cardiovascular disorders
Hypertension
Treatment of Hypertension
Weight loss and exercise Smoking cessation Adequate sleep duration (> 6 hours/night) Diet: Increased fruits and vegetables, decreased salt, limited alcohol Medications: Depending on BP and presence of cardiovascular disease or risk factors Primary hypertension has no cure, but some causes of secondary hypertension can be corrected. In all cases, control of blood pressure can significantly limit adverse consequences. Goal blood pressurefor the most patients, including patients with a kidney disorder or diabetes, is BP<130/80 mm Hg regardless of age up to age 80 years 120 mm Hg systolic or a diastolic BP approaching 60 mm Hg increases risk of these adverse events ( Treatment references ). Even older patients, including frail older patients, can tolerate a diastolic BP as low as 60 to 65 mm Hg well and without an increase in cardiovascular events ( Treatment references ). Ideally, patients or family members measure BP at home, provided they have been trained to do so, they are closely monitored, and the sphygmomanometer is regularly calibrated. Treatment of Treatment requires careful medication selection because some antihypertensive medications can harm the fetus. Lifestyle modifications are recommended for all patients with elevated BP or any stage hypertension (see also Table 15. Nonpharmacological Interventions in2017 Hypertension Guidelines). The best proven nonpharmacologic interventions for prevention and treatment of hypertension include the following: Increased physical activity, ideally with a structured exercise program Weight loss if the patient has overweight or obesity Healthy diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced saturated and total fat content Reduced dietary sodium to<1500 mg/day (<3.75 gsodium chloride) optimally, but at least a 1000 mg/day reduction Enhanced dietary potassium intake, unless contraindicated due to chronic kidney disease or use of medications that reduce potassium excretion Moderation in alcohol intake in those who drink alcohol to≤2 drinks daily for men and≤1 drink daily for women (one drink is about 12 oz of beer, 5 oz of wine, or 1.5 oz distilled spirits) Smoking Cessation None 5 or 6 hours per night in adults, has been associated with hypertension ( Treatment references ). For example, data suggest that optimizing sleep quality and duration (> 6 hours/night) improves blood pressure control in patients with chronic kidney disease ( Dietary modifications can also help control diabetes, obesity, and dyslipidemia. Patients with uncomplicated hypertension do not need to restrict their activities as long as blood pressure is controlled. (See also Medications for Hypertension .) The decision to treat with medication is based on the BP level and the presence of atherosclerotic cardiovascular disease (ASCVD) or its risk factors (see table). The presence of diabetes or kidney disease is not factored in separately because these diseases are part of ASCVD risk assessment. An important part of management is continued reassessment. If patients are not at goal BP, clinicians should strive to optimize adherence before switching or adding medications. Medication selection is based on several factors, including comorbidities and contraindications. For most patients, when selecting an agent formonotherapy, initial treatment may be with any of the following medication classes: Angiotensin-converting enzyme (ACE) inhibitor Angiotensin IIreceptor blocker (ARB) Dihydropyridine calcium channel blocker Thiazide diuretic (preferably a thiazide-like diuretic such aschlorthalidoneorindapamide) In addition, some experts recommend that for patients of African ancestry who are candidates for monotherapy, a calcium channel blocker or a thiazide diuretic should be used initially (unless patients also have stage 3 or higher chronic kidney disease). The preference for a calcium channel blocker or a thiazide diuretic in patients of African ancestry is based on evidence from randomized trials showing that these classes of medications have superior efficacy in lowering blood pressure and rates of cardiovascular events than ACE inhibitors or ARBs ( Treatment references ). However, subsequent data suggest that despite the use of this race-based approach, control of hypertension and racial disparities in blood pressure control have not improved ( therapy with 2 antihypertensive agents is selected, options include either an ACE inhibitor or ARB combined with either a diuretic or a calcium channel blocker. Many combinations are available as single pills, which are preferable to improve patient adherence ( Treatment references ). Signs of Hypertensive Emergencies require immediate blood pressure reduction with parenteral antihypertensives. Some antihypertensives are avoided in certain disorders (eg, ACE inhibitors in severe Aortic Stenosis ) whereas others are preferred for certain disorders (eg, calcium channel blockers for If the goal BP is not achieved within 1 month, assess adherence and reinforce the importance of following treatment. If patientsareadherent, the dose of the initial medication can be increased or a second medication added (selected from among the medications recommended for initial treatment). Note that an ACE inhibitor and an ARB should not be used together. Therapy is titrated frequently. If target BP cannot be achieved with 2 medications, a third medication from the initial group is added. If such a third medication is not tolerated or is contraindicated, a medication from another class (eg,aldosteroneantagonist) can be used. Patients with such difficult to control BP may benefit from consultation with a hypertension specialist. If initial systolic BP is>160 mm Hg, 2 medications should be initiated regardless of cardiovascular disease risk. An appropriate combination and dose are determined. For resistant hypertension (BP remains above goal despite use of 3 different antihypertensive medications), 4 or more medications are commonly needed. Achieving adequate blood pressure control often requires several evaluations and changes in pharmacotherapy. Reluctance to titrate or add medications to control BP must be overcome. Nonadherence to therapy, particularly because lifelong treatment is required, can interfere with adequate BP control. Education, with empathy and support, is essential for success. Percutaneous catheter-based radiofrequency ablation of the sympathetic nerves in the renal artery is used in Europe and Australia for resistant hypertension. Several industry-funded sham-controlled studies with different patient populations (eg, those with untreated hypertension [ Treatment references ], treated hypertension [ A physical intervention to lower blood pressure involves stimulating the carotid baroreceptor with a device surgically implanted around the carotid body. A battery attached to the device, much like a pacemaker, is designed to stimulate the baroreceptor and, in a dose-dependent manner, lower blood pressure. Long-term follow-up of patients with resistant hypertension who were included in earlier pivotal trials suggests that baroreflex activation therapy maintained its efficacy for persistent reduction of office BP without major safety issues ( Treatment references ). However, the 2017 American College of Cardiology/American Heart Association guidelines concluded that studies have not provided sufficient evidence to recommend the use of these devices in managing resistant hypertension ( 1.Gomadam P, Shah A, Qureshi W, et al. Blood pressure indices and cardiovascular disease mortality in persons with or without diabetes mellitus.J Hypertens36(1):85-92, 2018. doi:10.1097/HJH.0000000000001509 2.Williamson JD, Supiano MA, Applegate WB, et al. Intensive vs Standard Blood Pressure Control and Cardiovascular Disease Outcomes in Adults Aged≥75 Years: A Randomized Clinical Trial.JAMA315(24):2673-2682, 2016. doi:10.1001/jama.2016.7050 3.White WB, Wakefield DB, Moscufo N, et al. Effects of Intensive Versus Standard Ambulatory Blood Pressure Control on Cerebrovascular Outcomes in Older People (INFINITY).Circulation140(20):1626-1635, 2019. doi:10.1161/CIRCULATIONAHA.119.041603 4.Thomas SJ, Calhoun D. Sleep, insomnia, and hypertension: current findings and future directions.J Am Soc Hypertens11(2):122-129, 2017. doi:10.1016/j.jash.2016.11.008 5.Ali W, Gao G, Bakris GL. Improved Sleep Quality Improves Blood Pressure Control among Patients with Chronic Kidney Disease: A Pilot Study.Am J Nephrol51(3):249-254, 2020. doi:10.1159/000505895 6.Materson BJ, Reda DJ, Cushman WC, et al. Single-drug therapy for hypertension in men. A comparison of six antihypertensive agents with placebo. The Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents [published correction appears in N Engl J Med 1994 Jun 9;330(23):1689].N Engl J Med1993;328(13):914-921. doi:10.1056/NEJM199304013281303 7.Yamal JM, Oparil S, Davis BR, et al. Stroke outcomes among participants randomized tochlorthalidone,amlodipineorlisinoprilin ALLHAT.J Am Soc Hypertens2014;8(11):808-819. doi:10.1016/j.jash.2014.08.003 8.Wright JT Jr, Harris-Haywood S, Pressel S, et al. Clinical outcomes by race in hypertensive patients with and without the metabolic syndrome: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).Arch Intern Med2008;168(2):207-217. doi:10.1001/archinternmed.2007.66 9.Hall WD, Reed JW, Flack JM, Yunis C, Preisser J. Comparison of the efficacy of dihydropyridine calcium channel blockers in African American patients with hypertension. ISHIB Investigators Group. International Society on Hypertension in Blacks.Arch Intern Med158(18):2029-2034, 1998. doi: 10.1001/archinte.158.18.2029 10.Egan BM, Li J, Sutherland SE, Rakotz MK, Wozniak GD. Hypertension Control in the United States 2009 to 2018: Factors Underlying Falling Control Rates During 2015 to 2018 Across Age- and Race-Ethnicity Groups.Hypertension78(3):578-587, 2021. doi:10.1161/HYPERTENSIONAHA.120.16418 11.Mokwe E, Ohmit SE, Nasser SA, et al. Determinants of blood pressure response toquinaprilin black and white hypertensive patients: theQuinaprilTitration Interval Management Evaluation trial.Hypertension2004;43(6):1202-1207. doi:10.1161/01.HYP.0000127924.67353.86 12.Parati G, Kjeldsen S, Coca A, Cushman WC, Wang J. Adherence to Single-Pill Versus Free-Equivalent Combination Therapy in Hypertension: A Systematic Review and Meta-Analysis.Hypertension77(2):692-705, 2021. doi:10.1161/HYPERTENSIONAHA.120.15781 13.Williams B, Mancia G, Spiering W, et al. 2018 Practice Guidelines for the management of arterial hypertension of the European Society of Hypertension and the European Society of Cardiology: ESH/ESC Task Force for the Management of Arterial Hypertension [published correction appears in J Hypertens 2019 Feb;37(2):456].J Hypertens8;36(12):2284-2309, 2018. doi:10.1097/HJH.0000000000001961 14.Böhm M, Kario K, Kandzari DE, et al. Efficacy of catheter-based renal denervation in the absence of antihypertensive medications (SPYRAL HTN-OFF MED Pivotal): a multicentre, randomised, sham-controlled trial.Lancet395(10234):1444-1451, 2020. doi:10.1016/S0140-6736(20)30554-7 15.Mahfoud F, Kandzari DE, Kario K, et al. Long-term efficacy and safety of renal denervation in the presence of antihypertensive drugs (SPYRAL HTN-ON MED): a randomised, sham-controlled trial.Lancet399(10333):1401-1410, 2022. doi:10.1016/S0140-6736(22)00455-X 16.Bhatt DL, Vaduganathan M, Kandzari DE, et al. Long-term outcomes after catheter-based renal artery denervation for resistant hypertension: final follow-up of the randomised SYMPLICITY HTN-3 Trial.Lancet400(10361):1405-1416, 2022. doi:10.1016/S0140-6736(22)01787-1 17.de Leeuw PW, Bisognano JD, Bakris GL, Nadim MK, Haller H, Kroon AA, DEBuT-T and Rheos Trial Investigators: Sustained reduction of blood pressure with baroreceptor activation therapy: Results of the 6-year open follow-up.Hypertension69:836–843, 2017. 18.Whelton PK, Carey RM, Aronow WS, et al: 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.Hypertension71(6):e13–e115, 2018. doi: 10.1161/HYP.0000000000000065 