Rule out secondary causes – TRAC PADo
Isolated systolic HTN is common. Therapy has been shown to be effective and beneficial at preventing stroke and cardiovascular morbidity and all-cause mortality
Body mass index (BMI), waist circumference, BP in both arms,
peripheral pulse exam:
RFD in volume and timing (evaluation for CAA (especially in young persons)
Funduscopic exam – arteriolar narrowing, AV compression, hemorrhages, exudates, and papilledema
- Secondary HTN: ( low incidence of reversible secondary HTN)
special tests should be considered only if the history, physical exam, or basic laboratory evaluation suggest a higher likelihood.
Also, consider patients who prove nonresponsive to treatment.
- Whitecoat HTN: elevation of BP in the office setting and normal BP outside the office
- Masked HTN: elevated BP at home and normal BP in office
Initial Tests (lab, imaging)
- MSU (may reveal proteinuria, hematuria/nephritis)
- EUC and uric acid
- LP – CTHL
- FBS, HB A1c
- ECG – (LVH) or rhythm abnormalities
A sleep study, 24-hour ambulatory BP monitoring,
Treatment based on CV risk
CVS risk >15% – straight away start with statin
Mild<10% to mod 10-15% – after lifestyle except for BP > 160/100 — start
The potential harms of therapy must be weighed against the potential benefits. More intensive therapy may be considered for certain high-risk individuals.
Individual treatment goals should be jointly established with patients after discussion of the anticipated potential benefits and harms (shared decision making)
SNAPS C- salt
For initial monotherapy, choose from 1 of 4 classes of medications:
*ACE inhibitors, ARBs, calcium channel blockers (CCBs), or diuretics
* β-Blockers often benefit patients with ischemic heart disease, atrial fibrillation, CHF, migraine, and patients with a history of ST-segment elevation myocardial infarction (STEMI).
*ACE inhibitors should be used in patients with diabetes, proteinuria, atrial fibrillation, or heart failure with reduced ejection fraction (HFrEF) but not in pregnancy.
*α-Adrenergic blockers are not the first choice for monotherapy but remain as second-line after combination therapy of first-line agents; might benefit males with benign prostatic hypertrophy (BPH). α-Adrenergic antagonists: prazosin 1 to 10 mg BID, terazosin 1 to 20 mg/day, or doxazosin 1 to 16 mg/day
*CCB could be considered in patients with isolated systolic HTN, atherosclerosis, angina, migraine, or asthma; well documented to reduce risk of stroke
- Thiazide diuretics may worsen gout.
- β-Blockers in asthma, heart block, diabetes, and peripheral vascular disease; probably should be avoided in patients with metabolic syndrome or insulin-requiring diabetes
- Diltiazem or verapamil: Do not use with systolic dysfunction or heart block.
- Amlodipine may cause peripheral edema.
*Medication-refractory HTN (see Secondary and Resistant Hypertension): Spironolactone 25 to 100 mg/day or eplerenone 50 mg once to twice daily are especially effective.
*Centrally acting α-2 agonists: clonidine 0.1 to 1.2 mg BID or weekly patch 0.1 to 0.3 mg/day, guanfacine 1 to 3 mg daily, or methyldopa 250 to 2,000 mg BID
*Hydralazine: 10 to 25 mg QID; (SE: drug-induced systemic lupus erythematosus (SLE) ) risk of tachycardia, so generally combined with β-blocker;
*Minoxidil: rarely used due to adverse effects; may be more effective than other medications in renal failure and refractory HTN
*Metolazone and loop diuretics may be used with more severe renal impairment, but outcomes data are absent; loop diuretics (for volume overload): furosemide 20 to 320 mg/day or bumetanide 0.5 to 2 mg/day
*K+-sparing diuretics in patients with hypokalemia while taking thiazides: amiloride 5 to 10 mg/day or triamterene 50 to 150 mg/day
Aim to reduce CBV risk –
Risk factor modifications –
Modifiable – Lipids, BP, BMI, DM,
Smoking, nutrition, alcohol, physical activity, Stress, caffeine , salt ( SNAPS C salt )
Nonmodifiable – FH, Age, ethnicity, Sex, socioeconomic status
Other- OSA, Drugs, treat secondary causes, lack of education, cultural and religious
Heart failure, renal failure, LVH, myocardial infarction, retinal hemorrhage, stroke, hypertensive heart disease, drug side effects, erectile dysfunction