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LEARNING OBJECTIVES
Upon completion of the chapter, the reader will be able to:
Identify guideline-based treatment goals for patients with hypertension.
Recognize underlying causes and contributing factors in the development of hypertension.
Describe the appropriate measurement of blood pressure (BP).
Classify BP levels after measurement.
Recommend lifestyle modifications.
Determine patient-centered pharmacotherapy for individuals with hypertension.
Identify specific conditions and populations requiring special consideration when designing a treatment plan for hypertension.
Construct an appropriate monitoring plan to assess hypertension treatment.
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It is well established that reducing elevated blood pressure (BP) in patients at sufficient cardiovascular event risk provides significant benefit. However, despite efforts to promote awareness and widespread use of antihypertensive medications, BP control remains suboptimal.1
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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).2,3 BP-related definitions, 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 and the translatability of clinical data to their local practice. 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 This is not to minimize or discount other guidelines but to improve consistency for the learner.
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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 of 20 mm Hg in systolic BP (SBP), or approximately 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.
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The 2017 ACC/AHA guidelines classify elevations in BP beyond specific thresholds as elevated BP, stage 1 hypertension, and stage 2 hypertension (Table 6–1) to imply different levels of risk and the need for varying intensities of intervention with drug therapy.2 Specific BP thresholds for treatment and BP goals of therapy are established based on cardiovascular risk assessment or the presence of specific comorbid conditions (Figure 6–1 and Table 6–2).2 Recommendations for BP-lowering medications typically begin with one or two (in the case of stage 2 hypertension and average BP of 20/10 mm Hg above the BP target) ...