White coat hypertension can be better understood by using 24-hour ambulatory blood pressure monitoring to assess blood pressure patterns and determine if the patient has labile or nocturnal hypertension.
ACE inhibitors or ARBs should be used in hypertension management in patients with chronic kidney disease (CKD), despite concerns of kidney-related adverse effects, as they have proven benefits in blood pressure control and reducing cardiovascular risk.
Patients with CKD and proteinuria can benefit from ACE inhibitors or ARBs even with proteinuria less than 500 mg per day, as these medications have demonstrated cardiovascular benefits and may help slow kidney disease progression.
Deep dives
Managing White Coat Hypertension
In cases of white coat hypertension, where a patient's blood pressure is elevated in the clinic but normal at home, it is important to consider 24-hour ambulatory blood pressure monitoring to get a clearer picture of their blood pressure patterns. This can help determine if the patient has labile or nocturnal hypertension. If the patient truly has white coat hypertension, there is no increased risk of adverse cardiovascular events once they are on blood pressure medication. However, if the patient is not on medication, there is a small increased risk. Treatment should be individualized based on the patient's goals and preferences. For patients who prefer not to take multiple medications, starting with a diuretic may be an option. Thiazide diuretics like chlorthalidone have shown to be effective in advanced chronic kidney disease. Loop diuretics can also be considered, especially if the patient has fluid retention. Close monitoring of kidney function and potassium levels is important when initiating or titrating diuretic therapy.
Treating Hypertension in CKD Patients
In patients with hypertension and chronic kidney disease (CKD), it is crucial to use ACE inhibitors or ARBs, despite concerns about potential kidney-related adverse effects. These medications have been proven to be beneficial for both blood pressure control and reducing the risk of cardiovascular disease in CKD patients. Monitoring kidney function and potassium levels is important when initiating treatment, but a slight increase in creatinine or a modest increase in potassium may be acceptable. Diuretic therapy, such as chlorthalidone, can also be considered for blood pressure management in CKD patients, including those with advanced CKD. Recent studies have shown the effectiveness of thiazide diuretics in these patients, challenging the previous belief that they lose efficacy as kidney function declines.
Managing Hypertension in CKD Patients with Proteinuria
Patients with chronic kidney disease (CKD) and proteinuria can benefit from ACE inhibitors or ARBs, even if their proteinuria is less than 500 mg per day. These medications have demonstrated cardiovascular benefits in CKD patients and may help slow the progression of kidney disease. It is important to closely monitor kidney function and potassium levels when starting these medications. If hyperkalemia is a concern, potassium binders can be considered. Diuretics, such as chlorthalidone or loop diuretics, can also be used to manage hypertension in CKD patients, with consideration for fluid retention and potassium levels. Individualized treatment plans should be based on patient preferences and closely monitored for any adverse effects.
Dosage Considerations for Diuretics in CKD Patients
When prescribing diuretics for hypertension management in chronic kidney disease (CKD) patients, thiazide diuretics like chlorthalidone or loop diuretics such as furosemide or bumetanide can be effective. For thiazide diuretics, starting with a low dose of 20 mg and titrating based on blood pressure response is recommended. Loop diuretics may be started at a dose of 20-40 mg twice daily and adjusted as needed. Careful monitoring of kidney function and potassium levels is crucial during diuretic therapy. Patients with hyperkalemia can benefit from using potassium binders to help maintain potassium balance. Individual patient factors, preferences, and tolerability should guide diuretic dosing decisions.
Importance of Home Blood Pressure Monitoring
The podcast emphasizes the importance of using validated home blood pressure devices to obtain more accurate blood pressure measurements. By empowering patients to measure their blood pressure at home, healthcare providers can make better-informed decisions in managing hypertension.
Underutilization of Diuretics
The podcast highlights the underutilization of diuretics in managing hypertension. Diuretics, such as a milleride, can be highly effective, especially in patients who are sodium-sensitive or volume overloaded. Physicians are encouraged to consider diuretics as a treatment option and to monitor patients closely to ensure optimal dosing and minimize potential adverse effects.
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Master common hypertension scenarios in the clinic! Our guest Dr. Jordy Cohen (@jordy_bc) will lead us through the FAQs of outpatient hypertension management, including making a diagnosis of hypertension, managing blood pressure in patients with chronic kidney disease, working up refractory hypertension, and more.
The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit. See info sheet for further directions. Note: A free VCU Health CloudCME account is required in order to seek credit.
Show Segments
Intro, disclaimer, guest bio
Guest one-liner, Picks of the Week*
Case from Kashlak: New diagnosis of hypertension
How to make a diagnosis of hypertension
When to start anti-hypertensive medication
Initial blood pressure regimen
Case from Kashlak: White coat hypertension
Case from Kashlak: Hypertension in chronic kidney disease
ACEis and ARBs in chronic kidney disease
Diuretics in chronic kidney disease
Case from Kashlak: Refractory hypertension
History and initial workup for refractory hypertension
