Introduction

High Blood Pressure Exercise Program

Most Effective Hypertension Treatments

Get Instant Access

Despite efforts to promote awareness, treatment, and the means available to aggressively manage high blood pressure (BP), trends over the past 15 years demonstrate only modest improvements in its treatment and control. National and international organizations continually refine their recommendations of how clinicians should approach the management of patients with high BP, and although approaches vary to some degree, there are clear themes that emerge regardless of which national or international organization's algorithm is followed. The purpose of this chapter is to provide a summary of key issues associated with the management of patients with hypertension. We will discuss the basic approach to treating patients with hypertension and provide a functional summary of the currently prevailing themes of national guidelines, including their grounding in relevant landmark trials. Finally, we will summarize salient pharmaco-therapeutic issues essential for clinicians to consider when managing patients with hypertension.

Various algorithms recommending nonpharmacologic and pharmacologic management for typical and atypical patients are proposed, with the underlying theme that achievement of BP targets mitigate end-organ damage, leading to substantial reductions in stroke, myocardial infarction (MI), end-stage renal disease, and heart failure. Although references to other algorithms will be mentioned, this chapter will focus primarily on the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure, more commonly referred to as the Joint National Committee Seventh Report (JNC 7) report,1 with ad-

ditional reference to recent recommendations from the American Heart Association and European Society of Cardiology. It should be noted that an update of the JNC 7 report (JNC 8), as part of an integrated set of cardiovascular risk reduction guidelines, is expected to be released in 2010.

The JNC 7 report describes four stages of BP classification and provides guidance on nonpharmacologic and pharmacologic approaches to managing patients with hypertension. The four stages of BP classification include normal, prehypertension, stage 1 hypertension, and stage 2 hypertension (Table 5-1). These stages are defined as such to connote a level of risk and thus the need for varying intensities of intervention with drug therapy (Fig. 5-1). With the exception of individuals with "compelling indications," recommendations for drug therapy typically begin with one or two (in the case of stage 2) antihypertensive drugs as an initial step. Specific drug selection is guided by the presence of compelling indications—specific comorbid conditions. These compelling indications, such as heart failure, diabetes, and chronic kidney disease (CKD), represent specific conditions for which explicit evidence in the literature exists to document the utility of a particular agent or class of agents. Selection of drug therapy consequently involves an iterative process of considering multiple antihypertensive drugs as needed to achieve target BPs of less than 140/90 mm Hg for all patients, with more aggressive targets of less than 130/80 mm Hg for patients with diabetes or chronic) greater than 3 months (kidney disease) estimated glomerular filtration rate [GFR] less than 60 mL/min/1.73 m2 or the presence of albuminuria [300mg/day or 200 mg/g creatinine]).1 In addition, the AHA scientific statement expands those in whom a lower BP target of less than 130/80 mm Hg should be pursued to include patients with known coronary artery disease or coronary artery disease risk equivalents (carotid artery disease, peripheral arterial disease, abdominal aortic an-eurysm), or a 10-year Framingham risk score of greater than 10%. See Dyslipidemias chapter. In patients with left ventricular dysfunction, additional BP lowering to a target of less than 120/80 mm Hg may also be considered.

EPIDEMIOLOGY

© Hypertension is widely prevalent and accounts for significant morbidity and mortality, as well as billions of dollars in direct and indirect costs. Worldwide prevalence of hypertension is estimated to include 1 billion individuals. There are an estimated 7 million deaths per year that may be related to the diagnosis of hypertension.4 The prevalence of hypertension in the United States is among the highest in the world and is estimated to include 73 million individuals (1 in 3 adults) with an estimated 69.4 billion dollars spent annually in direct and indirect costs.5 Furthermore, it is estimated that 37.4% of the U.S. population older than 20 years of age has prehypertension.

The prevalence of hypertension differs based on age, sex, and ethnicity. As individuals become older, their risk of systolic hypertension increases. Individuals 55 years of age who do not have hypertension are estimated to have a lifetime risk of 90% of eventually developing hypertension. In the United States, hypertension is slightly more prevalent in women (33.6%) than men (33.2%).5 In addition, age-adjusted prevalence of hypertension is highest in non-Hispanic blacks or African Americans (41%) when compared to non-Hispanic whites (28.1%) and Mexican Americans (22%). However, Mexican Americans have lower rates of treatment and control.6

Table 5-1 Classification of BP in Children, Adolescents, and Adultsa

BP Claififkvticn

fldyft SPP(mmMg)

Adult PBP [mm HgJ

ChltdirnfArinlcKTntf SUP orDB-P Pcirmtil»1

Normal

TTmn 120

ard lew (Haneo

l.«Slhan

Riehypwlcniion

130-1»

w80-69

W-^tht* 120/60 rom Hg

fja^e I hypwiension

I4ÍI-IS9

Crf 90-W

9S-99rt> t SIÏV11 Hi/

Sl>>y(.L Î hytx;rlenyt)fi

GnaLf Ihjnor rquil to 160

GriMlur ItkHi or oqujl tu 100

GisaN.™ than ÍWth linimHtf

BT IA>ud pííWufí C6Í <JiJtlulii tikxxJ Of*4Juré¡ Í8P, tyllc*í bUod f>in«jrt.L. "Defined « old of more.

'latai« it*iwin ii1^ SOcK 9Cii\ and 99th ptríemiieicí sup and MP standards toed on r*i«iiiiehei<>in Liy ¿ce se^.vdiich ¡í used » wmpjre the WW'S mwwwl BP on three iffiAf ale tK^toni. The diffefenre In BP til che 9Sth anil ■Wrh percentiles aie 7 ti> 10 mm Hg, which i«(ü retén ■jdiuiLnx.th oí 5 nm Hy to docuut^jy cjlMjcxtn? itjyc 1 w 2 Irypci LiTiiifciri. It the Syilulk. jnd di-ululit píitÉtHjltííté^Oii« ■*(? difieie«i. (hen (testify typenifKloft Uyihe holier bp ujkie

BT IA>ud pííWufí C6Í <JiJtlulii tikxxJ Of*4Juré¡ Í8P, tyllc*í bUod f>in«jrt.L. "Defined « old of more.

'latai« it*iwin ii1^ SOcK 9Cii\ and 99th ptríemiieicí sup and MP standards toed on r*i«iiiiehei<>in Liy ¿ce se^.vdiich ¡í used » wmpjre the WW'S mwwwl BP on three iffiAf ale tK^toni. The diffefenre In BP til che 9Sth anil ■Wrh percentiles aie 7 ti> 10 mm Hg, which i«(ü retén ■jdiuiLnx.th oí 5 nm Hy to docuut^jy cjlMjcxtn? itjyc 1 w 2 Irypci LiTiiifciri. It the Syilulk. jnd di-ululit píitÉtHjltííté^Oii« ■*(? difieie«i. (hen (testify typenifKloft Uyihe holier bp ujkie

'Chikften jnd idülcíííriii' Ma^e I hypftinnsion ütlAiiiíitíd tiy ÉiP lewfc llvjn rangtiiom (he 95th fM^L ..'■nrik? to í mm Hlj p«ioefiiile.

'Children and adokstentt' stage 2 typei tension is clai-siÍKM) byflP le^eli that aie (jto.itoi than 5 mm Hg above the 991 h percent ita. From Reí. I.

FIGURE 5-1. Algorithm for treatment of hypertension when patients are not at their goal BP. Compelling indications refer to specific indications where the selection of a particular antihypertensive drug class for a defined high-risk population is highly recommended. These recommendations are usually based on results from landmark randomized placebo-controlled outcome trials or consensus statements from clinical guidelines and are usually based on findings documenting superior outcomes in terms of morbidity and mortality. (ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP, blood pressure; CCB, calcium channel blocker; DBP, diastolic blood pressure; SBP, systolic blood pressure.) (From Ref. 1.)

Hypertension is strongly associated with type 2 diabetes. The added comorbidity of hypertension in diabetes leads to a higher risk of cardiovascular disease (CVD), stroke, renal disease, and diabetic retinopathy leading to greater health care costs.8

Was this article helpful?

0 0
Diabetes Sustenance

Diabetes Sustenance

Get All The Support And Guidance You Need To Be A Success At Dealing With Diabetes The Healthy Way. This Book Is One Of The Most Valuable Resources In The World When It Comes To Learning How Nutritional Supplements Can Control Sugar Levels.

Get My Free Ebook


Post a comment