Hypertension

Disease State Overview

Hypertension is defined as a sustained elevation in systemic arterial blood pressure. Risk factors include genetic predisposition, overweight or obesity, high sodium diet, limited physical activity, other health conditions, and alcohol use. The American Heart Association and the American College of Cardiology have established four blood pressure categories which are outlined below.

AHA/ACC Blood Pressure Categories

Category	SBP (mmHg)		DBP (mmHg)
Normal	<120	and	<80
Elevated	120-129	and	<80
Stage 1 Hypertension	130-139	or	80-89
Stage 2 Hypertension	≥140	or	≥90

A diagnosis of hypertension requires 2 or more elevated readings on 2 or more occasions

Risk of Condition

If left untreated, hypertension can lead to several complications resulting from sustained pressure on blood vessels. These risks include cardiovascular disease, heart attack, stroke, heart failure, kidney disease or failure, vision loss, sexual dysfunction, chest pain, and peripheral artery disease.

Medication

Role of Medication

When lifestyle changes are not effective enough at lowering blood pressure, medications may be used. Current guidelines published by the American College of Cardiology and American Heart Association (ACC/AHA) and the Joint National Committee (JNC) provide guidance for treatment of hypertension. Choice of therapy should be based on multiple factors, including medication side effect profile, insurance coverage, patient preference, patient’s age and race, comorbid conditions, and concurrent medications.

Antihypertensive Drug Classes

Primary Agents

Drug Class: Angiotensin converting enzyme inhibitors (ACEi)
- Drug Names:
  - Benazepril
  - Captopril
  - Enalaopril
  - Fosinopril
  - Lsinopril
  - Moexipril
  - Peridopril
  - Quinapril
  - Ramipril
  - Trandolapril
- Side Effects & Considerations:
  - Hypotension
  - Electrolyte abnormalities
    - Hyperkalemia
  - Acute renal failure
  - Angioedema
  - Cough
- Compelling Indications for Use:
  - Stable ischemic heart disease, heart failure with reduced ejection fraction, chronic kidney disease, diabetes, coronary artery disease, recurrent stroke
Drug Class: Angiotensin II receptor antagonists (ARB)
- Drug Names:
  - Azilsartan
  - Candesartan
  - Eprosartan
  - Irbesartan
  - Losartan
  - Olmesartan
  - Telmisartan
  - Valsartan
- Side Effects & Considerations:
  - Hypotension
  - Electrolyte abnormalities
    - Hyperkalemia
  - Acute renal failure
  - Angioedema
- Compelling Indications for Use
  - Stable ischemic heart disease, heart failure with reduced ejection fraction, chronic kidney disease, diabetes, coronary artery disease, post-myocardial infarction
Drug Class: Thiazide diuretics
- Drug Names:
  - Chlorthalidone
  - Hydrochlorothiazide
  - Indapamide
  - Metolazone
- Side Effects & Considerations:
  - Electrolyte abnormalities
    - Hyponatremia
    - Hypokalemia
    - Hypercalcemia
    - Hyperuricemia
- Compelling Indications for Use
  - Diabetes, recurrent stroke prevention
Drug Class: Calcium channel blockers
- Drug Names:
  - Non-DHP:
    - Diltiazem
    - Verapamil
  - DHP:
    - Amlodipine Felodipine
    - Isradipine
    - Nicardipine
    - Nislodipine
- Side Effects & Considerations:
  - Peripheral Edema
  - Non-DHP
    - Drug interaction potential (CYP3A4 inhibitor)
    - Constipation (verapamil)
- Compelling Indications for Use:
  - Diabetes, coronary artery disease

- - Non-DPH: Do not use in patients with heart failure

Secondary Agents

Drug Class: Beta2 adrenergic blockers
- Drug Names:
  - Cardio- selective:
    - Atenolol
    - Betaxolol
    - Bisoprolol
    - Metoprolol
    - Nebivolol (+vasodilatory)
  - Non-Cardio Selective:
    - Nadolol
    - Propranolol
  - Combined alpha- and beta-receptor activity:
    - Carvedilol
    - Labetalol
  - Intrinsic sympatho-mimetic activity:
    - Acebutolol
    - Penbutolol
    - Pindolol
- Side Effects & Considerations:
  - Fatigue
  - Lung Conditions: non-selective options may worsen bronchospasms
  - Diabetes: may mask s/sx of hypoglycemia
  - Avoid abrupt discontinuation
- Compelling Indications for Use:
  - Stable ischemic heart disease, heart failure with reduced ejection fraction (only carvedilol, sustained-release metoprolol succinate, or bisoprolol), coronary artery disease, post-myocardial infarction
Drug Class: Aldosterone antagonists
- Drug Names:
  - Eplerenone
  - Spironolactone
- Side Effects & Considerations:
  - Gynecomastia (spironolactone)
    - Hyperkalemia
  - Use with caution in acute renal failure
- Compelling Indications for Use:
  - Heart failure with reduced ejection fraction
Drug Class: Loop diuretics
- Drug Names:
  - Bumetanide
  - Furosemide
  - Torsemide
- Side Effects & Considerations:
  - Frequent urination (avoid dosing close to bedtime)
  - Electrolyte abnormalities
    - Hyponatremia
    - Hypokalemia
- Compelling Indications for Use:
  - Heart failure with reduced ejection fraction
Drug Class: Alpha-1 blockers
- Drug Names:
  - Doxazosin
  - Prazosin
  - Terazosin
- Side Effects & Considerations:
  - Orthostatic hypotension (risk increased in older adults)
- Compelling Indications for Use:
  - Benign Prostatic Hyperplasia (BPH)
Drug Class: Central Alpha-2 agonist
- Drug Names:
  - Clonidine
  - Methyldopa
  - Guanfacine
- Side Effects & Considerations:
  - CNS (risk increased in older adults)
  - Avoid abrupt discontinuation (clonidine)
- Compelling Indications for Use:
  - Attention-deficit/hyperactivity disorder (clonidine, guanfacine)
Drug Class: Direct renin inhibitor
- Drug Names:
  - Aliskiren
- Side Effects & Considerations:
  - Electrolyte abnormalities
    - Hyperkalemia
  - Acute renal failure

Adherence

Medication adherence is an essential component of treating hypertension. Discuss barriers to adherence and provide appropriate solutions. You may use the DRAW tool located in the Worksheets & Forms category of this Knowledge Base.

Monitoring

Patients should be monitored by their provider monthly upon start of new therapy or after any therapy changes to ensure adherence to therapy and progression towards treatment goals. Routine monitoring should continue once treatment goals are reached to ensure continued adherence to treatment, maintenance of treatment goals, and to assess for any hypertension related complications that may arise.

Self-Monitoring: Certain patients may be instructed to self-monitor and track their blood pressure at home. It is important to provide education to these patients on the appropriate device(s) to use and how to use them appropriately. The American Heart Association recommends against the use of wrist or finger monitors to measure blood pressure. Patients should also be instructed how to monitor for signs and symptoms of hypo- and hypertension and be aware of when to seek medical attention. If a patient’s blood pressure is >180/120mmHg and is accompanied with signs of organ damage (chest pain, shortness of breath, changes in vision, difficulty speaking, etc.) they should be advised to call 911.

Therapy Goals: The blood pressure goals for people with hypertension is < 130/80 mmHg regardless of concomitant conditions or age. Clinical judgement should still be used to individualize blood pressure goals depending on a patient’s risk factors, life expectancy, and other factors.

Lifestyle Education

Lifestyle modifications along with medication can help improve blood pressure. Discussion points may include:

Advise patient to follow a healthy diet which should include limiting sodium intake because increased dietary sodium is associated with elevations in BP

Advise patient to maintain a healthy weight or lose weight if they are overweight or obese

Encourage regular physical activity with a structured exercise program as even moderate physical activity has been shown to improve BP

Recommend patient limit alcohol consumption because excessive alcohol consumption can increase blood pressure
In patients who smoke recommend smoking cessation and provide counseling on appropriate options and resources

Additional Points

When obtaining a blood pressure, pharmacists should encourage practices for accurate blood pressure measurement for both the patient and the provider.

Patient should:

Pharmacist should:

Relax and be seated in a chair with their back supported for > 5 minutes.

Keep their feet flat on the floor and legs uncrossed.

Avoid caffeine, nicotine, or exercise for 30 minutes beforehand.

Empty their bladder prior to the blood pressure measurement.

Have their bare arm supported on a table and resting near heart level.

Ensure proper cuff size for the patient.

Maintain a quiet environment; do not talk during measurement.

Begin measurement after the patient has rested 5 minutes.

Measure in both arms and use the arm that gives a higher reading for subsequent readings.

Separate repeated measurements by 1–2 minutes.

Use an average of ≥2 readings obtained on ≥2 occasions.

Inquire about timing of most recent BP medication taken before measurements.

Resources

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.
https://www.jacc.org/doi/full/10.1016/j.jacc.2017.11.006
American Heart Association (AHA). Hypertensive Crisis: When You Should Call 911 for High Blood Pressure. https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings/hypertensive-crisis-when-you- should-call-911-for-high-blood-pressure
James, P. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults - Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). Journal of the American Medical Association.
https://jamanetwork.com/journals/jama/fullarticle/1791497