Hypertension

New ACC/AHA High Blood Pressure Guidelines

Lower Definition of Hypertension

High blood pressure should be treated earlier with lifestyle changes and in some patients with medication – at 130/80 mm Hg rather than 140/90 – based on new ACC and American Heart Association (AHA) guidelines for the detection, prevention, management and treatment of high blood pressure.

The new guidelines – the first comprehensive set since 2003 – lower the definition of high blood pressure to account for complications that can occur at lower numbers and to allow for earlier intervention. The new definition will result in nearly half of the U.S. adult population (46 percent) having high blood pressure, with the greatest impact expected among younger people. Additionally, the prevalence of high blood pressure is expected to triple among men under age 45, and double among women under 45, the guideline authors note. However, only a small increase is expected in the number of adults requiring antihypertensive medication.

"You've already doubled your risk of cardiovascular complications compared to those with a normal level of blood pressure," said Paul K. Whelton, MB, MD, MSc, FACC, lead author of the guidelines. "We want to be straight with people – if you already have a doubling of risk, you need to know about it. It doesn't mean you need medication, but it's a yellow light that you need to be lowering your blood pressure, mainly with non-drug approaches."

Blood pressure categories in the new guideline are:
• Normal: Less than 120/80 mm Hg;
• Elevated: Systolic between 120-129 and diastolic less than 80;
• Stage 1: Systolic between 130-139 or diastolic between 80-89;
• Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg;
• Hypertensive crisis: Systolic over 180 and/or diastolic over 120, with patients needing prompt changes in medication if there are no other indications of problems, or immediate hospitalization if there are signs of organ damage.

The guidelines eliminate the category of prehypertension, categorizing patients as having either Elevated (120-129 and less than 80) or Stage I hypertension (130-139 or 80-89).
While previous guidelines classified 140/90 mm Hg as Stage 1 hypertension, this level is classified as Stage 2 hypertension under the new guidelines.
In addition, the guidelines stress the importance of using proper technique to measure blood pressure; recommend use of home blood pressure monitoring using validated devices; and highlight the value of appropriate training of health care providers to reveal "white-coat hypertension." Other changes include:

• Only prescribing medication for Stage I hypertension if a patient has already had a cardiovascular event such as a heart attack or stroke, or is at high risk of heart attack or stroke based on age, the presence of diabetes mellitus, chronic kidney disease or calculation of atherosclerotic risk (using the same risk calculator used in evaluating high cholesterol).
• Recognizing that many people will need two or more types of medications to control their blood pressure, and that people may take their pills more consistently if multiple medications are combined into a single pill.
• Identifying socioeconomic status and psychosocial stress as risk factors for high blood pressure that should be considered in a patient's plan of care.

In a corresponding analysis of the guidelines' impact, Paul Muntner, PhD, et al., suggests "the 2017 ACC/AHA hypertension guideline has the potential to increase hypertension awareness, encourage lifestyle modification and focus antihypertensive medication initiation and intensification on US adults with high CVD risk."

The new ACC/AHA guidelines were developed with nine other health professional organizations and were written by a panel of 21 scientists and health experts who reviewed more than 900 published studies. They are the successor to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC7), issued in 2003 and overseen by the National Heart, Lung, and Blood Institute (NHLBI). In 2013, the NHLBI asked the AHA and ACC to continue the management of guideline preparation for hypertension and other cardiovascular risk. The guidelines were published in the Journal of the American College of Cardiology and Hypertension. For a wide array of ACC-developed tools, resources and commentary for both clinicians and patients, visit the ACC's High Blood Pressure Guidelines Hub.

Measurement of BP

Proper methods of BP measurement, which are detailed in the guideline, are fundamental to categorizing BP, ascertaining BP-related CVD risk, and managing hypertension. The guideline urges clinicians to obtain accurate measurements and base their estimates of BP on an average of at least 2 readings obtained on at least 2 separate occasions (Table 2).

Table 2. Recommendations for Measurement of BP

The guideline recommends greater use of out-of-office BP measurements to confirm the diagnosis of hypertension and titrate medication.
In adults who are not using antihypertensive drugs, ambulatory BP monitoring (ABPM) or home BP monitoring (HBPM) should be used to detect white coat hypertension (high office BP but normal out-of-office BP) and masked hypertension (normal office BP but high out-of-office BP) (Figure 1).
White coat hypertension is associated with a CVD risk approximating that of normal BP, whereas masked hypertension carries a CVD risk similar to that of sustained hypertension.

Figure 1. Algorithm for detection of white coat hypertension or masked hypertension
in patients not receiving antihypertensive drug therapy.
Colors correspond to class of recommendation in the Appendix Figure. ABPM = ambulatory blood pressure monitoring; BP = blood pressure; HBPM = home blood pressure monitoring.

In adults already using antihypertensive drugs, the guideline recommends screening for masked uncontrolled hypertension if the office BP is at goal but CVD risk is increased or target organ damage is present. If the office BP is more than 5 to 10 mm Hg above goal in a patient using 3 or more antihypertensive drugs, the guideline recommends HBPM to detect a white coat effect (Figure 2).

Figure 2. Algorithm for detection of white coat effect or masked uncontrolled hypertension
in patients receiving drug therapy.
Colors correspond to class of recommendation in the Appendix Figure. ABPM = ambulatory blood pressure monitoring; BP = blood pressure; CVD = cardiovascular disease; HBPM = home blood pressure monitoring.

Appendix Figure. Applying class of recommendation and level of evidence
to clinical strategies, interventions, treatments, or diagnostic testing in patient care*.
COR (class (strength) of recommendation) and LOE (level (quality) of evidence) are determined independently (any COR may be paired with any LOE). A recommendation with LOE C does not imply that the recommendation is weak. Many important clinical questions addressed in guidelines do not lend themselves to clinical trials. Although RCTs are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective. (Reproduced with permission of the American College of Cardiology and the American Heart Association.) COR = class (strength) of recommendation; EO = expert opinion; LD = limited data; LOE = level (quality) of evidence; NR = nonrandomized; R = randomized; RCT = randomized controlled trial.

* The outcome or result of the intervention should be specified (an improved clinical outcome or increased diagnostic accuracy or incremental prognostic information).

† For comparative-effectiveness recommendations (COR I and IIa; LOE A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.

‡ The method of assessing quality is evolving, including the application of standardized, widely used, and preferably validated evidence grading tools and, for systematic reviews, the incorporation of an Evidence Review Committee.

Secondary Hypertension

A secondary cause of hypertension can be identified in approximately 10% of hypertensive adults, and specific treatment of the cause reduces CVD risk. Screening for a secondary cause is recommended in the circumstances listed in Table 3, with referral to a clinician with relevant expertise when screening results are positive.

Nonpharmacologic Interventions

Lifestyle changes alone are recommended for most adults newly classified as having stage 1 hypertension (130 to 139/80 to 89 mm Hg), and lifestyle changes plus drug therapy are recommended for those with existing CVD or increased CVD risk. Recommended lifestyle interventions are listed in Table 4.

Table 4. Recommendations for Nonpharmacologic and Pharmacologic Treatment and BP Goals*

BP Thresholds and Risk Estimation to Guide Pharmacologic Treatment

Figure 3 shows BP thresholds and recommendations for follow-up and treatment of normal BP, elevated BP, and stage 1 and 2 hypertension. Intensive BP-lowering therapies should be directed toward patients with the highest atherosclerotic cardiovascular disease (ASCVD) risk. Although drug treatment based on BP alone is cost-effective, basing treatment decisions on absolute ASCVD risk combined with BP is even more efficient and cost-effective in reducing CVD risk. Benefits of using a combination approach to guide drug treatment include focusing treatment on patients most likely to have CVD events and a larger absolute CVD risk reduction, preventing more CVD events, and saving more quality-adjusted life-years.

Figure 3. BP thresholds and recommendations for treatment and follow-up.
Colors correspond to class of recommendation in the Appendix Figure. ASCVD = atherosclerotic cardiovascular disease; BP = blood pressure; CVD = cardiovascular disease.

* Using the American College of Cardiology/American Heart Association Pooled Cohort Equations. Patients with diabetes mellitus or chronic kidney disease are automatically placed in the high-risk category. For initiation of use of a renin–angiotensin system inhibitor or diuretic therapy, clinicians should assess blood tests for electrolytes and renal function 2 to 4 wk after initiating therapy.

† Clinicians should consider initiation of pharmacologic therapy for stage 2 hypertension with 2 antihypertensive agents from different classes. Patients with stage 2 hypertension and BP ≥160/100 mm Hg should be promptly treated, carefully monitored, and subject to upward medication dose adjustment as necessary to control BP. Reassessment includes BP measurement, detection of orthostatic hypotension in selected patients (e.g., older patients or those with postural symptoms), identification of white coat hypertension or a white coat effect, documentation of adherence, monitoring of response to therapy, reinforcement of the importance of adherence, reinforcement of the importance of treatment, and assistance with treatment to achieve the BP target.

For high-risk adults with stage 1 hypertension who have preexisting CVD or an estimated 10-year ASCVD risk of at least 10%, the guideline recommends initiating drug treatment for those with an average BP of 130/80 mm Hg or higher (class I recommendation, high-quality evidence). For lower-risk adults without preexisting CVD and an estimated 10-year ASCVD risk less than 10%, the BP threshold for drug treatment is 140/90 mm Hg or higher (class I recommendation, low-quality evidence) (Table 4).

The ACC/AHA Pooled Cohort Equations (http://tools.acc.org/ASCVD-Risk-Estimator), which are based on age, race, sex, cholesterol levels (total, low-density lipoprotein, and high-density lipoprotein), statin use, SBP, treatment for hypertension, history of diabetes mellitus (DM), current smoking, and aspirin use, are recommended to estimate 10-year risk for ASCVD, which is defined as a first nonfatal myocardial infarction, coronary heart disease death, or fatal or nonfatal stroke among adults without CVD. Adults with DM, those with chronic kidney disease (CKD), and those aged 65 years or older are in the high–risk category for ASCVD.

BP Goals for Patients With Hypertension

Table 4 summarizes recommendations on BP thresholds and goals for treatment of adults with hypertension.
After initiation of antihypertensive drug therapy, regardless of ASCVD risk, the recommended BP target is less than 130/80 mm Hg.
The quality of evidence supporting this target is stronger for patients with known CVD or an estimated 10-year ASCVD risk of at least 10% than for patients without elevated risk.
A recent systematic review and network meta-analysis showed continuing reduction in CVD risk (major cardiovascular events, stroke, coronary heart disease, and all-cause mortality) at progressively lower levels of achieved SBP. A sensitivity analysis demonstrated a similar pattern when the results of SPRINT (Systolic Blood Pressure Intervention Trial) were excluded

Choice of Antihypertensive Drug Therapy

The evidence review conducted to inform the recommendations found some differences but general similarity in the efficacy and safety of drugs traditionally considered first-line agents, underscoring the importance of BP lowering above the choice of drug.
Recommendations on initial agents are summarized in Table 4. For adults without a compelling indication for use of a specific drug, clinicians should initiate therapy with thiazide diuretics, calcium-channel blockers, angiotensin-converting enzyme inhibitors, or angiotensin-receptor blockers.
Thiazide diuretics (especially chlorthalidone) and calcium-channel blockers are the preferred options for first-line therapy in most U.S. adults because of their efficacy.
In black patients, including those with DM, thiazide diuretics and calcium-channel blockers are recommended as first-line agents, whereas β-blockers and renin–angiotensin system inhibitors are less effective at lowering BP.

For patients with stage 2 hypertension, initiation of 2 antihypertensive agents from different classes is recommended when the average SBP and DBP are more than 20 and 10 mm Hg above target, respectively.
Patients with stage 2 hypertension and an average BP of 160/100 mm Hg or higher should be treated promptly, should be carefully monitored, and should have prompt adjustment of their regimen until control is achieved.

After initiation of drug therapy, management should include monthly evaluation of adherence and therapeutic response until control is achieved. Interventions to promote control, such as HBPM, team-based care, and telehealth, are useful in improving BP control.

Goals for treatment of adults with hypertension

Management of Resistant Hypertension

Resistant hypertension is defined as an average office BP of 130/80 mm Hg or higher in patients adhering to 3 or more antihypertensive agents from different classes at optimal doses, including a diuretic, or in those requiring 4 or more antihypertensive medications.
Using the former BP target of less than 140/90 mm Hg, the prevalence of resistant hypertension has been estimated to be 13% among hypertensive adults. Estimates suggest that the prevalence of resistant hypertension will be about 4% higher with the new BP target of less than 130/80 mm Hg.
Risk for myocardial infarction, stroke, end-stage renal disease, and death in adults with resistant hypertension (using the previous definition) is 2- to 6-fold higher than in adults with hypertension that is not resistant to treatment.

Clinicians caring for patients who fulfill the criteria for resistant hypertension should ensure that the diagnosis is based on accurate office BP measurements, assess for nonadherence to the prescribed antihypertensive medications, and obtain home or ambulatory BP readings to rule out the white coat effect. Contributing lifestyle factors should be identified and addressed. Use of substances that interfere with antihypertensive therapy, such as nonsteroidal anti-inflammatory drugs, stimulants, and oral contraceptives, should be discontinued or minimized, and secondary causes of hypertension should be excluded.

Treatment of resistant hypertension includes maximization of diuretic therapy (chlorthalidone or indapamide instead of hydrochlorothiazide), addition of a mineralocorticoid receptor antagonist (spironolactone or eplerenone), addition of other agents with different mechanisms of action, use of loop diuretics in patients with CKD, and referral to a hypertension specialist if BP remains uncontrolled (Table 5).

Table 5. Recommendations for Managing Resistant Hypertension
and Improving Hypertension Management*

Strategies to Improve Hypertension Treatment and Control

Every adult with hypertension should have an evidence-based care plan that promotes treatment and self-management goals, effective management of comorbid conditions, timely follow-up, and CVD guideline–directed management (Table 5).
Up to 25% of patients do not fill their initial prescription for antihypertensive drug therapy, and only 1 in 5 patients has sufficiently high adherence to achieve the benefits observed in randomized controlled trials.
Once-daily dosing of antihypertensive medication and use of combination pills can improve adherence.

A team-based care approach is recommended for adults with hypertension.
In addition, use of the electronic health record and patient registries is beneficial in recognizing uncontrolled hypertension and guiding initiatives for quality improvement in hypertension control.
Telehealth strategies also can be useful adjuncts to interventions shown to lower BP for adults with hypertension.

Summary

Hypertension is a leading risk factor for death and disability-adjusted life-years worldwide.
Blood pressure of 120/80 mm Hg or higher is linearly related to risk for fatal and nonfatal stroke, ischemic heart disease, and noncardiac vascular disease, and each increase of 20/10 mm Hg doubles the risk for a fatal CVD event.
The 2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults is the first comprehensive hypertension clinical practice guideline since 2003.
The 2017 guideline uses a different classification system for BP than previous guidelines; emphasizes out-of-office BP measurements to confirm the diagnosis of and monitor success in control of hypertension; advocates team-based care and use of the electronic health record and telehealth strategies for improved care; recommends nonpharmacologic interventions; and recommends addition of antihypertensive drug therapy based on a combination of average BP, ASCVD risk, and comorbid conditions.

Key points to remember
2017 Guideline for High Blood Pressure in Adults

May 07, 2018 | Melvyn Rubenfire, MD, FACC
Authors: Whelton PK, Carey RM, Aronow WS, et al.
Citation:2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018;71:e127-e248.

The following are key points to remember from the 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults:

Part 1: General Approach, Screening, and Follow-up

1. The 2017 guideline is an update of the “Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure” (JNC 7), published in 2003. The 2017 guideline is a comprehensive guideline incorporating new information from studies regarding blood pressure (BP)-related risk of cardiovascular disease (CVD), ambulatory BP monitoring (ABPM), home BP monitoring (HBPM), BP thresholds to initiate antihypertensive drug treatment, BP goals of treatment, strategies to improve hypertension treatment and control, and various other important issues.

2. It is critical that health care providers follow the standards for accurate BP measurement. BP should be categorized as normal, elevated, or stages 1 or 2 hypertension to prevent and treat high BP. Normal BP is defined as <120/<80 mm Hg; elevated BP 120-129/<80 mm Hg; hypertension stage 1 is 130-139 or 80-89 mm Hg, and hypertension stage 2 is ≥140 or ≥90 mm Hg. Prior to labeling a person with hypertension, it is important to use an average based on ≥2 readings obtained on ≥2 occasions to estimate the individual’s level of BP. Out-of-office and self-monitoring of BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication, in conjunction with clinical interventions and telehealth counseling. Corresponding BPs based on site/methods are: office/clinic 140/90, HBPM 135/85, daytime ABPM 135/85, night-time ABPM 120/70, and 24-hour ABPM 130/80 mm Hg. In adults with an untreated systolic BP (SBP) >130 but <160 mm Hg or diastolic BP (DBP) >80 but <100 mm Hg, it is reasonable to screen for the presence of white coat hypertension using either daytime ABPM or HBPM prior to diagnosis of hypertension. In adults with elevated office BP (120-129/<80) but not meeting the criteria for hypertension, screening for masked hypertension with daytime ABPM or HBPM is reasonable.

3. For an adult 45 years of age without hypertension, the 40-year risk for developing hypertension is 93% for African Americans, 92% for Hispanics, 86% for whites, and 84% for Chinese adults. In 2010, hypertension was the leading cause of death and disability-adjusted life-years worldwide, and a greater contributor to events in women and African Americans compared with whites. Often overlooked, the risk for CVD increases in a log-linear fashion; from SBP levels <115 mm Hg to >180 mm Hg, and from DBP levels <75 mm Hg to >105 mm Hg. A 20 mm Hg higher SBP and 10 mm Hg higher DBP are each associated with a doubling in the risk of death from stroke, heart disease, or other vascular disease. In persons ≥30 years of age, higher SBP and DBP are associated with increased risk for CVD, angina, myocardial infarction (MI), heart failure (HF), stroke, peripheral arterial disease, and abdominal aortic aneurysm. SBP has consistently been associated with increased CVD risk after adjustment for, or within strata of, SBP; this is not true for DBP.

4. It is important to screen for and manage other CVD risk factors in adults with hypertension: smoking, diabetes, dyslipidemia, excessive weight, low fitness, unhealthy diet, psychosocial stress, and sleep apnea. Basic testing for primary hypertension includes fasting blood glucose, complete blood cell count, lipids, basic metabolic panel, thyroid stimulating hormone, urinalysis, electrocardiogram with optional echocardiogram, uric acid, and urinary albumin-to-creatinine ratio.

5. Screening for secondary causes of hypertension is necessary for new-onset or uncontrolled hypertension in adults including drug-resistant (≥3 drugs), abrupt onset, age <30 years, excessive target organ damage (cerebral vascular disease, retinopathy, left ventricular hypertrophy, HF with preserved ejection fraction [HFpEF] and HF with reserved EF [HFrEF], coronary artery disease [CAD], chronic kidney disease [CKD], peripheral artery disease, albuminuria) or for onset of diastolic hypertension in older adults or in the presence of unprovoked or excessive hypokalemia. Screening includes testing for CKD, renovascular disease, primary aldosteronism, obstructive sleep apnea, drug-induced hypertension (nonsteroidal anti-inflammatory drugs, steroids/androgens, decongestants, caffeine, monoamine oxidase inhibitors), and alcohol-induced hypertension. If more specific clinical characteristics are present, screening for uncommon causes of secondary hypertension is indicated (pheochromocytoma, Cushing’s syndrome, congenital adrenal hyperplasia, hypothyroidism, hyperthyroidism, and aortic coarctation). Physicians are advised to refer patients screening positive for these conditions to a clinician with specific expertise in the condition.

6. Nonpharmacologic interventions to reduce BP include: weight loss for overweight or obese patients with a heart healthy diet, sodium restriction, and potassium supplementation within the diet; and increased physical activity with a structured exercise program. Men should be limited to no more than 2 and women no more than 1 standard alcohol drink(s) per day. The usual impact of each lifestyle change is a 4-5 mm Hg decrease in SBP and 2-4 mm Hg decrease in DBP; but diet low in sodium, saturated fat, and total fat and increase in fruits, vegetables, and grains may decrease SBP by approximately 11 mm Hg.

7. The benefit of pharmacologic treatment for BP reduction is related to atherosclerotic CVD (ASCVD) risk. For a given magnitude reduction of BP, fewer individuals with high ASCVD risk would need to be treated to prevent a CVD event (i.e., lower number needed to treat) such as in older persons, those with coronary disease, diabetes, hyperlipidemia, smokers, and CKD. Use of BP-lowering medications is recommended for secondary prevention of recurrent CVD events in patients with clinical CVD and an average SBP ≥130 mm Hg or a DBP ≥80 mm Hg, or for primary prevention in adults with no history of CVD but with an estimated 10-year ASCVD risk of ≥10% and SBP ≥130 mm Hg or DBP ≥80 mm Hg. Use of BP-lowering medication is also recommended for primary prevention of CVD in adults with no history of CVD and with an estimated 10-year ASCVD risk <10% and a SBP ≥140 mm Hg or a DBP ≥90 mm Hg. The prevalence of hypertension is lower in women compared with men until about the fifth decade, but is higher later in life. While no randomized controlled trials have been powered to assess outcome specifically in women (e.g., SPRINT), other than special recommendations for management of hypertension during pregnancy, there is no evidence that the BP threshold for initiating drug treatment, the treatment target, the choice of initial antihypertensive medication, or the combination of medications for lowering BP differs for women compared with men. For adults with confirmed hypertension and known CVD or 10-year ASCVD event risk of 10% or higher, a BP target of <130/80 mm Hg is recommended. For adults with confirmed hypertension, but without additional markers of increased CVD risk, a BP target of <130/80 mm Hg is recommended as reasonable.

8. Follow-up: In low-risk adults with elevated BP or stage 1 hypertension with low ASCVD risk, BP should be repeated after 3-6 months of nonpharmacologic therapy. Adults with stage 1 hypertension and high ASCVD risk (≥10% 10-year ASCVD risk) should be managed with both nonpharmacologic and antihypertensive drug therapy with repeat BP in 1 month. Adults with stage 2 hypertension should be evaluated by a primary care provider within 1 month of initial diagnosis, and be treated with a combination of nonpharmacologic therapy and 2 antihypertensive drugs of different classes with repeat BP evaluation in 1 month. For adults with a very high average BP (e.g., ≥160 mm Hg or DBP ≥100 mm Hg), prompt evaluation and drug treatment followed by careful monitoring and upward dose adjustment is recommended.

Part 2: Principles of Drug Therapy and Special Populations

9. Principles of drug therapy: Chlorthalidone (12.5-25 mg) is the preferred diuretic because of long half-life and proven reduction of CVD risk. Angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), and direct renin inhibitors should not be used in combination. ACE inhibitors and ARBs increase the risk of hyperkalemia in CKD and with supplemental K+ or K+-sparing drugs. ACE inhibitors and ARBs should be discontinued during pregnancy. Calcium channel blocker (CCB) dihydropyridines cause edema. Non-dihydropyridine CCBs are associated with bradycardia and heart block and should be avoided in HFrEF. Loop diuretics are preferred in HF and when glomerular filtration rate (GFR) is <30 ml/min. Amiloride and triamterene can be used with thiazides in adults with low serum K+, but should be avoided with GFR <45 ml/min.

Spironolactone or eplerenone is preferred for the treatment of primary aldosteronism and in resistant hypertension. Beta-blockers are not first-line therapy except in CAD and HFrEF. Abrupt cessation of beta-blockers should be avoided. Bisoprolol and metoprolol succinate are preferred in hypertension with HFrEF and bisoprolol when needed for hypertension in the setting of bronchospastic airway disease. Beta-blockers with both alpha- and beta-receptor activity such as carvedilol are preferred in HFrEF.

Alpha-1 blockers are associated with orthostatic hypotension; this drug class may be considered in men with symptoms of benign prostatic hyperplasia. Central acting alpha2-agonists should be avoided, and are reserved as last-line due to side effects and the need to avoid sudden discontinuation. Direct-acting vasodilators are associated with sodium and water retention and must be used with a diuretic and beta-blocker.

10. Initial first-line therapy for stage 1 hypertension includes thiazide diuretics, CCBs, and ACE inhibitors or ARBs. Two first-line drugs of different classes are recommended with stage 2 hypertension and average BP of 20/10 mm Hg above the BP target. Improved adherence can be achieved with once-daily drug dosing, rather than multiple dosing, and with combination therapy rather than administration of the free individual components.

For adults with confirmed hypertension and known stable CVD or ≥10% 10-year ASCVD risk, a BP target of <130/80 mm Hg is recommended. The strategy is to first follow standard treatment guidelines for CAD, HFrEF, previous MI, and stable angina, with the addition of other drugs as needed to further control BP. In HFpEF with symptoms of volume overload, diuretics should be used to control hypertension, following which ACE inhibitors or ARBs and beta-blockers should be titrated to SBP <130 mm Hg. Treatment of hypertension with an ARB can be useful for prevention of recurrence of atrial fibrillation.

11. CKD: BP goal should be <130/80 mm Hg. In those with stage 3 or higher CKD or stage 1 or 2 CKD with albuminuria (>300 mg/day), treatment with an ACE inhibitor is reasonable to slow progression of kidney disease. An ARB is reasonable if an ACE inhibitor is not tolerated.

12. Adults with stroke and cerebral vascular disease are complex. To accommodate the variety of important issues pertaining to BP management in the stroke patient, treatment recommendations require recognition of stroke acuity, stroke type, and therapeutic objectives, which along with ideal antihypertensive therapeutic class have not been fully studied in clinical trials. In adults with acute intracranial hemorrhage and SBP >220 mm Hg, it may be reasonable to use continuous intravenous drug infusion with close BP monitoring to lower SBP. Immediate lowering of SBP to <140 mm Hg from 150-220 mm Hg is not of benefit to reduce death, and may cause harm. In acute ischemic stroke, BP should be lowered slowly to <185/110 mm Hg prior to thrombolytic therapy and maintained to <180/105 mm Hg for at least the first 24 hours after initiating drug therapy. Starting or restarting antihypertensive therapy during the hospitalization when patients with ischemic stroke are stable with BP >140/90 mm Hg is reasonable. In those who do not undergo reperfusion therapy with thrombolytics or endovascular treatment, if the BP is ≥220/120 mm Hg, the benefit of lowering BP is not clear, but it is reasonable to consider lowering BP by 15% during the first 24 hours post onset of stroke. However, initiating or restarting treatment when BP is <220/120 mm Hg within the first 48-72 hours post-acute ischemic stroke is not effective.

Secondary prevention following a stroke or transient ischemic attack (TIA) should begin by restarting treatment after the first few days of the index event to reduce recurrence. Treatment with ACE inhibitor or ARB with thiazide diuretic is useful. Those not previously treated for hypertension and who have a BP ≥140/90 mm Hg should begin antihypertensive therapy a few days after the index event. Selection of drugs should be based on comorbidities. A goal of <130/80 mm Hg may be reasonable for those with a stroke or TIA. For those with an ischemic stroke and no previous treatment for hypertension, there is no evidence of treatment benefit if the BP is <140/90 mm Hg.

13. Diabetes mellitus (DM) and hypertension: Antihypertensive drug treatment should be initiated at a BP ≥130/80 mm Hg with a treatment goal of <130/80 mm Hg. In adults with DM and hypertension, all first-line classes of antihypertensive agents (i.e., diuretics, ACE inhibitors, ARBs, and CCBs) are useful and effective. ACE inhibitors or ARBs may be considered in the presence of albuminuria.

14. Metabolic syndrome: Lifestyle modification with an emphasis on improving insulin sensitivity by means of dietary modification, weight reduction, and exercise is the foundation of treatment of the metabolic syndrome. The optimal antihypertensive drug therapy for patients with hypertension in the setting of the metabolic syndrome has not been clearly defined. Chlorthalidone was at least as effective for reducing CV events as the other antihypertensive agents in the ALLHAT study. Traditional beta-blockers should be avoided unless used for ischemic heart disease.

15. Valvular heart disease: Asymptomatic aortic stenosis with hypertension should be treated with pharmacotherapy, starting at a low dose, and gradually titrated upward as needed. In patients with chronic aortic insufficiency, treatment of systolic hypertension is reasonable with agents that do not slow the heart rate (e.g., avoid beta-blockers).

16. Aortic disease: Beta-blockers are recommended as the preferred antihypertensive drug class in patients with hypertension and thoracic aortic disease.

17. Race/ethnicity: In African American adults with hypertension but without HF or CKD, including those with DM, initial antihypertensive treatment should include a thiazide-type diuretic or CCB. Two or more antihypertensive medications are recommended to achieve a BP target of <130/80 mm Hg in most adults, especially in African American adults, with hypertension.

18. Age-related issues: Treatment of hypertension is recommended for noninstitutionalized ambulatory community-dwelling adults (≥65 years of age), with an average SBP ≥130 mm Hg with SBP treatment goal of <130 mm Hg. For older adults (≥65 years of age) with hypertension and a high burden of comorbidity and/or limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions regarding intensity of BP lowering and choice of antihypertensive drugs. BP lowering is reasonable to prevent cognitive decline and dementia.

19. Preoperative surgical procedures: Beta-blockers should be continued in persons with hypertension undergoing major surgery, as should other antihypertensive drug therapy until surgery. Discontinuation of ACE inhibitors and ARBs perioperatively may be considered. For patients with planned elective major surgery and SBP ≥180 mm Hg or DBP ≥110 mm Hg, deferring surgery may be considered. Abrupt preoperative discontinuation of beta-blockers or clonidine may be harmful. Intraoperative hypertension should be managed with intravenous medication until oral medications can be resumed.

20. For discussion regarding hypertensive crises with and without comorbidities, refer to Section 11.2: Hypertensive Crises–Emergencies and Urgencies in the Guideline.

21. Every adult with hypertension should have a clear, detailed, and current evidence-based plan of care that ensures the achievement of treatment and self-management goals; effective management of comorbid conditions; timely follow-up with the healthcare team; and adheres to CVD evidence-based guidelines. Effective behavioral and motivational strategies are recommended to promote lifestyle modification. A structured team-based approach including a physician, nurse, and pharmacist collaborative model is recommended, along with integrating home-based monitoring and telehealth interventions. Outcome may be improved with quality improvement strategies at the health system, provider, and patient level. Financial incentives paid to providers can be useful.

Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults

Table of Contents Preamble e130
1. Introduction e133
1.1. Methodology and Evidence Review e133
1.2. Organization of the Writing Committee e133
1.3. Document Review and Approval e134
1.4. Scope of the Guideline e134
1.5. Abbreviations and Acronyms e134

2. BP and CVD Risk e134
2.1. Observational Relationship e134
2.2. BP Components e136
2.3. Population Risk e136
2.4. Coexistence of Hypertension and Related Chronic Conditions e136

3. Classification of BP e137
3.1. Definition of High BP e137
3.2. Lifetime Risk of Hypertension e138
3.3. Prevalence of High BP e138
3.4. Awareness, Treatment, and Control e139

4. Measurement of BP e140
4.1. Accurate Measurement of BP in the Office e140
4.2. Out-of-Office and Self-Monitoring of BP e141
4.3. Ambulatory BP Monitoring e142
4.4. Masked and White Coat Hypertension e143

5. Causes of Hypertension e146
5.1. Genetic Predisposition e146
5.2. Environmental Risk Factors e146
5.2.1. Overweight and Obesity e146
5.2.2. Sodium Intake e147
5.2.3. Potassium e147
5.2.4. Physical Fitness e147
5.2.5. Alcohol e147
5.3. Childhood Risk Factors and BP Tracking e147
5.4. Secondary Forms of Hypertension e148
5.4.1. Drugs and Other Substances With Potential to Impair BP Control e151
5.4.2. Primary Aldosteronism e152
5.4.3. Renal Artery Stenosis e153
5.4.4. Obstructive Sleep Apnea e154

6. Nonpharmacological Interventions e154
6.1. Strategies e154
6.2. Nonpharmacological Interventions e155

7. Patient Evaluation e158
7.1. Laboratory Tests and Other Diagnostic Procedures e159
7.2. Cardiovascular Target Organ Damage e159

8. Treatment of High BP e160
8.1. Pharmacological Treatment e160
8.1.1. Initiation of Pharmacological BP Treatment in the Context of Overall CVD Risk e160
8.1.2. BP Treatment Threshold and the Use of CVD Risk Estimation to Guide Drug Treatment of Hypertension e160
8.1.3. Follow-Up After Initial BP Evaluation e163
8.1.4. General Principles of Drug Therapy e164
8.1.5. BP Goal for Patients With Hypertension e167
8.1.6. Choice of Initial Medication e168
8.2. Achieving BP Control in Individual Patients e169
8.3. Follow-Up of BP During Antihypertensive Drug Therapy e170
8.3.1. Follow-Up After Initiating Antihypertensive Drug Therapy e170
8.3.2. Monitoring Strategies to Improve Control of BP in Patients on Drug Therapy for High BP e171

9. Hypertension in Patients With Comorbidities e171
9.1. Stable Ischemic Heart Disease e172
9.2. Heart Failure e173
9.2.1. Heart Failure With Reduced Ejection Fraction e174
9.2.2. Heart Failure With Preserved Ejection Fraction e174
9.3. Chronic Kidney Disease e175
9.3.1. Hypertension After Renal Transplantation e177
9.4. Cerebrovascular Disease e178
9.4.1. Acute Intracerebral Hemorrhage e178
9.4.2. Acute Ischemic Stroke e180
9.4.3. Secondary Stroke Prevention e182
9.5. Peripheral Artery Disease e184
9.6. Diabetes Mellitus e184
9.7. Metabolic Syndrome e185
9.8. Atrial Fibrillation e186
9.9. Valvular Heart Disease e187
9.10. Aortic Disease e188

10. Special Patient Groups e188
10.1. Race and Ethnicity e188
10.1.1 Racial and Ethnic Differences in Treatment e189
10.2. Sex-Related Issues e189
10.2.1. Women e190
10.2.2. Pregnancy e190
10.3. Age-Related Issues e191
10.3.1. Older Persons e191
10.3.2. Children and Adolescents e192

11. Other Considerations e193
11.1. Resistant Hypertension e193
11.2. Hypertensive Crises—Emergencies and Urgencies e194
11.3. Cognitive Decline and Dementia e197
11.4. Sexual Dysfunction and Hypertension e198
11.5. Patients Undergoing Surgical Procedures e199

12. Strategies to Improve Hypertension Treatment and Control e200
12.1. Adherence Strategies for Treatment of Hypertension e200
12.1.1. Antihypertensive Medication Adherence Strategies e201
12.1.2. Strategies to Promote Lifestyle Modification e202
12.1.3. Improving Quality of Care for Resource-Constrained Populations e202
12.2. Structured, Team-Based Care Interventions for Hypertension Control e203
12.3. Health Information Technology–Based Strategies to Promote Hypertension Control e204
12.3.1. EHR and Patient Registries e204
12.3.2. Telehealth Interventions to Improve Hypertension Control e204
12.4. Improving Quality of Care for Patients With Hypertension e205
12.4.1. Performance Measures e205
12.4.2. Quality Improvement Strategies e205
12.5. Financial Incentives e206

13. The Plan of Care for Hypertension e207
13.1. Health Literacy e207
13.2. Access to Health Insurance and Medication Assistance Plans e207
13.3. Social and Community Services e207

14. Summary of BP Thresholds and Goals for Pharmacological Therapy e208

15. Evidence Gaps and Future Directions e208

Appendix 1
Author Relationships With Industry and Other Entities (Relevant) e238
Appendix 2
Reviewer Relationships With Industry and Other Entities (Comprehensive) e240

2017 Guideline for High Blood Pressure in Adults
(A Selection of Tables and Figures)

Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults (2017)
(Executive Summery) Full Text
(Executive Summery)
A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA

• Chest pain (angina) ---> Beta blocker, which can lower your blood pressure and also prevent chest pain, reduce heart rate and decrease risk of death.
• Diabetes ---> Diuretic + ACE inhibitor can decrease risk of a heart attack and stroke.
• Diabetes and kidney disease ---> ACE inhibitor or an angiotensin II receptor blocker.

• Isolated systolic hypertension< ---> Diuretics, Calcium channel blockers

Younger people with high blood pressure (20-50 year olds):
• ACE Inhibitors, or angiotensin receptor blockers (ARBs), are recommended as first line therapy because they lower blood pressure and the risk of stroke and heart disease.
ACE inhibitors are cheap, well tolerated medications that end in -il (for example: lisinopril, enalapril, benazepril).
ARBs are very similar to ACE inhibitors but do not carry the dry cough side-effect that ACE inhibitors have. Common ARBs are losartan, irbesartan and valsartan.

• Beta blockers are a second option for younger patients who can’t take ACE inhibitors or ARBs, as some studies show that they don’t provide the same protection against stroke risk. Commonly used beta blockers include atenolol, metoprolol and carvedilol.

• Studies show improved blood pressure in patients taking the above options rather than diuretics (chlorthalidone, hydrochlorothiazide) and calcium channel blockers.

African Americans:
African American patients with high blood pressure have lower levels of renin activity, a hormone that controls blood pressure. For this reason ACE Inhibitors and ARBs are not as effective.
• Thiazide diuretics (hydrochlorothiazide, chlorthalidone) are suggested as a first line treatment. Chlorthalidone is preferred over hydrochlorothiazide as there is more evidence of improved outcomes and it is more potent and longer acting. Both are safe, effective, well tolerated, and cheap.
• Calcium channel blockers, namely amlodipine (Norvasc), or the less often prescribed felodipine, are also recommended as first choice to control blood pressure, specifically in African Americans.

People over 60-65 years old:
• According to many studies, thiazide diuretics (hydrochlorothiazide, chlorthalidone) and calcium channel blockers (amlodipine) are the place to start.
• ACE inhibitors (lisinopril, benazepril, etc) or ARBs (valsartan, irbesartan, losartan) are also recommended as a good place to start.
• Studies have shown that beta blockers should not be used as first line therapy for high blood pressure in patients over the age of 60, as they may be associated with inferior protection against stroke risk.

Folks with REALLY high blood pressure (approximately 160/90 and above):
• Combination medications (two drugs) as an initial therapy should be considered when the blood pressure is more than 20/10 mmHg above goal. Many combinations exist, so discuss the options with your doctor.

What about patients with heart failure, diabetes, or heart attack?
For people with diabetes, heart failure, and those who have had a heart attack, blood pressure medications are added to lower blood pressure and also improve outcomes. Simply put, beta blockers, ACE inhibitors and ARBs improve outcomes in people after a heart attack and in those with diabetes or heart failure.

Evidence-Based Answer
In comparing the effects of thiazide diuretics, beta blockers, angiotensin-converting enzyme (ACE) inhibitors, and calcium channel blockers (CCBs) with placebo, thiazide diuretics lowered mortality and morbidity from stroke, heart attack, and heart failure more than beta blockers. (However, only low-dose thiazide diuretics were effective; high-dose thiazide diuretics were no different than placebo in risk of mortality and cardiovascular events.)
ACE inhibitors and CCBs reduced mortality and morbidity as much as thiazide diuretics, but the evidence is less robust.
Because the use of thiazide diuretics is supported by a strong body of evidence and no other class of antihypertensive medications has been shown to be better at improving outcomes, they are the first-line drugs for most patients with hypertension.
Current evidence does not support using beta blockers as first-line therapy for hypertension

Summary

Thiazide diuretics are often the first, but not the only, choice in high blood pressure medications. Thiazide diuretics include chlorthalidone, hydrochlorothiazide (Microzide) and others.

Calcium channel blockers, or calcium antagonists, treat a variety of conditions, such as high blood pressure, chest pain and Raynaud's disease.
Some calcium channel blockers have the added benefit of slowing your heart rate, which can further reduce blood pressure, relieve chest pain (angina) and control an irregular heartbeat.
Diuretics or calcium channel blockers may work better for people of African heritage and older people than do angiotensin-converting enzyme (ACE) inhibitors alone.
Grapefruit juice interacts with some calcium channel blockers.

ACE inhibitor and ARBs
People with chronic kidney disease may benefit from having an angiotensin-converting enzyme (ACE) inhibitor or Angiotensin II receptor blockers (ARBs) as one of their medications.

Alpha blockers treat conditions such as high blood pressure and benign prostatic hyperplasia.
Alpha blockers might decrease low-density lipoprotein (LDL) cholesterol (the "bad" cholesterol).

Vasodilators
To prevent, treat or improve symptoms in a variety of conditions, such as:
High blood pressure
High blood pressure during pregnancy or childbirth (preeclampsia or eclampsia)
Heart failure
High blood pressure that affects the arteries in your lungs (pulmonary hypertension)
Direct vasodilators are strong medications that generally are used only when other medications haven't controlled your blood pressure adequately.

Additional medications sometimes used to treat high blood pressure
• Alpha blockers. These medications reduce nerve impulses to blood vessels, reducing the effects of natural chemicals that narrow blood vessels. Alpha blockers include doxazosin (Cardura), prazosin (Minipress) and others.
• Alpha-beta blockers. In addition to reducing nerve impulses to blood vessels, alpha-beta blockers slow the heartbeat to reduce the amount of blood that must be pumped through the vessels. Alpha-beta blockers include carvedilol (Coreg) and labetalol (Trandate).
• Beta blockers. These medications reduce the workload on your heart and open your blood vessels, causing your heart to beat slower and with less force. Beta blockers include acebutolol (Sectral), atenolol (Tenormin) and others.
Beta blockers aren't usually recommended as the only medication you're prescribed, but they may be effective when combined with other blood pressure medications.

• Aldosterone antagonists. Examples are spironolactone (Aldactone) and eplerenone (Inspra). These drugs block the effect of a natural chemical that can lead to salt and fluid retention, which can contribute to high blood pressure.

• Renin inhibitors. Aliskiren (Tekturna) slows down the production of renin, an enzyme produced by your kidneys that starts a chain of chemical steps that increases blood pressure. Aliskiren works by reducing the ability of renin to begin this process.
Due to a risk of serious complications, including stroke, you shouldn't take aliskiren with ACE inhibitors or ARBs.

• Vasodilators. These medications, including hydralazine and minoxidil, work directly on the muscles in the walls of your arteries, preventing the muscles from tightening and your arteries from narrowing.

• Central-acting agents. These medications prevent your brain from signaling your nervous system to increase your heart rate and narrow your blood vessels. Examples include clonidine (Catapres, Kapvay), guanfacine (Intuniv, Tenex) and methyldopa.

Managing Hypertension Using Combination Therapy

Diuretics

There are three types of diuretics:
• Thiazide diuretics, such as hydrochlorothiazide, chlorthalidone (Thalitone). Aquatensen®, Diucardin® or Trichlorex®. This type of diuretic reduces the amount of salt and water in the body. It is also the only type of diuretic that widens the blood vessels to lower blood pressure. Thiazide diuretics are often the first drug given to treat high blood pressure. • Loop-acting diuretics, such as Bumex®, Demadex®, Edecrin® or Lasix®. These cause the kidneys to get rid of more urine, lowering the amount of water in the body and the blood pressure.
• Potassium-sparing diuretics, such as Aldactone®, Dyrenium® or Midamor®. These drugs reduce the amount of water in the body, but while other diuretics cause the body to lose potassium in the process, this type does not. This type of diuretic is often prescribed with another diuretic because, while it spares potassium, it does not control blood pressure as well as thiazide diuretics do.

Diuretics are especially effective for salt-sensitive patients with hypertension and older patients with isolated systolic hypertension. Aside from hypertension, diuretics are often prescribed for fluid retention (edema) caused by heart failure, kidney disorders, liver disease, or premenstrual bloating.

Thiazide diuretics may cause an elevated blood sugar level. In some people, this may be enough to cause diabetes or to make their diabetes worse. Blood sugar levels therefore should be monitored in people taking diuretics for blood pressure control.

chlorthalidone (Thalitone)

Hepatic Impairment and Renal Impairment --- No dosage adjustments are needed
Severe - agranulocytosis, aplastic anemia, pancytopenia, hemolytic anemia
Moderate- hyperbilirubinemia, jaundice, thrombocytopenia, leukopenia

■ For use as adjunctive therapy in edema associated with heart failure, hepatic cirrhosis, nephrotic syndrome, acute glomerulonephritis, chronic renal failure, and corticosteroid and estrogen therapy.
Initially, 50 to 100 mg PO once daily or 100 mg PO every other day.
Adjust dosage according to clinical response. Maintenance dose may be lower than the initial dose. Some patients may require up to 200 mg/day.
Doses above 200 mg/day usually do not produce a greater response. Effectiveness is well sustained during continued use.
Heart failure guidelines suggest a lower initial dose of 12.5 to 25 mg PO once daily and a maximum of 100 mg/day and recommend adding a thiazide diuretic to standard therapy for hypertensive patients with reduced ejection fraction heart failure (HFrEF) and mild fluid retention.
Diuretics should also be used in preserved ejection fraction heart failure (HFpEF).

■ For the treatment of hypertension.
Initially, 25 mg PO once daily. Adjust dosage according to clinical response up to 100 mg PO once daily.
Maintenance dose may be lower than the initial dose. Doses above 100 mg/day usually do not increase effectiveness.
Effectiveness is well sustained during continued use.
Clinical practice guidelines recommend a dose range of 12.5 to 25 mg PO daily.
A thiazide-type diuretic, calcium channel blocker, ACE inhibitor or ARB is recommended as an initial antihypertensive therapy in the general population without certain comorbidities.
In the general black population without heart failure or chronic kidney disease, including those with diabetes, clinical practice guidelines recommend initial antihypertensive treatment with a thiazide-type diuretic or a calcium channel blocker instead of an ACE inhibitor or ARB.

atenolol/chlorthalidone (Tenoretic)
Oral Tab: 100-25mg, 50-25mg

chlorothiazide (Diuril)

SUPPLIED
Chlorothiazide Sodium/Diuril/Sodium Diuril Intravenous Inj Pwd F/Sol: 0.5g, 500mg
Chlorothiazide/Diuril Oral Tab: 250mg, 500mg
Diuril Oral Susp: 5mL, 250mg
■ For the treatment of hypertension.
500 to 1,000 mg/day PO given in 1 to 2 divided doses (Max: 2,000 mg/day).

■ For use as an adjunctive agent to treat peripheral edema associated with congestive heart failure, hepatic cirrhosis (ascites), corticosteroid therapy, or estrogen therapy; or to treat edema associated with renal dysfunction including nephrotic syndrome, acute glomerulonephritis, and chronic renal failure.
500 to 1,000 mg/day PO given in 1 to 2 divided doses. Many patients with edema respond to intermittent therapy (e.g., every other day or 3 to 5 days each week). With an intermittent schedule, excessive diuresis and associated electrolyte imbalances are less likely to occur. Heart failure guidelines recommend adding a thiazide diuretic to standard therapy for hypertensive patients with reduced ejection fraction heart failure (HFrEF) and mild fluid retention. Diuretics should also be used in preserved ejection fraction heart failure (HFpEF).

Lifestyle changes

Whether you're beginning to develop high blood pressure (prehypertension) or you already have it (hypertension), you can benefit from lifestyle changes that can lower your blood pressure.

Lifestyle changes can reduce or eliminate your need for medications to control your blood pressure.
• Eat a healthy diet, focusing on fruits and vegetables and, especially, reduce the sodium in your diet.
• Maintain a healthy weight.
• Exercise. Get 30 minutes of moderate activity on most days of the week. It's OK to break up your activity into three 10-minute sessions a day.
• Limit the amount of alcohol you drink. For healthy adults, that means up to one drink a day for women of all ages and men older than 65, and up to two drinks a day for men 65 and younger.
• Don't smoke.
• Manage stress.

Treatment

Changing your lifestyle can go a long way toward controlling high blood pressure. Your doctor may recommend you make lifestyle changes including:
• Eating a heart-healthy diet with less salt
• Getting regular physical activity
• Maintaining a healthy weight or losing weight if you're overweight or obese
• Limiting the amount of alcohol you drink

But sometimes lifestyle changes aren't enough. In addition to diet and exercise, your doctor may recommend medication to lower your blood pressure.
Your blood pressure treatment goal depends on how healthy you are.

Your blood pressure treatment goal should be less than 130/80 mm Hg if:
• You're a healthy adult age 65 or older
• You're a healthy adult younger than age 65 with a 10 percent or higher risk of developing cardiovascular disease in the next 10 years
• You have chronic kidney disease, diabetes or coronary artery disease

Although 120/80 mm Hg or lower is the ideal blood pressure goal, doctors are unsure if you need treatment (medications) to reach that level.

If you're age 65 or older, and use of medications produces lower systolic blood pressure (such as less than 130 mm Hg), your medications won't need to be changed unless they cause negative effects to your health or quality of life.

The category of medication your doctor prescribes depends on your blood pressure measurements and your other medical problems. It's helpful if you work together with a team of medical professionals experienced in providing treatment for high blood pressure to develop an individualized treatment plan.

Medications to treat high blood pressure
• Thiazide diuretics. Diuretics, sometimes called water pills, are medications that act on your kidneys to help your body eliminate sodium and water, reducing blood volume.

Thiazide diuretics are often the first, but not the only, choice in high blood pressure medications. Thiazide diuretics include chlorthalidone, hydrochlorothiazide (Microzide) and others.

If you're not taking a diuretic and your blood pressure remains high, talk to your doctor about adding one or replacing a drug you currently take with a diuretic.

Diuretics or calcium channel blockers may work better for people of African heritage and older people than do angiotensin-converting enzyme (ACE) inhibitors alone.
A common side effect of diuretics is increased urination.

• Angiotensin-converting enzyme (ACE) inhibitors. These medications — such as lisinopril (Zestril), benazepril (Lotensin), captopril (Capoten) and others — help relax blood vessels by blocking the formation of a natural chemical that narrows blood vessels. People with chronic kidney disease may benefit from having an ACE inhibitor as one of their medications.

• Angiotensin II receptor blockers (ARBs). These medications help relax blood vessels by blocking the action, not the formation, of a natural chemical that narrows blood vessels. ARBs include candesartan (Atacand), losartan (Cozaar) and others. People with chronic kidney disease may benefit from having an ARB as one of their medications.

• Calcium channel blockers. These medications — including amlodipine (Norvasc), diltiazem (Cardizem, Tiazac, others) and others — help relax the muscles of your blood vessels. Some slow your heart rate. Calcium channel blockers may work better for older people and people of African heritage than do ACE inhibitors alone.
Grapefruit juice interacts with some calcium channel blockers, increasing blood levels of the medication and putting you at higher risk of side effects. Talk to your doctor or pharmacist if you're concerned about interactions.

Additional medications sometimes used to treat high blood pressure
If you're having trouble reaching your blood pressure goal with combinations of the above medications, your doctor may prescribe:
• Alpha blockers. These medications reduce nerve impulses to blood vessels, reducing the effects of natural chemicals that narrow blood vessels. Alpha blockers include doxazosin (Cardura), prazosin (Minipress) and others.

• Alpha-beta blockers. In addition to reducing nerve impulses to blood vessels, alpha-beta blockers slow the heartbeat to reduce the amount of blood that must be pumped through the vessels. Alpha-beta blockers include carvedilol (Coreg) and labetalol (Trandate).

• Beta blockers. These medications reduce the workload on your heart and open your blood vessels, causing your heart to beat slower and with less force. Beta blockers include acebutolol (Sectral), atenolol (Tenormin) and others.
Beta blockers aren't usually recommended as the only medication you're prescribed, but they may be effective when combined with other blood pressure medications.

• Aldosterone antagonists. Examples are spironolactone (Aldactone) and eplerenone (Inspra). These drugs block the effect of a natural chemical that can lead to salt and fluid retention, which can contribute to high blood pressure.

• Renin inhibitors. Aliskiren (Tekturna) slows down the production of renin, an enzyme produced by your kidneys that starts a chain of chemical steps that increases blood pressure.
Aliskiren works by reducing the ability of renin to begin this process. Due to a risk of serious complications, including stroke, you shouldn't take aliskiren with ACE inhibitors or ARBs.

• Vasodilators. These medications, including hydralazine and minoxidil, work directly on the muscles in the walls of your arteries, preventing the muscles from tightening and your arteries from narrowing.

• Central-acting agents. These medications prevent your brain from signaling your nervous system to increase your heart rate and narrow your blood vessels. Examples include clonidine (Catapres, Kapvay), guanfacine (Intuniv, Tenex) and methyldopa.

To reduce the number of daily medication doses you need, your doctor may prescribe a combination of low-dose medications rather than larger doses of one single drug. In fact, two or more blood pressure drugs often are more effective than one. Sometimes finding the most effective medication or combination of drugs is a matter of trial and error.

Resistant hypertension: When your blood pressure is difficult to control
If your blood pressure remains stubbornly high despite taking at least three different types of high blood pressure drugs, one of which usually should be a diuretic, you may have resistant hypertension.

People who have controlled high blood pressure but are taking four different types of medications at the same time to achieve that control also are considered to have resistant hypertension. The possibility of a secondary cause of the high blood pressure generally should be reconsidered.

Having resistant hypertension doesn't mean your blood pressure will never get lower. In fact, if you and your doctor can identify what's behind your persistently high blood pressure, there's a good chance you can meet your goal with the help of treatment that's more effective.

Your doctor or hypertension specialist may:
• Evaluate potential causes of your condition and determine if those can be treated
• Review medications you're taking for other conditions and recommend you not take any that worsen your blood pressure
• Recommend that you monitor your blood pressure at home to see if you may have higher blood pressure in the doctor's office (white coat hypertension)
• Suggest healthy lifestyle changes, such as eating a healthy diet with less salt, maintaining a healthy weight and limiting how much alcohol you drink
• Make changes to your high blood pressure medications to come up with the most effective combination and doses
• Consider adding an aldosterone antagonist such as spironolactone (Aldactone), which may lead to control of resistant hypertension

Some experimental therapies such as catheter-based radiofrequency ablation of renal sympathetic nerves (renal denervation) and electrical stimulation of carotid sinus baroreceptors are being studied.

If you don't take your high blood pressure medications exactly as directed, your blood pressure can pay the price. If you skip doses because you can't afford the medications, because you have side effects or because you simply forget to take your medications, talk to your doctor about solutions. Don't change your treatment without your doctor's guidance.

Angiotensin-converting enzyme (ACE) inhibitors

ACE inhibitors treat a variety of conditions, such as high blood pressure, scleroderma and migraines.

Angiotensin-converting enzyme (ACE) inhibitors help relax blood vessels. ACE inhibitors prevent an enzyme in your body from producing angiotensin II, a substance in your body that narrows your blood vessels and releases hormones that can raise your blood pressure. This narrowing can cause high blood pressure and force your heart to work harder.

Examples of ACE inhibitors

Many ACE inhibitors are available. Which one is best for you depends on your health and the condition being treated. People with chronic kidney disease may benefit from having an ACE inhibitor as one of their medications. People of African heritage and older people respond less well to ACE inhibitors than do white and younger people.

Examples of ACE inhibitors include:
•Benazepril (Lotensin)
•Captopril
•Enalapril (Vasotec)
•Fosinopril
•Lisinopril (Prinivil, Zestril)
•Moexipril
•Perindopril (Aceon)
•Quinapril (Accupril)
•Ramipril (Altace)
•Trandolapril (Mavik)

Uses for ACE inhibitors

Doctors prescribe ACE inhibitors to prevent, treat or improve symptoms in conditions such as:
•High blood pressure
•Coronary artery disease
•Heart failure
•Diabetes
•Certain chronic kidney diseases
•Heart attacks
•Scleroderma
•Migraines

Your doctor may prescribe other medications in addition to an ACE inhibitor, such as a diuretic or calcium channel blocker, as part of your high blood pressure treatment. ACE inhibitors are usually taken once daily.

Side effects and cautions

Doctors commonly prescribe ACE inhibitors because they don't often cause side effects.

Possible ACE inhibitor side effects include:
•Dry cough
•Increased blood-potassium level (hyperkalemia)
•Fatigue
•Dizziness
•Headaches
•Loss of taste

In rare cases — but more commonly in people of African heritage and in smokers — ACE inhibitors can cause some areas of your tissues to swell (angioedema). If it occurs in the throat, the swelling can be life-threatening.

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve), decrease the effectiveness of ACE inhibitors. Taking an occasional dose of these medications shouldn't change the effectiveness of your ACE inhibitor, but talk to your doctor if you regularly take NSAIDs.

Because ACE inhibitors can cause birth defects, talk to your doctor about other options to treat your blood pressure if you're pregnant or you plan to become pregnant.

Angiotensin-converting enzyme (ACE) inhibitors

• A first-choice blood pressure treatment for many people.
• Lowers the risk of heart attack and stroke.
• Protects kidney function, which is especially useful for people with diabetes or mild-to-moderate kidney disease.
• Recommended for anyone with heart failure since it lowers the risk of death and further damage to your heart.
• lisinopril -- Very cheap drug, and comes available as a liquid for children over 6 years of age.
• enalapril -- The only ACE inhibitor that doctors can give through an IV if that's needed.
• Migraine prevention

Downsides
• Up to 10% of people can get a dry cough while using this medicine. It ranges from a mild tickle in the throat to a persistent hacking cough.
• Requires a yearly blood test to see how the medicine is affecting your body.
• Zestril (lisinopril) isn't safe to use if you're pregnant.
• Doesn't work as well in people of African descent, and can cause a greater chance of face, tongue, or lip swelling.
(People of African heritage and older people respond less well to ACE inhibitors than do white and younger people.)
• enalapril -- Compared to other ACE inhibitors, less flexible on when you take it. Enalapril needs to be taken multiple times a day on an empty stomach.

lisinopril (Prinivil, QBRELIS, Zestril)

■ For the treatment of hypertension.
Initially, 10 mg PO once daily. The usual dosage range is 20 to 40 mg PO once daily.
Lower dosage may be necessary in patients with impaired renal function, the elderly, and in those receiving diuretics.
In patients with a creatinine clearance of less than 30 mL/minute, initiate therapy with 5 mg PO once daily. Max: 80 mg/day.

■ For the treatment of heart failure.
Initially, 2.5 to 5 mg PO once daily. Consider lowering the dose of concomitant diuretic therapy to minimize hypovolemia.
Hypotension after the initial dose does not preclude further titration.
In patients with hyponatremia (serum sodium less than 130 mEq/L), initiate therapy with 2.5 mg PO once daily. Increase dose as tolerated, adjusting to the clinical response of the patient up to 20 to 40 mg/day.
A suggested rate of dose adjustment for tolerance is to adjust by 10 mg/day or less at intervals of approximately 2 weeks.
Guidelines recommend an angiotensin-converting enzyme (ACE) inhibitor in combination with an evidence-based beta blocker and aldosterone antagonist, in select patients, for patients with chronic reduced ejection fraction heart failure (HFrEF) NYHA class I to IV to reduce morbidity and mortality.
In patients with prior or current symptoms of chronic HFrEF, use of an ACE inhibitor is recommended.
Continued use of an ACE inhibitor is recommended for all classes of HFrEF for those patients for whom subsequent angiotensin receptor-neprilysin inhibitor (ARNI) use is inappropriate. Use of an ACE inhibitor in patients with preserved ejection fraction heart failure (HFpEF) and hypertension is reasonable to control blood pressure.

■ To reduce cardiovascular morbidity and mortality postmyocardial infarction† or to improve survival of hemodynamically stable patients when administered within 24 hours of acute myocardial infarction (AMI). [See PDR]
■ For the treatment of persistent albuminuria† in patients with diabetic nephropathy† or in at-risk hypertensive patients†. . [See PDR]
■ To control the rate of progression of diabetic retinopathy† in patients with normotensive type I diabetes mellitus. [See PDR]
■ For migraine prophylaxis†.
10 mg PO once daily for 1 week, then 20 mg PO once daily. Or alternately, 2.5 mg PO once daily for 1 week followed by 5 mg PO once daily. Clinical practice guidelines classify lisinopril as possibly effective for migraine prophylaxis.

ADVERSE REACTIONS: angioedema, hyperkalemia, hepatic failure, hepatic necrosis, jaundice, cholestasi, hepatitis, elevated hepatic enzymes, thrombocytopenia, neutropenia, leukopenia, eosinophilia, anemia

enalapril (Epaned, Vasotec)

■ For the treatment of hypertension.
Initially, 2.5 to 5 mg PO once daily.
In patients with hyponatremia, hypovolemia, moderate-severe CHF, renal dysfunction (i.e., Scr more than 1.6 mg/dL), or in those receiving diuretics, an initial dose of 2.5 mg is recommended.
In patients at risk for hypotension or deterioration of renal function, dosage increases are generally recommended at intervals of 4 days or more.
The usual dosage range is 10 to 40 mg/day PO, given in 1 to 2 divided doses.
If blood pressure is not controlled with monotherapy, a diuretic may be added.
Intravenous dosage
Initially, 0.625 to 1.25 mg IV every 6 hours. Dosage may be titrated up to 5 mg IV every 6 hours. For patients with hyponatremia, hypovolemia, moderate-severe CHF, renal dysfunction (i.e., Scr more than 1.6 mg/dL), or in those receiving diuretics, the initial dose is 0.625 mg IV every 6 hours. For patients not at risk for excessive hypotension, the initial dosage is 1.25 mg IV every 6 hours.
■ For the treatment of heart failure.
■ For the treatment of hypertensive emergency† or hypertensive urgency†.
Intravenous dosage (enalaprilat)
Doses ranging from 1.25 to 5 mg IV every 6 hours have been recommended.
■ For the treatment of asymptomatic left ventricular dysfunction including postmyocardial infarction† patients. .

Angiotensin II receptor blockers

Angiotensin II receptor blockers (ARBs) are used to treat conditions such as high blood pressure and heart failure.

Angiotensin II receptor blockers (ARBs) help relax your blood vessels, which lowers your blood pressure and makes it easier for your heart to pump blood.

Angiotensin is a chemical in your body that affects your cardiovascular system in various ways, including narrowing your blood vessels. This narrowing can increase your blood pressure and force your heart to work harder.

Angiotensin II receptor blockers block the action of angiotensin II, allowing blood vessels to widen (dilate).

Examples of angiotensin II receptor blockers

Several ARBs are available. Which one is best for you depends on your health and the condition being treated.

Examples of angiotensin II receptor blockers include:
•Azilsartan (Edarbi)
•Candesartan (Atacand)
•Eprosartan
•Irbesartan (Avapro)
•Losartan (Cozaar)
•Olmesartan (Benicar)
•Telmisartan (Micardis)
•Valsartan (Diovan)

Uses for angiotensin II receptor blockers

Doctors prescribe these drugs to prevent, treat or improve symptoms in various conditions, such as:
•High blood pressure
•Heart failure
•Kidney failure in diabetes
•Chronic kidney diseases

Side effects and cautions

Few people have side effects when taking angiotensin II receptor blockers. Possible side effects include:
•Dizziness
•Elevated blood potassium level (hyperkalemia)
•Localized swelling of tissues (angioedema)

There have been some reports of intestinal problems in those taking olmesartan. Talk to your doctor if you develop severe diarrhea or lose a lot of weight while taking olmesartan.

Because angiotensin II receptor blockers can injure a developing fetus, don't take them if you are pregnant or plan to become pregnant.

Angiotensin II receptor blockers

losartan (Cozaar)

SUPPLIED Oral Tab: 25mg, 50mg, 100mg

■ For the treatment of hypertension, either alone or in combination with other antihypertensive agents.
Initially, 50 mg PO once daily, unless the patient is volume depleted.
The maintenance dosage range is 25 to 100 mg/day PO, given in 1 to 2 divided doses.
Maximal effects generally occur within 3 to 6 weeks.
The addition of a diuretic has a greater effect on lowering blood pressure than increasing the losartan dosage beyond 50 mg/day.
The addition of hydrochlorothiazide 12.5 mg to losartan 50 mg daily results in an additional 50% reduction in DBP and SBP.
A modest reduction in blood pressure (up to 3 mm Hg) is achieved by increasing the daily dose of losartan from 50 to 100 mg.
When volume depletion is suspected (e.g., patients taking diuretics), initiate therapy with 25 mg PO once daily.
■ For stroke prophylaxis in hypertensive patients with left ventricular hypertrophy (LVH).
NOTE: There is evidence that this benefit does not apply to Black patients.
Initially, 50 mg PO once daily. Maximal antihypertensive effects generally occur within 3 to 6 weeks. If needed for blood pressure (BP) reduction, add hydrochlorothiazide (HCTZ) 12.5 mg PO once daily and/or increase the losartan dosage to 100 mg PO once daily. If further BP control is needed, increase the HCTZ dosage to 25 mg PO once daily. This FDA-approved indication is based on the findings of the LIFE trial which compared losartan vs. atenolol in patients with hypertension and LVH. In this trial, losartan reduced the risk of stroke (nonfatal and fatal) by 25% compared to atenolol. The overall findings demonstrate that losartan is more effective than atenolol in reducing total mortality and cardiovascular morbidity and mortality, and is associated with less drug-related adverse events. In a pre-specified subanalysis of the LIFE study in diabetic hypertensives with LVH, similar findings are reported.

■ For the treatment of proteinuria or diabetic nephropathy. (LVH).
■ For the treatment of heart failure†. (LVH).

ADVERSE REACTIONS ventricular fibrillation, atrial fibrillation, stroke, bradycardia, ventricular tachycardia, myocardial infarction, arrhythmia exacerbation, AV block, angioedema, thrombocytopenia, hepatitis, hyperbilirubinemia, elevated hepatic enzymes,

valsartan (Diovan)

SUPPLIED Oral Tab: 40mg, 80mg, 160mg, 320mg

■ For the treatment of hypertension.
80 to 160 mg PO once daily initially when used as monotherapy in patients who are not volume-depleted. Max: 320 mg/day.
Addition of a diuretic has a greater effect than dose increases beyond 80 mg/day.

■ For the reduction of cardiovascular mortality in stable patients with left ventricular failure or left ventricular dysfunction (LVD) following acute myocardial infarction.
NOTE: The VALIANT trial has demonstrated comparable efficacy of valsartan versus captopril to reduce cardiovascular mortality in postmyocardial infarction patients with cardiac failure and/or left ventricular dysfunction. This study has also reported that the combination of valsartan with captopril increased the adverse events rate without improving survival.
■ For the treatment of heart failure (NYHA class II to IV).

ADVERSE REACTIONS hyperkalemia, angioedema, neutropenia, thrombocytopenia, anemia, hepatitis, elevated hepatic enzymes,

Calcium channel blockers

Calcium channel blockers, or calcium antagonists, treat a variety of conditions, such as high blood pressure, chest pain and Raynaud's disease.

Calcium channel blockers prevent calcium from entering cells of the heart and blood vessel walls, resulting in lower blood pressure. Calcium channel blockers, also called calcium antagonists, relax and widen blood vessels by affecting the muscle cells in the arterial walls.

Some calcium channel blockers have the added benefit of slowing your heart rate, which can further reduce blood pressure, relieve chest pain (angina) and control an irregular heartbeat.

Examples of calcium channel blockers

Some calcium channel blockers are available in short-acting and long-acting forms. Short-acting medications work quickly, but their effects last only a few hours. Long-acting medications are slowly released to provide a longer lasting effect.

Several calcium channel blockers are available. Which one is best for you depends on your health and the condition being treated.

Examples of calcium channel blockers include:
•Amlodipine (Norvasc)
•Diltiazem (Cardizem, Tiazac, others)
•Felodipine
•Isradipine
•Nicardipine
•Nifedipine (Adalat CC, Afeditab CR, Procardia)
•Nisoldipine (Sular)
•Verapamil (Calan, Verelan)

In some cases, your doctor might prescribe a calcium channel blocker with other high blood pressure medications or with cholesterol-lowering drugs such as statins.

Uses for calcium channel blockers

Doctors prescribe calcium channel blockers to prevent, treat or improve symptoms in a variety of conditions, such as:
•High blood pressure
•Coronary artery disease
•Chest pain (angina)
•Irregular heartbeats (arrhythmia)
•Some circulatory conditions, such as Raynaud's disease

For people of African heritage and older people, calcium channel blockers might be more effective than other blood pressure medications, such as beta blockers, angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers.

Side effects and cautions

Side effects of calcium channel blockers may include:
•Constipation
•Headache
•Palpitations
•Dizziness
•Rash
•Drowsiness
•Flushing
•Nausea
•Swelling in the feet and lower legs

Certain calcium channel blockers interact with grapefruit products.

Calcium channel blockers

Calcium channel blockers are widely used in the treatment of hypertension, angina pectoris, cardiac arrhythmias, and other disorders.
The longer-acting preparations have been prescribed with increasing frequency.
According to recommendations from the Eighth Joint National Committee (JNC 8) members, calcium channel blockers are a recommended choice for initial management of hypertension, either as monotherapy or as part of antihypertensive combination therapy.
There are robust data suggesting that their use reduces the risk of subsequent cardiovascular events.
In addition, some meta-analyses have suggested that calcium channel blockers may be more effective than other drugs in reducing stroke risk.

UPDATE
Calcium channel blockers should generally be avoided in patients with heart failure with reduced ejection fraction (HFrEF) since they provide no functional or mortality benefit and some first generation agents may worsen outcomes
Calcium channel blockers have a better defined role in the treatment of HF due to diastolic dysfunction.

Calcium channel blocking agents (CCBs) inhibit the movement of calcium ions across the cell membrane by blocking the L-type (slow) calcium ion channel.
CCBs have Food and Drug Administration (FDA) indications for treating hypertension, angina, and supraventricular arrhythmias, depending on the specific drug.

Calcium channel blockers, originally developed for the treatment of angina and supraventricular arrhythmias, have been shown to lower elevated blood pressure effectively in hypertensive patients.
nifedipine, verapamil, and diltiazem represent prototype compounds for unique chemical classes with differing pharmacologic properties.
These drugs lower elevated blood pressure with efficacy comparable with other commonly used antihypertensives.
Combination therapy with other agents usually results in an additive response.
Side effects are usually mild and reversible and usually are an extension of the drug's pharmacologic effects.
Moreover, adverse metabolic effects on lipid, glucose, or potassium levels are not common.
Because of the excellent antihypertensive effects of calcium channel blockers and their potential importance in a variety of other disease states, these agents should be routinely considered for use as a first-line antihypertensive agent in appropriately selected patients with hypertension of any severity as part of a comprehensive plan to minimize cardiovascular risk.

Types of calcium channel blocker drugs
The three main classes of CCB drugs are based on their chemical structure and activity:
• Dihydropyridines. These work mostly on the arteries.
Dihydropyridine calcium antagonists usually end in the suffix “-pine” and include:
amlodipine (Norvasc), nifedipine (Adalat CC), felodipine (Plendil), isradipine, nicardipine (Cardene), nimodipine (Nymalize), nitrendipine, bepridil, felodipine, isradipine, nicardipine, nifedipine, and nisoldipine
• Phenylalkylamines. These work mostly on the heart muscle.
verapamil
• Benzothiazepines. These work on the heart muscle and arteries.
diltiazem

Because of their action, dihydropyridines are more commonly used to treat hypertension than other classes. This is due to their ability to reduce arterial pressure and vascular resistance.
Dihydropyridine calcium antagonists usually end in the suffix “-pine” and include:
amlodipine (Norvasc), nifedipine (Adalat CC), felodipine (Plendil), isradipine, nicardipine (Cardene), nimodipine (Nymalize), nitrendipine,

amlodipine (Norvasc) has very little effect on the heart rate and contraction. Therefore, amlodipine is not used for treating abnormal heart rhythm, but it is preferred when heart failure is present and dilation of arteries is desired.

FOR WHAT CONDITIONS ARE CALCIUM CHANNEL BLOCKERS USED?
Calcium channel blockers are approved for treating:
high blood pressure,
angina,
abnormal heart rhythms (for example, atrial fibrillation, paroxysmal supraventricular tachycardia) and subarachnoid hemorrhage.

They are also used for treating other conditions such as:
high blood pressure in the pulmonary arteries (pulmonary hypertension),
Raynaud's phenomenon, cardiomyopathy (disease of the heart's muscle), and
preventing migraine headaches.

ARE THERE ANY DIFFERENCES AMONG CALCIUM CHANNEL BLOCKERS?
Although calcium channel blockers have a similar mechanism of action, they differ in their ability to affect heart muscle vs. arteries, and they differ in their ability to affect heart rate and contraction. These differences determine how they are used and their side effects.
For example:
amlodipine (Norvasc) has very little effect on the heart rate and contraction. Therefore, amlodipine is not used for treating abnormal heart rhythm, but it is preferred when heart failure is present and dilation of arteries is desired.
verapamil (Covera-HS, Verelan PM, Calan), and diltiazem (Cardizem LA, Tiazac) reduce the strength and rate of the heart's contraction and are used in treating abnormal heart rhythms;
Commonly prescribed CCBs used to treat angina and irregular heartbeats are verapamil (Verelan) and diltiazem (Cardizem CD).

CCBs and grapefruit products, including whole fruit and juice, shouldn’t be taken together. Grapefruit products interfere with the normal excretion of the medication. It could be potentially dangerous if large amounts of the drug accumulate in your body. Wait at least four hours after you’ve taken your medication before drinking grapefruit juice or eating grapefruit.

Some CCBs can lower blood glucose levels in some people.

MEDSCAPE
Calcium channel blockers (CCBs) can be divided into dihydropyridines and nondihydropyridines.
Dihydropyridines bind to L-type calcium channels in the vascular smooth muscle, which results in vasodilatation and a decrease in blood pressure.
They are effective as monotherapy in black patients and elderly patients. Some examples of dihydropyridines include amlodipine, nifedipine, clevidipine, and felodipine.
Non-dihydropyridines such as verapamil and diltiazem bind to L-type calcium channels in the sinoatrial and atrioventricular node, as well as exerting effects in the myocardium and vasculature.
These agents may constitute a more effective class of medication for black patients.

Calcium channel blockers

Calcium channel blockers, or calcium antagonists, treat a variety of conditions, such as:
•High blood pressure
•Coronary artery disease
•Chest pain (angina)
•Arrhythmia
•Some circulatory conditions, such as Raynaud's disease

Classes
• • • Dihydropyridine
Amlodipine (Norvasc)
Nifedipine (Procardia, Adalat)
Nimodipine (Nimotop) This substance can pass the blood-brain barrier and is used to prevent cerebral vasospasm.?
■ For the reduction of the incidence and severity of ischemic deficits associated with subarachnoid hemorrhage (SAH) from ruptured berry aneurysms (regardless of post-ictus neurological condition, includes all Hunt and Hess Grades I-V).
■ For migraine prophylaxis†.

• • • Phenylalkylamine
Phenylalkylamine calcium channel blockers are relatively selective for myocardium, reduce myocardial oxygen demand and reverse coronary vasospasm, and are often used to treat angina. They have minimal vasodilatory effects compared with dihydropyridines and therefore cause less reflex tachycardia, making it appealing for treatment of angina, where tachycardia can be the most significant contributor to the heart's need for oxygen. Therefore, as vasodilation is minimal with the phenylalkylamines, the major mechanism of action is causing negative inotropy. Phenylalkylamines are thought to access calcium channels from the intracellular side, although the evidence is somewhat mixed.
Fendiline Gallopamil Verapamil (Calan, Isoptin)

• • • Benzothiazepine
Benzothiazepine calcium channel blockers belong to the benzothiazepine class of compounds and are an intermediate class between phenylalkylamine and dihydropyridines in their selectivity for vascular calcium channels. By having both cardiac depressant and vasodilator actions, benzothiazepines are able to reduce arterial pressure without producing the same degree of reflex cardiac stimulation caused by dihydropyridines.
Diltiazem (Cardizem) (also used experimentally to prevent migraine)

Are there any differences among calcium channel blockers?
Although calcium channel blockers have a similar mechanism of action, they differ in their ability to affect heart muscle vs. arteries, and they differ in their ability to affect heart rate and contraction. These differences determine how they are used and their side effects.
For example:
verapamil (Covera-HS, Verelan PM, Calan), and diltiazem (Cardizem LA, Tiazac) reduce the strength and rate of the heart's contraction and are used in treating abnormal heart rhythms; and amlodipine (Norvasc) has very little effect on the heart rate and contraction. Therefore, amlodipine is not used for treating abnormal heart rhythm, but it is preferred when heart failure is present and dilation of arteries is desired.

Sexual dysfunction, overgrowth of gums, and liver dysfunction also have been associated with calcium channel blockers. Verapamil (Covera-HS, Verelan PM, Calan) and diltiazem (Cardizem LA, Tiazac) worsen heart failure because they reduce the ability of the heart to contract and pump blood.

Uses for calcium channel blockers
For people of African heritage and older people, calcium channel blockers might be more effective than other blood pressure medications, such as beta blockers, angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers.

Side effects and cautions
•Constipation
•Headache
•Palpitations
•Dizziness
•Rash
•Drowsiness
•Flushing
•Nausea
•Swelling in the feet and lower legs

Certain calcium channel blockers interact with grapefruit products.

Amlodipine (NORVASC, Lotrel)

Oral dihydropyridine calcium channel blocker; potent peripheral vasodilator
SUPPLIED Oral Tab: 2.5mg, 5mg, 10mg
■ For the treatment of hypertension.
NOTE: The maximum hypotensive effects may require several weeks to become fully manifest.
Once daily dosing due to long half-life
Initially, 5 mg PO once daily. Max: 10 mg once daily. Dosage should be adjusted based on clinical response over a period of 7 to 14 days. The usual dosage is 5 to 10 mg PO once daily.

■ For the treatment of coronary artery disease (CAD), including chronic stable angina, vasospastic angina (variant angina), and CAD documented by angiography and without heart failure or ejection fraction < 40%.
NOTE: Based on the findings of the CAMELOT trial, amlodipine is indicated for use in patients with recently documented CAD to reduce the risk of hospitalization due to angina and to reduce the risk of a coronary revascularization procedure. Initially, 5 to 10 mg PO once daily. In debilitated or older patients, initiate at 5 mg PO once daily. The usual dosage is 10 mg PO once daily.

Combo
amlodipine besylate/benazepril hydrochloride (Benazepril is an ACE inhibitor)

Oral Administration
May be administered without regard to meals.
DOSING CONSIDERATIONS
Hepatic Impairment
Initiate adult dosage at 2.5 mg PO once daily for hypertension or 5 mg PO once daily for angina; adjust dosage based on clinical response. The elimination half-life of amlodipine is significantly prolonged in patients with hepatic disease.
Renal Impairment
No dosage adjustment is needed.
Intermittent hemodialysis
Amlodipine is highly protein bound and is not likely to be significantly removed by hemodialysis.

ADVERSE REACTIONS
Severe
pancreatitis angioedema visual impairment vasculitis arrhythmia exacerbation bradycardia ventricular tachycardia atrial fibrillation erythema multiforme myocardial infarction

Moderate
thrombocytopenia leukopenia hyperglycemia jaundice hepatitis elevated hepatic enzymes

verapamil hydrochloride (Calan, Calan SR, Isoptin, Isoptin SR, Verelan, Verelan PM)

Phenylakylamine Calcium Channel Blockers: 1) Anti-anginal Agents, 2) Anti-arrhythmics, Class IV,
Oral and IV calcium-channel blocker; used for angina, HTN, and supraventricular tachyarrhythmias; class IV antiarrhythmic agent; more effective than digoxin for controlling ventricular rate in AFIB; other uses include mania and migraine prophylaxis

Verapamil Hydrochloride Oral Tab/Capsule: 40mg, 80mg, 120mg
Verapamil Hydrochloride Oral Tab/Capsule ER: 120mg, 180mg, 240mg
Verapamil Hydrochloride Intravenous Inj Sol: 1mL, 2.5mg

diltiazem hydrochloride (Cardizem, Cardizem CD, Cardizem LA, Cardizem SR, Cartia XT, Dilacor XR, Dilt-CD, Diltia XT, Diltzac, Matzim LA, Taztia XT, Tiazac)

Oral and IV, benzothiazepine calcium-channel blocker; primarily used for angina, HTN, PST, and ventricular rate control in AFIB; slows AV conduction; vasodilatory properties; less negative inotropic effects than verapamil or nifedipine.

■ For long-term control of ventricular rate in atrial flutter† or atrial fibrillation†.
Oral dosage (extended-release formulations)
120 to 360 mg PO once daily. Clinical practice guidelines recommend a nondihydropyridine calcium channel blocker to slow the ventricular heart rate in patients with paroxysmal, persistent, or permanent atrial fibrillation. A nondihydropyridine calcium channel blocker is the preferred agent in patients with chronic obstructive pulmonary disease. Avoid use in patients with pre-excitation, left ventricular systolic dysfunction, or decompensated heart failure

What are the side effects of calcium channel blockers?
Sexual dysfunction, overgrowth of gums, and liver dysfunction also have been associated with calcium channel blockers. Verapamil (Covera-HS, Verelan PM, Calan) and diltiazem (Cardizem LA, Tiazac) worsen heart failure because they reduce the ability of the heart to contract and pump blood.

With which drugs do calcium channel blockers interact?
Calcium channel blockers interact with several drugs.
Verapamil (Covera-HS, Verelan PM, Calan) and diltiazem (Cardizem LA, Tiazac) reduce the elimination and increase the blood levels of carbamazepine (Tegretol), simvastatin (Zocor), atorvastatin (Lipitor), and lovastatin (Mevacor). This can lead to toxicity from these drugs.
Several calcium channel blockers [for example, diltiazem (Cardizem LA, Tiazac), felodipine (Plendil)] increase the level of cyclosporine (Sandimmune, Neoral, Restasis) and similarly lead to toxicity of cyclosporine.
Grapefruit juice (1 glass, approximately 200ml) may elevate serum concentrations of verapamil (Covera-HS, Verelan PM, Calan), felodipine (Plendil), nifedipine (Adalat, Procardia), nicardipine (Cardene), nisoldipine (Sular), and possibly amlodipine (Norvasc).

Beta blockers

Beta blockers, also called beta-adrenergic blocking agents, treat a variety of conditions, such as high blood pressure and migraines.

Beta blockers, also known as beta-adrenergic blocking agents, are medications that reduce your blood pressure. Beta blockers work by blocking the effects of the hormone epinephrine, also known as adrenaline.

When you take beta blockers, your heart beats more slowly and with less force, thereby reducing blood pressure. Beta blockers also help blood vessels open up to improve blood flow.

Examples of beta blockers
Some beta blockers mainly affect your heart, while others affect both your heart and your blood vessels. Which one is best for you depends on your health and the condition being treated.

Examples of oral beta blockers include:
•Acebutolol (Sectral)
•Atenolol (Tenormin)
•Bisoprolol (Zebeta)
•Metoprolol (Lopressor, Toprol-XL)
•Nadolol (Corgard)
•Nebivolol (Bystolic)
•Propranolol (Inderal LA, InnoPran XL)

Uses for beta blockers
Doctors prescribe beta blockers to prevent, treat or improve symptoms in a variety of conditions, such as:
•High blood pressure
•Irregular heart rhythm (arrhythmia)
•Heart failure
•Chest pain (angina)
•Heart attacks
•Migraine
•Certain types of tremors

Beta blockers aren't usually prescribed for blood pressure until other medications, such as diuretics, haven't worked effectively. Your doctor may prescribe beta blockers as one of several medications to lower your blood pressure, including angiotensin-converting enzyme (ACE) inhibitors, diuretics or calcium channel blockers.

Beta blockers may not work as effectively for people of African heritage and older people, especially when taken without other blood pressure medications.

Side effects and cautions
Side effects may occur in people taking beta blockers. However, many people who take beta blockers won't have any side effects.
Common side effects of beta blockers include:
•Fatigue
•Cold hands or feet
•Weight gain

Less common side effects include:
•Shortness of breath
•Trouble sleeping
•Depression

Beta blockers generally aren't used in people with asthma because of concerns that the medication may trigger severe asthma attacks. In people who have diabetes, beta blockers may block signs of low blood sugar, such as rapid heartbeat. It's important to monitor your blood sugar regularly.

Beta blockers can also affect your cholesterol and triglyceride levels, causing a slight increase in triglycerides and a modest decrease in high-density lipoprotein, the "good" cholesterol. These changes often are temporary. You shouldn't abruptly stop taking a beta blocker because doing so could increase your risk of a heart attack or other heart problems

Beta-adrenoceptor antagonists ("beta-blockers") are one of the most widely used classes of drugs in cardiovascular medicine (hypertension, ischaemic heart disease and increasingly in heart failure) as well as in the management of anxiety, migraine and glaucoma.
Where known, the mode of action in cardiovascular disease is from antagonism of endogenous catecholamine responses in the heart (mainly at beta1-adrenoceptors), while the worrisome side effects of bronchospasm result from airway beta2-adrenoceptor blockade.
Some compounds that are traditionally classed as "beta1-selective" actually have higher affinity for the beta2-adrenoceptor. There is therefore considerable potential for developing more selective beta-antagonists for clinical use and thereby reducing the side-effect profile of beta-blockers.
Reference: The selectivity of beta-adrenoceptor antagonists at the human beta1, beta2 and beta3 adrenoceptors.
Br J Pharmacol. 2005; 144(3):317-22 (ISSN: 0007-1188), Baker JG

Alpha blockers

Alpha blockers, also called alpha-adrenergic antagonists, treat conditions such as high blood pressure and benign prostatic hyperplasia. Find out more about this class of medication.

Alpha blockers relax certain muscles and help small blood vessels remain open. They work by keeping the hormone norepinephrine (noradrenaline) from tightening the muscles in the walls of smaller arteries and veins, which causes the vessels to remain open and relaxed. This improves blood flow and lowers blood pressure.

Because alpha blockers also relax other muscles throughout the body, these medications can help improve urine flow in older men with prostate problems.

Examples of alpha blockers
Several alpha blockers are available, in either short-acting or long-acting forms. Short-acting medications work quickly, but their effects last only a few hours. Long-acting medications take longer to work, but their effects last longer. Which alpha blocker is best for you depends on your health and the condition being treated.

Alpha blockers are also called alpha-adrenergic blocking agents, alpha-adrenergic antagonists, adrenergic blocking agents and alpha-blocking agents. Examples of alpha blockers used to treat high blood pressure include:
Doxazosin (Cardura)
Prazosin (Minipress)
Terazosin

Uses for alpha blockers
Doctors prescribe alpha blockers to prevent, treat or improve symptoms mainly in these conditions:
High blood pressure
Enlarged prostate (benign prostatic hyperplasia)

Though alpha blockers are commonly used to treat high blood pressure, they're typically not the first treatment option. Instead, they're used in combination with other drugs, such as diuretics, when your high blood pressure is difficult to control.

Side effects and cautions
Some alpha blockers might have what's called a "first-dose effect." When you start taking an alpha blocker, you might develop pronounced low blood pressure and dizziness, which can make you faint when you rise from a sitting or lying position. As a result, the first dose is often taken at bedtime.
Other side effects might include:
Headache Pounding heartbeat Weakness Dizziness Weight gain

On the positive side, alpha blockers might decrease low-density lipoprotein (LDL) cholesterol (the "bad" cholesterol).

Alpha blockers can increase or decrease the effects of other medications you take. Before taking an alpha blocker, be sure your doctor knows about other medications you take, such as beta blockers, calcium channel blockers or medications for erectile dysfunction.
Some research has found that long-term use of some alpha blockers can increase the risk of heart failure. More research is needed to confirm this finding.

Beta Blockers

Side effects and cautions
Side effects may occur in people taking beta blockers. However, many people who take beta blockers won't have any side effects.
Common side effects of beta blockers include: Fatigue, Cold hands or feet, Weight gain
Less common side effects include: Shortness of breath, Trouble sleeping, Depression

Beta blockers generally aren't used in people with asthma because of concerns that the medication may trigger severe asthma attacks.
In people who have diabetes, beta blockers may block signs of low blood sugar, such as rapid heartbeat. It's important to monitor your blood sugar regularly.
You shouldn't abruptly stop taking a beta blocker because doing so could increase your risk of a heart attack or other heart problems.

Beta blockers can also affect your cholesterol and triglyceride levels, causing a slight increase in triglycerides and a modest decrease in high-density lipoprotein, the "good" cholesterol. These changes often are temporary.

Why Do Antihypertensives Cause Cough?

What are the mechanisms of cough caused by angiotensin-converting enzyme inhibitors, beta-blockers, and calcium channel blockers, and how can this adverse effect be managed?
Response from Jenny A. Van Amburgh, PharmD, CDE

Although all 3 classes of antihypertensive drugs have been associated with cough as a side effect, the causal explanation differs between classes, and the level of evidence is strongest with angiotensin-converting enzyme (ACE) inhibitors -- a first-line antihypertensive drug class for many patients. ACE inhibitors affect the renin-angiotensin-aldosterone system and block the conversion of angiotensin I to angiotensin II, which is involved in vasoconstriction.
ACE inhibitors are associated with a dry, persistent cough in 5%-35% of patients who take them.
The mechanism of cough is likely multifactorial.

ACE inhibitors prevent the breakdown of bradykinin and substance P, resulting in an accumulation of these protussive mediators in the respiratory tract. In addition, bradykinin can stimulate the production of prostaglandin.
This side effect is not dose-dependent and often precludes the use of all agents within the drug class.
Patients experiencing ACE inhibitor-induced cough often can be prescribed an angiotensin receptor blocker for hypertension without the cough risk.

Beta-blockers are used for their antagonistic effect on cardiac beta-1 adrenoceptors. Two types of beta-blockers are available: beta-1 selective adrenoceptor antagonists (eg, metoprolol, atenolol) and nonselective beta-1/ beta-2 adrenoceptor antagonists (eg, carvedilol, propranolol, sotalol, timolol).
Beta-2 receptor antagonism is associated with bronchoconstriction.
Baker demonstrated that many commercially available beta-1 selective blockers have high affinity for beta-2 receptors. Therefore, both selective and nonselective beta-blockers may cause bronchoconstriction, which can lead some patients to experience a cough reflex.
For patients experiencing cough on beta-blocker therapy, ensure the cardioselective agent is at the lowest effective dose and underlying respiratory problems are being managed. Patients should not be withheld appropriate antihypertensive therapy due to cough.

Calcium channel blockers (CCBs) block calcium influx into cardiac muscle and vascular smooth muscle. Although there are reported incidences of cough associated with CCBs, the rates are low, ranging from < 1% to 6%. A literature search for drug-induced cough associated with CCBs yielded no relevant studies or case reports. However, the search yielded studies on the potential antitussive benefits of CCBs. It may be reasonable to suggest that the incidence of cough reported for CCBs may be more aptly associated with other concomitant antihypertensive medications for which cough is a well-documented adverse effect, such as the aforementioned ACE inhibitors.

atenolol (Tenormin)

For the treatment of hypertension.
Initially, 25 to 50 mg PO once daily. Increase up to 100 mg/day if needed after 7 to 14 days. Further increases generally will have no increased therapeutic effect, although daily doses of up to 200 mg have been efficacious.

For the treatment of angina pectoris.
■ For the treatment of chronic stable angina.
Initially, 50 mg PO once daily. Increase to 100 mg/day PO if needed after 7 days. Maximum dosage is 200 mg/day PO. In geriatric patients, use lower initial doses.
■ For the treatment of unstable angina†.
■ For the treatment of acute myocardial infarction, STEMI and for the reduction of cardiovascular mortality and secondary myocardial infarction prophylaxis
■ For paroxysmal supraventricular tachycardia (PSVT) prophylaxis† in patients with recurrent PSVT due to AV reentry.
Although the optimal dose is not well established, 0.3 to 1.3 mg/kg PO once daily has been used. An average dose of 1 mg/kg/day PO (range of 0.8 to 2 mg/kg/day) has also been reported to prevent recurrent PSVT.
■ For heart rate control in patients with atrial fibrillation† or atrial flutter†.
■ For migraine prophylaxis†.
100 mg PO daily. Clinical practice guidelines classify atenolol as probably effective for migraine prophylaxis.
■ For the adjunct treatment of alcohol withdrawal†.
50 to 100 mg PO once daily has been studied. Atenolol was compared to placebo in patients with ethanol withdrawal. 50 mg PO once daily was administered with a heart rate of 50 to 79 bpm; 100 mg PO once daily was administered in patients with a heart rate greater than or equal to 80 bpm. No drug was administered if heart rate was less than 50 bpm. Patients treated with atenolol were less likely to require concomitant benzodiazepine therapy, and lower daily doses of benzodiazepines were required in the atenolol group when supplemental benzodiazepine therapy was necessary. Vital signs become normal more rapidly with atenolol compared to placebo in patients who had withdrawal symptoms at baseline.
■ For the treatment of tremor†.

BOXED WARNING
Abrupt discontinuation
Abrupt discontinuation of any beta-adrenergic blocking agent, including atenolol, particularly in patients with preexisting cardiac disease, can cause myocardial ischemia, myocardial infarction, ventricular arrhythmias, or severe hypertension.

CONTRAINDICATIONS / PRECAUTIONS
Abrupt discontinuation
Hyperthyroidism, thyroid disease, thyrotoxicosis
AV block, bradycardia, cardiogenic shock, heart failure, hypotension, pheochromocytoma, pulmonary edema, sick sinus syndrome, vasospastic angina,
ventricular dysfunction
Cerebrovascular disease
Diabetes mellitus
Acute bronchospasm, asthma, bronchitis, chronic obstructive pulmonary disease (COPD), emphysema, pulmonary disease
Surgery
Dialysis, renal disease, renal failure, renal impairment
Labor, obstetric delivery, pregnancy
Breast-feeding
Driving or operating machinery
Peripheral vascular disease, Raynaud's phenomenon
Depression
Psoriasis
Myasthenia gravis
Geriatric
Beta-blocker hypersensitivity

Thrombocytopenia, elevated hepatic enzymes, hyperbilirubinemia

metoprolol (Tenormin)

BOXED WARNING Abrupt discontinuation Abrupt discontinuation of any beta-adrenergic-blocking agent, including metoprolol, can result in the development of myocardial ischemia, myocardial infarction, ventricular arrhythmias, or severe hypertension, particularly in patients with preexisting cardiac disease. Even in hypertensive patients without overt coronary artery disease (CAD), it is prudent to taper the dosage of metoprolol since CAD is common and frequently unrecognized. DOSING CONSIDERATIONS Hepatic Impairment Since metoprolol is extensively metabolized by the liver, blood levels are likely to increase substantially in patients with hepatic impairment. Therefore, metoprolol should be initiated at a low dose and titrated slowly according to clinical response. Renal Impairment No dosage adjustment is needed. Severe heart failure / Delayed / 1.0-27.5 bradycardia / Rapid / 1.5-15.9 AV block / Early / 4.7-5.3 bronchospasm / Rapid / 1.0-1.0 stroke / Early / 1.0-1.0 visual impairment / Early / Incidence not known laryngospasm / Rapid / Incidence not known agranulocytosis / Delayed / Incidence not known thrombotic thrombocytopenic purpura (TTP) / Delayed / Incidence not known tissue necrosis / Early / Incidence not known retroperitoneal fibrosis / Delayed / Incidence not known lupus-like symptoms / Delayed / Incidence not known

Vasodilators

Vasodilators treat a variety of conditions, including high blood pressure. Find out more about this class of medication.
Vasodilators are medications that open (dilate) blood vessels. They affect the muscles in the walls of your arteries and veins, preventing the muscles from tightening and the walls from narrowing.
As a result, blood flows more easily through your vessels. Your heart doesn't have to pump as hard, reducing your blood pressure.

Some drugs used to treat hypertension, such as calcium channel blockers — which prevent calcium from entering blood vessel walls — also dilate blood vessels. But the vasodilators that work directly on the vessel walls are hydralazine and minoxidil.

Uses for vasodilators
Doctors prescribe vasodilators to prevent, treat or improve symptoms in a variety of conditions, such as:
High blood pressure
High blood pressure during pregnancy or childbirth (preeclampsia or eclampsia)
Heart failure
High blood pressure that affects the arteries in your lungs (pulmonary hypertension)

Side effects and cautions
Direct vasodilators are strong medications that generally are used only when other medications haven't controlled your blood pressure adequately. These medications have a number of side effects, some of which require taking other medications to counter.
Side effects include:
Rapid heartbeat (tachycardia) Heart palpitations Fluid retention (edema) Nausea Vomiting Flushing Headache Excessive hair growth Joint pain Chest pain

Orthostatic hypotension

Proamatine (Midodrine Hydrochloride)
Warning: Because ProAmatine® can cause marked elevation of supine blood pressure, it should be used in patients whose lives are considerably impaired despite standard clinical care. The indication for use of ProAmatine® in the treatment of symptomatic orthostatic hypotension is based primarily on a change in a surrogate marker of effectiveness, an increase in systolic blood pressure measured one minute after standing, a surrogate marker considered likely to correspond to a clinical benefit. At present, however, clinical benefits of ProAmatine®, principally improved ability to carry out activities of daily living, have not been verified.

Dosage Form: 2.5-mg, 5-mg and 10-mg tablets for oral administration.
INDICATIONS AND USAGE
ProAmatine® is indicated for the treatment of symptomatic orthostatic hypotension (OH). Because ProAmatine® can cause marked elevation of supine blood pressure (BP>200 mmHg systolic), it should be used in patients whose lives are considerably impaired despite standard clinical care, including non-pharmacologic treatment (such as support stockings), fluid expansion, and lifestyle alterations. The indication is based on ProAmatine®’s effect on increases in 1-minute standing systolic blood pressure, a surrogate marker considered likely to correspond to a clinical benefit. At present, however, clinical benefits of ProAmatine®, principally improved ability to perform life activities, have not been established. Further clinical trials are underway to verify and describe the clinical benefits of ProAmatine® .
After initiation of treatment, ProAmatine® should be continued only for patients who report significant symptomatic improvement.
CONTRAINDICATIONS
ProAmatine® is contraindicated in patients with severe organic heart disease, acute renal disease, urinary retention, pheochromocytoma or thyrotoxicosis. ProAmatine® should not be used in patients with persistent and excessive supine hypertension.

Antiarrhythmic drugs

Most antiarrhythmic drugs are grouped into 4 main classes (Vaughan Williams classification) based on their dominant cellular electrophysiologic effect (see Table: Antiarrhythmic Drugs (Vaughan Williams Classification) ).

Class I: Class I drugs are subdivided into subclasses a, b, and c. Class I drugs are sodium channel blockers (membrane-stabilizing drugs) that block fast sodium channels, slowing conduction in fast-channel tissues (working atrial and ventricular myocytes, His-Purkinje system).
Class II: Class II drugs are beta-blockers, which affect predominantly slow-channel tissues (sinoatrial [SA] and atrioventricular [AV] nodes), where they decrease rate of automaticity, slow conduction velocity, and prolong refractoriness.
Class III: Class III drugs are primarily potassium channel blockers, which prolong action potential duration and refractoriness in slow- and fast-channel tissues.
Class IV: Class IV drugs are the nondihydropyridine calcium channel blockers, which depress calcium-dependent action potentials in slow-channel tissues and thus decrease the rate of automaticity, slow conduction velocity, and prolong refractoriness.

Situation

labetalol hydrochloride (Normodyne, Trandate)

Beta-Blockers with Alpha Blockade
SUPPLIED
Labetalol/Labetalol Hydrochloride/Normodyne/Trandate Intravenous Inj Sol: 1mL, 5mg
Labetalol/Labetalol Hydrochloride/Normodyne/Trandate Intravenous Sol: 1mL, 5mg
Labetalol/Labetalol Hydrochloride/Normodyne/Trandate Oral Tab: 100mg, 200mg, 300mg

For the treatment of hypertensive emergency.
■ For the treatment of hypertension associated with severe preeclampsia or eclampsia.
• Intravenous dosage labetalol 20 mg IV over 2 minutes for systolic blood pressure (SBP) 160 mmHg or more or diastolic blood pressure (DBP) 110 mmHg or more.
Check blood pressure (BP) in 10 minutes and if either BP threshold is exceeded, give 40 mg IV over 2 minutes.
Check BP in 10 minutes and if either threshold is exceeded, give 80 mg IV over 2 minutes.
Check BP in 10 minutes and if either threshold is exceeded, switch to hydralazine 10 mg IV over 2 minutes and check BP in 20 minutes.
If either threshold is exceeded, obtain emergency consultation, and give additional antihypertensive medication per specific order.
Once SBP is less than 160 mmHg and DBP is less than 110 mmHg, check BP every 10 minutes for 1 hour, then every 15 minutes for 1 hour, then every 30 minutes for 1 hour, and then every hour for 4 hours.
• Intravenous dosage (Intermittent)
Initially, 20 mg IV over 2 minutes; additional doses of 20 to 80 mg IV over 2 minutes may be administered every 10 minutes until desired blood pressure response is achieved or a total of 300 mg has been administered. Maximum blood pressure response is usually noted within 5 minutes of each dose.
• Intravenous dosage (Continuous Infusion)
0.5 to 2 mg/minute IV infusion may be used. Adjust rate to patient response. The total dose should not exceed 300 mg IV.

New ACC/AHA High Blood Pressure Guidelines

Lower Definition of Hypertension

Measurement of BP

Secondary Hypertension

Nonpharmacologic Interventions

BP Thresholds and Risk Estimation to Guide Pharmacologic Treatment

BP Goals for Patients With Hypertension

Choice of Antihypertensive Drug Therapy

Management of Resistant Hypertension

Strategies to Improve Hypertension Treatment and Control

Summary

Key points to remember2017 Guideline for High Blood Pressure in Adults

Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults

Summary

Managing Hypertension Using Combination Therapy

Diuretics

chlorthalidone (Thalitone)

chlorothiazide (Diuril)

Lifestyle changes

Treatment

Angiotensin-converting enzyme (ACE) inhibitors

Angiotensin-converting enzyme (ACE) inhibitors

lisinopril (Prinivil, QBRELIS, Zestril)

enalapril (Epaned, Vasotec)

Angiotensin II receptor blockers

Angiotensin II receptor blockers

losartan (Cozaar)

valsartan (Diovan)

Calcium channel blockers

Calcium channel blockers

Calcium channel blockers

Amlodipine (NORVASC, Lotrel)

verapamil hydrochloride (Calan, Calan SR, Isoptin, Isoptin SR, Verelan, Verelan PM)

diltiazem hydrochloride (Cardizem, Cardizem CD, Cardizem LA, Cardizem SR, Cartia XT, Dilacor XR, Dilt-CD, Diltia XT, Diltzac, Matzim LA, Taztia XT, Tiazac)

Beta blockers

Alpha blockers

Beta Blockers

Why Do Antihypertensives Cause Cough?

atenolol (Tenormin)

metoprolol (Tenormin)

Vasodilators

Orthostatic hypotension

Antiarrhythmic drugs

Situation

labetalol hydrochloride (Normodyne, Trandate)

Key points to remember
2017 Guideline for High Blood Pressure in Adults