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chronic hypertension

Classification: - see hypertension Etiology: 1) primary (essential) hypertension (risk factors) a) excessive dietary salt (see salt-sensitive HTN) b) excessive calorie intake c) stress d) African-American origin e) obesity f) family history of hypertension (see genetics) g) migraine or severe headaches (RR=1.25) [157] 2) secondary hypertension a) renal parenchymal disease b) coarctation of the aorta c) alcohol increases early morning blood pressure surge d) smoking increases early morning blood pressure surge e) sleep deprivation [49,50] f) sleep apnea [51] g) occupational noise exposure [126] 3) also see hypertension & etiology of arterial hypertension Epidemiology: 1) 10-20% of persons age 25-45 years 2) 30-40% of persons age 55-74 years 3) 60% of persons > 65 years of age 5) African Americans a) have higher prevalence b) more aware of hypertension c) more likely to be treated for HTN d) less likely to be in good BP control [55] e) Southern-style diet may contribute to higher risk of hypertension blacks [138] 6) greatest contributor to cardiovascular disease worldwide [4] 7) 50% of patients with chronic hypertension are poorly controlled (BP > 140/90) [4] 8) 54% of strokes & 47% of ischemic heart disease can be attributed to chronic hypertension [4] 9) > 25% of Medicare recipients to not adhere to antihypertensive regimens [102] 10) blood pressure goals achieved in < 1/2 of patients who receive antihypertensive therapy [120] 11) ~1/2 of hypertension cases in middle-age & older adults in U.S., China, England, & India are concordant within heterosexual couples [161] - women married to men with hypertension are more likely to have hypertension themselves - men married to women with hypertension are more likely to have hypertension themselves Pathology: - renal sympathetic hyperactivity - the renin angiotensin pathway is the major system influencing blood pressure - wide variability of blood pressure in hypertensive adults is associated with increased cardiovascular risk [89] - also see blood pressure in the very old Clinical manifestations: 1) see hypertension 2) patients are generally asymptomatic 3) a single blood pressure reading is inadequate; multiple measurements are needed (5-6); combining home BP measurement with office-based measurements improves assessment [46] Laboratory: 1) see hypertension 2) serum chemistries a) urea nitrogen b) serum creatinine c) plasma aldosterone/renin [4] Special laboratory: - electrocardiogram: - evidence of left ventricular hypertrophy suggests chronic hypertension - left ventricular hypertrophy with normal blood pressure readings suggests masked hypertension [4] - ambulatory blood pressure monitor - goals: daytime systolic BP < 136 mm Hg; nighttime systolic BP < 125 mm Hg - ambulatory BP monitoring is a better predictor of mortality than clinic-based measurements [130] - masked hypertension seems to have the worst prognosis [130] - Proof BP calculator suggested as a surrogate for ambulatory blood pressure monitor [134] Radiology: - echocardiogram - indications: - known heart disease - left bundle branch block on electrocardiogram - suspected white coat hypertension [4] - electrocardiogram suggesting left ventricular hypertrophy [4] Complications: - elevated systolic BP (> 140 mm Hg) & diastolic BP (> 90 mm Hg) independently predict risk for adverse cardiovascular events [145] - risk still elevated for threshold of > 130/80 [145] - increased risk of peripheral arterial disease (PAD) - each 20 mm Hg increase in systolic BP & each 10 mm Hg increase in diastolic BP is associated with 63% & 35% higher risks for PAD [93] - peripheral arterial disease in turn is associated with a 50% increase in risk of cardiovascular events [93] - increased risk of stroke* - non-compliance with antihypertensive medications is associated with increased risk of stroke [69] - morning home systolic blood pressure >= 145 mm Hg associated with increased risk for stroke & for acute coronary syndrome relative to < 125 mm Hg [99] - RR=6.0 for stroke & 6.2 for acute coronary syndrome comparing morning home systolic blood pressure >= 155 mm Hg vs < 125 mm Hg [99] - early-onset hypertension confers greater cardiovascular risk than late-onset hypertension [112] - early-onset hypertension also is associated with excess risk of hypertension in offspring [112] - hypertension defined by ACC/AHA 2017 guidelines before age 40 confers risk for cardiovascular events later in life [140] - greater BP variablity associated with increase risk of carotid atherosclerosis, white matter hyperintensities, stroke, & cognitive impairment in older patients [72] - increased risk of chronic kidney disease - during midlife, increases risk of cognitive impairment in the elderly [78] - children & adolescents (age 10-18 years) with untreated hypertension score lower on neurocognitive testing compared with normotensive controls, in particular, on measures of memory, attention, & executive functions [103] * treatment of stage 1 hypertension (BP=140-159/90-99 mm Hg) reduces cardiovascular risk & mortality (RR=0.7-0.8) [84] Management: 1) a single blood pressure reading is inadequate; multiple measurements are needed (2-5); - combining home BP measurement with office-based measurements improves assessment [46] - home BP measurement for self-titration of antihypertensives improves outcomes vs clinic-based BP measurement [128] - home BP measurement (digital) with automated prompts for medication changes [150] - note: goals of home systolic BP may be different than office-based measurements [4] 2) goals of treatment a) reduce blood pressure to < 140/90 without adverse effects - same threshold applied to patients with diabetes mellitus or chronic renal failure [74,116] (JNC8) - American College of Physicians recommends blood pressure < 130/80 for most patients, including those with chronic renal failure [4] - American College of Cardiology/American Heart Association (ACC/AHA) recommends BP goal of < 130/80 mm Hg in most adults, including those with chronic kidney disease [4] - American Diabetes Association 2018 recommends target BP of < 140/90 despite AHA/ACC guidelines [116] - American Academy of Family Physicians recommends target BP of < 140/90 mm Hg despite AHA/ACC guidelines [118] - preventive BP lowering is associated with reduced risk for cardiovascular death & if baseline systolic BP is >= 140 mm Hg [113] - treatment not associated with benefit in primary prevention at lower systolic BP [113] - antihypertensive treatment may not benefit patients with low cardiovascular risk & BP < 160/100 [139] - no benefit in mortality - higher risk for hypotension, syncope, electrolyte imbalance, & acute kidney injury [139] b) for patients >= 60 years reduce blood pressure to < 150/90 without adverse effects [74] (JNC 8) [108] (ACP) - JNC 8 guidelines may allow more patients to achieve blood pressure goals [83] - recommendations still < 140/90 for patients >= 60 with diabetes mellitus or chronic renal disease [74] c) American College of Cardiology/American Heart Association (ACC/AHA) defines hypertension: - stage 1 hypertension: 130-139/80-89 mm Hg - stage 2 hypertension: 140-149/90-99 mm Hg - nonpharmacological interventions for stage 1 hypertension - add pharmacological intervention for 10-year risk of ASCVD >= 10% - add pharmacological intervention for stage 2 hypertension [114] - evidence of lack of benefit & even harm [113] - ACC/AHA fails to consider high pulse pressures in elderly & harms of low diastolic blood pressure [121] - guideline hailed as 'robust prevention strategy' with benefits dwarfing risks [131] - ACC/AHA guidelines would label ~2/3 of Americans 45-75 with hypertension [132] - ACC/AHA guidelines not firmly rooted in evidence [132] - an early drop in eGFR of > 15% with intensive treatment (< 4 months) is associated with increased risk of end-stage renal disease [159] - intensive blood pressure control reduces risk of cardiovascular disease or all-cause mortality regardless of orthostatic hypotension [160] - meta-analysis of 9 trials at least 1/2 of which used JNC8 guidelines [160] - in patients with high cardiovascular risk, targeting systolic BP <120 mm Hg vs <140 mm Hg reduces major vascular events [163] d) recommendations for patients with heart failure or coronary artery disease not found in JNC 8 - target BP of < 140/90 mm Hg AHA/ACC/ASH in patients with coronary artery disease, including elderly [48,85] - target BP of < 150/90 in elderly >= 80 with CAD [88] - may be lower in some patients [85] - authors recommend a minimum diastolic blood pressure of 60 mm Hg with a caveat that 70-75 mm Hg is generally considered safe [85,88] - cognitive effects of lowering blood pressure not discussed [85,88] e) goal may be to reduce left ventricular hypertrophy [18] f) goal may be especially difficult to achieve in high-risk patients [28] g) goal may be < 160/90 in elderly (> 80 years of age) - see blood pressure in the very old - risk of attempting to lower blood pressure in the frail elderly may exceed potential benefit [4] h) use caution in treating systolic hypertension in patients with wide pulse pressure (see diastolic blood pressure) i) reducing the diastolic blood pressure below 70 mm Hg may increase cardiovascular events & all-cause mortality [4] j) no obvious benefit of pharmacologic treatment in patients with mild hypertension (systolic BP = 140-159 mm Hg &/or diastolic BP = 90-99 mm Hg) in terms of total mortality or cardiovascular events at 5 years' follow-up [52] k) systolic BP target of < 140 mm Hg reduces cardiovascular events, cardiovascular mortality & heart failure but not MI or stroke in persons > 65 years of age (from 4 'cherry-picked' trials) [107] - may be increased risk of renal failure [107] l) intensity of blood pressure control based on cardiovascular risk may improve cardiovascular outcomes [80,94,146] - systolic blood pressure goal < 130 mm Hg [94] - blood pressure lowering therapy for all patients with history of cardiovascular disease, coronary heart disease, stroke, diabetes mellitus, heart failure, or chronic kidney disease [94] - more intensive systolic blood pressure control, target < 120 mm Hg vs 140 mm Hg for patients at high risk for heart disease or with kidney disease may reduce cardiovascular events & mortality [90] (see SPRINT study) - two trials (ONTARGET & TRANSCEND trials) report that lowering systolic BP <120 mm Hg is associated with greater CV-related & all-cause mortality [109] - target BP of < 130/80 mm Hg (AHA) in patients with coronary artery disease [4] - target BP in patients with LVEF < 40% is < 120/80 (AHA) [2] - average BP of 133/76 mm Hg reduces risk for MI, stroke, & albuminuria vs average BP of 140/81 (meta-analysis) [91] - no difference in risk of heart failure, ESRD, or mortality - serious hypotensive events more common with more-intensive BP control (also see Notes: section) [91] - benefits of intensive control may be greatest in patients with vascular disease, renal disease, or diabetes [91] - target systolic blood pressure < 140 mmg Hg associated with higher cardiovascular mortality in patients with diabetes m) Blood Pressure Lowering Treatment Trialists' Collaboration meta-analysis concludes pharmacological blood pressure reduction is effective into old age, with no evidence that relative risk reductions for prevention of major cardiovascular events vary by systolic or diastolic blood pressure levels at randomisation, down to less than 120/70 mm Hg [37] - the group analyzed their own data to support their conclusions - no discussion of diet or lifestyle changes, quality of life or cognition - no benefit found in elderly over 85 years n) a systematic review of blood pressure guidelines in the elderly [155] - conclusions differ from ref [37] o) prevent fluctuations in blood pressure [72] p) minimize drug adverse effects q) an early drop in eGFR of > 15% with intensive treatment (< 4 months) is associated with increased risk of end-stage renal disease [159] 3) strategy a) AHA,ACC, & CDC takes one size fits all approach [73] 1] diet & lifestyle 1st line for stage 1 HTN & stage 2 HTN - diet & lifestyle should be part of any hypertension management strategy - overweight persons can reduce their need for antihypertensives within 4 months with diet & exercise [136] - MKSAP19 suggests 3 month trial of diet & lifestyle - begin pharmaceutical treatment if - daytime ambulatory BP or home BP remains elevated > 130/80 [4] - evidence of masked hypertension & LVH [4] 2] for stage 1 hypertension (140-159/90-99 (JNC8) 130-139/80-89 (AHA/ACC) mm Hg), start with single agent if known cardiovsascular disease or 10 year cardiovascular risk is > 10% [4] - ACP uses AHA/ACC staging for hypertension, does not recognize JNC8 [4] 3] start with thiazide diuretic for stage 1 HTN - add ACE inhibitor or calcium channel blocker if needed 4] for diabetic with CKD3 or microalbuminuria, start with ACE inhibitor - add thiazide diuretic if needed 5] start with thiazide diuretic + ACE inhibitor for stage 2 HTN - two line antihypertensives for stage 2 HTN [4] 6] calcium channel blocker may be used for stage 1 or stage 2 HTN 7] blacks: start with thiazide diuretic &/or calcium channel blocker [4] - use calcium channel blocker + thiazide diuretic for combination therapy - amlodipine + HCTZ or perindopril slightly more effective than perindopril + HCTZ in blacks [144] 8] initial therapy with once daily combination - telmisartan: 20 mg; amlodipine: 2.5 mg; chlorthalidone: 12.5 mg [149] b) AHA updates recommendations for patients with CAD 1] patients with CAD, hypertension & stable angina should receive beta-blocker, ACE inhibitor, or thiazide diuretic [88] 2] if beta-blockers are contraindicated, patients without LV systolic dysfunction can receive a nondihydropyridine calcium-channel blocker [88] c) JNC 8 [74] 1] initial antihypertensive options include ACE inhibitor, ARB, calcium channel blocker or thiazide diuretic 2] in black population, initial therapy options include a thiazide diuretic or calcium channel blocker [4] - use calcium channel blocker + thiazide diuretic for combination therapy 3] in patients with chronic renal failure, initial or add on therapy should include ACE inhibitor or ARB, but not both d) no benefit to anti-hypertensive agents for treatment of mild hypertension [86] e) cardiovascular benefit to treating systolic hypertension depends on age & gender [87] f) 1 in 12 patients experience adverse drug effects from antihypertensive agents [86] g) 1/4 dose of 2 antihypertensives lowers blood pressure (6.7/4.4 mm Hg vs placebo) as effectively as standard-dose monotherapy [111] h) BMI should not be a factor in selecting antihypertensive therapy [82] j) nighttime hypertension may be associated increased risks for diabetes mellitus type 2, cardiovascular risk & heart failure - taking antihypertensives at bedtime may reduce these risks [91,92,97] - findings not reproduced in a large, randomized trial in 2022 [97] k) team approaches are more effective than individual patient- level or provider-level interventions in reaching blood pressure goals [120] 4) behavioral therapy a) involving patients in their own care improves BP control [19]; may be sole therapy for Stage 1 hypertension if 10 year cardiovascular risk < 10% b) self-monitoring of blood pressure with self-titration of antihypertensives - more effective than usual care in managing blood pressure in high-risk patients [81] - telemonitoring & self-titration of antihypertensives may improve BP control [37,64] c) diet: 1] reduce salt [34], fat, calories, increase fiber [20] (see DASH diet); - GRS8 recommends HCTZ over DASH diet for systolic hypertension in elderly losing weight on current diet [48] (see notes) - diet rich in whole grains reduces diastolic BP in obese & overweight adults [104] 2] Mediterranean diet & DASH diet may have cardiovascular benefits 3] vegetable protein/vegetarian diet may lower BP a few mm Hg [9,23] 4] K+ rich foods (3.5 g or 75 meq/day of K+) may be of some benefit in reducing risk of stroke [5] 5] K+ (60-100 meq/day) decreases BP by 4.4/2.5 mm Hg (systolic/diastolic) [9] 6] high dietary potassium is associated with lower blood pressure & a reduced risk of stroke in hypertensive patients [60] 7] reducing consumption of sugar-sweetened beverages; average benefit ~ 2 mm Hg lower systolic BP [36] 8] polyphenols in dark chocolate may be of some benefit 9] probiotics may help reduce blood pressure - 3.6 mm Hg systolic BP - 2.4 mm Hg diastolic BP [79] d) aerobic exercise - may improve diastolic BP but not systolic BP in the elderly [22] - stair climbing may reduce arterial stiffness & BP in postmenopausal women & improve leg strength [123] - see exercise & blood pressure for effects of exercise on blood pressure e) weight reduction f) reduce alcohol intake to < 1 oz/day - alcohol in moderation may diminish all-cause mortality & cardiovascular mortality in hypertensive men [14] g) smoking cessation - no effect on blood pressure but recommended for cardiovascular risk reduction h) sleeping in prone position lowers systolic blood pressure in men as much as 15 mm Hg [21] i) culturally appropriate storytelling of benefit [42] j) low-level tragus stimulation blocks sympathetic activity in young adults [164] - 8 mm Hg reduction in systolic BP, 7 mm Hg reduction in diastolic BP [164] 5) first line pharmacologic agents*# a) diuretics (thiazide)* 1] advantages a] decrease in morbidity & mortality b] may be essential for efficacy of other agents; counteracts reactive sodium retention c] often effective in small doses with few side effects d] effective in African-American individuals [40] e] low doses effective in elderly patients f) may diminish risk of hip fracture in elderly [105] g] inexpensive 2] disadvantages a] K+ & Mg+2 depletion b] hyperuricemia c] increase in LDL cholesterol d] glucose intolerance & increased risk of diabetes [24] e] hypercalcemia [4] f] cost of monitoring & treating metabolic changes g) not effective in patients with GFR < 30 mL/min (use loop diuretic) [4] 3] uncertainties a] effect of coronary artery disease b] use with coexisting diabetes c] use with coexisting dyslipidemia d] no proof that low-dose HCTZ (most commonly used antihypertensive) improves outcomes; at least 50 mg of HCTZ QD ... or chlorthalidone or indapamide used in trials that found improved outcomes [44] e] probably work best in patients with edema or volume overload [53] f] thiazides may be more cardioprotective in overweight than in lean patients [58] 4] chlorthalidone more effective than HCTZ [48] 5] loop diuretic may be needed if GFR < 30 mL/min/1.73 m2 b) ACE inhibitors* 1] advantages a] useful for patients with coexisting disorders: congestive heart failure (CHF); diabetic nephropathy post-MI systolic dysfunction b] enhancement of insulin sensitivity c] no effect of lipids 2] disadvantages a] cough 5-15% b] deterioration of renal function with reno-vascular disease 3] paraxodical pressure response may occur in patients with low plasma renin [39] c) angiotensin II receptor antagonists (ARB)* 1] advantages a] may reduce risk of ischemic stroke b] reduced incidence of cough relative to ACE inhibitor c] may allow cognitive protection through activation of angiotensin II receptor type 2 in the brain [54] (ARBs block only type 1 receptors) d] antihypertensives that stimulate vs inhibit type 2 & 4 angiotensin II receptors may result in a lower risk of dementia (see angiotensin II type 2 & 4 stimulating agent) e] similar cardiovascular outcomes vs ACE inhibitors with fewer adverse effects [153] 2] disadvantages: a] may not benefit diabetic nephropathy b] may not reduce mortality 3] ARBs potentiate adverse effects of ACE inhibitors, [6] avoid combination d) calcium channel blockers* 1] advantages a] reduction in morbidity & mortality in elderly men with systolic hypertension (dihydropyridines) b] useful with coexisting angina c] effective in African-Americans [40] d] effective with concomitant NSAID therapy e] improvement in diastolic function f] increase in renal blood flow g] may be best agents for reducing risk of stroke [32] h] useful for cyclosporine-induced hypertension i] may lower systolic BP variability more effectively than other classes of antihypertensives [72] 2] disadvantages a] peripheral edema b] headache c] may exacerbate systolic dysfunction (except vasoactive dihydropyridines) d] short acting nifedipine: negative inotropic effect; may produce marked hypotension; reflex increase in sympathetic activity 3] avoid short-acting calcium channel blockers 4] only diltiazem & verapamil block the AV node 6) alternative agents a) centrally acting alpha-adrenergic agonists 1] clonidine 2] alpha methyl dopa b) alpha-adrenergic antagonists 1] doxazosin (Cardura) 2] terazosin (Hytrin) 3] advantages a] improvement in lipid profile b] enhancement of insulin sensitivity c] usefulness with coexisting prostatic hypertrophy 4] disadvantages a] tachycardia b] orthostatic hypotension, especially after 1st dose c] increased mortality in ALLHAT study c) beta-adrenergic receptor blockers (beta-blocker) [27] 1] not 1st line for uncomplicated hypertension 2] less effective in blacks than in whites & south Asians [39] 3] advantages a] decrease in morbidity & mortality in younger patients b] improves survival after myocardial infarction c] useful for patients with coexisting angina d] useful for patients with coexisting migraine e] may be best agents for reducing risk of recurrent MI [32] 4] disadvantages a] decreases HDL cholesterol b] increased insulin resistance & risk of diabetes [24] c] decreased exercise tolerance d] contraindicated in patients with coexisting asthma e] may exacerbate chronic bronchitis (COPD) f] may exacerbate coexisting peripheral vascular disease (PVD) g] may be less effective in the elderly [25] h] unopposed alpha-adrenergic activity (elevated in the elderly) i] paradoxical pressor response may occur in patients with low plasma renin [39] 5] uncertainties a] effect on coronary artery disease b] safety with coexisting diabetes mellitus: beta blockers may mask symptoms of hypoglycemia c] safety with coexisting dyslipidemia 7) drug combinations a) more often than not two or more agents are needed [11,16] b) starting with combination therapy may be superior to starting with monotherapy [41] c) if systolic blood pressure reduction of >= 20 mm Hg needed to reach target BP or stage 2 hypertension, combination therapy indicated [4] d) 3 low-dose antihypertensives more likely to achieve BP target than fewer but higher dose antihypertensives [135] - with 3 drugs, include a diuretic to prevent edema [40] e) 4 low dose antihypertensives more likely to achieve BP target than maximum single-dose irbesartan [152] - 37.5 mg irbesartan, 1.25 mg amlodipine, 0.625 mg indapamide, 2.5-mg bisoprolol f) addition of antihypertensive from a new class may lower systolic BP & cardiovascular risk [137] g) adding a new medication is associated with better blood pressure control than maximizing a current medication [154] h) combinations of choice [38] 1] ACE inhibitor plus thiazide diuretic a] chlorthalidone more effective than HCTZ [48] b] diuretic enhances antihypertensive effect & mitigates hyperkalemic effect of ACE inhibitor c] combination pill once a day improves compliance with HEDIS measure (BP < 140/90) [71] d] loop diuretic may be needed if GFR < 30 mL/min/1.73 m2 2] ACE inhibitor plus dihydropyridine Ca+2 channel blocker (amlodipine, felodipine, nifedipine ...) a] ACE inhibitor plus calcium channel blocker was better than ACE inhibitor plus diuretic in slowing progression of nephropathy in ACCOMPLISH trial [68] b] amlodipine plus perindopril less effective in blacks than in whites & south Asians [39] 3] angiotensin receptor blocker (ARB) plus thiazide diuretic 4] angiotensin receptor blocker (ARB) plus dihydropyridine Ca+2 channel blocker (CCB) - moderate-dose ARB plus Ca+2 channel blocker may be superior to high-dose ARB monotherapy, especially in patients with cardiovascular disease or renal disease [57] 5] amlodipine/indapamide/telmisartan [166] (may be combination of choice) i) alternative combinations [38] 1] Ca+2 channel blocker plus thiazide diuretic 2] thiazide diuretic plus potassium-sparing diuretic 3] Aliskiren plus thiazide diuretic or CCB 4] beta-blocker plus diuretic or dihydropyridine CCB j) combinations to avoid [38] 1] ACE inhibitor plus angiotensin receptor blocker (ARB) 2] beta-blocker plus verapamil or diltiazem 3] beta-blocker plus central-acting alpha agonist (clonidine, etc) 8) drug indications with comorbid & specific conditions a) diabetes mellitus (DM) 1] ACE inhibitors 2] angiotensin II receptor antagonists 3] effects of ACE inhibitors & ARBs may be additive 4] calcium channel blockers a] verapamil & diltiazem appear to prevent diabetic nephropathy b] nifedipine may increase proteinuria 5] target BP for patients with DM is < 130/80 b) heart failure 1] ACE inhibitor 2] carvedilol or other beta-blocker 3] add diuretic as needed 4] hydralazine plus isordil (BiDil 1-2 tabs PO TID) - an adjunct to standard therapy in blacks [4,66] - add to ACE inhibitor, beta-blocker & diuretic in black patients with NYC class 3 or 4 heart failure c) isolated systolic hypertension 1] Maxzide, HCTZ or other thiazide diuretic 2] calcium channel blocker d) myocardial infarction with systolic dysfunction 1] beta-blocker 2] ACE inhibitor e) coronary artery disease (CAD) 1] beta-blocker 2] calcium channel blocker (risk of CAD) [48] f) atrial tachycardia/fibrillation 1] calcium channel blocker 2] beta-blocker g) cyclosporine-induced hypertension - calcium channel blocker h) dyslipidemia - prazosin i) essential tremor - propranolol j) hyperthyroidism - propranolol k) migraine 1] propranolol 2] metoprolol l) osteoporosis - thiazide diuretic (HCTZ, chlorthalidone) m) pre-operative hypertension - atenolol n) benign prostatic hypertrophy - prazosin o) renal insufficiency - ACE inhibitor or ARB - see hemodialysis for treatment of hypertension in dialysis patients p) elderly (see blood pressure in the very old) 1] control of isolated systolic hypertension 2] low-dose diuretic q) blacks (high prevalence of salt-sensitive hypertension) 1] diuretics a] thiazide plus ACE inhibitor [4] b] chlorthalidone more effective than HCTZ [48] 2] calcium channel blockers [24] 3] all agents are effective r) pregnancy 1] alpha-methyl dopa (Aldomet) 2] hydralazine 3] diuretics, alpha-blockers & calcium channel blockers may be continued if prescribed prior to conception s) gout - losartan (unique among ARBS) has uricosuric effect [57] - calcium channel blockers also lower serum uric acid 9) no age-specific antihypertensive selection guidelines [30] see [35] for dosing of antihypertensives in children 10) see antihypertensive agent for number needed to treat 11) taking medications in AM results in better compliance than taking them in PM (see medication compliance) - younger age, female gender, more prescribed medications, & prescription of a diuretic reduces medication compliance] [110] 12) surgery for resistant hypertension - renal sympathetic denervation [31] - fails to lower systolic BP by > 10 mm Hg [31] 13) alternative therapies that may be beneficial a) breathing entrainment device (RespErate) b) Tai Chi c) CoQ10 100-200 mg/day [9,47] d) dark chocolate [9] (see diet above) 14) therapies without proven benefit: - calcium, magnesium, garlic, fish oil - biofeedback [75] - soy may improve systolic & diastolic blood pressure in patients with hypertension* [4,26] (benefit < 15 mm Hg) 15) pay for performance does not benefit patients [43] 16) pharmacists in black barbershops in connection with health promotion by barbers may help reduce uncontrolled hypertension [125,141] 17) pharmacist-led telehealth as effective as clinic-based control of managing chronic hypertension [156] 18) follow-up - every 6 months equivalent to every 3 months for stable, controlled hypertension [14] Guidelines from Joint National Committee on High Blood Pressure * Joint National Committee recommends thiazide diuretic as preferred 1st line agent. A second agent is selected in accord with comormid conditions. [16] * diuretic 1st line [147] * USPSTF recommends a thiazide, calcium channel blocker, ACE inhibitor or ARB 1st line in non-black patients * USPSTF recommends a thiazide or calcium channel blocker as 1st line in black patients * 23-year mortality same for ACE-inhibitor, calcium channel blocker, diuretic [162] # most patients need at least 2 agents to control hypertension [11,16]; single pill once a day improves compliance [71] Notes: - GRS8 recommends HCTZ over DASH diet for systolic hypertension in elderly losing weight on current diet [48], even if patient does not like the food they are losing weight on [48] - GRS8 cites HVET study (funded by manufacturer of study drugs) to support choice of HCTZ although: a) patient not member of study population b) indapamide not HCTZ was diuretic in HVET study - meta-analysis of 19 trials concludes average BP of 133/76 mm Hg reduces risk of major cardiovascular events 14% vs average BP of 140/81 [91] - risk reduction for MI, stroke, & albuminuria - no difference in risk of heart failure, ESRD, or mortality - serious hypotensive events more common with more-intensive BP control - benefits of intensive control greatest in trials limited to patients with vascular disease, renal disease, or diabetes - authors say serious hypotensive events likely would not outweigh benefits in high-risk patients - no discussion of effects on cognition noted [91] - a systolic BP consistently > 120-125 mm Hg may signal incipient chronic hypertension [124]

Interactions

disease interactions

Related

ambulatory blood pressure monitoring (ABPM) antihypertensive agents & diabetes risk blood pressure & hypertension in diabetes blood pressure (BP) blood pressure in the very old complication of chronic hypertension Dietary Approaches to Stop Hypertension (DASH) diet etiology of arterial hypertension exercise & blood pressure home blood pressure monitoring hypertension clinical trials Joint National Committee on High Blood Pressure medications that may raise blood pressure prehypertension screening for hypertension secondary hypertension

Specific

diastolic hypertension resistant hypertension; refractory hypertension salt-sensitive hypertension (ssHTN) systolic hypertension (hypertension in the elderly)

General

hypertension (HTN, high blood pressure, HBP) chronic disease

References

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