Essential HTN

Question 1

Goals of treating hypertension?

Answer 1

Reduce the risk of cardiovascular events (e.g. stroke, HF)

Question 2

Difference between clinic, home and ambulatory BP?

Answer 2

1. Clinic: measured when visiting doctor
2. Home: Measured at home
3. Ambulatory: measured in regular intervals to reduce white coat hypertension (inpatient setting)

Generally, clinic BP is expected to be the highest

Question 3

ACC/AHA Blood pressure classification

Answer 3

• Normal: < 120/80
• Elevated: 120-129/<80
• HTN stage 1: 130-139 OR dBP 80-89
• HTN stage 2: ≥140 or ≥ 90

Question 4

According to the ten-year estimation of CVD risk, what are the threshold (%) for each classifications?

Answer 4

1. Very-high risk: ≥10%
2. High-risk: 5-10%
3. Moderate risk: 1-5%
4. Low risk: <1%

Question 5

What conditions would set a patient to be at a very high risk for CVD/ASCVD (aside from 10-year CVD risk of ≥10%)?

Answer 5

1. Clinical CVD (e.g. MI, CAD)
2. Documented CVD on imaging (e.g. ≥50% stenosis on angiography)
3. DM with target organ damage
4. Severe CKD (eGFR < 30)

Question 6

What conditions would set a patient to be at a high risk for CVD/ASCVD (aside from 10-year CVD risk of ≥ 5-10%)?

Answer 6

1. Marked elevation of a single risk factor (e.g. cholesterol > 8mmol/dL)
2. Most people with T2DM (unless young, or T1DM without major risk factors)
3. Hypertensive LVH
4. Moderate CKD (eGFR 30 - 59)

Question 7

Lifestyle interventions for HTN?

Answer 7

1. Diet (reduce sodium, increase potassium), weight loss
2. Exercise
3. Reduce alcohol intake

Question 8

According to ACC/AHA, when are antihypertensives indicated?

Answer 8

1. sBP ≥140 mmHg OR dBP ≥ 90, irrespective of CVD risk
2. sBP 130 - 139 or dBP 80-89 at high risk of CVD/ASCVD

Question 9

Recommended initial therapy for HTN without any other comorbidities (similar for both ACC/AHA and ESC)

Answer 9

• Choose: ACEI/ARB, diuretics, CCB
• ESC: ACEI/ARB + CCB or ACEI/ARB + diuretic
• If still above target, add spironolactone or other diuretic
• Recommend single combination pill over separate pills

Question 10

Blood pressure target for most patients?

Answer 10

130/80 mmHg

Question 11

Follow-up frequency in patients with HTN?

Answer 11

• Normal BP: Yearly
• Only on non-pharmacotherapy: 3-6 monthly
• Initiated antihypertensives: monthly, then 3-6 monthly after meeting BP goal

Question 12

Name two thiazide diuretics and their dosage range for essential hypertension.

Answer 12

1. Hydrochlorothiazide (HCTZ) 12.5 - 25 mg OD, max 50 mg
2. Indapamide 1.25 - 2.5 mg OD, max. 5 mg

Question 13

Name two CCBs and their dosage range for essential hypertension

Answer 13

1. Amlodipine 2.5 - 10 mg OD
2. Nifedipine LA 30 - 60 mg OD up till 90 - 120 mg OD

Question 14

Name two ACE and their dosage range for essential hypertension

Answer 14

1. Enalapril 5 - 40 mg OD in 1-2 divided doses
2. Lisinopril 5 - 40 mg OD

Question 15

General frequency of titrating up antihypertensives?

Answer 15

Every 2-4 weeks

Question 16

Name two ARBs and their dosage range for essential hypertension

Answer 16

1. Losartan 25 - 100 mg OD
2. Valsartan 40 - 160 mg BD

Question 17

Mr HTHT is a 46 yo male who has essential HTN. He has no other comorbidities. NKDA. His current medications are Amlodipine 5 mg OM and indapamide 2.5 mg OM. His blood pressure is not well controlled, with multiple home readings above 140/90. What is the next step of management for Mr HTHT’s HTN?

Answer 17

Titrate up either amlo or indapamide is fine. no need to introduce third medication