Recap and review the top pearls from recent episodes #321 Hypertension FAQ and #326 Cardiorenal Syndrome (NephMadness 2022) with Watto and Paul. It’s Tales from the Curbside! (TFTC), our monthly series providing a rapid review of recent Curbsiders episodes for your spaced learning.
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Featuring Dr. Jordana Cohen and production and graphics by Malini Gandhi
The latest guidelines (ISH, KDIGO, ACC/AHA) recommend stricter BP targets with hypertension diagnosed as BP above 130/80 mmHg (ACC/AHA).
Beware the casual office BP, which does not meet quality standards (Unger et al., ISH guidelines, 2020) and may not reflect a patient’s home blood pressure. Dr. Cohen recommends home BP readings to confirm the diagnosis, consistent with USPSTF guidelines. She instructs patients to take at least two readings each morning and evening over a three day period. Patients should choose a BP cuff listed on validateBP.org.
Use a 24-hour ambulatory BP monitor to clarify a patient’s true blood pressure (e.g., when considering white coat hypertension or masked hypertension).
Paul says, “Dr. Cohen validates my feeling on ARBs, which work as well as ACE inhibitors for the same indications (nephroprotection, systolic heart failure, etc.), but have a more favorable side effect profile” (Chen, 2021). There is less cough and angioedema with ARBs. Paul worries that if these adverse effects occur with an ACE inhibitor, then prescribers are often uncomfortable prescribing the ARB, and you have effectively lost TWO classes of medications.
Dr. Cohen favors olmesartan as initial therapy, as it has a longer half-life (t ½ 13 hours, Lexicomp). Losartan should ideally be dosed twice daily (t ½ is ~2 hours and t ½ active metabolites ~7 hours per Lexicomp), and valsartan is somewhat less potent (expert opinion). Note: Candesartan and telmisartan also have a longer duration of action (~24 hours per Lexicomp).
Most patients require two agents to control their BP (Chobanian, 2008) and side effects are less likely when using low doses (Salaam et al, 2019). Further, a lower BP target is probably better (SPRINT 2015; Zhang, 2021). Thus, a low dose combination of two meds at 25% or 50% max dose of each agent is a good option, especially if BP is more than 20/10 mmHg above target.
For hydrochlorothiazide, Dr. Cohen recommends a starting dose of 25 mg (she notes that 12.5 mg, a commonly used starting dose, is much too low!) For chlorthalidone, Dr. Cohen recommends a starting dose of 12.5 mg daily or even 25 mg every other day (expert opinion)!
Dr. Cohen is honest with her younger patients who may warrant therapy for their hypertension. This is largely an evidence-free zone, but she discusses the risks and benefits. In general, data suggest that tighter control is better in the long run, but decides on a case-by-case basis using shared decision-making (expert opinion).
White coat and masked hypertension
White coat and masked hypertension are prevalent, and both confer cardiovascular risk. They are also both good arguments for out-of-office blood pressure measurement. A reminder that white coat hypertension is one of the few reasons insurers might pay for 24-hour blood pressure monitoring. Interestingly, masked hypertension is more common in men who smoke or use alcohol (Franklin et al, 2015).
Dr. Cohen dislikes hydralazine which can worsen edema and contribute to labile readings. Instead, she prefers diuretics and ACEIs/ARBs, which can be safely used in CKD!
Chlorthalidone lowered blood pressure in the CLICK trial (Agarwal et al, 2021). Dr. Cohen starts at chlorthalidone 25 mg daily and titrates up. Loop diuretics can also be used as patients with CKD often carry extra volume. Typical diuretic doses in CKD include torsemide 20 mg daily, bumetanide 1 mg twice daily, or furosemide 20-40 mg twice daily.
ACEIs/ARBs can delay CKD progression and reduce CV risk (Jafar et al., 2001, Mann et al., 2001). Dr. Cohen tolerates a creatinine bump of up to 30% (Cheung et al., KDIGO guidelines, 2021) and potassium of up to 5.5 (expert opinion). Suspect bilateral renal artery stenosis if creatinine bumps more than 30%.
Resistant Hypertension Patients with uncontrolled hypertension on more than three medications have resistant hypertension.
Dr. Cohen diagnoses primary hyperaldosteronism by plasma aldosterone above 15 and suppressed renin.
She recognizes salt-sensitive hypertension in patients with suppressed renin but normal or equivocal plasma aldosterone values (expert opinion).
Plasma aldosterone and renin can be tested on all BP meds except MRAs and amiloride.
Treat primary hyperaldosteronism with spironolactone or eplerenone.
Consider amiloride for isolated renin suppression (expert opinion).
Permissive hypercreatininemia is the idea that a bump in creatinine during diuretic therapy for heart failure is expected and should be tolerated. As the expanded plasma volume contracts, the patient’s true creatinine is unmasked (expert opinion) similar to changes seen with hemoglobin concentration. Post hoc analysis of patients in the DOSE trial found improved outcomes in those who experienced a creatinine bump (Brisco 2016).
It’s okay to continue a hospitalized patient’s ACEI/ARB and/or SGLT2 inhibitor in the absence of hyperkalemia or hypotension. Make sure to resume them on discharge if held during admission!
While an elevated troponin in a hospitalized patient with chronic kidney disease may not necessitate urgent intervention, it is not entirely benign. These patients have a worse prognosis (Michos et al, 2014), and these elevations may be helpful in long term risk stratification. Similarly, while BNP is often chronically elevated in patients with chronic kidney disease, Dr. Khan looks at the change in relation to baseline to help determine volume status.
We talked about diuretic resistance with Dr. Topf on his first Curbsiders appearance (#31 Diuretics and Leg Cramps). First, determine whether or not the patient’s diuretic threshold is met (i.e., Are they experiencing increased urine output with each dose?). Next, increase the frequency as needed to meet your goal (e.g., 2-3 times daily dosing of IV bumetanide) once the dose threshold is met.
Thiazides, thiazide-like, acetazolamide, MRAs, and SGLT2 inhibitors can be employed to overcome diuretic resistance (NephMadness blog post).
Hyperdiuresis can be accomplished by adding hypertonic saline to a loop diuretic. It’s believed that this turns off the renin-aldosterone-angiotensin-system (NephMadness blog post; Paterna 2011; Griffin 2020).
Choice of diuretic
Furosemide is much beloved and commonly used, but bumetanide has higher bioavailability, and levels are less affected by changes in GFR, so large dose adjustments often are not needed in renal insufficiency. This may be especially relevant in patients who “hide” their excess volume in their abdomen, where gut edema may decrease absorption of oral agents.
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Williams PN, Watto MF. “#343 Hypertension FAQ and Cardiorenal Syndrome: A Rapid Review (TFTC)”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date June 29, 2022.
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