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HTN Treatment & Management

Mar 17, 20256 min read

Management of Hypertension

  • Investigate appropriately a patient with hypertension.
  • Advice initial management plan for a patient with hypertension according to recent guidelines (SHAMS - 2018).
  • Discuss non-drug management of hypertension.
  • Identify long term complications of hypertension.
  • Discuss the screening criteria for HTN.

HTN Treatment

  1. Non-Pharmacological
  2. Pharmacological

Blood Pressure Target

  • General Population ≥ 60 years … < 150/90 mmHg
  • Adults ≥ 30 years … diastolic BP < 90 mmHg
  • Adults ≥ 60 years … Systolic BP < 150 mm Hg
  • Patients with DM and Chronic Kidney Diseases (CKD) … < 140/90

1. Lifestyle Modifications

  1. Adoption of the Dietary Approaches to Stop HTN (DASH) Diet.
  2. Salt restriction
  3. Weight reduction
  4. Alcohol consumption abstinent
  5. Regular aerobic physical activity
  6. Smoking cessation

Dietary Approach to Stop HTN (DASH)

  • Low content of cholesterol and total fat
  • Focuses on fruits, vegetables, and fat-free or low-fat dairy products
  • Rich in whole grains, fish, poultry, beans, seeds, and nuts
  • Contains fewer sweets, added sugars and sugary beverages, and red meats
  • Dietary sodium restriction ideally to 1.5 g/day

What is the DASH Diet?

  • Total fat: 27% of calories
  • Saturated fat: 6% of calories
  • Cholesterol: 150 mg
  • Carbohydrates: 55% of calories
  • Fiber: 30 g
  • Protein: 18% of calories
  • Sodium: 1,500 mg
  • Potassium: 4,700 mg
  • Calcium: 1,250 mg
  • Magnesium: 500 mg

Special Conditions/Groups

  • Resistant hypertension
    • Prevalence is estimated to be around 10%.
    • Defined as seated office BP > 140/90 mm Hg in people managed with three or more antihypertensive medications at optimal (or maximally tolerated) doses including a diuretic.
    • Secondary hypertension and pseudo-resistant hypertension (poor BP measurement technique, white coat effect, nonadherence, and suboptimal choices in antihypertensive therapy) should be first excluded.

National Heart Center/Saudi Heart Association 2023 Guidelines on the Management of Hypertension

Treatment Guidelines

General Treatment Recommendations

  • Both diuretics and ARB may affect treatment outcomes. The thiazide-like diuretics chlorthalidone and indapamide might be favored.

  • Spironolactone should be considered in treatment-resistant hypertension.

  • In case of treatment failure refer to a specialized care center.

Diabetes Mellitus

  • Initiate therapy when BP is equal to or higher than 130/80 mmHg and target a BP level below 130/80 mmHg.
  • ACEs or ARBs are recommended especially in the presence of albuminuria or renal involvement.
  • CCBs and beta blockers are also safe to use.
  • Combination of a CCB and an ACE was found to consistently lead to BP lowering as well as significantly lower cardiovascular mortality.

Chronic Kidney Disease

  • The most effective are ACEs and ARBs.
  • Combination therapy with an ACE and ARB carries a notable risk of hyperkalemia and acute kidney injury and is therefore not recommended.
  • When more BP lowering is needed, ACEs or an ARB can be combined with other antihypertensive drugs, such as dihydropyridine CCBs.

Coronary Artery Disease

  • It is recommended that a SBP range 120-130 mmHg be targeted for all people with CAD, with a higher range 130-139 mmHg for older people. Maintained DBP between 70 and 80 mmHg.

  • Beta blockers and RAS blockers (ACEs or ARBs) are preferred.

  • CCBs are also beneficial.

Heart Failure

  • Target SBP < 130 but not < than 120.

  • Trials have demonstrated the efficacy of diuretics, beta-blockers and RAS blockers (ACEs or ARBs).

Acute Stroke and CVD

  • Immediate reduction of BP should only be attempted in case of acute intracerebral hemorrhage and very severe HTN (SBP 220 mmHg).

  • The SBP of people who suffered a transient ischemic attack or an ischemic stroke should be maintained at 120-130 mmHg in order to reduce the risk of future stroke.

  • As for drug choice, a RAS blocker in combination with a CCB or a thiazide-like diuretic is recommended for stroke prevention.

Atrial Fibrillation

  • Prevention with oral anticoagulation is necessary.
  • Beta blockers or non-dihydropyridine CCBs are recommended.

Pregnancy

  • In general, antihypertensive drugs are recommended when SBP is ≥150 mmHg or DBP ≥95 mmHg.
  • Treatment of choice for non-severe HTN includes methyldopa, labetalol, and CCBs.
  • As for severe HTN, nifedipine, hydralazine, labetalol, and methyldopa have been shown to be effective.
  • Intravenous (IV) labetalol or nicardipine and magnesium sulphate are recommended for hypertensive crisis in pregnant women.

Older Age (>65 Years Old)

  • If tolerated, a treatment target of < 130 is reasonable.

  • Combination therapy might not be favorable in very old people.

  • Avoid loop diuretics and alpha blockers due to risk of fall.

Hypertensive Emergencies

  • A hypertensive crisis denotes severe elevations of blood pressure (>180/120 mm Hg) associated with acute target organ damage, typically present as acute aortic dissection, acute myocardial ischemia, or acute heart failure.

  • It is recommended to admit the patient & use I/V medications.

Main Target of Treatment

The main target of treatment is to control BP. Antihypertensive medications that can be considered for initial treatment:

  1. Diuretics (thiazide and thiazide-like agents)
  2. ACEis
  3. ARBs
  4. Long-acting dihydropyridine CCBs
  5. Beta blockers (when indicated)

Beta blockers can be used in specific indications (young age, sympathetic overdrive, ischemic disease, heart failure, obesity/bariatric surgery).

Indications & Contraindications of Medications

Influence of Comorbidity on the Choice of Antihypertensive Drug Therapy

Class of DrugCompelling IndicationsPossible IndicationsCautionCompelling Contraindications
α-blockersBenign prostatic hypertrophy–Postural hypotension, heart failure¹Urinary incontinence
ACE inhibitorsHeart failureChronic renal disease²Renal impairment²Pregnancy
Left ventricular dysfunction, post-MI or established coronary heart diseaseType 2 diabetic nephropathyPeripheral vascular disease³Renovascular disease²
Type 1 diabetic nephropathy
Secondary stroke prevention⁴
Angiotensin II Receptor BlockersACE inhibitor intoleranceLeft ventricular dysfunction after MIRenal impairment²Pregnancy
Type 2 diabetic nephropathyIntolerance of other antihypertensive drugsPeripheral vascular disease³
Hypertension with left ventricular hypertrophyProteinuric renal disease, chronic renal disease²
Heart failure in ACE-intolerant patients, after MIHeart Failure

Indications & contraindications of medications

Isolated Systolic Hypertension

  • Persistent high Office SBP ≥140 mm Hg and Office DPB <90 mm Hg.

  • Effective treatment for isolated systolic HTN is CCB & Diuretics.

Antihypertensive Drug Treatment for People Aged Under 80 Years with Stage 1 Hypertension

  • Target organ damage
  • Established cardiovascular disease
  • Renal disease
  • Diabetes
  • A 10-year cardiovascular risk equivalent to 20% or greater.

Follow-Up

  • Labs: Potassium and Creatinine, may be sodium
    • At initiation of treatment
    • 2-4 weeks after starting
    • Again after every dose adjustment
    • Annually

Strategies Regarding Dosage and Medication Titration

  • A- Start one drug, titrate to maximum dose, and then add a second drug

  • B- Start one drug and then add a second drug before achieving maximum dose of the initial drug

  • C- Begin with 2 drugs at the same time, either as 2 separate pills or as a single pill combination

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