1. drug induced
2. pheochromocytoma
3. sleep apnea
4. chronic kidney disease
5. renovascular disease
6. cushing's syndrome
7. coarctation of the aorta
8. thyroid/parathyroid disease

1. HTN
2. obesity
3. dyslipidemia
4. cigarette smoking
5. physical inactivity
6. microalbuminuria
7. age (>55 men, >65 women)
8. family history of premature CVD (>55 men, >65 women)

1. NSAIDs, COX-2 Inhibitors
2. Cocaine, amphetamines
3. Sympathomimetics (decongestants)
4. Oral contraceptives (esp. high dose estrogen)
5. Steroids
6. Cyclosporine and tacrolimus
7. Erythropoietin
8. Licorice (including some chewing tobacco)
9. OTC weight loss and CNS stimulants (ephedra, ma huang)

1. Diabetes Mellitus
2. Chronic Kidney Disease
3. Coratid Artery Disease
4. Peripheral Artery Disease
5. Abdominal aortic aneurysm

Goal BP is 130/80

• HCTZ, Beta-Blocker, ACEI, or ARB is OK 1st line
• if patient has microproteinuria, use ACEI or ARB
• if patient has gross proteinuria, use ACEI or ARB (NOT ACEI and ARB)

Beta-Blockers in Diabetes:

• may mask the signs of hypoglycemia
• Beta-1 specific preferred

Goal BP is 130/80

Use ACEI or ARB:

• Do not use if SrCr > 2.5 M, or 2.0 F
• Do not use if K > 5.0

• Loop diuretics may be needed later in disease (CrCl < 30 generally)

If "prediabetic" or at high risk for T2DM:

• ACEI or ARB may decrease incidence
• HCTZ or beta-blocker may increase incidence

• Use beta-blocker or alpha blocker + ACEI (ARB if not tolerated)
• Aldosterone antagonists should be added if stage 3 or 4 HF or EF < 40%

Loop diuretics if fluid overload occurs:

-peripheral edema

-positional shortness of breath

• Thiazides may be added if additional control is needed
• Hydralazine/isosorbide dinitrate has added benefit in blacks

Contraindicated: 

Non-DHP, clonidine, alpha-blockers

Beta-Blocker (B1 preferred) + ACEI (ARB if not tolerated)

-patient should be hemodynamically stable before adding beta-blocker

• aldosterone antagonist may add benefit
• thiazides may add additional benefit if tolerated
• Non-DHP may be used rather than beta-blocker if contraindicated (unless HF is present)

• Beta-blocker (beta1 preferred) is 1st choice
• Long acting DHP CCB may be added
• Long acting non-DHP may be used instead of beta-blocker if absolutely necessary
• Use combination of beta-blocker and non-DHP very cautiously (heart block) 

• Do not lower BP precipitously after a stroke (goal of 160/100 until stable)
• Thiaze with/without ACEI (ARB if not tolerated)

Non-Selective Beta-Blocker:

Propranolol (crosses BBB)

• Avoid beta-blocker generally
• If strong indication (post-MI), asses risk for the patient and if risk is thought to be low, use a very low dose beta1 selective agent -> afterwards, monitor patient very closely

• Beta-Blocker or Non-DHP CCB
• Use extreme caution in the combination of both classes

• HTN not at goal despite concurrent use of > 3 drugs from different classes (ideally, one of the 3 agents is a diuretic)
• 20-30% of patients with HTN will have Resistant HTN

1. Older age
2. Diabetes
3. High baseline BP
4. Left Ventricular Hypertrophy
5. Obesity
6. Black race
7. Excessive dietary salt intake
8. Female sex
9. Chronic Kidney Disease
10. Residence in southeastern US

• Almost always, HTN is secondary to something else
• Lifestyle modifications may be more useful in children

Use caution with ACEI or ARB in sexually active girls:

-ACEI and ARB are teratogens

-The younger you are the more likely you are to have unplanned pregnancies

Goal BP is 140/90

• Methyldopa is 1st choice
• Labetolol or DHP CCB are alternate agents
• Avoid ACEI, ARB, Renin Atntagonists, Loop Diuretics
• Thiazides (may continue if used prior to pregnancy) --> contraindicated and only used for fluid overload

• typically occurs post week 20 in primigravid women
• BP > 140/90 appearing post week 20 in the presence of proteinuria

Treatment:

• delivery
• bed rest, limited activity, close monitoring
• drug therapy prior to delivery with goal DBP of 95 to 105 mm Hg

• Defined as BP > 180/120
• Treated with Captopril, clonidine, or labetolol
• Avoid precipitous BP reductions
• Avoid immediate acting DHPs

• those with evidence of acute target-organ damage and markedly elevated BP (> 180/120)

Examples of target-organ damage:

1. MI or unstable angina
2. head trauma, CNS changes, stroke
3. abdominal pain, bruising or bloating

• Requires immediate hospitalization
• Lower MAP by 25% in minutes to hrs
• Avoid precipitous drops in BP

• Goal BP of BP 160/100 in 2-6 hrs
• Goal BP of 140/90 in 24-48 hrs
• Na Nitroprusside is agent of 1st choice in most (may be dangerous in patients with kidney disease) 

Drugs: 

Chlorthalidone 12.5 mg QD, then 25 mg QD, then add atenolol 25 mg

Outcome:

Drug therapy reduced the incidence of cardiovascular events and stroke

Drugs:

Randomized to placebo, HCTZ, atenolol, clonidine, captopril, prazosin, or diltiazem

Outcomes:

• HCTZ was the best in blacks, captopril was the worst
• HCTZ was least effective in young whites

Drugs:

Ramipril vs placebo

Outcomes: 

• ACEI reduces the rates of death, MI, and stroke
• Also slows the progession of diabetes in people at risk for diabetes

Drugs:

DHP CCB vs ACEI in patients with diabetes

Outcomes:

• BP reduction was nearly identical
• DHP CCB has some small benefit
• Those receiving ACEI had lower rates of coronary events and death

First Part

Drugs:

Compared chlorthalidone, amlodipine, and lisinopril

Outcomes:

Thiazide diuretics are superior to ACEI or CCB in preventing coronary outcomes related to HTN and should be considered first line therapy for HTN

Second Part

Drugs:

doxazosin vs. chlorthalidone

Outcome:

• Trial was stopped
• Those receiving doxazosin had 25% more cardiovascular events and were twice as likely to be hospitalized for CHF compared to chlorthalidone

Drugs:

Telmisartan and Ramipril

Outcome:

• ARBs are just as effective as ACEI at reducing mortality and morbidity in patients with a high risk for heart and cardiovascular events
• The combination of these two drugs resulted in increased incidence of renal failure and dialysis than either agent alone