Hypertension

Key Points

• Hypertension is highly prevalent in men and women and people of all ethnic and racial groups

• Hypertension tends to be undertreated in patients with both complicated and uncomplicated forms.

• In uncomplicated HTN the specific choice of drug is less important than the attainment of goal blood pressure.

Hypertension (HTN) is highly prevalent and is a significant risk factor for CAD, left ventricular hypertrophy (LVH), CHF, PVD, stroke, sudden death, nephropathy, and diabetes mel-litus. The incidence of HTN increases as a function of age; patients who are normotensive at age 55 have a 90% risk of developing HTN at some point in their lives. Risk for hypertension is regulated by genetic background (e.g., mutations in cell membrane cation transporters in the renal proximal tubular epithelium and vasculature, cell surface receptors, endocrine influences, calcium handling in smooth muscle cells) and environmental factors. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) provides the current framework for defining and managing HTN in the U.S. population (Chobanian et al., 2003). Table 27-3 summarizes the JNC-7 classification of blood pressure (BP), soon scheduled for revision. The reduction of BP to guideline-specified targets in patients with complicated and uncomplicated HTN substantially reduces risk for acute cardiovascular events, progression of atherosclerosis, and endorgan injury.

As demonstrated by the Framingham Study, BP is a continuous risk factor for CVD, with no threshold effect yet identified (Vasan et al., 2002). For every increase of 20/10 mm Hg in BP above 115/75 mm Hg, risk for CVD increases twofold. Contrary to a widely held misconception in medicine, among patients older than 50 years, the treatment of systolic blood pressure (SBP) reduces risk for CVD and renal disease significantly more than diastolic blood pressure (DBP). Despite the recognized dangers of HTN and the large number of medications available, only one third of patients are treated to target levels in the United States (Whelton et al., 2002). Hypertension is a defining feature of the metabolic syndrome and usually suggests that the patient has some degree of underlying endothelial dysfunction, with an imbalance between vasodilatory and vasoconstrictive influences impacting the arterial wall.

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