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Management of Hypertension in HIV
(based on JNC 7)

[print pdf 37kb] Upated 1/3/06

    1. Lifestyle Changes
    2. Diagnosis
    3. Therapy
    4. Drug Interactions

The JNC VII report released in 2003 categorizes BP as follows:

SBP (mm Hg) DBP (mm Hg)
Normal <120 <80
Prehypertension 120-139 or 80-89
Stage 1 hypertension 140-159 or 90-99
Stage 2 >159 or >99

I. Lifestyle Changes

  • With prehypertension or hypertension, lifestyle changes should be emphasized.

Lifestyle changes consist of :

    1. Weight loss in overweight and obese individuals
    2. The DASH diet which is high in potassium and calcium
    3. Dietary sodium reduction to 2.4 g/day
    4. Physical activity
    5. Moderation of alcohol consumption

II. Diagnosis

  • Blood pressure should be measured with patient in chair (rather than on exam table) with feet on floor and with the arm supported at heart level after 5 minutes of rest.
  • The bladder of the blood pressure cuff should encircle at least 80% of the arm.
  • At least 2 measurements should be made at different clinic visits before a diagnosis of HTN is made.
  • For blood pressures measured at home, blood pressure >135/85 is considered hypertensive.

III. Therapy

  • In clinical trials, antihypertensive treatment has been associated with 35-40% reduction in stroke, 20-25 percent reduction in MI, and over 50% reduction in CHF. By lowering the SBP by 12mm Hg in 11 patients with stage 1 hypertension and one additional CAD risk factor, one death will be prevented for every 10 years of treatment.
  • For the majority of patients with hypertension, a thiazide diuretic should be the first line of therapy.
  • For stage 2 hypertension, it may be appropriate to initiate therapy with more than one drug since a patient will most likely not achieve goal blood pressure on monotherapy.
  • The goal of therapy for most patients is BP<140/90 except in patients with chronic renal insufficiency, diabetes, or proteinuria where the goal blood pressure is <130/80.
  • There are some “compelling indications” where a non-diuretic may offer benefit such as:
    1. Ischemic heart disease - beta blockers (BBs), long-acting calcium channel blockers (CCBs)
    2. Heart failure - BBs, ACE inhibitors (ACEIs)
    3. Diabetes - ACEIs, angiotensin receptor blockers (ARBs), thiazide diuretics, BBs, CCBs
    4. Chronic kidney disease (GFR<60 or proteinuria) – ACEIs, ARBS (tolerate increase of 35% in creatinine on treatment unless hyperkalemia intervenes)
    5. Left ventricular hypertrophy - ARBs or ACEIs
  • In African Americans there is an improved response to thiazide diuretics or CCB vs. BBs, ACEIs, or ARBs.
  • There is increasing evidence that a beta blocker should not be used as the first line agent for hypertension unless there is a “compelling indication” as listed above, given higher event rates with beta blockers in comparison to other first line drugs.

IV. Drug Interactions

  • There are important drug interactions between calcium channel blockers (especially amlodipine, nifedipine, and verapamil) and PIs and NNRTIs.
  • Carvedilol interacts with both PIs and NNRTIs.
  • Beta blockers should be used with caution with atazanavir due to the possibility of additive prolongation of the PR interval.
  • Further details regarding these and other drug interactions can be found at www.hiv-druginteractions.org.
  • The full JNC 7 report on hypertension can be found at www.nhlbi.nih.gov/guidelines/hypertension.

 

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