines, or asthma.


Initial Line
Thiazide diuretics could not work well if the creatinine clearance is below 30.
- Chlorthalidone: 12.5 to 25.0 mg/day (longer half-life and more potent than hydrochlorothiazide but causes more hyponatremia and hypokalemia); strongest evidence base for this medication - Hydrochlorothiazide: 12.5 to 50.0 mg/day; indapamide: 1.25 to 2.50 mg/day; metolazone: 2.5 to 5.0 mg daily is more effective in patients with impaired renal function than other thiazides, but outcomes studies lacking.
ARBs: losartan: 25 to 100 mg in 1 or 2 doses, has a unique but modest uricosuric effect; valsartan: 80 to 320 mg/day; irbesartan: 75 to 300 mg/day; candesartan: 4 to 32 mg/da Blockers (relatively) in diabetes, peripheral vascular disease, asthma, heart block, and heart block; probably shouldn't be taken by individuals with metabolic syndrome or insulin-dependent diabetes. Do not take diltiazem or verapamil if you have heart block or systolic dysfunction. Peripheral edema is brought on by amlodipine.


Next Line
Make sure the patient is adhering to the prescribed regimen before intensifying therapy. Most classes are usually mixable.
Select additional medications that have beneficial interactions, such as ACE inhibitors/ARBs and diuretics or vasodilators and -blockers. ARB and ACE inhibitor shouldn't be combined.
Spironolactone 25 to 100 mg/day or eplerenone 50 mg once or twice a day are particularly useful for treating medication-refractory HTN.
Patients with resting tachycardia may find that beta-blockers are helpful. With metoprolol succinate, once-daily administration is possible throughout a large dosage range (25 to 400 mg per day).
Labetalol and carvingilol work together to block.
Centrally acting 2-agonists: guanfacine 1 to 3 mg daily, clonidine 0.1 to 1.2 mg BID, or weekly patch 0.1 to 0.3 mg/day, and methyldopa 250 to 2,000 mg BID
Vasodilators: hydralazine: 10 to 25 mg QID; risk of tachycardia, therefore often taken with -blocker; also drug-induced systemic lupus erythematosus (SLE). -Adrenergic antagonists: prazosin 1 to 10 mg BID, terazosin 1 to 20 mg/day, or doxazosin 1 to 16 mg/day.
Due to its side effects, minoxidil is infrequently used, yet it may be more effective than other drugs in treating renal failure and HTN that is resistant.
With more severe renal impairment, metolazone and loop diuretics may be given, however there are no evidence on their effectiveness;
K+-sparing diuretics in individuals with hypokalemia while taking thiazides: amiloride 5 to 10 mg/day or triamterene 50 to 150 mg/day. Loop diuretics (for volume overload): furosemide 20 to 320 mg/day or bumetanide 0.5 to 2.0 mg/day.

Alternative therapies include relaxation exercises and biofeedback.

Patient Follow-Up Monitoring

Caution 

To check for drug-related problems, repeat electrolytes, BUN/creatinine, and thiazide diuretics 3 to 6 weeks after starting them. Patients should be reevaluated every 3-6 months until they are stable, then every 6-12 months. Self-monitoring of blood pressure is an option, as are other quality-of-life concerns including sexual function.
One of the main reasons for apparent drug failure is poor medication adherence.
Patients on diuretics, ACE inhibitors, and ARBs should have at least annual creatinine and potassium tests.

20% of patients will benefit from a low-sodium diet (6 g NaCl or 2.4 g Na per day). Keep daily alcohol intake to no more than 1 oz.


Complication

Heart and kidney failure, LVH, myocardial infarction, retinal hemorrhage, stroke, hypertensive heart disease, pharmacological side effects, and erectile dysfunction are all examples of conditions.