277.1 🎓 醫學生版

277.1.0.1 📌 一頁重點

277.1.0.1.1 Treatment Targets (Updated 2024)

277.1.0.1.1.1 2024 ACC/AHA (Aligned with 2017 + SPRINT)

General target: SBP < 130, DBP < 80
CKD / DM / ASCVD ≥ 10%: < 130/80
Elderly (≥ 65) ambulatory: < 130/80 (individualize, watch for orthostasis)
Very frail: ≤ 140 (avoid falls)

277.1.0.1.1.2 2023 ESC

Office BP:
- First step: < 140/90
- Then: 120-129 SBP if tolerated for most
- Frail elderly: < 140 acceptable
Out of office: ABPM < 130/80, HBPM < 135/85

277.1.0.1.1.3 Taiwan 2022 Guidelines

Aligned with ACC/AHA: < 130/80
Home BP-based goal: < 130/80 (HBPM)

277.1.0.1.2 Lifestyle Modifications (First-Line)

277.1.0.1.2.1 DASH Diet

↓ BP by 8-14 mmHg
↑ fruits, vegetables, whole grains, nuts, low-fat dairy
↓ saturated fat, sweets, red meat

277.1.0.1.2.2 Sodium Restriction

< 2.3 g/d → ↓ BP 5/3 mmHg
< 1.5 g/d optimal (further benefit)
Salt substitute (75% NaCl + 25% KCl) ↓ stroke (SSaSS 2021)

277.1.0.1.2.3 Weight Loss

1 mmHg per kg lost (5-10% body weight target)
BMI < 25 ideal

277.1.0.1.2.4 Exercise

150 min/week moderate aerobic
Resistance 2-3x/week
↓ BP 4-9 mmHg

277.1.0.1.2.5 Alcohol

≤ 2 drinks/day ♂, ≤ 1 ♀
Each drink ↑ BP ~ 1 mmHg

277.1.0.1.2.6 Other

Smoking cessation (BP effect modest but huge CV)
Stress management, yoga, meditation
Sleep (treat OSA)
Mediterranean diet (PREDIMED — ↓ MACE 30%)

277.1.0.1.3 Pharmacologic Therapy

277.1.0.1.3.1 First-Line Agents

1. ACEi or ARB (Class I) - Mechanism: ↓ Ang II → vasodilate, ↓ aldosterone - Drugs: - ACEi: lisinopril, enalapril, ramipril, perindopril, captopril - ARB: losartan, valsartan, telmisartan, candesartan, olmesartan - Indications: - HTN with DM (↓ albuminuria) - HTN with CKD - HTN with HFrEF, post-MI, LV dysfunction - Younger patients (< 60) - Side effects: - ACEi: cough (5-20%, bradykinin), angioedema, hyperkalemia - ARB: similar but no cough/angioedema - Both: hyperkalemia, AKI in RAS, fetal toxicity - Contraindications: pregnancy, bilateral RAS, angioedema

2. Calcium Channel Blocker (CCB) (Class I) - Dihydropyridine (DHP): amlodipine, felodipine, nifedipine ER, lercanidipine - Vasodilation, peripheral edema, gum hyperplasia - Non-DHP: verapamil, diltiazem - ↓ HR + contractility; useful for AF rate control - Indications: HTN with stable angina, elderly, African Americans, pregnancy (DHP) - Side effects: peripheral edema (DHP), constipation (verapamil), bradycardia (non-DHP) - Avoid: non-DHP + β-blocker (heart block); verapamil/diltiazem in HFrEF

3. Thiazide-like Diuretic (Class I) - Preferred: chlorthalidone, indapamide (longer-acting, more effective) - Alternative: HCTZ (less preferred per SPRINT) - Mechanism: ↓ Na reabsorption in DCT - Indications: HTN, African Americans, elderly, HFpEF - Side effects: hypokalemia, hyperuricemia (gout), hyponatremia, hyperglycemia, hypercalcemia, ↑ lipids - Loop diuretics (furosemide, torsemide): use in CKD (eGFR < 30) or HF

4. β-Blocker (Class IIa for HTN alone) - No longer first-line for HTN alone unless specific indication - Indications: - Post-MI - HFrEF (carvedilol, bisoprolol, metoprolol succinate) - Stable angina - Migraine prophylaxis - Pregnancy (labetalol) - Atrial fibrillation rate control - Drugs: - β1-selective: metoprolol, atenolol, bisoprolol - Non-selective: propranolol, nadolol - Carvedilol, labetalol: combined α/β block - Side effects: fatigue, bradycardia, bronchospasm, sexual dysfunction, masked hypoglycemia

277.1.0.1.3.2 Second-Line / Add-On Agents

Aldosterone Antagonists (MRA) - Spironolactone 25-50 mg (PATHWAY-2 — best 4th drug) - Eplerenone 25-100 mg (less gynecomastia) - Hyperkalemia risk; avoid with K+ supplement

Direct Vasodilators - Hydralazine, minoxidil (resistant HTN) - Side effects: reflex tachy, lupus-like (hydralazine), hirsutism (minoxidil)

α-Blockers - Doxazosin, terazosin, prazosin - ALLHAT: doxazosin arm stopped early (↑ HF) - Reserve for resistant or BPH coexistence

Central α2-Agonists - Clonidine, methyldopa (pregnancy first-line), guanfacine - Rebound HTN if abrupt withdrawal

Direct Renin Inhibitor - Aliskiren — limited role - Avoid with ACEi/ARB in DM (ALTITUDE — neg)

Endothelin Receptor Antagonist - Aprocitentan (Tryvio) — FDA approved 2024 for resistant HTN - PRECISION trial — added BP reduction

277.1.0.1.4 Combination Therapy

277.1.0.1.4.1 Why Combination?

Most patients need 2+ drugs
Different mechanisms = synergy
Lower doses = fewer side effects
Faster BP control

277.1.0.1.4.2 Preferred Combinations

ACEi/ARB + CCB: ASCOT-BPLA — better outcomes than β-blocker + diuretic
ACEi/ARB + thiazide-like: synergistic, common
CCB + thiazide: less common but effective

277.1.0.1.4.3 Avoid

ACEi + ARB: ONTARGET — ↑ harm, no benefit
Non-DHP CCB + β-blocker: heart block (in selected cases OK)

277.1.0.1.4.4 Single-Pill Combinations (SPC) — 2024 Standard

ARB + CCB + thiazide (triple) → “single pill”
↑ adherence by 30-50%
↓ inertia of titration
2024 ESC + ACC: first-line for stage 2 HTN

277.1.0.1.5 Algorithm (Simplified)

277.1.0.1.5.1 Stage 1 HTN (130-139/80-89, ACC/AHA)

Low CV risk: lifestyle alone for 3-6 months
High CV risk (ASCVD ≥ 10%, DM, CKD, age ≥ 65): drug + lifestyle

277.1.0.1.5.2 Stage 2 HTN (≥ 140/90)

Drug + lifestyle, often with 2-drug SPC initially

277.1.0.1.5.3 Step-Up

Mono → dual (ACEi/ARB + CCB or thiazide)
Dual → triple (ACEi/ARB + CCB + thiazide)
Resistant → add spironolactone (PATHWAY-2)
Refractory → α-blocker, β-blocker, hydralazine, minoxidil
Investigate adherence, secondary, ABPM

277.1.0.1.6 Special Populations

277.1.0.1.6.1 Diabetes

Goal < 130/80
ACEi or ARB first-line (renal protection, albuminuria)
Add CCB or thiazide
SGLT2i has BP-lowering effect (~ 4 mmHg)

277.1.0.1.6.2 CKD

ACEi/ARB renoprotective
Watch K+, Cr
Loop diuretic if eGFR < 30
Finerenone (FIDELIO-DKD, FIGARO-DKD): non-steroidal MRA — albuminuric DKD

277.1.0.1.6.3 African Americans

Better response to CCB + thiazide than ACEi/ARB monotherapy
Add ACEi/ARB for proteinuria/DM
ALLHAT: chlorthalidone good first-line

277.1.0.1.6.4 Elderly

Start low, go slow
Watch orthostasis (check standing BP)
Frail: target ≤ 140
SPRINT-Senior + STEP confirm benefit < 130

277.1.0.1.6.5 Pregnancy

Methyldopa, labetalol, nifedipine (long-acting)
Avoid: ACEi/ARB (teratogenic), MRA, atenolol (IUGR)
Treat if BP > 140/90 (preeclampsia)
Severe (> 160/110): IV labetalol, hydralazine, oral nifedipine

277.1.0.1.6.6 Stroke / Post-Stroke

Acute ischemic stroke: permissive HTN (≤ 220/120) unless thrombolysis (then < 185/110)
Acute hemorrhagic stroke: target < 140 (INTERACT-2, ATACH-II)
Secondary prevention: < 130/80; thiazide + ACEi (PROGRESS)

277.1.0.1.6.7 Resistant HTN

Confirm with ABPM
Lifestyle, adherence, secondary HTN workup
Add spironolactone (PATHWAY-2)
Consider renal denervation (2024 FDA approved)
Aprocitentan (Tryvio) approved 2024

277.1.0.2 🩺 床邊速查

Goal < 130/80 for most (ACC/AHA, Taiwan 2022)
First-line drugs: ACEi/ARB, CCB, thiazide-like — β-blocker only for specific indications
Best 4th drug for resistant HTN: spironolactone (PATHWAY-2)
SPC (single-pill combo) improves adherence 30-50%
Pregnancy: methyldopa, labetalol, nifedipine (avoid ACEi/ARB)
New 2024: renal denervation, aprocitentan (Tryvio)