Hypertension Management

Antihypertensive treatment in primary care

Sources: uptodate, JNC7, Lexicomp’s Drug information handbook, medscape article
  • Normal BP <120/<80,
  • pre 120-139/80-89
  • stage 1 40-159/90-99
  • stage 2 =>160/100
Why treat? hypertension is a RF for cardiovascular event
Monotherapy -> indicated for BP <20/10 above goal
First line (3 medications can be 1st line)
  1. ACE (…prils)/ARB =>cardioprotective. ACCOMPLISH Trial ->start with ACE or CCB
    1. 1st line for NSTEMI/STEMI, DM2, systolic dysfx, CKD
    2. if cannot tolerate ACE switch to ARB
    3. side effects -> dry cough, angioedema (rare by dangerous)
    4. Ace/arb take at bedtime 
    5. lisinopril -> initially 10mg (if on diuretic then 5mg), max 40
      1. eldery start at 2.5 or 5mg, can increase at 1-2 week intervals
    6. benzapril  -> initially 10mg, BID 20-80mg
    7. ramipril  -> usual dose 5 to 10mg, can start with 2.5 if on diuretic
  2. Thiazide – go to choice if no comorbidities
    1. Chlorthalidone is superior in trials but expensive – dose 12.5-25mg
      1. longer lasting, decrease CV events
      2. check Na, K after 2 to 3 weeks
    2. hydrochlorothiazide (HCTZ) 12.5 to 25mg (max 50mg) – most commonly used in the USA
      1. take w/o regard for food, earlier in day to avoid nocturia
      2. can be used for volume control in CHF, CKD
  3. CCB
    1. no contraindications
    2. good for COPD, a fib, Angina
    3. amlodipine (Norvasc) – 5 to 10 mg
    4. Verapamil – 240-480 mg daily extended release (several dosing options, lookup specifics)
  4. Beta Blockers = not first line
    1. post MI for acute tx
    2. can combo with ACE.I
    3. avoid for >60, incr risk of DM2 (glucose impairment)
  5. Alpha-blockers =>only if prostate symptoms
1st => ACE/ARB + CCB
— if on thiazide +ACE.i then switch to ACE + CCB (unless obese)
— if on beta blocker add CCB or thiazide
General approach (uptodate.com)
1st -> mono for <20/10 above goal and combo for >20/10
2nd -> limit dose titration to 1 step
3rd -> switch medication, switch again
4th -> add second agent (if on Monotherapy)
JNC says to titrate to max dose or add a second rather than switching.
  • follow up monthly until BP is controlled, then every 3 to 6 months
  • check K and Cr twice per year
Specific populations
  • Young = ace/arb
  • blacks = CCB, thiazide
    • blacks combo = ACE (benazapirl) + CCB (amlodipine) or Thiazide + ACE
    • Don’t do ace+arb, or use beta blocker in combo (unless another indication)
  • most blacks will require combo to gain effective control
  • Ace as Monotherapy not as effective in blacks
  • elderly with HF, prior MI, CKD -> ACE.i
  • elderly without CHF, prior MI, CKD = >CCB, thiazide