🩺 Hypertension (HTN)
📖 Definition
HTN is a persistent, nonphysiologic elevation of blood pressure (BP). It is defined as:
🔹 Systolic BP (SBP) ≥ 130 mm Hg and/or
🔹 Diastolic BP (DBP) ≥ 80 mm Hg
📌 A. Background
📊 1. Prevalence
✅ Most common chronic disease in the United States
✅ Affects 46% of the population
✅ Prevalence increases with age
✅ Major modifiable risk factor for cardiovascular (CV) disease and stroke
🏥 2. Etiology
| 🔹Essential HTN (90%) – No identifiable cause | 🔹 Secondary HTN – Identifiable causes: |
| ⚖️ Obesity is a contributor 🧂 Evaluate sodium intake | ⚡ Primary aldosteronism 🩺 Renal parenchymal disease 🚫 Renal artery stenosis 😴 Obstructive sleep apnea 🏋️ Cushing syndrome 🦋 Thyroid or parathyroid disease 💊 Medications (e.g., cyclosporine, NSAIDs, sympathomimetics) 🔬 Pheochromocytoma |
🩸 3. Diagnosis
📝 Periodic screening for everyone >18 years
✔️ Patient should be seated quietly for 5 minutes
✔️ Use appropriate cuff size (bladder length ≥ 80% arm circumference)
✔️ Take BP at least twice, separated by 2 minutes
✔️ Diagnosis: Requires average BP on two separate visits
✔️ Confirm with:
- 🏠 Home BP monitoring (HBPM)
- 🎛️ Ambulatory BP monitoring (ABPM)
📌 Special BP Conditions:
💉 White-Coat HTN: Office BP 130/80 – 160/100 mm Hg but normal HBPM/ABPM (<130/80 mm Hg) after 3 months of lifestyle changes
🎭 Masked HTN: Office BP 120-129 / <80 mm Hg, but elevated HBPM/ABPM (≥130/80 mm Hg)
🎯 4. Benefits of Treating Elevated BP
📉 Lower Risk of Serious Conditions:
🧠 Stroke ↓ by 35-40%
❤️ Myocardial Infarction (MI) ↓ by 20-25%
💓 Heart Failure (HF) ↓ by 50%
🍏5. Effects of Lifestyle Modifications on BP
| Modification | Recommendation | Approximate SBP Reduction |
| 🍏 Weight reduction | 🧘♀️ Maintain a normal body weight (BMI 18.5–24.9 kg/m²) | 📉 5–20 mm Hg per 10 kg weight loss |
| 🥗 Adopt DASH eating plan | 🍎 Consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat | 📉 8–14 mm Hg |
| 🧂 Reduce Na intake | ⚖️ Reduce Na intake to < 1500 mg/day 🚰 Reducing Na intake by at least 1000 mg/day will lower BP if desired daily Na intake goal is not achieved | 📉 2–8 mm Hg |
| 🏃♀️ Physical activity | 👟 Engage in regular aerobic physical activity such as brisk walking (at least 30 min/day most days of the week) | 📉 4–9 mm Hg |
| 🍷 Moderation of alcohol consumption | 🍺 Limit consumption to: Men: 2 drinks/day (24 oz of beer, 10 oz of wine, or 3 oz of 80-proof whiskey). Women and those of lower body weight: 1 drink/day | 📉 2–4 mm Hg |
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📌B. Therapeutic Management
1. Patient Classification
| BP Classification | SBP (mm Hg) | and/or | DBP (mm Hg) |
| 💚 Normal | < 120 | and | < 80 |
| ⚠️ Elevated | 120-129 | and | < 80 |
| 🩺 Stage 1 Hypertension | 130-139 | or | 80-89 |
| 🚨 Stage 2 Hypertension | ≥ 140 | or | ≥ 90 |
| 🚑 Hypertensive Urgency/Emergency | > 180 | or | > 120 |
2. Blood Pressure Thresholds and Goals*
| Clinical Condition | BP Threshold (mm Hg) | BP Goal (mm Hg) |
| 💖 Clinical CVD or 10-year ASCVD risk ≥10% | ≥ 130/80 | < 130/80 for all |
| 🚫 No clinical CVD and 10-year ASCVD risk <10% | ≥ 140/90 | |
| 🍬 Diabetes mellitus | ≥ 130/80 | |
| 🧑⚕️ Chronic kidney disease | ≥ 130/80 | |
| 🏥 Chronic kidney disease after renal transplantation | ≥ 130/80 | |
| ❤️ Heart failure | ≥ 130/80 | |
| 💓 Stable ischemic heart disease | ≥ 130/80 | |
| 🧠 Secondary stroke prevention | ≥ 140/90 | |
| 🧠 Secondary stroke prevention (lacunar) | ≥ 130/80 | |
| 🦵 Peripheral arterial disease | ≥ 130/80 | |
| 👵 Older persons (≥65 years; noninstitutionalized, ambulatory, community-living) | ≥ 130 (SBP) | < 130 (SBP) |
*According to the 2017 ACC/AHA HTN guideline
- Blood Pressure Treatment Strategies According to BP and ASCVD Risk
| BP Classification | Action | Reassessment |
| 💚 Normal BP < 120/80 | ➡️ Promote healthy lifestyle | 🔄 Reassess in 1 year |
| ⚠️ Elevated BP 120-129 / < 80 | ➡️ Non-drug therapy | 🔄 Reassess in 3-6 months |
| 🩺 Stage 1 HTN 130-139 / 80-89 estimate ASCVD risk | ➡️ Clinical ASCVD or estimated 10-year ASCVD risk ≥10%: Non-drug therapy and BP-lowering medication | 🔄 Reassess in 1 month If BP goal met: 🔄 Reassess in 3-6 month If not: optimize |
| ➡️ No Clinical ASCVD or estimated 10-year ASCVD risk <10%: Non-drug therapy | 🔄 Reassess in 3-6 months | |
| 🚨 Stage 2 HTN ≥ 140 / ≥ 90 | ➡️ Non-drug therapy and BP-lowering medication | 🔄 Reassess in 1 month If BP goal met: 🔄 Reassess in 3-6 month If not: optimize |
4. Select an Appropriate Drug Therapy Regimen
- 💊 Initiating with single antihypertensive drug is reasonable for adults with :
- stage 1 HTN and
- BP goal of < 130/80 mm Hg.
- 💉 Initiating with two first-line agents is recommended for adults with :
- stage 2 HTN and
- BP ≥ 20/10 mm Hg above their BP target.
- 🧪 First-line agents include:
- 💧 Thiazide diuretics
- 💊 Calcium Channel Blockers (CCBs)
- 💉 ACE inhibitors or ARBs
- 🏥 First-line agents for patients with comorbidities are described in the table :
| Disease State | Initial Medication Choice |
| 🍬 Diabetes | ACEI, ARB, CCB, or thiazide; ACEI/ARB preferred in albuminuria |
| 🩺 CKD | ACEI or ARB in patients with albuminuria |
| 🧠 Stroke or TIA | Thiazide, ACEI, or ARB |
| ❤️ Coronary Disease | BB + ACEI/ARB |
| 💓 HFrEF reduced | ACEI, ARB, or ARNi; BB;AA; PRN diuretic |
| 💗 HFpEF preserved | Diuretic, ACEI, ARB, or BB |
AA: aldosterone agonist
5. Considerations with Specific Antihypertensive Agents
| Agent | Considerations |
| 💊 β-Blockers | – Insufficient evidence for initial therapy without CV comorbidities. – Caution with asthma or severe COPD (esp. nonselective/high-dose selective β-blockers). – Higher risk of DM than ACEI, ARB, and CCB; caution in high-risk DM pts. – Can mask hypoglycemia signs in DM. – Can cause depression. |
| 💧 Thiazides | – Can worsen gout (↑ serum uric acid). – ↓ efficacy in impaired renal fxn. Higher risk of DM than ACEI, ARB, and CCB; caution in high-risk DM pts. – May help manage osteoporosis (↓ urine Ca loss). – Monitor for hypoNa and hypoK. |
| 🩸 ACEI & ARBs | – Contraindicated in pregnancy. – Contraindicated with bilateral renal artery stenosis. – Monitor K, esp. in renal impairment or if other K-sparing drugs are used. |
| 💊 Direct Renin Antagonist (Aliskiren) | – Avoid concurrent use with ACEI or ARB in renal impairment (CrCl < 60 mL/min). – Contraindicated in pregnancy. – Contraindicated with DM when combined with ACEI/ARB (renal, K, and ↓BP risks). – Avoid with cyclosporine or itraconazole. |
| ⚡ CCBs | Dihydropyridine : Amlodipine, Felodipine, Nifedipine: Monitor for peripheral edema, reflex tachycardia, and orthostatic hypotension. Useful for isolated systolic HTN or in AA pts. Nondihydropyridine (Diltiazem, Verapamil): Indicated in conditions needing HR reduction (e.g., aFib, stable angina). Contraindicated in heart block and sick sinus syndrome. Potential drug interactions (CYP450 inhibition). |
6. Considerations within Specific Patient Populations
| Population | Considerations |
| ❤️ Patients with CHD | – Potent vasodilators (hydralazine, minoxidil, DHP CCBs) may cause reflex tachycardia, ↑ myocardial O2 demand. can be attenuated by AV nodal blockers (BB or non-DHP CCB) |
| 👵 Older Adults (65+) | – SBP goal of <130 recommended for noninstitutionalized, ambulatory, community-dwelling adults with SBP ≥ 130 mm Hg. – For HTN with high comorbidity burden and limited life expectancy, use clinical judgment. – SPRINT trial (2015) showed that targeting SBP <120 reduced CV events and death in high-risk, non-DM patients, including those >75 years old. – Caution with antihypertensives and orthostatic hypotension. |
| 🖤 Black Patients | – BB and ACEI less effective as monotherapy. – In Black adults without HF or CKD, initial treatment should include thiazide-type or CCB. – BB and ACE inhibitors are used if comorbid conditions dictate. |
| 👩 Women | – Oral estrogen-containing contraceptives can increase BP; risk increases with duration of use. – HTN increases risk to mother and fetus during pregnancy. Preferred meds: methyldopa, nifedipine, labetalol. – Avoid ACEI, ARB, and aliskiren during pregnancy due to fetal defects risk. |
- Monitoring
🔄 Return in 4 weeks to assess efficacy (sooner if clinically indicated).
💊 If inadequate response with the 1st agent (optimal dose & verified adherence), and no compelling indication, add 2e agent of different class.
8. Resistant HTN
a. Confirm Dx
🏥 Office BP ≥ 130/80 & pt on ≥ 3 antihypertensive meds (incl. diuretic) at optimal doses (verified adherence)
OR
🏥 Office BP < 130/80 but pt requires ≥ 4 antihypertensive meds.
b. Exclude Pseudoresistance
📊 Ensure accurate office BP readings.
🚶♀️ Exclude white-coat HTN.
✅ Ensure adherence.
c. Identify & Reverse Contributing Factors
- 🍔 Lifestyle Factors:
⚖️ Obesity
🧂 High-salt, low-fiber diet
🛋️ Physical inactivity
🍷 Excessive alcohol use
- 💊 Interfering Meds:
💉 NSAIDs
🧨 Sympathomimetics
⚡ Stimulants
💊 Oral contraceptives
d. Screen & Treat for Secondary Causes (Described earlier)
e. Assess for Target Organ Damage
f. Pharm Tx
💧 Maximize diuretic tx:
💊 Use thiazide or thiazide-like diuretics if eGFR > 25-30 mL/min/m².
- 🔬 Chlorthalidone & indapamide have the most evidence for reducing CV outcomes.
- 🔬 Chlorthalidone is more effective for eGFR 30-45 mL/min/m².
💧 Use loop diuretics if eGFR < 30 mL/min/m².
💊 Add ARA (spironolactone or eplerenone).
🕓 Alter dosing times to include nocturnal doses or divide doses of meds with half-lives <12-15 hrs.
💊 Add agents from different classes.
🔄 Addition of Hydralazine or minoxidil requires concomitant use of BB & diuretic.
g. Follow-up
- 📅 Ensure target BP after 6 mos of therapy.
- 🩺 If not at goal, refer to specialists.