hypertension

Risk Factors of Hypertension and Why You Shouldn’t Take Your Stress with a Grain of Salt

It would not be an understatement to say almost all cases of high blood pressure are likely to be classified under the term “primary” or “essential” hypertension. Even so, primary hypertension can be a real head scratcher as we have a very poor understanding of the etiology despite an estimated 90% of patients fitting the bill. As such, primary hypertension is often labeled as “idiopathic”, which is medical terminology for “no identifiable cause” that we are aware of at this time. We do, however, have an inkling for several risk factors which are associated with the development of hypertension. In this post, we will break them down using a mnemonic that helps tie everything together and provides a system to recall these characteristics moving forward. Can you think of what might be a good mnemonic for this cause? That is right: stress!

We’ve all experienced stress at some point in our lives. Imagine yourself in peak rush hour traffic, the time is now 7:45 AM and your final starts at 8:00 AM. You are moving 5 miles per hour bumper to bumper with at least a 40-minute estimated delay. Can you feel your heart racing? Maybe not, but the point stands that stress can exacerbate blood pressure and it is an excellent way to outline the following known risk factors:

“S” is for SODIUM
Excessive sodium consumption can increase risk for hypertension and even blunt antihypertensive medications. It is generally recommended patients limit their intake to less than 1,500 milligrams a day which can further help in reducing systolic blood pressure by ~5-6 mmHg2
“T” is for TIMESPAN
Time refers to patients greater than 65 years of age as they are more likely to acquire hypertension and are therefore at a further increased risk of cardiovascular disease1
“R” is for RAZZAMATAZZ  Did you know razzamatazz is a type of alcoholic beverage? Neither did we, but the name has a ring to it and highlights the fact that excessive alcohol consumption should be avoided! Men who lower consumption to 2 drinks a day and women who lower consumption to 1 drink a day can expect systolic blood pressure to decrease by ~4 mmHg1
“E” is for ETHNICITY
A family history of hypertension is a significant factor to keep in mind alongside the disproportionate degree of African American cases for this disease state: here is a study entitled, “Differences in Stroke Mortality Among Adults Aged 45 and Over: United States, 2010–2013” from the CDC. It details the implications of the “stroke belt” in the United States
“S” is for SUNDAES
Yes, we all love sundaes, but it would be wise to lay off the ice cream occasionally as Obesity and Diabetes Mellitus are commonly associated with hypertension. Exercise and a healthy well-balanced diet like the “Dietary Approaches to Stop Hypertension” (DASH) diet is crucial for hypertensive individuals as a 1-kilogram reduction in weight generally equals 1 mmHg reduction in blood pressure2
“S” is for SMOKING
Smoking is classified as a risk factor for hypertension alongside obstructive sleep apnea and should be avoided prior to blood pressure measurements1

As you soak in all these risk factors and suggested lifestyle changes, if there is only one thing you remember from this blog post it is the following: hypertension tends to be a disease state where adherence to therapy can be particularly troublesome. This is understandable as hypertensive patients generally feel no different but may still be expected to take several classes of medications, follow up routinely, and tolerate various adverse effects of medications that can interfere with their overall quality of life. Therefore hypertension is known as a “silent killer” and as with any disease state, a solid line of communication is vital to ensuring appropriate therapy and patient satisfaction.

Sincerely,

Jean Hanna

References

  1. Hypertension.  (n.d.).  In Micromedex.  Retrieved December 26, 2020, from https://www.micromedexsolutions.com
  2. Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Jr, Collins, K. J., Dennison Himmelfarb, C., DePalma, S. M., Gidding, S., Jamerson, K. A., Jones, D. W., MacLaughlin, E. J., Muntner, P., Ovbiagele, B., Smith, S. C., Jr, Spencer, C. C., Stafford, R. S., Taler, S. J., Thomas, R. J., Williams, K. A., Sr, Williamson, J. D., … Wright, J. T., Jr (2018). 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: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension (Dallas, Tex. : 1979), 71(6), 1269–1324. https://doi.org/10.1161/HYP.0000000000000066

A Brief Review on Hypertension for Pharmacists

With so many organ systems, disease states, and medications to remember, preparation for the NAPLEX may often times seem like a daunting task. While there can be a considerable amount of material to go over for each clinical module, there are certainly some things that deserve more focus than others. This brief review will cover some of the most important information you need to know about hypertension when preparing for your upcoming exam.

General information:

  • Hypertension (HTN) is asymptomatic
  • HTN increases the risk for heart attacks, strokes, and kidney failure
  • Risk factors include the following:
    • High sodium and fat diet, physical inactivity, obesity, tobacco use, excessive alcohol consumption, genetics and family history, age, sex (women more likely than men), and race (African Americans more likely than any other race)
    • Drugs can also increase blood pressure, including the following:
      • Amphetamines, cocaine, pseudoephedrine, immunosuppressants, Nonsteroidal anti-inflammatory drugs (NSAIDs), steroids, ethanol, caffeine, serotonin and norepinephrine reuptake inhibitors (SNRIs), oral contraceptives, erythropoietin

Blood pressure categories:

 Ultimate blood pressure goal:

  • 130/80 mmHg

Treatments:

Four preferred drug classes for the following patient subgroups:

  • Non-African American: Thiazide diuretic, CCB, ACE inhibitor or ARB
  • African American: Thiazide diuretic
  • Patients with chronic kidney disease or diabetes with albuminuria ACE inhibitor or ARB
  • Initiate two drugs regimens if blood pressure is > 150/90 mmHg

Additional information:

  • ACE inhibitors, ARBs, Aliskiren
    • Do not use with Entresto
    • Do not use any combination of ACE inhibitors, ARBs, and aliskiren for treatment
  • CCBs
    • CYP3A4 substrates, avoid CYP3A4 inhibitors (eg, grapefruit)
    • Caution with ankle swelling and/or irregular heartbeat
    • Amlodipine and felodipine are the safest to use in patients with HF
  • BBs
    • No longer preferred for HTN treatment
      • Primarily used first-line for heart disease, post myocardial infarction, and HF
    • Use with caution when taking other drugs that decrease HR
    • Mask symptoms of hypoglycemia
  • Diuretics
    • Take doses in the morning or afternoon to avoid frequent urination symptoms at night
    • Provide K+ supplementation to compensate for decreased K+ levels
      • This does not remain true for K+ sparing diuretics
  • Hypertensive emergency
    • Blood pressure > 180/120 mmHg
    • Acute organ damage
    • IV medication used for treatment
      • Clevidipine, nicardipine, diltiazem, verapamil, enalaprilat, esmolol, labetalol, metoprolol tartrate, propranolol, nitroglycerin, nitroprusside, chlorothiazide
    • Goal is to decrease blood pressure by < 25% within first hour
  • Hypertensive urgency
    • Blood pressure > 180/20 mmHg
    • No organ damages
    • Oral medication for treatment
  • Pregnancy
    • Treatment with labetalol, methyldopa or nifedipine XR

Treatments (non-pharmacological):

  • Lifestyle modifications
    • DASH diet, limit salt intake (<1,500 mg/day), exercise, limit alcohol consumption, maintain proper weight (BMI between 18.5 – 24.9)

Be on the look-out for our next review, which will focus on diabetes.

Best of luck,

Sam Tamjidi

RxPharmacist Team

References: Micromedex Solutions. Greenwood Village, CO: Truven Health Analytics. http://micromedex.com/. Accessed October 12, 2020.

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