Adrenergic antagonist drug

Hypertension definition

Simply defined as persistently elevated arterial blood pressure.

Hypertension ICD-10-CM codes I10-I16 

• I10 : Essential (primary) hypertension
• I11 : Hypertensive heart disease
• I12 : Hypertensive chronic kidney disease
• I13 : Hypertensive heart and chronic kidney disease
• I15 : Secondary hypertension
• I16 : Hypertensive crisis

Etiology

• 90-95% of cases have unknown etiology (primary or essential hypertension).
• Secondary hypertension < 10% of cases.

Risk factors of hypertension

• Age

• Family history of the disease

• Diabetes mellitus

• physical inactivity

• high sodium intake 

• obesity

• smoking

Causes of secondary hypertension

• Renal diseases (most common cause): eg; renal failure. 

• Endocrine diseases: hyperaldosteronism (Conn disease), hypercortizolism (cushing syndrome), pheochromocytoma or pre-eclampsia.

• Vascular causes: renal artery stenosis.

Hypertension diagnosis 

Hypertension is diagnosed by daily B.P measurement for 2 successive weeks.

Important considerations should be taken when measuring B.P

• Avoid smoking, caffeinated beverages, coffee or exercise 30 minutes before B.P measurement.
•  Ensure 5 min of rest before B.P measurement.
•   Sit with back straight and supported.
• Sit with flat feet on the floor and legs uncrossed

Classification of B.P according to guidelines

1-  ACC/AHA guideline

Normal : Systolic B.P less than 120 and diastolic B.P less than 80.

Elevated : Systolic B.P is 120-129 and diastolic B.P less than 80.

Hypertension stage 1 : Systolic B.P is 130-139 or diastolic B.P is 80-89.

Hypertension stage 2 : Systolic B.P is 140 or higher or diastolic B.P is 90 or higher.

Hypertensive crisis : Systolic B.P > 180 and/or diastolic B.P > 120

2-  ESH/ESC guideline

Optimal: Systolic B.P less than 120 and diastolic B.P less than 80.

Normal: Systolic B.P is 120-129 and/or diastolic B.P is 80-84.

High normal : Systolic B.P is 130-139 and/or diastolic B.P is 85-89.

Hypertension stage 1 : Systolic B.P is 140-159 and/or diastolic B.P is 90-99.

Hypertension stage 2 : Systolic B.P is 160-179 and/or diastolic B.P is 100-109.

Hypertensive stage 3 : Systolic B.P is 180 or higher and/or diastolic B.P is 110 or higher.

3- JNC 8 guideline 

Normal : Systolic B.P less than 120 and diastolic B.P less than 80.

Prehypertension: Systolic B.P is 120-139 or diastolic B.P less than 80-89.

Hypertension stage 1 : Systolic B.P is 140-159 or diastolic B.P is 90-99.

Hypertension stage 2 : Systolic B.P is 160 or higher or diastolic B.P is 90 or higher.

White coat hypertension 

B.P is elevated in clinical setting but not elevated in other setting.

• Consider for 24-ABPM (Ambulatory B.P measurement).

Clinical Vs home B.P measurements 

Typically a B.P of 140/90 corresponds to home B.P of 130/80 mmHg.

Hypertension and cardiovascular risk

• Risk of M.I, angina, stroke, heart failure and renal failure are directly correlated to hypertension.
• Starting with B.P of 115/75 mm Hg, risk of cardiovascular disease doubles with every 20/10 increase in B.P pressure.

 

Hypertension treatment and management 

Goals of therapy

To reduce hypertension associated cardiovascular morbidity and mortality related to target organ damage ( cardiovascular and cerebrovascular events, heart failure and renal failure).

 Desired B.P targets

• According to JNC 8 guideline:

If the patient is < 60 years , the target B.P is less than 140/90 mmHg.

If the patient is > 60 years without D.M or CKD , the target B.P is less than 150/90 mmHg.

If the patient is >60 years with D.M or CKD , the target B.P is less than 140/90 mmHg.

 

• According to ACC/AHA and ESH/ESC guidelines:

The target B.P for all patients is less than 130/80 mmHg.

 

Non pharmacological therapy “life style modification “

There is 5 important life style modifications strongly recommended by guidelines  for hypertensive patients:

•  Weight reduction:

 Maintain the normal body weight (mass index 18.2-24.9).

•  Adopt DASH eating plan:

Eat diet rich of fruits and vegetables and avoid saturated fats and full fat dairy products.

•  Dietary sodium restriction:

Limit sodium intake to no more than 2.4g sodium or 6g sodium chloride).

•     Physical activity:

Brisk walking for at least 30 min for at least 5 days a week.

• Alcohol consumption reduction:

Limit consumption to no more than 2 standard drinks per day in men and to no more than 1 standard drinks per day in women.

Pharmacological therapy

Primary antihypertensive drugs:

ACEIs, ARBs, CCBs and diuretics.

 

Alternative antihypertensive drugs:

B blockers, alpha blockers , centrally acting drugs and vasodilators.

Are hypertension medications also are blood thiners ?

No, there is no medication that substantially lower B.P and make thinning of blood. 

B.P thresholds and recommendations for treatment and follow up

Pharmacological management of hypertension without comorbidities

Start with ACEIs or any one of primary drugs and reassess the patient after a month of treatment:

If the goal of B.P is not reached within a month of treatment, increase the dose of the initial drug or add another drug from the primary drugs.

 

Best combinations of primary drugs:

• ACEIs or ARBs + CCBs
• ACEIs or ARBS + thiazide diuretics
• CCBs + thiazide diuretics

Not to combine:

ACEIs + ARBs or ACEIs + renin inhibitors or ARBs + renin inhibitors.

 

If goal B.P cannot be reached by  primary drugs, titrate a third drug from the primary drugs.

If the goal B.P cannot be reached using primary drugs because of a contraindication or the need to add more than  drugs to reach the goal B.P, alternative antihypertensive can be used.

 

Resistant hypertension

B.P is not controlled with optimal doses of 3 different antihypertensive drugs including diuretic.

 

Causes of resistant hypertension

1. Adherence to therapy.
2. Adherence to non-pharmacological therapy ( special sodium intake)
3.  Secondary causes of hypertension (eg; use of NSAIDs, corticosteroids or sympathomimetices).

Management of resistant hypertension 

• Add aldosterone antagonist (spironolactone).
• or add bisoprolol or doxazosin ( also were effective). 

Pharmacological management of hypertension with comorbidities

Hypertension medications preferred in patients with hypertension and other comorbidities are simply discussed in the table below:

Are hypertension and stroke related to each other ?

Yes, hypertensive crisis is associated with hemorrhagic stroke.

Are hypertension and kidney diseases related to each other ?

Yes, uncontrolled hypertension worsen and considered an initiation and progression factor for chronic renal failure and chronic renal failure leads to uncontrolled B.P .

Is headache associated with hypertension ?    

No, most hypertensive patient don’t suffer headache unless B.P rises to >180/120 " hypertension crises ".

References

• Pharmacotherapy principles and practice 4 edition.
• http://www.icd10data.com
• Healthcentral.com