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