Ace Inhibitor Blood Pressure Medication Causes Least Dizziness

Summary

Hypertension is a common condition that affects one in every three adults in the United States. The ACC/AHA 2017 guidelines define it as a blood pressure of ≥ 130/80 mm Hg and the JNC 8 criteria as ≥ 140/90 mm Hg. Hypertension can be classified as either primary (essential) or secondary. Primary hypertension accounts for approx. 95% of cases of hypertension and has no detectable cause, whereas secondary hypertension is due to a specific underlying condition. Typical underlying conditions include renal, endocrine, or vascular diseases (e.g., renal failure, primary hyperaldosteronism, or coarctation of the aorta). Clinically, hypertension is usually asymptomatic until organ damage occurs, which then commonly affects the brain, heart, kidneys, or eyes (e.g., retinopathy, myocardial infarction, stroke). Common early symptoms of hypertension include headache, dizziness, tinnitus, and chest discomfort. Hypertension is diagnosed if blood pressure is persistently elevated on two or more separate measurements. Further diagnostic measures include evaluation of possible organ damage (e.g., kidney function tests) and additional tests if an underlying disease is suspected. Treatment of primary hypertension includes lifestyle changes (e.g., diet, weight loss, exercise) and pharmacotherapy. Commonly prescribed antihypertensive medications include ACE inhibitors, angiotensin receptor blockers, thiazide diuretics, and calcium channel blockers. Management of pediatric patients and pregnant women differs from that of nonpregnant adults because some of these drugs are contraindicated in these patient groups. To treat secondary hypertension, the underlying cause needs to be addressed.

See also "Hypertensive crisis."

Definition

• Definition of hypertension in adults : persistent systolic blood pressure of ≥ 140 mm Hg and/or diastolic blood pressure ≥ 90 mm Hg
• ACC/AHA 2017 definition ^[1]

AHA/ACC 2017 BP categories
BP category	Systolic blood pressure (mm Hg)		Diastolic blood pressure (mm Hg)
Normal blood pressure	< 120	AND	< 80
Elevated	120–129	AND	< 80
Stage 1 hypertension	130–139	OR	80–89
Stage 2 hypertension	≥ 140	OR	≥ 90

Epidemiology

• Prevalence
  • One in three adults in the US is affected. ^[4]
  • Prevalence increases with age (65% of men and 75% of women develop hypertension by the age of ≥ 70 years). ^[5]
  • Rates are highest in African Americans and lowest in Asian Americans, with white individuals falling in the middle. ^{[6] [7]}
  • 60–75% of obese and overweight patients are affected. ^[8]
• Sex ^[9]
  • ♂ > ♀ below 45 years of age
  • The sex ratio is almost balanced at > 45 years of age (i.e., after menopause)

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Primary (essential) hypertension

• Epidemiology
  • Accounts for 85–95% of cases of hypertension in adults
  • Accounts for 15–20% of cases of hypertension in children < 12 years of age
  • Age at onset: 25–55 years (prevalence is increasing in adolescents)
• Etiology
• Risk factors
  • Nonmodifiable risk factors
    • Positive family history
    • Ethnicity
    • Advanced age
  • Modifiable risk factors
    • Obesity
    • Diabetes
    • Smoking, excessive alcohol or caffeine intake
    • Diet high in sodium , low in potassium
    • Physical inactivity
    • Psychological stress

Secondary hypertension ^{[10] [11]}

• Epidemiology
  • Accounts for 5–10% of cases of hypertension in adults ^[12]
  • Accounts for 70–85% of cases of hypertension in children < 12 years of age
  • Age at onset < 25 years or > 55 years
• Etiology: caused by an identifiable underlying condition
  • Renal hypertension
    • Renovascular hypertension (the most common cause of secondary hypertension) can be due to:
      • Renal artery stenosis
      • Polyarteritis nodosa
      • Fibromuscular dysplasia of the renal arteries
    • Polycystic kidney disease (ADPKD)
    • Renal failure (renal parenchymal hypertension)
    • Glomerulonephritis
    • Systemic lupus erythematosus
    • Renal tumors
    • Atrophic kidney
  • Endocrine hypertension
    • Primary hyperaldosteronism
    • Hypercortisolism (Cushing syndrome)
    • Hyperthyroidism
    • Pheochromocytoma
    • Primary hyperparathyroidism
    • Acromegaly
    • Congenital adrenal hyperplasia
  • Other
    • Coarctation of the aorta
    • Obstructive sleep apnea
  • Medication: sympathomimetic drugs, corticosteroids, NSAIDs, oral contraceptives
  • Recreational drug use: amphetamines, cocaine, phencyclidine
  • Isolated systolic hypertension: See "Subtypes and variants" below.

RECENT: Renal (e.g., renal artery stenosis, glomerulonephritis), Endocrine (e.g., Cushing syndrome, hyperthyroidism, Conn syndrome), Coarctation of the aorta, Estrogen (oral contraceptives), Neurologic (raised intracranial pressure, psychostimulants use), Treatment (e.g., glucocorticoids, NSAIDs) are the causes of secondary hypertension.

Clinical features

• Hypertension is usually asymptomatic until:
  • Complications of end-organ damage arise (see "Complications" below)
  • Or an acute increase in blood pressure occurs (see " Hypertensive crisis ")
• Secondary hypertension usually manifests with symptoms of the underlying disease (e.g., abdominal bruit in renovascular disease, edema in CKD, daytime sleepiness in obstructive sleep apnea).
• Nonspecific symptoms of hypertension
  • Headaches, esp. early morning or waking headache
  • Dizziness, tinnitus, blurred vision
  • Flushed appearance
  • Epistaxis
  • Chest discomfort, palpitations
  • Strong, bounding pulse on palpation
  • Nervousness
  • Fatigue, sleep disturbances

Since hypertension is often asymptomatic, regular screening is necessary to prevent end-organ damage.

Subtypes and variants

Diagnostics

Blood pressure monitoring

Initial evaluation of newly diagnosed hypertensive patients

Approach to diagnosing secondary hypertension ^{[11] [14] [15]}

Treatment

Nonpharmacological measures ( lifestyle changes for managing hypertension )

Nonpharmacological measures should be pursued in any patient with a systolic BP > 130 mm Hg or a diastolic BP > 90 mm Hg .
Patients should be taught to measure their own blood pressure to allow for long-term monitoring and assessment of treatment efficiency.

Pharmacologic treatment ^{[12] [14] [15] [18]}

Overview of antihypertensive drugs
Drug class		Comments	Side effects
First-line drugs
ACEIs (e.g., lisinopril, captopril, enalapril)		Preferred as a first-line drug in patients with diabetes mellitus, renal disease (nephroprotective) , ischemic heart disease, and heart failure ACEIs and ARBs should not be used in combination. Consider combining ARBs with sacubitril in HF.	Dry cough, angioedema Hyperkalemia Teratogenic
ARBs (e.g., losartan, valsartan)			Hyperkalemia Teratogenic
Thiazide diuretics (e.g., hydrochlorothiazide, chlorthalidone)		Preferred as a first-line drug in African Americans , salt-sensitive patients, and patients with isolated systolic hypertension	Hypokalemia, hyponatremia ↑ Glucose and cholesterol
CCBs	Dihydropyridines (e.g., nifedipine, amlodipine)	Preferred as a first-line drug among African Americans and patients with isolated systolic hypertension Dihydropyridines should be avoided in patients with HFrEF.	Pedal edema Nausea Flushing Headache Gastroesophageal reflux Gingival hyperplasia
	Nondihydropyridines (e.g., diltiazem, verapamil)	Not commonly used Contraindicated in patients with reduced ejection fraction	Bradycardia AV block Constipation Hyperprolactinemia (Verapamil)
Second-line drugs
Beta blockers (e.g., propranolol , metoprolol , labetalol )		Should be avoided in hypertension due to aortic regurgitation Often used as a primary drug in patients with any of the following comorbidities: Ischemic heart disease Heart failure Atrial fibrillation Thoracic aortic disease (e.g., aortic dissection, aortic aneurysm) Thyrotoxicosis Migraine Essential tremor Beta blockers with intrinsic sympathomimetic activity (e.g., acebutolol) should not be used as antihypertensives	Bronchoconstriction with noncardioselective beta blockers Increased triglycerides Blunted effects of hypoglycemia
Loop diuretics (e.g., furosemide, torsemide)		Used in symptomatic heart failure and CKD (if GFR < 30 mL/min)	Hypokalemia, hyponatremia ↑ Glucose ↑ Cholesterol
Aldosterone antagonists (e.g., eplerenone, spironolactone)		Used in hypertension due to primary aldosteronism Can be used as add-on therapy in resistant hypertension	Hyperkalemia Gynecomastia (spironolactone)
Direct renin inhibitors (e.g., aliskiren)		Should not be used in combination with ACEIs or ARBs	Hyperkalemia
Alpha-1 blockers (e.g., prazosin, doxazosin)		Used in hypertension due to pheochromocytoma May be used as an adjunct in patients with benign prostatic hypertrophy	Postural hypotension Headache
Alpha-2 agonists (e.g., clonidine)		Rarely used	CNS depression Bradycardia Rebound hypertension
Direct arteriolar vasodilators (e.g., hydralazine , nitroprusside)		Increases release of cGMP → relaxation of smooth muscle → vasodilation Hydralazine acts more on arterioles than veins Nitroprusside acts on arteries and veins equally Reduces afterload Hydralazine is a first-line treatment in pregnancy. Sodium nitroprusside is used only in hypertensive emergencies. Organic nitrates in CHF	Reflex tachycardia can be prevented by coadministering beta blockers. Angina Sodium and water retention Cyanide toxicity with long-term use of sodium nitroprusside Drug-induced lupus erythematosus (DILE)

Treatment according to subgroups ^{[12] [14] [15] [18]}

• Primary hypertension: thiazide diuretics, ACEIs, ARBs, and/or dihydropyridine CCBs
• Patients with CHF
  • Diuretics, aldosterone antagonists, ACEIs, and ARBs
  • ARBs can be combined with sacubitril
  • Beta blockers
    • Safe to use in compensated CHF
    • Must be used cautiously in decompensated CHF
    • Contraindicated in cardiogenic shock
• Patients with diabetes mellitus
  • ACEIs, ARBs, CCBs, thiazide diuretics, beta blockers
  • ACEIs/ARBs are protective against diabetic nephropathy. Beta blockers can mask hypoglycemia symptoms.
• Patients with asthma
  • ARBs, CCB, thiazide diuretics, cardioselective beta blockers (nonselective beta blockers can cause bronchoconstriction)
  • Avoid ACEIs (can cause bradykinin-induced cough).
• Treatment of hypertension in pregnancy
  • First-line treatment: methyldopa , labetalol , hydralazine , and nifedipine
  • Second-line treatment: thiazides, clonidine
  • Contraindicated: furosemide, ACEI, ARB, renin inhibitors (e.g., aliskiren)
  • See "Treatment of gestational hypertension."

Moms Love Healthy Newborns: Use Methyldopa, Labetalol, Hydralazine, or Nifedipine for hypertensive pregnant women.

Beta blockers are not recommended for initial treatment of hypertension in children due to their metabolic side effects (e.g., impaired glucose tolerance) and the fact that they exacerbate asthma!

Complications

• Arterial hypertension is the most common risk factor for cardiovascular disease
• It leads to changes in the vascular endothelium, particularly of the small vessels, and can therefore affect any organ system.
• See also "Hypertensive crisis."

Cardiovascular system ^{[11] [19]}

• Left ventricular hypertrophy, hypertrophic cardiomyopathy , dilated cardiomyopathy
• Congestive heart failure
• Coronary artery disease and myocardial infarction
• Atrial fibrillation
• Aortic aneurysm
• Aortic dissection
• Carotid artery stenosis
• Peripheral artery disease
• Atherosclerosis

Brain ^{[11] [19] [20]}

• Stroke , TIA
• Subcortical leukoencephalopathy
• Cognitive changes such as memory loss

Kidneys ^{[19] [21]}

• Hypertensive nephrosclerosis : a renal vascular injury secondary to long-standing arterial hypertension
• Chronic kidney disease

Eyes ^{[11] [19]}

• Hypertensive retinopathy : arteriosclerotic and hypertension-related changes of the retinal vessels
  • Fundoscopic examination:
    • Cotton-wool spots
    • Retinal hemorrhages (i.e., flame-shaped hemorrhages)
    • Microaneurysms
    • Macular star (results from exudation into the macula)
    • Arteriovenous nicking : a tapering of a retinal venule at the point where a retinal arteriole crosses the retinal venule
    • Marked swelling and prominence of the optic disk with indistinct borders due to papilledema and optic atrophy ( end-stage disease)
• Presence of papilledema in a hypertensive patient may indicate a hypertensive crisis and warrants urgent lowering of the blood pressure (see "Hypertensive crisis")

Local treatment of retinopathy is not possible, therefore, systemic reduction of blood pressure is critical!

We list the most important complications. The selection is not exhaustive.

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References

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