Dx¹

Category	SBP	DBP
Normal	< 120	< 80
Elevated	120-129	< 80
Stage 1	130-139	80-89
Stage 2	≥ 140	≥ 90

Causes of Secondary HTN

Renal disease
Hyperaldosteronism
OSA
Drug / EtOH induced
- Amphetamines
- NE acting antidepressants
- Caffeine
- Atypical antipsychotics
- Stimulant decongestants
- Immunosuppressants
- Hormonal contraceptives
- NSAIDs
- GCs
- MCs
- Angiogenesis inhibitors
- Tyrosine Kinase inhibitors
Pheochromocytoma
Cushing’s
Hyper / hypothyroidism
Aortic coarctation
Hyperparathyroidism
Adrenal hyperplasia
Acromegaly

Misc Recommendations

Screen for primary aldosteronism in its with resistant HTN, especially those w/ hypokalemia, stroke at a young age, or FHx of early-onset HTN

Tx¹

General Treatment Algorithm
- Stage 1ASCVD Risk < 10%: Non-pharm and reassess in 3-6mo
- Otherwise, non-pharm and pharmacotherapy and reassess in 1mo
Target < 130/80 for all pts
- Consider starting 2 drugs if in Stage 2 or > 20/10 above target
- Stroke pts w/ previously Dx HTN before stroke are the exception, target < 140/90
ACEI / ARB Best first Choice
- SIHD (also β-blockers)
- CKD (≥ Stage 3 or w/ significant albuminuria)
Use CCBs and Thiazides in AA pts d/t inherently low levels of RAAS activity
DM
- All 1st line agents now appropriate

Non-pharm Interventions and BP Impact

Intervention	Decrease
Wt loss	1 / kg
Healthy diet	11
Na < 1500mg QD	5-6
K 3500-5000mg QD	4-5
Exercise	4-8
Decreased EtOH	4

First-Line Drugs and Doses

Drug	Usual Daily Dose (mg)	Frequency
Thiazides
Chlorthalidone	12.5-25	QD
HCTZ	25-50	QD
Indapamide	1.25-2.5	QD
Metolazone	2.5-5	QD
ACEIs
Enalapril	5-40	QD or BID
Lisinopril	10-40	QD
Quinapril	10-80	QD or BID
Ramipril	2.5-20	QD or BID
ARBs
Candesartan	8-32	QD
Irbesartan	150-300	QD
Losartan	50-100	QD or BID
Valsartan	80-320	QD
DHP CCBs
Amlodipine	2.5-10	QD
Nicardipine SR	60-120	BID
Nifedipine LA	30-90	QD
Non-DHP CCBs
Diltiazem ER	120-360	QD
Verapamil IR	120-360	TID
Verapamil SR	120-360	QD or BID

HTN Crisis¹^,²

Dx

BP > 180/120
Evidence of end-organ damage ⇒ emergency, otherwise ⇒ urgency
- ICH
- HTN encephalopathy
- Cerebral infarct
- Acute pulmonary edema
- Acute HF
- ACS
- AKI
- LFT elevation (most commonly w/ HELLP syndrome)
- Retinal hemorrhage
- Eclampsia
- Aortic dissection

Tx

Urgency
- Restart or intensify home PO regimine w/ close f/u
Emergency
- IV antihypertensives
- Target 25% BP decrease in 1hr, then 160/110 in the following 2-6hrs, then normal BP w/i 24-48hrs
- Pre-/eclampsia, aortic aneurism, stroke, and pheochromocytoma have special therapies
Ischemic Stroke
- Treat to 185/110 before thrombolysis and 180/105 after thrombolysis
- Treat if not thrombolysing and have evidence of end-organ damage or > 220/120

IV Antihypertensives

Drug	Initial Dose	Max Dose	Onset	Duration	Comments
CCBs
Nicardipine	5 mg/hr Increase 2.5 mg/hr Q5-10min	15mg/hr	5-10min	2-6hr	CI in advanced aortic stenosis
Clevidipine	1-6mg/hr Titrate 1-2 mg/hr Q90s	32mg/h 72hr use	1-4min	5-15min	Low end of range in elderly
Vasodilators
Nitroprusside	0.25-0.5 mcg/kg/min Titrate 0.1-0.2 mcg/kg/min Q5-10min	10 mcg/kg/min	Seconds	1-2min	Give thiosulfate to prevent CN poisoning if > 30min or ≥ 4 mcg/kg/min
NTG	5 mcg/min Titrate by 0.1-0.2 mcg/kg/min Q5min	200 mcg/min	2-5min	5-10min	Preferred in ACS or acute pulmonary edema CI in volume dependent states (e.g. right-ventricular infarct)
Hydralazine	10mg slow IV infusion Q4-6hr IM: 10mg Q30min	20mg initial IM: 40mg	IV: 10min IM: 20min	IV: 1-4hr IM: 2-6hr	Highly unpredictable 10-30min to start, and lasts 4-6hr
β-Blockers
Esmolol	500-1000 mcg/kg over 1min then 50 mcg/kg/min infusion Titrate 25 mcg/kg/min Q3-5min	200 mcg/kg/min	1-2min	10-20min	β₁ selective Don’t use in HF, other β-blocker use, or existing bradycardia / heart block
Labetalol	0.3-1 mg/kg (20-80mg) Q5-10min or 0.4-1 mg/kg/hr (0.5-10 mg/min)	Titrate infusion by 1-2mg/min Q2hr	2-5min (peak 5-15min)	2-6hr (up to 18hr in some pts)	Non-selective blockade CI in reactive airway disease Avoid in heart block / bradycardia / HF
Metoprolol	5-15mg Q5-15min		5-20min	2-6hr
α-Blockers
Phentolamine	5mg Q10min PRN		Seconds	15min	Most useful in catecholamine excess (pheochromocytoma, MAOI interactions, cocaine / amphetamine overdose, etc)
D₁ Antagonist
Fenoldopam	0.1-0.3 mcg/kg/min	Increase 0.05-0.1 mch/kh/min Q15min to target BP NTE 1.6 mcg/kg/min	10-15min	10-15min	CI in pts w/ increase IOP or ICP or sulfite allergy
ACEI
Enalaprilat	1.25mg over 5min	Increase 5mg Q6h PRN	15-30min	12-24hr	CI in pregnancy, bilateral renal artery stenosis, acute MI Slow onset (15min) Unpredictable

Preferred Agents in Specific Circumstances¹

Condition	Preferred Drug	Notes
Aortic Dissection	Esmolol, labetolol	Rapidly lower to SBP ≤ 120 w/i 20min If needed, can add vasodilator, but must add rate-control first
Acute Pulmonary Edema	Clevidipine, NTG, nitropruside	β-blockers CI
ACS	Esmolol, labetolol, nicardipine, NTG	Watch for PDE inhibitors if giving nitrate based therapy
Acute renal Failure	Clevidipine, fenoldopam, nicardipine
Pre-/Eclampsia	Hydralazine, labetolol, nicardipine	Lower rapidly
Perioperative HTN	Clevidipine, esmolol, nicardipine, NTG
Sympathetic Excess (cocaine, amphetamines, pheochromocytoma, etc)	Clevidipine, nicardipine, phenotolomine

IV Antihypertensive Hemodynamic Effects

Drug	Preload	Afterload	CO
CCBs
Nicardipine	↔	↓	↑
Clevidipine	↔	↓	↑
Vasodilators
Nitroprusside	↓	↓↓	↑
NTG	↓↓	↓↔	↔↑
Hydralazine	↔	↓	↑
β-Blockers
Esmolol	↔	↔	↓
Labetolol	↔	↓	↓
Metoprolol	↔	↔	↓
α-Blockers
Phentolamine	↔	↓	↑
D₁ Antagonists
Fenoldopam	↔↓	↓	↑
ACEI
Enalaprilat	↓	↓	↑

References

Whelton PK, Carey RM, Aronow WS, et al. 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. Journal of the American College of Cardiology. 2018;71(19):e127-e248. doi:10.1016/j.jacc.2017.11.006 ↩ ↩² ↩³ ↩⁴
Benken ST. ACCP Hypertensive Emergencies. 2018. Available at: https://www.accp.com/docs/bookstore/ccsap/ccsap2018b1_sample.pdf ↩

HTN

Dx1

Causes of Secondary HTN

Misc Recommendations

Tx1

HTN Crisis1, 2

Dx

Tx

References

Dx¹

Tx¹

HTN Crisis¹^,²