Managing Patients with Hypertension

Written by: Guadalupe Navarro, RN and FNP student

As a provider, it is imperative that one is aware of how to appropriately manage patients with hypertension. To achieve this one must understand how each anti-hypertensive class works. Ace-inhibitors work by interfering with the body’s renin-angiotensin-aldosterone system. Thus, dilating the blood vessels and increasing blood flow. This class of medications has shown to have the greatest effect on blood pressure compared to others. It also decreases the risk of cardiovascular events. Individuals who cannot tolerate Ace-Inhibitors due to cough are commonly prescribed Angiotensin-Receptor Blockers as an alternative.

In the primary care setting, one will encounter patients with new-onset or chronic hypertension. For new-onset hypertension, one should initiate monotherapy depending on the patient’s age and ethnicity. Those younger than 50 years of age respond best to Ace Inhibitors or Angiotensin-Receptor Blockers and beta-blockers. However, beta-blockers are not recommended as first-line therapy. This is because they have decreased protection against stroke risk and mortality. They also can intervene with glycemic control thus putting those without diabetes at risk of getting it. Furthermore, they should be avoided in those with respiratory conditions. For those who are older than 65 years old or of African American descent thiazide diuretics and calcium channel blockers are considered first-line drugs for hypertension management. The most used being thiazide diuretics.

Individuals whose blood pressure is less than 20/10 mmHG above goal blood pressure should be started on a single anti-hypertensive. One should choose the anti-hypertensive class based on the above-stated recommendations based on age, ethnicity, and medical history. The patient should keep a daily blood pressure log and bring it to their next provider visit to aid in determining the efficacy of blood pressure management. This follow up should occur within four to six weeks of when the anti-hypertensive is initiated. One should emphasize medication side effects that would prompt the patient to follow up with the provider sooner, such as the ace-cough with ace inhibitors.

However, if the blood pressure is still not controlled after starting monotherapy and the blood pressure is greater than 20/10 mmHG above goal, another anti-hypertensive should be added to the plan of care. It is recommended that the second anti-hypertensive be a thiazide diuretic if the patient is not already on one. Their preferred type of thiazide diuretic is a thiazide-like diuretic. The two most common thiazide-like diuretics are chlorthalidone and indapamide. These diuretics are preferred over thiazide-type diuretics because they provide increased blood pressure reduction and have an increased duration of action. Thus, they typically act on the body over twenty-four hours which aids in nighttime blood pressure control. When compared to the thiazide-type diuretics, chlorthalidone is associated with decreased rates of blood pressure reduction in all hypertensive patients despite age. It is also associated with decreased rates of heart failure than amlodipine and lisinopril. Additionally, it aids in decreasing LDL levels and thus preventing or reducing the number of cardiovascular artery disease complications.

Despite all the benefits of chlorthalidone use, there are some negative aspects of this drug. First, chlorthalidone has an increased risk of adverse metabolic effects, the primary one being hypokalemia. These complications are most likely to occur within the first two weeks of therapy initiation. However, hypokalemia, hyponatremia, and acute kidney injury risks are significantly decreased by week three. The risk of hypokalemia is minimal by week six. Henceforth, patients who are started on chlorthalidone will require frequent metabolic panels being drawn and replacements if needed until their levels stabilize. Thus, not making them the most convenient option for a patient who has memory issues or disability.

Another disadvantage of chlorthalidone use is that the pill comes in a standard 25 mg dose without scoring. Thus, if a patient is prescribed half the dose, there is no real way of ensuring the 12.5mg dose will be safely administered when the pill is cut in half. There also is no combination drug of chlorthalidone with an ace inhibitor. Hence, making it difficult to safely initiate combo-therapy on patients. Instead, one would have to use a combination pill with an alternative thiazide-like diuretic called indapamide that is premixed with lisinopril.

Consequently, the efficacy of an antihypertensive is not correlated to an increased dose. Therefore, one should attempt to increase the patient’s dose once and if that does not demonstrate an improvement a second anti-hypertensive should be initiated. This is because titrations that exceed one dose with any given anti-hypertensive drug demonstrate plateau blood pressure effects. Hence, only increasing side effect risk for the patient. When choosing an additional anti-hypertensive, it is important that it is chosen from a different class type because each class provides different bodily effects. There may be individuals whose blood pressure is resistant to dual combination therapy thus requiring multiple anti-hypertensives for adequate management. There will also be other individuals who despite being on multiple anti-hypertensives their hypertension is not sufficiently managed and although that is not ok, sometimes one must outweigh the risk versus the benefits. Overall, the amount of blood pressure reduction is the major determinant of reduction in cardiovascular risk in all hypertensive patients despite the age.