BP Classification

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

BP Goals

Condition	Goal
CVD	< 130/80
10y ASCVD Risk > 10%	< 130/80
Hx of Stroke \& HTN Before Stroke	< 140/90
Hx of Stroke \& HTN After Stroke	< 130/80
DM	< 130/80

HTN Agent Selection

• Caucasion: RAAS Inhibitors 1st Line
• AA: CCB or Thiazides 1st Line
• SIHD: β-blockers 1st Line in combo with RAAS Inhibitors
• CKD 3 or CKD 1-2 w/ Albuminuria: RAAS Inhibitor
• Two or more agents often necessary in AA pts
• Pregnancy: Methyldopa, nifedipine, and/or labetalol are safe

HTN Crisis

• BP ≥ 180/120
• Urgency: No other SSx except HA
• Emergency: SSx of organ dysfunction
  • SOB
  • Altered
  • EKG Changes
  • Increase in SCr of ≥ 0.5 if baseline is < 3 or ≥ 1 if baseline is > 3

Goals

• Urgency
  • BP < 160/110
  • MABP reduction by no more than 25% w/i 24hr using PO therapy
• Emergency
  • MAPB reduction of 10% in the 1st hour, then 15% in the next 2-3hrs

Treatment

Urgency

• Restart home PO therapy
• Add PO captopril, nicardipine, labetalol, or clonidine as appropriate
  • Captopril: 25mg q90-120min PRN (onsets in 15-30min)
  • Nicardipine: 30mg q8h PRN (onset in 0.5-2hr)
  • Labetalol: 200mg q3-4h PRN (onest in 1-2hr)
  • Clonidine: 0.1-0.2mg q1h NTE 0.7mg (onset in 15-30min)

Emergency

• Nitroprusside: 0.3-0.5 mcg/kg/min NTE 2 mcg/kg/min
  • Last line due to cyanide toxicity
• Nicardipine: 5-15 mg/hr
• Esmolol: 500 mcg/kg Bolus q5min x1 OR 50-100 mcg/kg/min (cardioselective β-blocker)
  • Good for CAD and anxiety
• Labetalol: 20-80mg Bolus q10min OR 0.5-2 mg/min
  • Good for brain syndromes and pregnancy
• NTG: 5-100 mcg/min
  • A loading dose of 400 mcg/min x2min may be kinetically appropriate, but not endorsed in guidelines
  • Good for CHF and Angina
• Hydralazine
  • 5-10mg q20-40min x1
  • Not recommended in HTN emergency
  • Drug of choice in pregnancy

References

• 2017 AHA HTN Guidelines