Guide to the

Management of Hypertension

February 2004

Provided by Pharmacy and Therapeutics Subcommittee Medication Use va!uation Subcommittee

This poc"et card is adapted from The Seventh #eport of the $oint %ationa! &ommittee on Prevention' (etection' va!uation' and Treatment of High )!ood Pressure *$%& +,.mportant .nformation #egarding $%& + Guide!ines/ Goa! b!ood pressure *)P, is 0140230 mm Hg or 0140250 mm Hg for patients 6ith diabetes or chronic "idney disease For patients over age 70' systo!ic b!ood pressure *S)P, is more important than diasto!ic b!ood pressure *()P, as a ris" factor for the deve!opment of coronary heart disease *&H(, Starting at 1172+7 mm Hg' &H( ris" doub!es 6ith each increment of 20210 mm Hg throughout the b!ood pressure range Patients 6ho are normotensive at age 77 have a 308 !ifetime ris" for deve!oping hypertension *HT%, Hea!th9promoting !ifesty!e modifications *See Tab!e 4, to prevent &H( shou!d be considered for those patients 6ho are considered prehypertensive *See Tab!e 1, Thiazide-type diuretics should be initial drug therapy for most patients, either a!one or combined 6ith other drug c!asses un!ess the patient has a compe!!ing indication for use of drug therapy from another drug c!ass Many patients 6i!! re:uire t6o or more drugs to achieve the goa! )P ;o6 doses of t6o drugs may be more effective and better to!erated than a high dose of one drug Patients 6ith mean )P< 147257 measured at home are genera!!y considered to be hypertensive-

Table 1

Blood Pressure Classification

BP Classification %orma! Prehypertension Stage 1 Hypertension Stage 2 Hypertension Table SBP mm Hg 0120 120 to 143 140 to 173 <1=0 DBP mm Hg 050 50 to 53 30 to 33 <100

Benefits of !o"ering Blood Pressure

#$erage Percent %eduction

Stro"e Myocardia! .nfarction Heart fai!ure

47 to 408 20 to 278 708

Table &

#lgorithm for Treatment of Hypertension

!ifestyle 'odifications (ffects on BP)

'odification #ppro*imate SBP %eduction >eight reduction 7 to 20 mm Hg210 "g 6eight !oss ?dopt (?SH eating p!an 5 to 14 mm Hg (ietary sodium reduction 2 to 5 mm Hg Physica! activity 4 to 3 mm Hg Moderation of a!coho! consumption 2 to 4 mm Hg )See Table 7 for more detailed information + Table , *Secondary causes account for 07 to 108 of a!! HT% cases,

;ifesty!e Modifications *See Tab!es 4 B +,

%ot at Goa! )P *0140230 mm Hg or 0140250 mm Hg for those 6ith diabetes or chronic "idney disease, .nitia! (rug &hoices *See Tab!es 5 B 3,

-dentifiable Causes of Hypertension

'ore Common S!eep apnea (rug9induced or re!ated causes &hronic "idney disease #enovascu!ar disease Table . !ess Common to %are Pheochromocytoma Primary a!dosteronism &oarctation of the aorta Thyroid or parathyroid disease
&hronic steroid use2&ushing@s syndrome
Hypertension 6ithout &ompe!!ing .ndication Hypertension 6ith &ompe!!ing .ndication *See Tab!e 5,

Causes of %esistant Hypertension

.mproper )P measurement Acess sodium inta"e .nade:uate diuretic therapy Acess a!coho! inta"e .dentifiab!e causes of HT% *See Tab!e 4, Medication issues/ .nade:uate doses (rug interactions *%S?.(s and ora! contraceptives, Use of over9the9counter drugs and herba! products

Stage 1 Hypertension/ S)P 140 to 173 mm Hg or ()P 30 to 33 mm Hg Thiazide diuretics are first choice

Stage Hypertension/ S)P <1=0 mm Hg or ()P <100 mm Hg Drug Combination 0Thiazide 1 #C(- or Beta Bloc2er3

(rugs for &ompe!!ing .ndications

%ot at Goa! )P

CptimiDe (osages or add ?dditiona! (rugs unti! Goa! )P is achieved

Table 4

Classification and 'anagement of Blood Pressure for #dults #ged 15 6ears or 7lder
%is2 8roup %orma! Prehypertension Stage 1 HT% Stage 2 HT% SBP mm Hg 0 120 120 to 143 140 to 173 < 1=0 DBP mm Hg 0 50 50 to 53 30 to 33 < 100 !ifestyle 'odification 0Table &3 ncourage Ees Ees Ees Drug Therapy %o &onsider for patients 6ith compe!!ing indications *See Tab!e 5, Ees Ees

Table 9

!ifestyle 'odification %ecommendations 'odification %ecommendation

>eight reduction (?SHG eating p!an Maintain norma! body 6eight *body mass indeA 15-7 to 24-3 Fg2m2, ?dopt a diet rich in ca!cium and potassium inc!uding fruits' vegetab!es' and !o6fat dairy products 6ith reduced content of saturated and tota! fat#educe dietary sodium inta"e to 0100 mmo! per day *2-4 g sodium or = g sodium ch!oride,#egu!ar aerobic physica! activity *e-g-' bris" 6a!"ing, at !east 40 minutes per day' most days of the 6ee"Men/ !imit to 02 drin"sGG per day >omen and !ighter 6eight persons/ !imit to 01 drin"GG per day-

(ietary sodium reduction ?erobic physica! activity Moderation of a!coho! consumption

G(ietary ?pproaches to Stop Hypertension GG1 drin" H I oD or 17 m; ethano! *e-g-' 12 oD beer' 7 oD 6ine' 1-7 oD 509proof 6his"ey,-

Table 5+ Clinical Considerations for Prescribing #ntihypertensi$e Therapy

Drug Class Dose %ange Thiazide Diuretics Hydroch!orothiaDide *H&TK, 12-7 to 27 mg dai!y &h!ortha!idone 12-7 to 27 mg dai!y H&TK2Triamterene 2724+-7 mg dai!y Beta-Blockers (cardioselective) ?teno!o! 27 to 100 mg dai!y Metopro!o! 27 to 100 mg ).( Beta-Blockers (noncardioselective) ;abeta!o! *a!pha B beta9b!oc"er, 100 to 400 mg ).( Pindo!o! 10 to 40 mg ).( %ado!o! 40 to 120 mg dai!y Proprano!o! *immed- re!ease, 40 to 1=0 mg ).( to L.( Proprano!o! ;? *!ong acting, =0 to 1=0 mg dai!y Angiotensin Converting nz!me "nhibitors (AC ") ;isinopri! 10 to 40 mg dai!y &aptopri! 27 to 100 mg ).( to T.( na!apri! 2-7 to 40 mg dai!y or divided ).( Calcium Channel Blockers (CCB) - dih!dro#!ridine Fe!odipine 2-7 to 20 mg dai!y ?m!odipine 2-7 to 10 mg dai!y %ifedipine eAtended re!ease 40 to 150 mg dai!y CCB $ non-dih!dro#!ridine Merapami! eAtended re!ease 120 to 240 mg dai!y to ).( (i!tiaDem &( 120 to 450 mg dai!y Angiotensin %ece#tor Blockers (A%B) .rbesartan 170 to 400 mg dai!y ;osartan 27 to 100 mg dai!y :;C <-- Compelling -ndications and=or Considerations) (ecrease &H( in patients 6ith diabetes- ?!so consider for patients 6ith recurrent stro"e' osteoporosisCaution in gout' hyponatremia?cute coronary syndrome *?&S,' heart fai!ure *HF,' post myocardia! infarction *M.,' &H(' atria! fibri!!ation' tachyarrhythmia' migraine' essentia! tremor' preoperative hypertension' periphera! vascu!ar diseaseCaution in asthma2&CP(' depression' second or third degree heart b!oc" *contraindication,' and !iver disease *!abeta!o!,?&S' a!so to decrease &H( in patients 6ith diabetes' HF' post M.' high &H( ris"' "idney disease' recurrent stro"e- Caution in pregnancy *contraindication,' renovascu!ar disease' and history of angioedemaMay decrease &H( in patients 6ith diabetes and high &H( ris"- &onsider in patients 6ith angina pectoris' atria! fibri!!ation' cyc!osporine9induced hypertension' #aynaud@sCaution in second or third degree heart b!oc"%outine Drug %elated !aboratory 'onitoring )ase!ine/ %aJ' FJ' )U%' S&r- Fo!!o69up soon after initiation' after dose changes' or changes in patient status- &hec" periodica!!y *e-g-' annua!!y, if patient status is stab!e%o routine drug9re!ated !aboratory monitoring recommended-

)ase!ine FJ' S&r- Fo!!o69up soon after initiation' after dose changes' or changes in patient status- &hec" periodica!!y *e-g-' annua!!y, if patient status is stab!e%o routine drug9re!ated !aboratory monitoring recommended-

(iabetes' HF' "idney diseaseCaution in pregnancy *contraindication,' renovascu!ar disease-

Al#ha-Blockers )enign Prostatic Hyperp!asia *)PH,Caution/ not to be used as first9!ine or monotherapy (oAaDosin 1 to 1= mg dai!y for HT% due to possib!e increased ris" of HFTeraDosin 1 to 10 mg dai!y to ).( &iscellaneous &ontact pharmacy for information on these therapies and methy!dopa' minoAidi!' B guanfacine&!onidine tab!et 0-1 to 0-5 mg ).( to T.( &!onidine patch 0-1 to 0-4 mg2dayN 6ee"!y Hydra!aDine 27 to 100 mg ).( to L.( G%ot an inc!usive !ist' refer to prescribing information for a more comp!ete !ist

)ase!ine FJ' S&r- Fo!!o69up soon after initiation' after dose changes' or changes in patient status- &hec" periodica!!y *e-g-' annua!!y, if patient is stab!e%o routine drug9re!ated !aboratory monitoring recommended%o routine drug9re!ated !aboratory monitoring recommended-