Management of Hypertension in HIV
(based on JNC 7)
[print pdf 37kb] Upated 1/3/06
- Lifestyle Changes
- Drug Interactions
The JNC VII report released in 2003 categorizes BP as follows:
||SBP (mm Hg)
||DBP (mm Hg)
|Stage 1 hypertension
I. Lifestyle Changes
- With prehypertension or hypertension, lifestyle changes should be emphasized.
Lifestyle changes consist of :
- Weight loss in overweight and obese individuals
- The DASH diet which is high in potassium and calcium
- Dietary sodium reduction to 2.4 g/day
- Physical activity
- Moderation of alcohol consumption
- 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.
- 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:
- Ischemic heart disease - beta blockers (BBs), long-acting calcium channel blockers (CCBs)
- Heart failure - BBs, ACE inhibitors (ACEIs)
- Diabetes - ACEIs, angiotensin receptor blockers (ARBs), thiazide diuretics, BBs, CCBs
- Chronic kidney disease (GFR<60 or proteinuria) – ACEIs, ARBS (tolerate increase of
35% in creatinine on treatment unless hyperkalemia intervenes)
- 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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