Classification A dults BP Classification Systolic BP mmHg Diastolic BP mmHg Normal lt 120 and lt 80 Prehypertension 120 139 or 80 89 Stage 1 hypertension ID: 731508
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Slide1
Llewellyn F Mensah, MD
HypertensionSlide2
Classification (A
dults)
BP Classification
Systolic BP (mmHg)
Diastolic BP (mmHg)
Normal
< 120
and <
80
Prehypertension
120 – 139
or 80 - 89
Stage 1 hypertension
140 – 159
or
90 – 99
Stage 2 hypertension
≥ 160
or
≥ 100Slide3
Measuring BP
Seated quietly for 5 minutes in chair
Feet on floor, arm supported at heart level
No caffeine, exercise or smoking for 30 minutes
Cuff bladder should encircle at least 80% arm circumference
Inflate 20 – 30 mmHg above pulse examination
Deflate at rate of 2 mmHg/sec
Take at least 2 measurements separated by > 2
mins
and averageSlide4
Etiologies
Essential
onset 25 to 55 years
P
ositive family history
Unclear mechanism but ?additive
microvascular
renal injury over time with contribution of hyperactive
sympathetics
Older age leads to decreased arterial compliance and systolic HTN
Secondary
Consider if patient < 20 or > 50 y or if sudden onset, severe, refractory HTNSlide5
Standard Workup
Goals:
Identify CV risk factors or other diseases that would modify prognosis or treatment
Reveal secondary causes of hypertension
Assess for target organ damage
History:
CAD, HF, TIA/CVA, PAD, DM, Renal insufficiency, sleep apnea, preeclampsia,
Fhx
of HTN, diet, Na intake, smoking, alcohol, prescription and OTC meds, OCP
Physical exam:
Check BP in both arms,
fundoscopy
, CV exam, abdominal,
neuro
Testing:
K, BUN, Cr,
Ca
,
glc
,
Hct
, U/A, Lipids, TSH, urinary
albumin:creatinine
(if
Cr, DM, peripheral edema), ?renin, ECG (for LVH), CXR, TTE (
eval
for valve abnormalities, LVH)Slide6
Complications of HTN
Each 20 mmHg increase in SBP or 10 mmHg increase in DBP leads to a 2 fold increase in CV complications
Neurologic: TIA/CVA, ruptured aneurysms, vascular dementia
Retinopathy: stage I - arteriolar narrowing; II – copper wiring, AV nicking; III – hemorrhages and exudates; IV – papilledema
Cardiac: CAD, LVH, HF, AF
Vascular: aortic dissection, aortic aneurysm (HTN is key risk factor for aneurysms)
Renal: proteinuria, renal failureSlide7
BP and cardiovascular risk
The relationship between BP and risk of CVD events is continuous, consistent and independent of other risk factors
Death from IHD and stroke increase progressively and exponentially from a normal pressure of 115/75 mmHg
For every 20 mmHg systolic or 10 mmHg diastolic increase in BP, there is a doubling of mortality from both IHD and strokeSlide8
Management
Goal: < 140/90 mmHg; if DM or CKD goal is <
140/90
mmHg (in DM, target of < 120 systolic does not decrease CV risk and increases adverse events)
Treatment results in 50% decrease in HF, 40% decrease in stroke, 20 – 25% decrease in MISlide9
Lifestyle modifications
Modification
Recommendation
Approx. SBP
reduction
Weight reduction
Maintain normal body weight (BMI 18.5 – 24.9)
5 – 20 mmHg/10 kg
DASH eating plan
Fruits, vegetables, low fat dairy products
8 – 14 mmHg
Dietary Na
reduction
No more than 100
mmol
per day (2.4 g Na/6 g
NaCl
)
2 – 8 mmHg
Physical activity
Regular aerobics
e.g. brisk walking (at least 30
mins
/d, most days of the week)
4 – 9 mmHg
Moderation of alcohol consumption
No more than 2 drinks (e.g. 24
oz
beer, 10
oz
wine, or 3
oz
80 – proof whiskey) per day in most men, and to no more than 1 drink per day in women and lighter weight persons
2 – 4 mmHgSlide10
JNC 8 summary
60 years or older, treat to SBP < 150 mmHg and a DBP < 90 mmHg
Y
ounger than 60 years, treat to a SBP of < 140 mmHg and a diastolic BP of < 90 mmHg
CKD (
eGFR
< 60) and in patients with albuminuria (> 30 mg of albumin per gram of
creatinine
), treat to SBP < 140 and a DBP < 90 mmHg
In DM, treat to a SBP < 140 and DBP < 90
mmHg
If minimal or no response to
monotherapy
, optimize drug dosing before attempting to add a second drugSlide11
JNC 8 summary
In the general black population, including those with diabetes, the appropriate initial choice is a thiazide diuretic or CCB
.
In
the general nonblack population, including patients with diabetes, the appropriate initial choice is a thiazide
diuretic,
CCB, ACE-I, or
ARB
Initial Rx with a thiazide diuretic is most effective in improving heart failure
outcomes
βB and alpha blockers are not recommended for initial
treatment
Do not use an ACE-I and an ARB togetherSlide12
Evidence based summary
The AHA and European Society of Hypertension/European Society of Cardiology, as well as various meta analyses all concluded that the amount of BP reduction is the major determinant of reduction in CV risk and not the choice of antihypertensive drug
This conclusion also applies to patients at increased CV risk (ALLHAT, VALUE, CAMELOT trials)
ACCOMPLISH trial however demonstrated that with combination drug therapy, choice may be important (20% lower rate of CV events with amlodipine plus benazepril
vs
hctz
plus benazepril)Slide13
Evidence based
summary
Monotherapy
: for patients who are less than 20/10 mmHg above goal
Consider ACE/ARB for
monotherapy
in younger patients and
dihydropyridine
CCB for elderly/black patients
If a thiazide diuretic is chosen evidence is stronger for use of
chlorthalidone
rather than HCTZ.
Patients who have minimal or no response to the initial antihypertensive drug should be treated with sequential
monotherapy
c.f. JNC 8 guidelines (50% will respond after a change
Materson
et al 1995). If
monotherapy
is with a thiazide switch to a long acting ACE/ARB plus a long acting CCBSlide14
Evidence
based
summary
Combination therapy recommended for patients with initial BP > 20/10 mmHg above goal
Start off with long acting ACEI/ARB plus long acting
dihydropyridine
CCB
Among
nonobese
patients who are already being treated with an ACEI/ARB plus a thiazide, d/c the thiazide and use long acting
dihydropyridine
CCB
Among obese patients can continue this regimen
Continue any other combination regimens if they are working
At least one antihypertensive should be taken at bedtime if on multiple medicines (not the diuretic)Slide15
Evidence based summary
UKPDS – United Kingdom Prospective Diabetes Study (BMJ 1998)
VALUE –
Valsartan
Antihypertensive Long Term Use Evaluation (Lancet, 2004)
ACCOMPLISH - Avoiding Cardiovascular Events through Combination Therapy in Patients living with Systolic Hypertension (NEJM, 2008)
ALLHAT - Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (JAMA 2002)
CAMELOT – Comparison of
Amlodipine
vs
Enalapril
to Limit Occurrences of Thrombosis (JAMA 2004)Slide16
Antihypertensives
in diabetes
20 – 60% of diabetics have concomitant HTN
Diabetics with HTN have twice the risk of cardiovascular disease as non diabetics with HTN
In
the UKPDS, each 10 mmHg decrease in mean SBP was associated with reductions in risk of:
12% for any complication related to diabetes
15% for deaths related to diabetes
11% for MI
13% for
microvascular
complicationsSlide17
Antihypertensives
in diabetes
Reduction in CV events and
microvascular
complications in diabetics is seen with multiple drug classes including ACE-Is, ARBs, diuretics, β blockers
Dihydropyridine
CCBs appear inferior to ACE-Is and β – blockers in reducing MI and heart failure
Non
dihydropyridine
CCBs have been shown to reduce albumin excretion
The α2 blocker arm of the ALLHAT study was terminated due to an increase in cases of new onset heart failure in patients assigned to the α
2
blocker.Slide18
HTN and erectile dysfunction
ARBs, ACEIs and CCBs have a
neutral
effect on erectile function.
Centrally acting α1 agonists, β blockers and diuretics have a
negative
effect on erectile function
Nitrates are contraindicated with PDE-5 inhibitor use; combination may trigger severe hypotension/circulatory collapse
Allow 48 h after last
tadalafil
dose
Allow 24 h after last sildenafil or
vardenafil
dose
α2 blockers should be used with caution; combination may trigger hypotension
Initiate PDE – 5 inhibitor at lowest doseSlide19
HTN in minority populations
African American patients exhibit somewhat reduced BP responses to
monotherapy
with ACEIs, ARBs, β – blockers when compared with diuretics or CCBs
These differential responses are largely eliminated by drug combinations that include adequate doses of a diuretic
Thiazide diuretics should be used in drug treatment for most patients with uncomplicated hypertension either alone or combined with drugs from other classes
ACEI induced angioedema occurs 2 – 4 times more frequently in African American patients than in other groupsSlide20
Treatment induced decline in renal function
A 20 – 30% increase in
creatinine
, which then stabilizes, represents a hemodynamic change, and not a structural change
Slight rise in
creatinine
serves as an indirect indicator that
intraglomerular
pressure has been reduced
ACEI/ARBs also dilate efferent arteriole, exaggerating decline in
intraglomerular
pressure
If
creatinine
increases by more than 30%, agent should be discontinued and other causes of renal dysfunction should be evaluatedSlide21
Thiazide diuretics in HTN
Should be used in drug treatment for most, either alone or combined with drugs from other classes
Reduce excretion of
Calcium (slow demineralization in osteoporosis)
Uric acid (increasing likelihood of gout)
Lithium
Increase excretion of
Potassium (average decrease of 0.3 – 0.4
mmol
/L; dietary salt restriction can minimize thiazide induced K loss)
Magnesium (complicates correction of hypokalemia)Slide22
Thiazide diuretics in HTN
Average increase in glucose attributed to thiazide use: 3 – 5 mg/
dL
Presence of diabetes is not a contraindication to use of thiazides
Typically considered ineffective when GFR < 30 – 40 mL/min (exception is
metolazone
)
Substitute furosemide or
torsemideSlide23
Systolic hypertension in the elderly
Approx
2/3 of those over 60 have HTN
Most cases of isolated systolic HTN are caused by reduced elasticity and compliance of large arteries resulting from age and atherosclerosis
In the systolic hypertension in the elderly program (SHEP study), treatment with
chlorthalidone
resulted in reduction of:
Stroke incidence (36%)
Coronary heart disease (27%)
CHF (55%)
The therapeutic approach and goals for isolated systolic HTN are similar to those for other types of HTN: target < 140/90
;
140/90
mmHg in diabetics and those with CKDSlide24
Secondary causes
of hypertension
Renal
DISEASES
SUGGESTIVE
FINDINGS
INITIAL WORKUP
Renal parenchyma
(2 – 3%)
DM, Polycystic kidneys,
GN
CrCl
, albuminuria
Renovascular
(1 – 2 %)
ARF induced by ACE-I/ARB, Recurrent flash pulmonary edema, renal bruit
MRA,
CTA, Duplex U/S,
angio
, plasma renin (low
Sp
)
Endocrine
Conn’s /
Cushings
(1 – 5%)
Hypokalemia
Metabolic
alkalosis
Pheo
(< 1%)
Paroxysmal HTN, H/A, Palp
Myxedema (< 1%)
TFTs
Ca
2+
(< 1%)
Polyuria, dehydration, AMS
iCa
Other
Obstructive sleep apnea
Medications: OCP, Steroids, licorice, NSAIDs
(
esp
COX-2),
Epo
, cyclosporine
Aortic
coarctation
:
LE pulses, systolic murmur, radial – femoral artery delay, abnormal TTE, CXR
Polycythemia
vera
:
HctSlide25
Secondary causes
Renovascular
:
control BP with diuretic + ACE-I/ARB or CCB
Atherosclerosis risk – factor modification: quit smoking, decrease cholesterol
If refractory HTN, recurrent flash pulmonary edema, worse CKD, consider
revascularisation
For atherosclerosis: stenting decreases restenosis compared with PTA alone, but no clear improvement in BP or renal function compared with medical therapy
For FMD (usually more distal lesions): PTA +/- bailout stenting
Renal parenchymal disease: salt and fluid restriction, +/- diuretics
Pregnancy: methyldopa, labetalol,
nifedipine
, hydralazine; avoid diuretics; no ACE-I/ARBSlide26
Resistant HTN
Failure to reach goal BP taking at least 3 drugs, one of which is a diuretic
Identify and treat secondary causes
Centrally acting alpha agonists
Direct vasodilators
Aldosterone antagonists
Renal artery denervationSlide27
Hypertensive crises
Hypertensive urgency: SBP > 180 or DBP > 120 (?110) with minimum or no target organ
damage
Hypertensive emergency:
neurologic ischemia: encephalopathy, stroke, papilledema
cardiac ischemia: ACS, HF/Pulmonary edema, aortic dissection
renal ischemia: proteinuria, hematuria, AKI, scleroderma renal crisis,
microangiopathic
hemolytic anemia, pre-
eclampsia
/
eclampsiaSlide28
Precipitants
Progression of essential HTN +/- medical noncompliance (esp. clonidine) or change in diet
Progression of
renovascular
disease; acute GN, scleroderma, preeclampsia
Endocrine:
pheochromocytoma
, Cushing’s
Sympathomimetics
: cocaine, amphetamines, MAOIs + foods rich in
tyramine
Cerebral injury (do not treat HTN in acute ischemic stroke unless patient is getting lysed, extreme BP > 220/120, aortic dissection, active ischemia or HF)Slide29
Treatment
Tailor goals to clinical context (e.g. more rapid lowering for aortic dissection)
Emergency: Decrease MAP by ~ 25% in minutes to 2 hours with IV agents (may need arterial line for monitoring); goal DBP < 110 within 2 – 6 h, as tolerated
Urgency: decrease BP in hours using oral agents; goal normal BP in ~ 1 – 2 days
Watch urine output,
creatinine
, mental status: may indicate a lower BP is
not tolerated
Drugs for hypertensive crises
IV –
nitroprusside
, nitroglycerin, labetalol,
esmolol
,
fenoldopam
, hydralazine,
nicardipine
,
clevidipine
,
phentolamine
,
enalaprilat
PO – captopril, labetalol, clonidine, hydralazineSlide30
Summary of pharmacologic options
Pre – HTN: ARB prevents onset of HTN
HTN:
uncomplicated: thiazide if likely salt sensitive (e.g. elderly, black, obese), otherwise start with ACE-I or CCB. βB not first line.
+ high risk CAD: ACE-I or ARB; ACE-I + CCB superior to ACE-I + thiazide or βB + diuretic
+ angina: βB, CCB, nitrates
+ post – MI: ACE-I, βB +/- aldosterone antagonist
+ HF: ACE-I/ARB, βB, diuretics, aldosterone antagonist, hydralazine,
isosorbide
+ secondary stroke prevention: ACE-I, ?ARB
+ diabetes mellitus: ACE-I or ARB; can also consider diuretic, βB or CCB
+ CKD: ACE-I/ARBSlide31
Indications for individual drug classes
Indication
Diuretics
Β
B
ACEI
ARB
CCB
Aldo
st
antagonist
Heart failure
✓
✓
✓
✓
✓
Post - MI
✓
✓
✓
High coronary disease risk
✓
✓
✓
✓
Diabetes
✓
✓
✓
✓
✓
CKD
✓
✓
Recurrent stroke prevention
✓
✓Slide32
ABFM Questions
A postmenopausal female who has recently been diagnosed with hypertension returns
for follow
-up 3 months after the initiation of therapeutic lifestyle changes. Her blood pressure
has improved
but remains higher than goal at 142/90 mm Hg, and pharmacologic treatment
is indicated
. The patient has a family history of
osteoporosis. Which
one of the following may slow the demineralization of bone in this patient?
A) An ACE inhibitor
B) An -blocker
C) A -blocker
D) A calcium channel blocker
E) A thiazide diureticSlide33
ANSWER:
E
Thiazide
-type diuretics are
useful in
slowing demineralization from
osteoporosis.Slide34
A 58-year-old male has a history of type 2 diabetes mellitus that is not well controlled. He
has recently
developed mild hypertension that has not been controlled by lifestyle changes.
You prescribe
lisinopril
(
Prinivil
, Zestril), 20 mg daily, for the hypertension and 2 months later
you note
that his serum
creatinine
level has increased from 1.25 mg/
dL
to 1.5 mg/
dL
(N 0.64–1.27
) and
his blood pressure has decreased from 142/88 mm Hg to 128/78 mm
Hg. Which
one of the following should you do now?
A) Continue the current dosage of
lisinopril
B) Decrease the dosage of
lisinopril
to 10 mg
C) Increase the dosage of
lisinopril
to 40 mg
D) Discontinue
lisinopril
and initiate
chlorthalidone
E) Discontinue
lisinopril
and initiate losartan (
Cozaar
)Slide35
ANSWER: A
ACE inhibitors such as
lisinopril
do not need to be discontinued unless baseline
creatinine
increases
by >
30%. (This patient’s
creatinine
increased by 20%.) The current dosage of
lisinopril
is appropriate,
as the
blood pressure meets the diabetic goal of <130/80 mm Hg. Small increases in
creatinine
have
been associated
with long-term preservation of renal function, and may be a marker of changes
in
intraglomerular
pressure.Slide36
A 62-year-old male underwent percutaneous coronary intervention and placement of two
stents for
a myocardial infarction yesterday. He is currently taking simvastatin (Zocor), aspirin
,
lisinopril
(
Prinivil
, Zestril), and hydrochlorothiazide. His last LDL-cholesterol level was
70 mg
/
dL
and his blood pressure is 130/80 mm
Hg. Which
one of the following additions to his current regimen would be most appropriate at
this time
?
A) Amlodipine (Norvasc)
B)
Diltiazem
(Cardizem)
C) Verapamil (
Calan
,
Verelan
)
D)
Metoprolol
(Lopressor, Toprol-XL)
E) No changesSlide37
ANSWER: D
β-
Blockers are first-line antihypertensive medications for patients with coronary artery disease (CAD)
and have
been shown to reduce the risk of death by 23% at 2 years. They should also be given to
normotensive patients
with CAD if tolerated.
Cardioselective
(1) -blockers such as
metoprolol
and atenolol
are preferred
, as they cause fewer adverse effects.Slide38
A 55-year-old male with a 4-year history of type 2 diabetes mellitus was noted to
have
microalbuminuria
6 months ago, and returns for a follow-up visit. He has been on an
ACE inhibitor
and his blood pressure is 140/90 mm
Hg. The
addition of which one of the following medications would INCREASE the likelihood
that dialysis
would become necessary?
A) Hydrochlorothiazide
B) Amlodipine (Norvasc)
C) Atenolol (Tenormin)
D) Clonidine (
Catapres
)
E) Losartan (
Cozaar
)Slide39
Answer: E
Do not use an ACE and ARB togetherSlide40
A 48-year-old female presents as a new patient to your office. She has not seen a physician
for several
years and her medical history is unknown. Her BMI is 24.4 kg/m2 and she is not
taking any
medication. Her blood pressure is 172/110 mm Hg in the left arm sitting and 176/114
mmHg
in the right arm sitting; her cardiovascular examination is otherwise unremarkable.
A baseline
metabolic panel reveals a
creatinine
level of 0.68 mg/
dL
(N 0.6–1.1) and a
potassium level
of 3.3
mEq
/L (N 3.5–5.5)
. If
the patient’s hypertension should prove refractory to treatment, which one of the
following tests
is most likely to reveal the cause of her secondary hypertension?
A) A 24-hour urine catecholamine level
B) A plasma aldosterone/renin ratio
C) MRA of the renal arteries
D) Echocardiography
E) A sleep study (
polysomnography
)Slide41
ANSWER: B
Primary
hyperaldosteronism
is the most common cause of secondary hypertension in the middle-
aged population
, and can be diagnosed from a renin/aldosterone ratio. This diagnosis is further suggested
by the
finding of hypokalemia, which suggests
hyperaldosteronism
even though it is not present in
the majority
of
cases. Slide42
Which one of the following is a preferred first-line agent for managing hypertension in
patients with
stable coronary artery disease?
A) A thiazide diuretic
B) An angiotensin receptor blocker
C) A
β-
blocker
D) A long-acting calcium channel blocker
E) A long-acting nitrateSlide43
ANSWER: C
American Heart Association guidelines recommend treating hypertension in patients with stable
heart failure
with ACE inhibitors and/or
β-
blockers. Other agents, such as thiazide diuretics or calcium
channel blockers
, can be added if needed to achieve blood pressure goals (SOR B). Slide44
An 11-year-old male is brought to your clinic for follow-up after a recent well child
visit revealed
elevated blood pressure. The parents have restricted his intake of sodium and
fatty foods
during the last several weeks. His blood pressure today is 140/92 mm Hg, which is
similar to
the reading at his last visit. The parents checked the child’s blood pressure with a home
unit several
times and found it consistently to be in the 130s systolic and low 80s diastolic. The
child had
a normal birth history and has no known chronic medical conditions. Both of his parents
and his
two younger siblings are healthy. He is at the 75th percentile for both height and weight
with a
BMI in the normal range. He eats a balanced diet and is
active. What
should be the next step for this patient?
A) Reassurance that this is likely white-coat hypertension
B) A goal weight loss of at least 5
lb
C) Evaluation for causes of secondary hypertension
D) Hydrochlorothiazide
E)
Lisinopril
(
Prinivil
, Zestril)Slide45
ANSWER: C
Hypertension
in a patient this young should prompt a search for
secondary causes
, which are more common in young hypertensive patients than in adults with hypertension.
The recommended
workup includes blood and urine testing, as well as renal ultrasonography. An
evaluation for
end-organ damage is also recommended, including retinal evaluation and echocardiography.Slide46
A 54-year-old male sees you for a 6-month follow-up visit for hypertension. He feels well,
but despite
the fact that he takes his medications faithfully, his blood pressure averages 150/90
mmHg
. He has had an intensive workup for hypertension in the recent past, with normal
repeat laboratory
results, including a CBC, serum
creatinine
, an electrolyte panel, and a urinalysis.
His medications
include
chlorthalidone
, 12.5 mg daily;
carvedilol
(Coreg), 25 mg twice daily
; amlodipine
(Norvasc), 10 mg daily;
and
lisinopril
(
Prinivil
, Zestril), 40 mg daily. He has
been intolerant
to clonidine (
Catapres
) in the
past. Which
one of the following medication changes would be most reasonable?
A) Adding
isosorbide
mononitrate
(
Imdur
)
B) Adding spironolactone (
Aldactone
)
C) Substituting furosemide (Lasix) for
chlorthalidone
D) Substituting losartan (
Cozaar
) for
lisinoprilSlide47
ANSWER: B
Spironolactone is now recommended for treating resistant hypertension, even when
hyperaldosteronism
is
not present. A longer-acting diuretic such as
chlorthalidone
is also recommended for
treating hypertension
, particularly in resistant cases with normal renal function. Slide48
A 62-year-old African-American male is admitted to the hospital for the third time in 6
months with
heart failure. He has dyspnea with minimal activity. Echocardiography reveals an
ejection fraction
of 40%
. Which
one of the following combinations of medications is most appropriate for long-
term management
of this patient?
A)
Enalapril
(
Vasotec
) plus digoxin
B) Hydralazine plus
isosorbide
dinitrate
C) Losartan (
Cozaar
) plus amlodipine (Norvasc)
D) Spironolactone (
Aldactone
) plus
bisoprolol
(
Zebeta
)Slide49
ANSWER: B
The combination of the vasodilators hydralazine and
isosorbide
dinitrate
has been shown to be
effective in
the treatment of heart failure when standard treatment with diuretics
, β-
blockers, and an ACE
inhibitor (
or ARB) is insufficient to control symptoms or cannot be tolerated. This combination is
particularly effective
in African-Americans with NYHA class III or IV heart failure, with advantages including
reduced mortality
rates and improvement in quality-of-life measures. Slide50
Treatment with which one of the following antihypertensive medications may mimic the
effects of
primary hyperparathyroidism?
A) Amlodipine (Norvasc)
B)
Doxazosin
(Cardura)
C) Hydrochlorothiazide
D)
Lisinopril
(
Prinivil
, Zestril)
E)
Metoprolol
(Lopressor, Toprol-XL)Slide51
ANSWER: C
These
laboratory findings
may
occur with lithium or thiazide
use.Slide52
A 32-year-old
gravida
2
para
1 with long-standing untreated hypertension presents at 8
weeks gestation
for prenatal care. Her physical examination is normal except for a blood pressure
of 156
/114 mm
Hg. Which
one of the following would be most appropriate as initial treatment?
A) Labetalol (
Trandate
)
B)
Lisinopril
(
Prinivil
, Zestril)
C) Losartan (
Cozaar
)
D)
Metoprolol
(Lopressor, Toprol-XL)
E)
Nifedipine
, immediate release (Procardia)Slide53
Answer: A
The
drug most often recommended as first-line therapy for hypertension in pregnancy is labetalol
. Immediate
-
release
nifedipine
is not recommended due to the risk of hypotension.Slide54
A 60-year-old male is referred to you by his employer for management of his hypertension.
He has
been without primary care for several years due to a lapse in insurance coverage.
During a
recent employee health evaluation, he was noted to have a blood pressure of 170/95 mm
Hg. He
has a 20-year history of hypertension and suffered a small lacunar stroke 10 years ago.
He has
no other health problems and does not smoke or drink alcohol. A review of systems
is negative
except for minor residual weakness in his right upper extremity resulting from
his remote
stroke. His blood pressure is 168/98 mm Hg when initially measured by your nurse,
and you
obtain a similar reading during your
examination. In
addition to counseling him regarding lifestyle modifications, which one of the following is
the most
appropriate treatment for his hypertension?
A) An angiotensin receptor blocker
B) A -blocker
C) A calcium channel blocker
D) A thiazide diuretic/ACE inhibitor combination
E) No medicationSlide55
Answer: D
This
patient has stage 2 hypertension, and his history of stroke is a compelling indication to use
combination
therapy with a diuretic and an ACE
inhibitor.Slide56
A 45-year-old male has diabetes mellitus and hypertension. He has no other medical
problems. Which
one of the following classes of medications is the preferred first-line therapy for
the treatment
of hypertension in this patient?
A) Potassium-sparing diuretics
B) ACE inhibitors
C) -Receptor blockers
D) Calcium channel blockers
E) -BlockersSlide57
ANSWER: B
ACE inhibitors and
angiotensin receptor blockers (ARBs) are the preferred first-line agents for the management of
patients with
hypertension and
diabetes.