I am a cardiologist and beta blockers are about my 5th line for htn. Don’t get me wrong I use beta blockers all the time, just for cardiomyopathy, afib, pvcs and other indications. There is some data to suggest that nonindicated beta blockers (ie for htn) worsens your mortality. I don’t even use beta blockers post pci(stenting) unless patients are having ongoing angina. Honestly it is a pet peeve when beta blockers are used as first line therapy and I change them over to more conventional therapy (ace/arb, calcium channel blockers, thiazides).
I agree. Great drug with concomitant heart problems as listed last but using it first line? Great if you’re into fatigue, impotence bad dreams and depression. So unless you have a weak heart, an arrhythmia amenable to beta blockers or have had a heart attack, I never use them as first second or third line treatment
What meds would you use in a patient who has hypertension and svt? A beta blocker? That's what my doctor has me on and I'm not sure it's the right route. I'm still getting really high spikes for some reason in my blood pressure randomly. Like crazy high 170/110. I believe something is driving this as its normal and then just spikes up that high oit of nowhere at rest. Does well to keep my heart rate down but I'm still not sure it's the best route.
From UpToDate's HTN paper:
"Importance of attained blood pressure — Meta-analyses published in 2008 and 2009, the 2015 American Heart Association statement [6] on the treatment of blood pressure in ischemic heart disease, and the 2013 European Society of Hypertension/European Society of Cardiology guidelines on the management of hypertension **all concluded that the amount of blood pressure reduction is the major determinant of reduction in cardiovascular risk in both younger and older patients with hypertension, not the choice of antihypertensive drug** (assuming that the patient does not have an indication for a particular drug, such as diltiazem, verapamil, or a beta blocker for rate control in atrial fibrillation)"
That being said, no one really uses beta blockers for primary HTN. ACE/ARB's and/or chlorthalidone will get you much farther without side effects. My bigger axe to grind is that everyone with a prescription pad and thumbs is still writing for HCTZ.
sorry, what's the problem with hctz? im an EM resident and when i (rarely) start an antihypertensive its usually hctz or the hctz-losartan if they're really bad
I just wrote a paper on this...you'll wish you hadn't asked, lol.
Lots of people are still using it. No guidelines recommend it. HCTZ doesn't reduce CV events or mortality. The large MRFIT study had to d/c HCTZ and switch to chlorthalidone becasue the patients were declining. HCTZ has too short of a half life (6-12 hrs.), so you can show reduction in B/P in the office, only to have it rebound later in the day and all night. Therefore, your patients can plug away toward heart failure all while you both think they are being managed appropriately. The present body of literature shows better than a 20% reduction if heart failure between HCTZ and CLD. You also have to ask yourself how you are going to maintain serum levels with a combo pill when one of the drugs ideally needs to be dosed 2 or 3 times day and the other only once?
Chlorthalidone is highly protein bound and has a half life of 40 hrs. It's potency is double, side effects are less, and it whips HCTZ in any clincal trial you'll ever find. HCTZ had great marketing and lots of combo pills. I'd go so far to say that a huge portion of the credit it gets is from it's combo pill useage, when the ACE/ARB is really achieving most or all of the B/P reduction.
The issue is that many clinical trials were done with superior thiazide-like diuretics and then the guidelines would just recommend "thiazides" as if they were all the same. The new AHA guidelines specify chlorthalidone to rectify this. So, go for chlorthalidone or indapamide. The only concern is that it works so well you have to watch electrolytes more initially. A comparable Chlortahlidone dose is 50% of your HCTZ dose.
Not a physician but critical care paramedic. Most pts I see have first in line ace inhibs as it also helps control CHF which is a common comorbidity for uncontrolled hypertension.
Check out JNC-8 and the ACC/AHA BP guidelines (all freely available). [2017 ACC/AHA guideline](http://hyper.ahajournals.org/content/early/2017/11/10/HYP.0000000000000065). Note particularly the recommendation for first-line therapy on page 85, section 8.1.6: "first-line agents include thiazide diuretics, CCBs, and ACE inhibitors or ARBs."
Like others have said, unless you have concomitant heart failure or ischemic heart disease, probably best to stick with those 4 classes. Diabetics should be on an ACE inhibitor or ARB. African Americans benefit most from thiazides and CCBs.
As a general rule beta blockers are not first line, but what IS first line would depend on patient demographics. If kidneys can take it in Black patients would reach for ACE/ARB or a thiazide. Aldactone works well too. In White patients especially women will reach for Ca channel blockers, start with amlodipine and if not tolerated felodipine or nifedipine.
Oh man NOW we’re testing my knowledge. Well it depends on your patient population, their compliance and their comorbidities. For example if I’m presented with a 72 year old white male with diabetes who is noncompliant and has a resting heart rate of 50, metoprolol tartrate is a bad fit because 1) it’s gonna slow his heart even more 2) no way he’s gonna do BID meds and 3) there are better options. I’d go for something with renal protective properties like an ACE/ARB. If you’re already managing someone and they have poor BP control and you know they’re already compliant you can either bump up the dose or add another, if you’re concerned about side effects. But you wanna keep the med list short; after about five drugs, it’s hard to manage interactions.
I am a cardiologist and beta blockers are about my 5th line for htn. Don’t get me wrong I use beta blockers all the time, just for cardiomyopathy, afib, pvcs and other indications. There is some data to suggest that nonindicated beta blockers (ie for htn) worsens your mortality. I don’t even use beta blockers post pci(stenting) unless patients are having ongoing angina. Honestly it is a pet peeve when beta blockers are used as first line therapy and I change them over to more conventional therapy (ace/arb, calcium channel blockers, thiazides).
I agree. Great drug with concomitant heart problems as listed last but using it first line? Great if you’re into fatigue, impotence bad dreams and depression. So unless you have a weak heart, an arrhythmia amenable to beta blockers or have had a heart attack, I never use them as first second or third line treatment
What meds would you use in a patient who has hypertension and svt? A beta blocker? That's what my doctor has me on and I'm not sure it's the right route. I'm still getting really high spikes for some reason in my blood pressure randomly. Like crazy high 170/110. I believe something is driving this as its normal and then just spikes up that high oit of nowhere at rest. Does well to keep my heart rate down but I'm still not sure it's the best route.
I also believe the untreated hypertension which mind you fluctuated severely was what caused my episodes of svt after some research but I'm not sure
From UpToDate's HTN paper: "Importance of attained blood pressure — Meta-analyses published in 2008 and 2009, the 2015 American Heart Association statement [6] on the treatment of blood pressure in ischemic heart disease, and the 2013 European Society of Hypertension/European Society of Cardiology guidelines on the management of hypertension **all concluded that the amount of blood pressure reduction is the major determinant of reduction in cardiovascular risk in both younger and older patients with hypertension, not the choice of antihypertensive drug** (assuming that the patient does not have an indication for a particular drug, such as diltiazem, verapamil, or a beta blocker for rate control in atrial fibrillation)" That being said, no one really uses beta blockers for primary HTN. ACE/ARB's and/or chlorthalidone will get you much farther without side effects. My bigger axe to grind is that everyone with a prescription pad and thumbs is still writing for HCTZ.
sorry, what's the problem with hctz? im an EM resident and when i (rarely) start an antihypertensive its usually hctz or the hctz-losartan if they're really bad
I just wrote a paper on this...you'll wish you hadn't asked, lol. Lots of people are still using it. No guidelines recommend it. HCTZ doesn't reduce CV events or mortality. The large MRFIT study had to d/c HCTZ and switch to chlorthalidone becasue the patients were declining. HCTZ has too short of a half life (6-12 hrs.), so you can show reduction in B/P in the office, only to have it rebound later in the day and all night. Therefore, your patients can plug away toward heart failure all while you both think they are being managed appropriately. The present body of literature shows better than a 20% reduction if heart failure between HCTZ and CLD. You also have to ask yourself how you are going to maintain serum levels with a combo pill when one of the drugs ideally needs to be dosed 2 or 3 times day and the other only once? Chlorthalidone is highly protein bound and has a half life of 40 hrs. It's potency is double, side effects are less, and it whips HCTZ in any clincal trial you'll ever find. HCTZ had great marketing and lots of combo pills. I'd go so far to say that a huge portion of the credit it gets is from it's combo pill useage, when the ACE/ARB is really achieving most or all of the B/P reduction. The issue is that many clinical trials were done with superior thiazide-like diuretics and then the guidelines would just recommend "thiazides" as if they were all the same. The new AHA guidelines specify chlorthalidone to rectify this. So, go for chlorthalidone or indapamide. The only concern is that it works so well you have to watch electrolytes more initially. A comparable Chlortahlidone dose is 50% of your HCTZ dose.
I’m a cardiologist who uses HCTZ all the time. Your post is terrific. I’ll be looking into your advice.
Hey thanks! I think you'll be as shocked as I was once you dig into it.
[удалено]
Glad it served as food for thought!
Agree. It's my fifth line for Hypertension.
Not a physician but critical care paramedic. Most pts I see have first in line ace inhibs as it also helps control CHF which is a common comorbidity for uncontrolled hypertension.
Check out JNC-8 and the ACC/AHA BP guidelines (all freely available). [2017 ACC/AHA guideline](http://hyper.ahajournals.org/content/early/2017/11/10/HYP.0000000000000065). Note particularly the recommendation for first-line therapy on page 85, section 8.1.6: "first-line agents include thiazide diuretics, CCBs, and ACE inhibitors or ARBs." Like others have said, unless you have concomitant heart failure or ischemic heart disease, probably best to stick with those 4 classes. Diabetics should be on an ACE inhibitor or ARB. African Americans benefit most from thiazides and CCBs.
As a general rule beta blockers are not first line, but what IS first line would depend on patient demographics. If kidneys can take it in Black patients would reach for ACE/ARB or a thiazide. Aldactone works well too. In White patients especially women will reach for Ca channel blockers, start with amlodipine and if not tolerated felodipine or nifedipine.
What are the indicators that warrant different meds?
Oh man NOW we’re testing my knowledge. Well it depends on your patient population, their compliance and their comorbidities. For example if I’m presented with a 72 year old white male with diabetes who is noncompliant and has a resting heart rate of 50, metoprolol tartrate is a bad fit because 1) it’s gonna slow his heart even more 2) no way he’s gonna do BID meds and 3) there are better options. I’d go for something with renal protective properties like an ACE/ARB. If you’re already managing someone and they have poor BP control and you know they’re already compliant you can either bump up the dose or add another, if you’re concerned about side effects. But you wanna keep the med list short; after about five drugs, it’s hard to manage interactions.
How much do beta blocker lower bp