Primary Care Update on Hypertension

General Comments

Epidemiology

50 million Americans have B/P > 140 systolic

20-30% of blacks and 15% of whites in the U.S. have hypertension.

Most hypertension is diagnosed in adults ages 25-50.

Most of the patients we care for with HIV and AIDS are within this age range.

Why Treat Hypertension? To avoid end organ disease.

Left ventricular hypertrophy results in CHF, ischemia, ventricular arrhythmias, and

Nephrosclerosis results in end-stage renal disease, necessitating dialysis.

troke-either hemorrhagic or infarction.

Etiology

Essential HTN is multifactorial.

Salt intake alone may not be significant but if combined with strong genetics it may play an important role for a select group. Exacerbating factors include obesity, salt intake, excessive alcohol (> 2 drinks a day) or alcohol binging, tobacco use and low K+ intake. NSAIDS should be avoided especially in patients with borderline HTN as it can cause a 5 mm Hg or greater rise in B/P. Secondary HTN: Consider in those <20 and >50 and a diagnosis of HTN or those with previous good control who become refractory to treatment. Consider renal disease, hyperaldosterone states, Cushing's, hypercalcemia, pheochromocytoma, coartaction, or thyroid disease.

 Indications for Medical Therapy. Goal is to prevent morbidity (end-organ disease) and mortality. Decision to treat with medications should be based on an individual assessment of risk factors versus B/P measurement alone. Twenty randomized trials of Stage H and HI HTN showed ~incidence of stroke by 30-50% and incidence of CHF by 40-50% and ,b fatal and nonfatal CHD by 10-15%. Several studies in older adults with predominantly systolic HTN demonstrated that treatment prevents fatal and nonfatal MI and overall  decrease in cardiovascular morbidity and mortality..

New Classification of Stages of HTN

Choosing Medication Treatments

Often times associated medical conditions point to use of a particular agent. 

Specific HIV/AIDS drug interactions with PI's

Indinavir: Avoid diuretics of all classes. Hydration of 2-3L is often required to avoid crystalluria/nephrolithiasis syndromes.

Nevirapine will induce metabolism of beta blockers, felodipine, and nifedipine and decrease their plasma concentration.

Ritonavir will increase to > 3X the AUC of the following medications: amlodipine, diltiazem, felodipine, isradipine, nicardipine, nifedipine, nimodipine, and verapamil.

Ritonavir will increase to 1.5 - the AUC of the following medications: metroprolol, pindolol, propranolol, and timolol.

Ritonavir will increase or decrease to 1.5 - the AUC of losartan