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Hypertension

LEARNING OBJECTIVES

LEARNING OBJECTIVES

Upon completion of the chapter, the reader will be able to:

  1. Identify guideline-based treatment goals for patients with hypertension.

  2. Recognize underlying causes and contributing factors in the development of hypertension.

  3. Describe the appropriate measurement of blood pressure (BP).

  4. Classify BP levels after appropriate measurement.

  5. Recommend appropriate lifestyle modifications.

  6. Determine patient-centered pharmacotherapy for individuals with hypertension.

  7. Identify specific conditions and populations requiring special consideration when designing a treatment plan for hypertension.

  8. Construct an appropriate monitoring plan to assess hypertension treatment.

INTRODUCTION

It is well established that reducing elevated blood pressure (BP) in patients at sufficient risk provides significant cardiovascular benefit. However, despite efforts to promote awareness, treatment, and management of high BP, control remains suboptimal. Worldwide, approximately one-third of adults have controlled BP, and in the United States, slightly over one-half of adults experience 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 prevailing themes of contemporary guidelines; and (c) summarize pharmacotherapeutic issues essential for clinicians to consider when treating hypertension.

Various algorithms recommend nonpharmacologic and pharmacologic management, with the underlying premise that lowering elevated BP reduces target organ damage leading to reductions in stroke, myocardial infarction (MI), end-stage renal disease, and heart failure (HF). BP targets and treatment recommendations for a particular patient may vary based on different guidelines and/or position statements, depending on their interpretation of the clinical evidence available at the time of development. This chapter primarily focuses on the most recent comprehensive, evidence-based 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, put forth by the American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Clinical Practice Guidelines and hereafter referred to as the 2017 ACC/AHA guidelines.2

Image not available. The 2017 ACC/AHA guidelines classify BP and provide guidance on accurate assessment of BP as well as the nonpharmacologic and pharmacologic approaches to managing hypertension. Various guidelines recognize that the lowest risk of adverse cardiovascular or renal outcomes is at a BP around 115/75 mm Hg, with risk rising as BP increases. For each increase by 20 mm Hg in systolic BP (SBP), or approximate 10 mm Hg increase in diastolic BP (DBP), the risk of death from ischemic heart disease, stroke, and other vascular diseases increases by twofold in individuals aged 40 to 69 years. The risk is even greater in older individuals.

Image not available. The 2017 ACC/AHA guidelines classify elevations in BP beyond specific thresholds as elevated BP, stage 1 hypertension, and stage 2 hypertension (Table 5–1) to imply different levels of risk and the need for varying intensities of ...

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