Hypertension

Author: Raymond Lengel

Course Expiration: 6/28/2015

Hypertension | Copyright 2010 CEUFast.com

Course Contents

Purpose
Objectives

Angiotensin Converting Enzyme Inhibitors

Angiotensin II Receptor Blockers

What is Elevated Blood Pressure?

Beta blockers

Pathophysiology

Other drugs

Hypertension Management

Old Age and Blood Pressure Treatment

Who is at risk?

Compelling Indications

Work up

Combination therapy

Lab work

Resistant Hypertension

Medications

How to Prevent Hypertension

General strategy

Conclusion

Diuretics

References

Click any section in the index above to browse to the corresponding course section

Purpos
e
This continuing education course will supply an overview and update of hypertension including its definition, complications,
risk factors, evaluation, etiology and treatments options.

Objective
s

1. Discuss the incidence and prevalence of hypertension

2. Identify three body systems affected by long term hypertension
3. Differentiate between primary and secondary hypertension
4. Discuss the role of diet, exercise and other lifestyle choices in the management of hypertension
5. Discuss the role of five medication classes in the management of hypertension
Hypertension is a critical risk factor for many cardiovascular diseases including coronary heart disease, congestive heart
failure, stroke and peripheral vascular disease. In 2001, there were approximately 7.6 million deaths across the globe that

- See more at: http://www.ceufast.com/courses/viewcourse.asp?id=243#sthash.iOJhWgOc.dpuf

Hypertension
Review of Guidelines and Drug Therapy Management
CE506 :: 1.00 Hours

Authors:
Sherri Konzem Boehringer, PharmD, BCPS
Sherri Konzem Boehringer, PharmD, BCPS, is a lecturer for the TxPharm
program at the University of Houston: College of Pharmacy, Texas.
Victoria Devore Woodard, PharmD
Victoria Devore Woodard, PharmD, is a consultant pharmacist in the Fort
Collins, Colo., area, and was a clinical assistant professor at the
University of Houston: College of Pharmacy, Texas.
Susanne J. Pavlovich-Danis, RN, MSN, ARNP-C, CDE, CRRN
Susanne J. Pavlovich-Danis, ARNP-C, MSN, CDE, CRRN, is an adult health
nurse practitioner in private practice in Plantation, Fla., specializing in the
management of patients with diabetes. She is also a professor at the
University of Phoenix, South Florida campus.

Objectives
The purpose of this program is to inform nurses, dietitians, paramedics
and EMTs, pharmacists, physical therapists, physicians and radiologic
technologists about current guidelines and drug therapy for the
management of hypertension. After studying the information presented
here, you will be able to:

State blood pressure goals in patients with uncomplicated

hypertension and in patients with diabetes or renal disease

Discuss the five components of lifestyle modification

Discuss the five classes of antihypertensive drugs known to reduce

the complications

Accreditation Information
This course is intended for an interprofessional audience, including
nurses, dietitians, paramedics and EMTs, pharmacists, physical therapists,
physicians and radiologic technologists.
Nurses: Take this version of the course to ensure you receive appropriate
credit.
For the version accredited or approved for another profession, go to your
specific profession at www.continuingeducation.com orNurse.com/CE. If
you have a CE Direct login ID and password (generally provided by your
employer), please log in as you normally would at lms.nurse.com and
search for this topic title.
The prevalence of high blood pressure (BP), or hypertension, in the U.S.
has increased from about 50 million in 1988 to 76.4 million people in
2008.1
In 2008, an estimated one-third of the population, more than 76.4 million
Americans, had hypertension.1 From 1998 to 2008, the death rate from
high BP increased 20.2% and the actual number of deaths increased
49.7%. In 2008, high BP contributed to 347,689 deaths.1
The Seventh Report of the Joint National Committee on Prevention,
Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) is the
current guideline to aid in the management of hypertension. This
guideline provides information about risk assessment, classification and
treatment.2
Risk Assessment
Of the estimated 76.4 million Americans with hypertension in 2008, about
47.8% had met established BP goals.1 One in five was not even aware
they had the disease.1 The prevalence of hypertension was highest in
non-Hispanic blacks, tended to be higher in women and increased with
advancing age.1 Recent data suggest that even people free of
hypertension at age 55 still have a 90% lifetime risk of developing high
BP.2
Hypertension is a major risk factor for cardiovascular disease and renal
disease, and early data indicate that untreated high BP shortens life
expectancy by about five years.3(Level C) The higher the BP, the greater the
risk of myocardial infarction (MI), heart failure, stroke and kidney
disease.2 The risk of cardiovascular disease beginning at a BP of 115/75

mmHg doubles with each 20 mmHg incremental increase in systolic BP or

10 mmHg incremental increase in diastolic BP.2 In younger people,
elevated diastolic BP is associated with more cardiovascular disease risk
than increased systolic BP.2 However, starting at age 50, systolic BP
becomes the more important risk factor.2,3
Hypertension Classification
BP classification is based on the average of two or more properly
measured, seated BP measurements made on each of two or more office
visits.2 See the Blood Pressure Classification in Adults table for a
summary of the JNC 7 BP classification. 2 This classification differs from
JNC 6 in two ways. First, a prehypertension category was added. 2 These
patients are at increased risk for clinical hypertension. Although they
dont require drug therapy, they should practice lifestyle
modification.3 Lifestyle changes can potentially lower BP and reduce the
risk of progression to hypertension. Also in JNC 7, stages 2 and 3
hypertension were combined into a single stage 2 category to simplify
treatment. 2
Blood Pressure Classification in Adults2
BP Classification

Systolic BP

Diastolic BP

Normal

< 120

< 80

Prehypertension

120 to 139

80 to 89

Stage 1
hypertension

140 to 159

90 to 99

Stage 2
hypertension

160

100

Treatment Rationale and Goals

One of the best ways to lower the complications associated with
hypertension is to reduce BP. In clinical trials, antihypertensive therapy
has been associated with a 35% to 40% reduction in stroke, a 20% to
25% reduction in MI, and a more than 50% reduction in heart failure. 1,2
The ultimate goal of antihypertensive therapy is to reduce cardiovascular
and renal morbidity and mortality.2 In most people, the BP goal is less
than 140/90 mmHg.2 However, in people with diabetes or renal disease,

the goal is less than 130/80 mmHg.2 This is because people with
hypertension and diabetes or renal disease are at higher risk for
developing cardiovascular disease and kidney failure. 2,4 Traditionally,
hypertension management has emphasized the treatment of elevated
diastolic BP.4 However, because most people with hypertension (especially
older people) will meet the diastolic goal once the systolic goal is met,
therapy should be targeted at meeting systolic BP goals.2,4
Lifestyle modifications: Even in people with normal BP, a healthy
lifestyle is encouraged to prevent high BP.2 In those with prehypertension
and hypertension, lifestyle intervention is essential and should be used
even when drug therapy is required. Lifestyle modifications reduce BP,
enhance antihypertensive drug efficacy and reduce cardiovascular disease
risk.2
The JNC 7 recommends five methods of lifestyle modification to manage
hypertension:2
Weight reduction: In the overweight or obese, a 10 kg (22 pounds)
weight loss may decrease systolic BP by 5 mmHg to 20 mmHg.
Dietary approaches to stop hypertension diet: The DASH eating
plan is rich in fruits, vegetables and low-fat dairy products with a reduced
content of saturated and total fat. This diet may reduce systolic BP by 8
mmHg to 14 mmHg.
Dietary sodium reduction: Reducing dietary sodium intake to no more
than 100 mmol per day (2.4 g of sodium or 6 g of sodium chloride) may
decrease systolic BP by 2 mmHg to 8 mmHg.
Physical activity: Regular aerobic exercise (at least 30 minutes daily,
most days of the week) may reduce systolic BP by 4 mmHg to 9 mmHg.
Moderate consumption of alcohol: Limiting alcohol to two drinks daily
in men and one drink daily in women and lighter-weight people may
reduce systolic BP by 2 mmHg to 4 mmHg.
Drug therapy: The complications of hypertension are reduced by several
classes of drugs including thiazide-type diuretics, angiotensin-converting
enzyme inhibitors, angiotensin receptor blockers, beta blockers and
calcium channel blockers.2 Based on clinical outcome data, the JNC 7
recommends thiazide diuretics as initial therapy in most patients with
hypertension, either alone or combined with an ACEI, ARB, BB or
CCB.2 (For a list of high-risk conditions that are compelling indicators for
these other agents, see the sidebar.)

Compelling Indications for Individual Drug Classes2

Heart failure

Diuretic BB, ACEI, ARB, aldosterone

antagonist

Post MI

BB, ACEI, aldosterone antagonist

High coronary disease

risk

Diuretic BB, ACEI, CCB

Diabetes

Diuretic BB, ACEI, ARB, CCB

Chronic kidney disease

ACEI, ARB

Recurrent stroke
prevention

Diuretic ACEI

Most people with hypertension require two or more drugs to meet BP

goals.2,4 In patients who fail to achieve BP goals with adequate doses of
one drug, a second agent from another class should be added. 3 When BP
is greater than 20 mmHg above the systolic BP goal or 10 mmHg above
the diastolic BP goal, consider initiating therapy with two drugs, one of
which usually should be a thiazide-type diuretic. 2,4 Initial combination
therapy should be used cautiously in people at high risk for orthostatic
hypotension (e.g., people with diabetes, the elderly). 2,5(Level C)
The following represents a review of antihypertensive therapy by drug
class. Information about individual agents and dosing is available as part
of the JNC 7 report.
Diuretics: Thiazide diuretics, such as hydrochlorothiazide, are usually
less expensive than other antihypertensive agents and are the
recommended initial therapy in most patients with
hypertension.3 Thiazides have favorable effects in hypertensive patients at
high risk for coronary disease and in those with diabetes or heart
failure.2 They also decrease the incidence of first-time and recurrent
strokes.2 Thiazides have decreased efficacy in patients with advanced
renal disease. In these patients and those with symptomatic heart failure,
loop diuretics (e.g., furosemide [Lasix]) are preferred. 2
Thiazide diuretics may cause electrolyte disturbances including
hypokalemia,hypomagnesemia, hyponatremia and
hypercalcemia.6,7Electrolyte effects are similar with loop diuretics except
hypocalcemia may occur.6 In patients receiving thiazide or loop diuretics,
a potassium supplement may be given to prevent hypokalemia, or they

may be used in combination with a potassium-sparing diuretic (e.g.,

hydrochlorothiazide with triamterene [Maxzide]). Thiazide and loop
diuretics may cause elevations in lipids and serum glucose. 6These effects
are usually transient and are lessened by using lower diuretic doses.
Thiazide and loop diuretics may increase uric acid levels and should be
used cautiously in people with gout.2,6,7 Serum electrolytes, uric acid
levels, renal function and glucose should be monitored
periodically.6 Thiazide and loop diuretics are generally contraindicated in
patients allergic to sulfonamide-derived drugs (e.g., sulfonylureas such as
glipizide [Glucotrol]) because of a potential for cross-hypersensitivity.6
Angiotensin-converting enzyme inhibitors: The ACEIs are beneficial
in treating hypertension in patients with acute coronary syndromes
(unstable angina or MI), heart failure, diabetes and chronic kidney
disease.2,7 Recurrent stroke rates may be lowered by combining an ACEI
and a thiazide diuretic.2 ACEIs also reduce albuminuria in patients with
diabetes and slow the progression of diabetic and nondiabetic renal
disease.2
The most common adverse effect of ACEIs is a persistent cough. 6,7 These
drugs may also cause hyperkalemia and renal insufficiency, so serum
potassium levels and renal function should be monitored. 6 They should be
used cautiously in patients receiving drugs known to increase potassium
(e.g., potassium supplements, potassium-sparing diuretics). The ACEIs
are contraindicated in patients with previous ACEI-induced angioedema or
with bilateral renal artery stenosis and in pregnancy.2,6,7
Angiotensin receptor blockers: The ARBs are useful BP-lowering
agents in patients with heart failure, diabetes and chronic kidney disease.
Research indicates that ARBs are equally efficient as ACEIs in reducing the
risk for MI, stroke and death.8,9 (Level A) Like ACEIs, ARBs have been shown
to decrease albuminuria and slow the progression of diabetic and
nondiabetic kidney disease.2Occasionally, ARBs may be used in
combination with ACEIs, especially for the treatment of kidney disease. 10
(Level C)
ACEIs and ARBs may also prevent or delay the onset of new type 2
diabetes. This has been demonstrated in the results of several large
clinical trials.11,12 (Level C)
ARBs often are used as an alternative to ACEIs because cough is much
less common.2,7 Like ACEIs, ARBs also may cause hyperkalemia and renal
dysfunction.6 Potassium levels and renal function should be
monitored.6 They should be used cautiously in patients receiving drugs
known to increase potassium levels and in patients with a history of ACEIinduced angioedema.2 ARBs are contraindicated in pregnancy and in
bilateral renal artery stenosis.2,6,7

Direct renin inhibitors: The direct inhibitors bind with renin and prevent
the conversion of angiotensinogen to angiotensin I. Only one drug in this
class, aliskiren (Tekturna) is approved by the Food and Drug
Administration for use in the U.S. However, several other drugs in this
class are in drug safety trial phases in anticipation of release. Like ACEIs
and ARBs, direct renin inhibitors also may cause hyperkalemia and renal
dysfunction. Potassium levels and renal function should be monitored.
They should be used cautiously in patients receiving drugs known to
increase potassium levels and in patients with a history of ACEI- or ARBinduced angioedema. The direct renin inhibitors are contraindicated in
pregnancy and during breastfeeding. They are also not to be used with
ARBs or ACEIs in patients with diabetes.13
Beta blockers: Beta blockers reduce cardiovascular mortality in
hypertensive patients with ischemic heart disease, diabetes and heart
failure.2 In patients with ischemic heart disease (including stable and
unstable angina and acute MI), antihypertensive therapy should be
initiated with a beta blocker unless contraindicated.2,7
Many of the adverse effects of beta blockers are an extension of their
pharmacological effects. Blocking beta-1 receptors in the heart is
associated with bradycardia, so heart rate should be monitored
regularly.6 Beta blockers may cause atrioventricular conduction
abnormalities and are contraindicated in second- and third-degree heart
block.2,6 Heart failure may develop when beta blockers are used at high
initial doses in patients with pre-existing left ventricular
dysfunction.6 When using beta blockers in patients with stable heart
failure, they should be initiated at a low dose and slowly titrated upward. 6
Blocking beta-2 receptors in the lungs may lead to bronchospasm in
patients with bronchospastic diseases, such as asthma. In general, beta
blockers should be avoided in patients with bronchospastic
diseases.6 Beta-1 selective or cardioselective agents (e.g., metoprolol
[Toprol]) can be used cautiously in low doses in patients who cannot
tolerate or do not respond to other antihypertensive therapies. 6
Beta blockers also may increase serum glucose and lipid levels. 7 These
effects are usually transient and of little clinical significance. Beta
blockers, especially nonselective agents, may blunt hypoglycemic
awareness in diabetics.2,6 Cardioselective agents are preferred in
diabetics.2
CCBs: Long-acting CCBs are beneficial in hypertensive patients with
stable angina as an alternative to beta blockers.2 They have also been
shown to decrease CVD risk in patients with diabetes.2 There are two
types of CCBs: dihydropyridines (e.g., amlodipine [Norvasc]) and
nondihydropyridines (verapamil [Calan] and diltiazem

[Cardizem]).6 Short-acting CCBs should not be used for the treatment of

hypertension.2,6 In particular, the short-acting dihydropyridines (e.g.,
nonsustained-release nifedipine [Procardia]) have been associated with
increased cardiovascular risk.2 Both dihydropyridine and
nondihydropyridine CCBs are similar in antihypertensive efficacy, but their
pharmacodynamic effects and potential adverse effects differ.
The dihydropyridines cause peripheral vasodilation, which may in turn
cause an increase in heart rate, flushing, dizziness and peripheral
edema.6 The nondihydropyridines, verapamil in particular, have cardiac
depressive effects and decrease heart rate and slow atrioventricular
conduction.6 These properties make the nondihydropyridines useful for
treating supraventricular arrhythmias.2However, because of these same
properties, the nondihydropyridines should not be used in second- or
third-degree heart block and severe heart failure.6,7 Caution is warranted
when administering beta blockers and nondihydropyridine CCBs together
(especially intravenous formulations) because of a potential for added
cardiac depressive effects.6 Long-acting dihydropyridine CCBs are
preferred when combination therapy with beta blockers is
necessary.2 Consuming grapefruit or grapefruit juice with many of the
CCBs may result in elevated serum concentrations with subsequent
toxicity and should be avoided.14
Alternative antihypertensive agents: Aldosterone blockade has been
shown to be cardioprotective.15 Spironolactone (Aldactone), a potassiumsparing diuretic and first-generation aldosterone blocker, reduces
mortality in heart failure.15 A newer agent, eplerenone (Inspra), is a
derivative of spironolactone but has more specific affinity for aldosterone
receptors.15 It is the first agent approved in a new class of
antihypertensive agents called selective aldosterone receptor
antagonists.4 Eplerenone is approved for treating hypertension and
congestive heart failure after acute MI.15 The most common adverse effect
of eplerenone is hyperkalemia.4 It is contraindicated in patients with a
serum potassium greater than 5.5 meq/L and those with renal
dysfunction.4,15 Caution is warranted when combining aldosterone
antagonists with ACEIs and ARBs.2,4,15
Regarding alpha 1-blockers (e.g., doxazosin [Cardura]), in
the Antihypertensive and Lipid Lowering Treatment to Prevent Heart
Attack Trial, the doxazosin treatment arm was stopped prematurely
because of a higher rate of cardiovascular events compared with diuretictreated patients.4,7 However, these agents are useful in treating prostate
enlargement. They now generally are reserved for the treatment of
hypertension in men with benign prostatic hypertrophy, usually in addition
to other standard antihypertensive therapy.4

Other classes of agents available for the treatment of hypertension

include central alpha2-agonists (e.g., clonidine [Catapres]) and
vasodilators (e.g., hydralazine [Apresoline]). These drugs tend to have
more adverse effects than other agents and are generally reserved for
patients whose BP is more difficult to control.2
New therapies for high BP currently under study include darusentan
(endothelin receptor type A antagonist) for resistant hypertension, a
vaccine to block the activity of angiotensin II, cannabinoid-1 receptor
antagonists and alagebrium (interferes with cross-linkages of collagen and
elastin to reduce arterial and myocardial stiffness).16-18,19 (Levels A,C)
Special Populations
In older people, drug therapy is started at lower doses and titrated slowly
to avoid orthostatic hypotension.2 In African-Americans, BP response
during monotherapy is usually better with diuretics or CCBs than with
ACEIs, ARBs or beta blockers, but combination regimens that include a
diuretic are equally effective in African-Americans and Caucasians. 2 In
pregnancy, methyldopa (Aldomet) is usually the drug of
choice.2 Alternative agents include beta blockers, CCBs and
vasodilators.2 ACEIs and ARBs are contraindicated in pregnancy because
of possible serious neonatal problems.6 For people with diabetes mellitus,
ACEIs and ARBs are usually the drugs of choice. 2
Implications for Healthcare Professionals
The final message of the JNC 7 guidelines is the importance of motivation.
Hypertension will be controlled only if patients are motivated to adhere to
their treatment plan. As frontline care providers, we are in an ideal
position to motivate patients to modify their lifestyles and adhere to
antihypertensive drug therapy. With effective communication, healthcare
professionals as a team can help patients understand hypertension,
complications of the disease, goals of therapy and medication use.
Gannett Education guarantees that this educational activity is free from
bias.

References
1. American Heart Association. High blood pressure statistical fact sheet.
2012 update. AHA Web site.http://www.heart.org/idc/groups/heartpublic/@wcm/@sop/@smd/documents/downloadable/ucm_319587.pdf.
Accessed July 26, 2012.

2. Chobanian AB, Bakris GL, Black HR, et al. Seventh report of the Joint
National Committee on Prevention, Detection, Evaluation, and Treatment
of High Blood Pressure. Hypertension. 2003;42(6):1206-1252.
3. Chobanian AV. The hypertension paradox more uncontrolled disease
despite improved therapy. New Engl J Med. 2009;361(9):878-887.
4. Polonsky T, Bakris G. Cardiovascular risk assessment and summary of
guidelines for the management of hypertension. In: Aiyagari V, Gorelick
PB, eds. Hypertension and Stroke - Pathophysiology and
Management. 2011. New York, NY: Humana Press; 2011:97-113.
5. Gradman AH, Basile JN, Carter BL, Bakris GL; American Society of
Hypertension Writing Group. Combination therapy in hypertension. J Clin
Hypertens (Greenwich). 2011;13(3):146-154.
6. Killion KH, Kastrup EK. Drug Facts and Comparisons. St. Louis, MO:
Wolters Kluwer Health; 2012.
7. Bakris G. Are there effects of renin-angiotensin system antagonists
beyond blood pressure control? Am J Cardiol. 2010;105(1):21A-29A.
8 Webb AJS, Fischer U, Mehta Z, Rothwell PM. Effects of antihypertensivedrug class on interindividual variation in blood pressure and risk of stroke:
a systematic review and meta-analysis. Lancet. 2010;375(9718):906915.
9. Bangalore S, Kumar S, Wetterslev J, Messerli FH. Angiotensin receptor
blockers and risk of myocardial infarction: meta-analyses and trial
sequential analyses of 147020 patients from randomised trials. BMJ.
2011;342:d2234.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3082637.
Published April 26, 2011. Accessed July 26, 2012.
10. Krause MW, Fonseca VA, Shah SV. Combination inhibition of the reninangiotensin system: is more better? Kidney Int.2011;80(3):245-255.
11. Stohr R, Marx N. Renin-angiotensin-aldosterone system antagonists
and the prevention of type 2 diabetes mellitus. Curr Pharm
Des. 2012;18(7):958-962.
12. Hershon KS. Mechanistic and clinical aspects of renin-angiotensinaldosterone system blockade in the prevention of diabetes mellitus and
cardiovascular disease. Endocr Pract. 2011;17(3):430-440.
13. Novartis. Highlights of prescribing information. Tekturna (aliskiren)
tablets, for oral use. US Food and Drug Administration Web

site.http://www.accessdata.fda.gov/drugsatfda_docs/label/2012/021985s
023lbl.pdf. Published March 2012. Accessed July 26, 2012.
14. Elliott WJ, Ram CV. Calcium channel blockers. J Clin Hypertens
(Greenwich). 2011;13(9):687-689.
15. Physicians Desk Reference. 66th ed. Oradell, NJ: Medical Economics;
2012.
16. Black HR, Bakris GL, Weber MA, et al. Efficacy and safety of
darusentan in patients with resistant hypertension: results from a
randomized, double-blind placebo-controlled dose-ranging study. J Clin
Hypertens (Greenwich). 2007;9(10):760-769.
17. Unger T, Paulis L, Sica DA. Therapeutic perspectives in hypertension:
novel means for renin-angiotensin-aldosterone system modulation and
emerging device-based approaches. Eur Heart J. 2011;32(22):27392747.
18. Cunha P, Romao AM, Mascarenhas-Melo F, et al. Endocannabinoid
system in cardiovascular disorders - new pharmacotherapeutic
opportunities. J Pharm Bioallied Sci. 2011;3(3):350-360.
19. Hartog JW, Willemsen S, van Veldhuisen DJ, et al. Effects of
alagebrium, an advanced glycation endproduct breaker, on exercise
tolerance and cardiac function in patients with chronic heart failure. Eur J
Heart Fail. 2011;13(8):899-908.