Upon completion of the chapter, the reader will be able to:
Classify blood pressure (BP) levels and treatment goals.
Recognize underlying causes and contributing factors in the development of hypertension.
Describe the appropriate measurement of BP.
Recommend appropriate lifestyle modifications and pharmacotherapy for patients with hypertension.
Identify populations requiring special consideration when designing a treatment plan.
Construct an appropriate monitoring plan to assess hypertension treatment.
Despite blood pressure (BP) being a surrogate target for reducing cardiovascular risk, it has been well established that reducing elevated BP in patients at sufficient risk provides a significant cardiovascular benefit. However, in spite of efforts to promote awareness, treatment, and the means available to aggressively manage high BP, global control remains suboptimal. Worldwide, only about one-third of adults have their BP controlled, and in the United States, slightly over one-half of adults experience BP control.1 Based on clinical evidence, national and international organizations continually refine recommendations on the management of patients with high BP. The purpose of this chapter is to: (a) provide a summary of key issues associated with the management of hypertension; (b) discuss the basic approach to treating hypertension and provide a functional summary of the currently prevailing themes of recent guidelines; and (c) summarize salient pharmacotherapeutic issues essential for clinicians to consider when treating hypertension. In doing so, we hope to provide the practicing clinician with a contemporary view on a defensible approach to managing BP and therefore risk in patients with elevated BP.
Various algorithms recommend nonpharmacologic and pharmacologic management, with the underlying premise that lowering elevated BP reduces end-organ damage leading to reductions in stroke, myocardial infarction (MI), end-stage renal disease, and heart failure (HF). Although other guidelines are mentioned, this chapter focuses primarily on two recent guidelines: the American Society of Hypertension (ASH) and the International Society of Hypertension (ISH) Joint Clinical Practice Guidelines for the Management of Hypertension in the Community,2 and the 2014 Evidence-Based Guideline for the Management of High BP in Adults by the former panel members appointed to the Eighth Joint National Committee (JNC 8).3 Guidelines from the American Heart Association and American College of Cardiology are anticipated to be released in 2015.
The ASH/ISH hypertension guidelines classify BP and provide guidance on nonpharmacologic and pharmacologic approaches to managing hypertension. These guidelines state that the lowest risk of adverse cardiovascular or renal outcomes is at a BP of around 115/75 mm Hg, with risk rising as BP increases. They further classify elevations in BP beyond specific thresholds as prehypertension, stage 1 hypertension, and stage 2 hypertension (Table 5–1). These classifications imply different levels of risk and thus the need for varying intensities of intervention with drug therapy.2 Recommendations for drug therapy typically begin with one or two (in the case of stage 2 hypertension) antihypertensive drugs as an initial step. Compelling indications, ...