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Subsections
Hypertension: General Information

Hypertension: General Information

Background

  1. Definitions
    • Normal: SBP < 120 and DBP < 80 mm Hg
    • Elevated: SBP 120-129 and DBP < 80 mmHg
    • Hypertension
      • Stage 1: SBP 130-139 or DBP 80-89 mmHg
      • Stage 2: SBP ≥ 140 or DBP ≥ 90 mmHg
    • Isolated systolic hypertension: ≥130 mmHg systolic and < 80 mmHg diastolic
    • Isolated diastolic hypertension: < 130 mmHg systolic and ≥ 80 mmHg diastolic
    • Mixed systolic/diastolic hypertension: ≥ 130 mmHg systolic and ≥ 80 mmHg diastolic
    • Hypertensive Crisis (SBP ≥ 180 mmHg or DBP ≥ 120 mmHg)
    • If SBP and DBP in 2 categories: designate to the higher BP category
      • Based on average of ≥ 2 careful readings obtained on ≥ 2 occasions
    • White coat hypertension
      • Blood pressure consistently elevated by office readings but does not meet diagnostic criteria for HTN based on out-of-office readings
    • Masked hypertension
      • Blood pressure consistently elevated by out-of-office measurements but does not meet criteria for HTN based upon office readings
  2. Synopsis
    • Highly prevalent worldwide, carrying significant risk for cardiovascular, renal, and neurologic morbidity/mortality
      • Prevalence increases with advancing age
      • Affects > 50% of those 60-69 yo and 75% of those > 70 yo

Pathophysiology

  1. Mechanism
    • Multi-factorial causes for essential (primary) HTN
      • Genetic predisposition, immunological, health condition/situation of patient
      • Dietary
      • Occupational/psychosocial, environmental
    • However, no exact, specific mechanism has been discovered
    • HTN can be a progressive disease
  2. Etiology/Risk Factors
    • 90% risk of developing HTN in lifetime (even if normotensive at 55 yo)
    • Two types based on cause:
      • Essential (Primary) HTN (~95%)
      • Secondary HTN
        • Renal artery stenosis, chronic kidney disease, PCKD, nephritic syndromes
        • Coarctation of aorta, sleep apnea
        • Cushing's, pheochromocytoma, thyroid or parathyroid disease
        • Pregnancy (eclampsia)
        • Drugs (e.g., stimulants)
    • Modifiable Risk Factors for CVD Risk
      • Currently smoking/second-hand smoking (cigarettes)
      • DM
      • Dyslipidemia/hypercholesterolemia
      • Overweight/obesity
      • Physical inactivity/low fitness
      • Unhealthy diet
    • Relatively Fixed Risk Factors for CVD Risk
      • CKD
      • Family history
      • Increased age
      • Low socioeconomic/educational status
      • Male
      • Obstructive sleep apnea
      • Psychosocial stress
  3. Epidemiology
    • Incidence/Prevalence
      • 45% or 108 million US adults have hypertension (AHA)
        • Most do not have it under control
      • NHANES (2017-2018)
        • By gender
          • Males: 51%
          • Females: 39.7%
        • By age
          • 18-39 yo: 22.4%
          • 40-59 yo: 54.5%
          • > 60 yo: 74.5%
        • By race
          • Non-Hispanic blacks: 57.1%
          • Hispanics: 43.7%
          • Non-Hispanic whites: 43.6%
      • Among persons with high blood pressure:
        • 81.5% are aware they have it
        • 74.9% are under current treatment
        • 52.5% have it controlled
        • 47.5% do not have it controlled
      • Estimates based on 130/80 mmHg cut-off point Dx of HTN, or currently taking antihypertensive medications
    • Morbidity/Mortality
      • Increased risks of CVA, CVD, MI, renal disease
      • In USA: accounts for more CVD deaths than any other modifiable CVD risk factor
        • Second only to cigarette smoking as preventable cause of death for any reason
        • Second leading cause of ESRD (behind DM)

Diagnostics

  1. History/Symptoms
    • Rule out Whitecoat HTN
    • Previous episodes of elevated BP, pain level, anxiety
    • Tobacco use, drugs, alcohol
    • Current medications and compliance
    • Cholesterol status
    • Obesity, DM, family history, lifestyle situation (diet, physical inactivity)
    • Any history that suggests acute end-organ damage caused by elevated BP, or causes of secondary hypertension
    • History of microalbuminuria, eGFR < 60 mL/min
    • Headaches, palpitations, any other history that may indicate secondary HTN
      • Chest pain, dyspnea, diaphoresis, confusion, weight loss
  2. Physical Exam/Signs
    • Criteria for secondary HTN screening
      • Drug-resistant/induced hypertension
      • Abrupt onset of HTN
      • Onset of HTN at < 30 years old
      • Exacerbation of previously controlled HTN
      • Disproportionate target organ damage for degree of HTN
      • Accelerated/malignant HTN
      • Onset of diastolic HTN in older adults (age ≥ 65 years old)
      • Unprovoked or excessive hypokalemia
    • Blood Pressure Measurement Protocol [COR:I; LOE:C-EO]
      • Only devices with validated measurement protocol should be used
        • Growing evidence base supporting use of automated office BP measurements
        • Out-of-office measurements can be useful
          • Ambulatory blood pressure monitoring is generally accepted as best out-of-office measurement method
          • Home BP monitoring is more practical in clinical practice
          • General agreement that office BPs > ABPM/HBPM BPs (especially at higher BPs)
      • Step 1: Prepare patient
        • Allow patient to relax for > 5 min
          • Patient should avoid caffeine, exercise, smoking for ≥ 30 min before measurement
        • Empty bladder, no talking before or during measurement
        • Remove any clothing/covering the entire area of the cuff
        • Patient in sitting position, back supported on chair, feet flat on floor
        • Sitting or lying on exam table does not fulfill these criteria
      • Step 2: Proper technique
        • Use validated/calibrated BP measurement devices
        • Support arm of patient (i.e., rest it on a desk)
        • Use correct cuff size, position cuff properly (i.e., upper arm, level of atrium)
        • Learn/practice proper technique with stethoscope
      • Step 3: Take proper measurements
        • First visit, measure BP in both arms (legs if possible coarctation)
          • Use higher reading arm for subsequent measures
          • Repeat measurements 1-2 min apart
        • For auscultatory determinations
          • Use a palpated estimate of radial pulse obliteration pressure to estimate SBP
            • Inflate cuff 20-30 mmHg above this level for an auscultatory determination of the BP level
        • For auscultatory readings
          • Deflate cuff pressure 2 mmHg per second, listen for Korotkoff sounds
      • Step 4: Document findings
        • Can use nearest even number
        • Note time of recent BP medication prior to measurements
      • Step 5: Average findings
        • Average of ≥ 2 readings obtained ≥ 2 occasions
      • Step 6: Provide patient with BP findings
        • Both verbally and in writing
    • Search for signs of end-organ damage
      • Heart rate, mental status (anxiety, intoxication, cerebral edema)
      • Palpate pulses, auscultate bruits, masses, aneurysms, thyroid, edema
      • Fundal exam (retinal hemorrhage, papilledema)
  3. Labs/Tests
    • CBC +Diff, BUN/Cr, electrolytes, CMP
    • Fasting blood glucose
    • Lipid profile
    • Serum Creatinine with eGFR
    • TSH measurement
    • Urinalysis
    • Uric acid
    • Urinary albumin to creatinine ratio
  4. Imaging
    • Echocardiogram
    • Imaging for signs and visualization of end-organ damage
      • Abdominal, head CT/MRI: hemorrhage, aneurysms, edema, mass
      • Chest CT: PE, dissection, pulmonary edema, LVH, mass
      • Abdominal CT: PCKD, aneurysms, pheochromocytoma, mass
  5. Other Tests/Criteria
    • EKG
      • Look for signs of ischemia, MI, LVH
    • 2017 Classification of Recommendation and Level of Evidence
    • 2017 ACC/AHA Guidelines
      • If SBP and DBP in 2 categories: designate to the higher BP category
        • Based on average of ≥ 2 careful readings obtained on ≥ 2 occasions
      • Elevated: SBP 120-129 and DBP < 80 mmHg
      • Hypertension
        • Stage 1: SBP 130-139 or DBP 80-89 mmHg
        • Stage 2: SBP ≥ 140 or DBP ≥ 90 mmHg

Treatment

  1. Initial/Prep/Goals
    • Goals for the EM physician: prevent long-term sequelae, avoid harm
      • ED BP measurements have been shown to be unreliable
      • Focus to make sure patient is not having a hypertensive emergency
      • Acute lowering of BP in patients with truly asymptomatic markedly elevated BP (> 160/100) is not recommended and could be harmful
      • Patients with asymptomatic marked BP elevations (hypertensive urgency) should receive close outpatient follow-up
      • In certain populations (e.g., poor access to care) EM physicians may decide to
        • Initiate treatment of asymptomatic markedly elevated BP in the ED
        • Refer for outpatient follow-up with the goal of slowly lowering BP
      • Lifestyle modification can prevent and help manage HTN
        • Weight reduction, DASH diet, limit alcohol, increase physical activity (i.e., exercise), salt restrictions
      • Target BP goals
        • If confirmed HTN with CVD and 10-yr ASCVD risk of ≥ 10%: < 130/80 mmHg is recommended
        • If confirmed HTN without risk(s): < 130/80 mmHg is reasonable
    • Recommendations for Management (Initial blood pressure elevation)
      • Adults with elevated BP/stage 1 HTN with estimated 10-year ASCVD risk < 10%
        • Non-pharmacological therapy
        • Repeat BP eval within 3-6 months
      • Adults with stage 1 HTN with estimated 10-year ASCVD risk ≥ 10%
        • Initially with non-pharmacological and drug therapy
        • Repeat BP eval in 1 month
      • Adults with stage 2 HTN
        • Refer to primary care provider within 1 month of the initial diagnosis
        • Non-pharmacological and drug therapy (with 2 agents of different classes)
        • Repeat BP eval in 1 month
      • For adults with very high average BP (e.g., SBP ≥ 180 mmHg or DBP ≥ 110 mmHg)
        • Evaluation followed by prompt antihypertensive drug treatment
      • For adults with a normal BP
        • Annual evaluation is reasonable
    • Indications for pharmacological therapy
      • If no specific indications for a specific drug therapy (i.e., comorbidities), 2017 ACC/AHA guidelines recommend initial therapy from the following 4 classes of medications
      • Stage 1 HTN with clinical atherosclerotic CVD or ≥ 10% 10-yr CVD risk
      • Stage 2 HTN
      • Consider 2 antihypertensive agents of different classes
        • Many patients started on a single agent will subsequently require ≥ 2 drugs from different pharmacological classes to reach BP goals
        • Concomitant use of ACE inhibitor, ARB, and/or renin inhibitor is potentially harmful/not recommended
        • Drug combinations with similar mechanisms of action or clinical effects should be avoided
    • Choosing Monotherapy vs Combination Drug therapy
      • Recommended in adults with stage 2 HTN and average BP > 20/10 mmHg above BP target
        • Initiate antihypertensive drug therapy with 2 first-line agents of different classes
          • Either as separate agents or in a fixed-dose combination
      • Reasonable in adults with stage 1 HTN
        • Initiate antihypertensive drug therapy with a single antihypertensive drug
        • Dosage titration and sequential addition of other agents to achieve BP target
        • BP goal < 130/80 mmHg
  2. Medical/Pharmaceutical
    • Primary Agents (Guideline-based dosing)
      • Thiazide Diuretics
        • Chlorthalidone: 12.5-25 mg PO once daily
          • Preferred due to prolonged half-life and proven trial reduction of CVD
        • HCTZ: 25-50 mg PO once daily
        • Indapamide: 1.25-2.5 mg PO once daily
        • Metolazone: 2.5-10 mg PO once daily
        • Notes
          • Monitor for hyponatremia and hypokalemia, uric acid and calcium levels
          • Use with caution if history of acute gout
            • Unless patient is on uric acid-lowering therapy
          • In black adults with HTN, including those with DM, but without HF/CKD [COR:I;LOE:B-R]
            • Initial antihypertensive treatment should include a thiazide-type diuretic or CCB
          • In most adults with HTN (especially in black adults with HTN) [COR:I;LOE:C-LD]
            • ≥ 2 antihypertensive medications recommended to achieve BP target < 130/80 mmHg
      • ACE Inhibitors
        • Benazepril: 10-40 mg PO qD-BID
        • Captopril: 12.5-150 mg PO BID-TID (max 450 mg/day)
        • Enalapril: 5-40 mg PO qD-BID
        • Fosinopril: 10-40 mg PO once daily
        • Lisinopril: 10-40 mg PO once daily
        • Moexipril: 7.5-30 mg PO qD-BID
        • Perindopril: 4-16 mg PO once daily
        • Quinapril: 10-80 mg PO qD-BID
        • Ramipril: 2.5-10 mg PO qD-BID
        • Trandolapril: 1-4 mg PO once daily
        • Notes
          • Do not use in combination with ARBs or direct renin inhibitor
          • Increased risk of hyperkalemia (especially in CKD, if on K+ supplements or K+-sparing drugs)
          • Risk of acute renal failure in severe bilateral renal artery stenosis
          • Do not use if history of angioedema with ACE inhibitors
          • Avoid in pregnancy
      • ARBs
        • Azilsartan: 40-80 mg PO once daily
        • Candesartan: 8-32 mg PO once daily
        • Eprosartan: 600-800 mg PO qD-BID
        • Irbesartan: 150-300 mg PO once daily
        • Losartan: 50-100 mg PO qD-BID
        • Olmesartan: 20-40 mg PO once daily
        • Telmisartan: 20-80 mg PO once daily
        • Valsartan: 80-320 mg PO once daily
        • Notes
          • Do not use in combination with ACE inhibitors or direct renin inhibitor
          • Increased risk of hyperkalemia in CKD, if on K+ supplements or K+-sparing drugs
          • Risk of acute renal failure in severe bilateral renal artery stenosis
          • Do not use if history of angioedema with ARBs
            • If history of angioedema with an ACE inhibitor can receive ARB beginning 6 weeks after ACE inhibitor is discontinued
          • Avoid in pregnancy
      • CCBs
        • Non-hydropyridines
          • Diltiazem: 180-360 mg PO BID (SR); 120-480 mg PO once daily (ER)
          • Verapamil: 40-80 mg PO TID (IR); 120-480 mg PO qD-BID (SR); 100-480 mg PO qPM (delayed ER)
          • Notes
            • Avoid routine use with beta blockers (increased risk of bradycardia and heart block)
            • Do not use in patients with HFrEF
            • Drug interactions: diltiazem and verapamil (CYP3A4 major substrate and moderate inhibitor)
        • Dihydropyridines
          • Amlodipine: 2.5-10 mg PO once daily
            • May be used in HFrEF patients
          • Clevidipine: 1-2 mg/hr IV
            • Ultra fast-acting agent
          • Felodipine: 5-10 mg PO once daily
            • May be used in HFrEF patients
          • Isradipine: 5-10 mg PO BID
          • Nicardipine: 5-20 mg PO once daily
          • Nifedipine: 60-120 mg PO once daily
          • Nisoldipine: 30-90 mg PO once daily
          • Notes
            • Avoid use in patients with HFrEF (except amlodipine and felodipine)
            • Associated with dose-related pedal edema (women > men)
    • Secondary Agents (Guideline-based dosing)
      • Loop Diuretics (Preferred in symptomatic heart failure)
        • Furosemide: 20-80 mg PO BID
        • Bumetanide: 0.5-4 mg PO BID
        • Torsemide: 5-10 mg PO once daily
        • Notes
          • Preferred diuretics in symptomatic heart failure
          • Preferred over thiazides in moderate-severe CKD (e.g., GFR < 30 mL/min)
      • Potassium-sparing Diuretics
        • Amiloride: 5-10 mg PO qD-BID
        • Triamterene: 50-100 mg PO qD-BID
        • Notes
          • These are monotherapy agents; minimally effective antihypertensive agents
          • Consider combo therapy of potassium-sparing diuretic with thiazide in hypokalemia on thiazide monotherapy
          • Avoid in significant CKD (e.g., GFR < 45 mL/min)
      • Aldosterone-antagonist Diuretics (Preferred in primary aldosteronism, resistant HTN)
        • Spironolactone: 25-100 mg PO once daily
        • Eplerenone: 50-100 mg PO once daily
        • Notes
          • These are preferred agents in primary aldosteronism and resistant HTN
          • Spironolactone is associated with greater risk of gynecomastia and impotence as compared with eplerenone
          • Common add-on therapy in resistant HTN
          • Avoid use with K+ supplements, other K+-sparing diuretics, or significant renal dysfunction
          • Eplerenone often requires twice-daily dosing for adequate BP lowering
      • Beta blockers (Avoid abrupt cessation)
        • Preferred in bronchospastic airway disease requiring a beta blocker
          • Atenolol: 25-100 mg PO once daily
          • Betaxolol: 5-20 mg PO once daily
          • Preferred in HFrEF
            • Bisoprolol: 2.5-10 mg PO once daily
            • Metoprolol: 100-400 mg PO BID (Tartrate); 50-200 mg PO once daily (Succinate)
          • Notes
            • Not recommended as first-line agents unless IHD or HF
        • Avoid if reactive airway disease
          • Nadolol: 40-120 mg PO once daily
          • Propranolol: 160-480 mg PO BID (IR); 80-320 mg PO once daily (LA)
        • Nebivolol: 5-40 mg PO once daily
          • Induces nitric oxide-induced vasodilation
        • Combined alpha-beta receptor blocker
          • Labetalol: 200-800 mg PO BID
          • Carvedilol: 12.5-50 mg PO BID; 20-80 mg PO once daily (Carvedilol phosphate)
            • Preferred if HFrEF
        • Generally avoid
          • Acebutolol
          • Carteolol
          • Penbutolol
          • Pindolol
      • Direct Renin Inhibitor
        • Aliskiren: 150-300 mg PO once daily
        • Notes
          • Do not use in combination with ACE inhibitors or ARBs
          • Very long acting
          • Increased risk of hyperkalemia in CKD or if on K+ supplements or K+-sparing drugs
          • May cause acute renal failure in severe bilateral renal artery stenosis
          • Avoid in pregnancy
      • Alpha blockers
        • Doxazosin: 1-8 mg PO once daily
        • Prazosin: 2-20 mg PO once BID-TID
        • Terazosin: 1-20 mg PO qD-BID
        • Notes
          • Associated with orthostatic hypotension (especially in older adults)
          • Consider as second-line agent in concomitant BPH
      • Direct Vasodilators
        • Hydralazine: 250 mg PO BID or 200 mg PO TID
        • Minoxidil: 5-100 mg PO qD-TID
        • Notes
          • Associated with sodium/water retention and reflex tachycardia
          • Use with a diuretic and beta blocker
          • Hydralazine is associated with drug-induced lupus-like syndrome at higher doses
          • Minoxidil is associated with hirsutism; requires a loop diuretic
          • Minoxidil can induce pericardial effusion
    • Last-line Agents
      • Clonidine: 0.1-0.8 mg PO BID; 0.1-0.3 mg patch weekly
        • Avoid abrupt cessation of clonidine
        • May induce hypertensive crisis
        • Must be tapered to avoid rebound HTN
      • Methyldopa: 250-1000 mg PO BID
      • Guanfacine: 0.5-2 mg PO once daily
      • Notes
        • Significant CNS adverse effects (especially in older adults)
    • Special Considerations (comorbidities)
      • Stable Ischemic Heart Disease (SIHD)
        • In adults with SIHD and HTN, recommend BP target < 130/80 mmHg
        • Adults with SIHD and HTN (BP ≥ 130/80 mmHg), treat with medications if indicated (e.g., previous MI, stable angina)
          • First-line therapy: guideline-directed management and therapy (GDMT) beta blockers, ACE inhibitors, or ARBs, etc.
          • Addition of other drugs as needed to further control HTN (e.g., dihydropyridine CCBs, thiazide diuretics, mineralocorticoid receptor antagonists)
        • In adults with SIHD with angina and persistent uncontrolled HTN, recommend add dihydropyridine CCBs to GDMT beta blockers
        • In adults with previous MI or ACS, it is reasonable to continue GDMT beta blockers > 3 years as long-term therapy for HTN
        • May consider beta blockers and/or CCBs to control HTN in CAD (without HFrEF) who had an MI > 3 years prior and have angina
      • Heart Failure
        • In adults at increased risk of HF, the optimal BP in those with HTN should be < 130/80 mmHg
        • According to current ACC/AHA guidelines (i.e., ACE-I, B-blockers, if Sx add loop diuretic, spironolactone)
        • Heart Failure with reduced Ejection Fraction (HFrEF)
          • Adults with HFrEF and HTN: prescribe GDMT titrated to attain a BP < 130/80 mmHg
          • Nondihydropyridine CCBs not recommended for HTN with HFrEF
        • Heart Failure with preserved Ejection Fraction (HFpEF)
          • In adults with HFpEF and symptoms of volume overload: diuretics
          • Adults with HFpEF and persistent HTN after management of volume overload: ACE inhibitors or ARBs and beta blockers titrated to attain SBP < 130 mmHg
      • Diabetes Mellitus
        • Adults with DM and HTN: start antihypertensive drug treatment if BP ≥ 130/80 mmHg with goal BP < 130/80 mmHg
          • All first-line classes of antihypertensive are useful and effective (i.e., diuretics, ACE inhibitors, ARBs, and CCBs)
        • Adults with DM and HTN with albuminuria: consider ACE inhibitors or ARBs
      • Chronic Kidney Disease (View image)
        • Adults with HTN and CKD: BP goal < 130/80 mmHg
        • Adults with HTN and CKD: reasonable indications for treatment with ACE inhibitor to slow kidney disease progression
          • ≥ Stage 3
          • Stage 1 or 2 with albuminuria ≥ 300 mg/day, or ≥ 300 mg/g albumin-to-creatinine ratio or equivalent in first morning void
        • Adults with HTN and CKD: reasonable indications for treatment with an ARB if ACE inhibitor is not tolerated
          • ≥ Stage 3
          • Stage 1 or 2 with albuminuria ≥ 300 mg/day, or ≥ 300 mg/g albumin-to-creatinine ratio or equivalent in first morning void
        • ARBs/ACE-I plus others as needed (usually need 3+)
          • Increase of Cr of up to 35% acceptable if K+ normal
      • Cerebrovascular Disease
        • Acute ICH
          • Adults with ICH with SBP > 220 mmHg
            • Reasonable to use continuous IV drug infusion
            • Close BP monitoring
          • Adults with ICH presenting SBP between 150-220 mmHg within 6 hrs of acute event
            • Immediate lowering of SBP to < 140 mmHg can be potentially harmful
        • Acute Ischemic Stroke
          • Adults with acute ischemic stroke and elevated BP who are eligible for treatment with IV tPA
            • BP slowly lowered to < 185/110 mmHg before thrombolytic therapy is initiated
          • Adults with acute ischemic stroke
            • BP should be < 185/110 mmHg before administration of IV tPA
            • Should be maintained < 180/105 mmHg for ≥ 24 hrs after initiating drug therapy
          • Starting/restarting antihypertensive therapy during hospitalization is safe and reasonable
            • If BP > 140/90 mmHg who are neurologically stable, and
            • No contraindications
            • Improves long-term BP control
          • Benefit of initiating/reinitiating treatment of HTN within first 48-72 hrs is uncertain if
            • BP ≥ 220/120 mmHg who did not receive IV alteplase or endovascular treatment, and
            • Have no comorbid conditions requiring acute antihypertensive treatment
            • It might be reasonable to lower BP by 15% during first 24 hrs after onset of stroke
          • Initiating/reinitiating treatment of HTN within first 48-72 hrs after an acute ischemic stroke is not effective to prevent death or dependency if
            • BP < 220/120 mmHg who did not receive IV thrombolysis/endovascular treatment, and
            • No comorbid condition requiring acute antihypertensive treatment
        • Secondary Stroke Prevention
          • Adults with previously treated HTN who experience stroke/TIA
            • Restart on antihypertensive treatment after first few days of event
              • Reduces risk of recurrent stroke/other vascular events
          • Adults who experience stroke/TIA
            • Treatment with a thiazide diuretic, ACE inhibitor, or ARB, or
            • Combination treatment consisting of a thiazide diuretic plus ACE inhibitor
          • Adults not previously treated for HTN who experience stroke/TIA and BP ≥ 140/90 mmHg
            • Prescribe antihypertensive treatment within a few days after event
              • Reduces risk of recurrent stroke/other vascular events
          • Adults who experience stroke/TIA: select specific drugs based on comorbidities and agent pharmacological class
          • Adults who experience stroke/TIA: BP goal < 130/80 mmHg may be reasonable
          • Adults with lacunar stroke: target SBP goal < 130 mmHg may be reasonable
          • Adults previously untreated for HTN with ischemic stroke/TIA and SBP < 140 mmHg/DBP < 90 mmHg [COR:IIa; LOE:C-LD]
            • Usefulness of antihypertensive treatment not well established
      • Peripheral Arterial Disease
      • Metabolic Syndrome
        • Linked to several other disorders, including:
          • Nonalcoholic steatohepatitis
          • Polycystic ovary syndrome
          • Certain cancers
          • CKD
          • Alzheimer's disease
          • Cushing's syndrome
          • Lipodystrophy
          • Hyperalimentation
        • Foundation of treatment of metabolic syndrome
          • Lifestyle modification
            • Improving insulin sensitivity via dietary modification, weight reduction, exercise
        • Antihypertensive drug therapy for HTN in metabolic syndrome not clearly defined
        • Caution
          • Thiazide diuretics due to:
            • Increased insulin resistance
            • Dyslipidemia
            • Hyperuricemia
            • Accelerated conversion to overt DM
            • No data available demonstrating deterioration in cardiovascular or renal outcomes
          • Newer vasodilating beta blockers have shown neutral or favorable effects compared with traditional beta blockers
            • For example: labetalol, carvedilol, nebivolol
      • Atrial Fibrillation
        • Treatment of HTN with ARB can be useful for prevention of recurrence of AF
          • Especially if LVH or LV dysfunction
          • No available trials compare ACE inhibitors with other drugs or any RAS-blocking agents with diuretics
      • Valvular Heart Disease
        • Adults with asymptomatic aortic stenosis
          • Treated HTN with pharmacotherapy: start at low dose, titrate upward as needed
        • If chronic aortic insufficiency
          • Reasonable to treat systolic HTN with agents that do not slow heart rate (i.e., avoid beta blockers)
      • Aortic Disease
        • If HTN in thoracic aortic disease: beta blockers are recommended as preferred antihypertensive agents
    • Pregnancy and HTN
      • Pregnant, or are planning to become pregnant
        • Transition to methyldopa, nifedipine, and/or labetalol during pregnancy
      • HTN who become pregnant: avoid ACE inhibitors, ARBs, or direct renin inhibitors
    • Resistant HTN
      • Diagnosis of resistant HTN
        • Does not achieve control with 3 antihypertensives with complementary mechanisms of action (a diuretic should be 1 component), or
        • Requires ≥ 4 medications to achieve BP control
      • Algorithm
        • Confirm resistance
          • Exclude pseudoresistance
        • Identify/reverse contributing lifestyle factors
          • Discontinue/minimize interfering substances
        • Screen for secondary causes of HTN
          • Primary aldosteronism: elevated aldosterone/renin ratio
          • CKD: eGFR < 60 mL/min/1.73 m2
          • Renal artery stenosis: young female, known atherosclerotic disease, worsening kidney function
          • Pheochromocytoma: episodic hypertension, palpitations, diaphoresis, headache
          • Obstructive sleep apnea: snoring, witnessed apnea, excessive daytime sleepiness
        • Pharmacological treatment
          • Maximize diuretic therapy
          • Add mineralocorticoid receptor antagonist
          • Add agents with different mechanism of actions
          • Loop diuretics if CKD or using vasodilators
        • Refer to specialist

Disposition

  1. Admission criteria
    • End organ damage, poor follow up or unreliable
  2. Discharge/Follow-up instructions
    • Monitor BP response (monthly) until stable then every 3-6 months
    • Monitor K/Cr 1-2 times/yr
    • Monitor other risk factors, comorbidities
    • Reassessment includes
      • BP measurement
      • Detection of orthostatic hypotension in selected patients (e.g., older or with postural symptoms)
      • Identification of white coat HTN (white coat effect)
      • Documentation of adherence
      • Monitoring response to therapy
      • Reinforcement of importance of adherence/treatment/assistance with treatment to achieve BP target

References

  1. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. Nov 2017;70(6):1-481
  2. Unger T, Borghi C, et al. 2020 International Society of Hypertension Global Hypertension Practice Guidelines. Hypertension. Jun 2020; 75(6): 1334-1357
  3. Wolf SJ, Lo B, Shih RD, Smith MD, et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients in the Emergency Department With Asymptomatic Elevated Blood Pressure. Ann Emerg Med. 2013;62(1):59-68
  4. James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults. JAMA. 2014;311(5):507
  5. Zeller KR et al. Rapid Reduction of Severe Asymptomatic Hypertension: A Prospective Controlled Trial. JAMA. Oct 1989;149(10):2186-2189
  6. US Dept of Health and Human Services: NIH, NHLBI, NHBPEP. (JNC-7) Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. NIH publication August 2004;No. 04-5230. Available at: https://www.ncbi.nlm.nih.gov/books/NBK9630/. [Accessed April 2023]
  7. AHA. Blood Pressure Fact Sheets. Available at: https://www.heart.org/en/health-topics/high-blood-pressure/find-high-blood-pressure-tools--resources/blood-pressure-fact-sheets. [Accessed April 2023]
  8. Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 8th ed, McGraw-Hill Education, 2016;Chapter 57
  9. Adebayo O, Rogers RL. Hypertensive emergencies in the emergency department. Emerg Med Clin North Am 2015;33:539-551
  10. Suneja M, Sanders ML. Hypertensive emergency. Med Clin North Am 2017;101:465-478.
  11. Powers WJ, Rabinstein AA, Ackerson T, et al; American Heart Association Stroke Council. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2018;49:e46-e110.
  12. Ostchega Y, Fryar CD, Nwankwo T, Nguyen DT. Hypertension Prevalence Among Adults Aged 18 and Over: United States, 2017–2018. NCHS Data Brief No. 364, April 2020. Available at: https://www.cdc.gov/nchs/products/databriefs/db364.htm. [Accessed April 2023]

Contributor(s)

  1. Cotter, Bradford V., MD
  2. Farzad, Ali, MD
  3. Ballarin, Daniel, MD

Updated/Reviewed: April 2023