Chapter 30: Hypertension

KEY CONCEPTS

• The risk of cardiovascular (CV) morbidity and mortality is directly correlated with blood pressure (BP).

• Evidence from clinical trials definitively demonstrates that antihypertensive drug therapy substantially reduces the risks of CV events and death in patients with high BP.

• Essential hypertension is usually an asymptomatic disease. A diagnosis cannot be made based on one elevated BP measurement. An elevated BP value from the average of two or more BP measurements, present during two or more clinical encounters, is required to establish a diagnosis of hypertension.

• The overall goal of treating hypertension is to reduce associated morbidity and mortality from CV events. Antihypertensive drug therapy should be selected based on evidence demonstrating CV event reduction.

• A goal BP of <130/80 mm Hg is appropriate for most patients with hypertension.

• The magnitude of BP elevation should be used to guide the number of antihypertensive agents to start when implementing drug therapy. Most patients with stage 1 hypertension should start on one medication as initial therapy. Most patients presenting with stage 2 hypertension should be started on two medications as initial therapy.

• Lifestyle modifications should be prescribed to all patients, especially those with elevated BP and hypertension.

• Angiotensin-converting enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARBs), calcium channel blockers (CCBs), and thiazides are preferred first-line antihypertensive agents for most patients with hypertension. These first-line options are for patients with hypertension who do not have a compelling indication for a specific antihypertensive drug class.

• For most patients with hypertension, a β-blocker is not an appropriate first-line treatment because it will not reduce CV events as much as has been demonstrated with an ACEi, an ARB, a CCB, or thiazide.

• Compelling indications are comorbid conditions where specific antihypertensive drug classes have been shown in clinical trials to reduce CV events in patients with the specific comorbidity.

• Older patients are often at higher risk for orthostatic hypotension related to antihypertensive medications. While antihypertensive drug therapy selection should be the same as in younger patients, lower initial doses should be used to minimize the risk of orthostatic hypotension in older patients.

• Patients have resistant hypertension when they fail to achieve goal BP while adherent to a regimen that includes three antihypertensive agents (one of which includes a diuretic) at full doses, or when four or more antihypertensive agents are needed to treat hypertension regardless of goal BP achievement.

• Alternative antihypertensive agents should only be used in combination with first-line antihypertensive agents to provide additional BP lowering because they do not have sufficient evidence demonstrating CV event reduction.

• Hypertensive urgency is ideally managed by adjusting current antihypertensive drug therapy or by adding a new antihypertensive medication. This provides a gradual reduction in BP, which is a safer treatment approach than rapid reductions in BP. ...