Hypertension

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Hypertension is a multisystem disease whose hallmark is the elevation of blood pressure.

Classification

Classification of blood pressure for adults
Blood pressure classification Initial blood pressure mm Hg Followup recommended
SBP DBP
Normal <120 and <80 Recheck in 2 years
Prehypertension 120-139 or 80-99 Recheck in 1 year
Stage 1 Hypertension 140-159 or 90-99 Confirm within 2 months
Stage 2 Hypertension >160 or >100 "Evaluate or refer to source of care within 1 month. For those with higher pressures (e.g., >180/110 mmHg), evaluate and treat immediately or within 1 week depending on clinical situation and complications."

Diagnosis

A systematic review by the Rational Clinical Examination has reviewed the research on measuring the blood pressure.[1]

If the diastolic pressure is below 110 mm Hg, it should be confirmed on two addition visits as some patients will have a lower blood pressure on repeat measurements.[2] A larger cuff should be used for obese patients.[3]

21% of patients with untreated borderline hypertension (diastolic pressure between 90 and 104 mm Hg) may have normal blood pressures outside of the doctor's office.[4]

Some patients may have their blood pressure rise by as much as 25 mm Hg due to an alarm reaction upon seeing a doctor.[5]

Elderly patients may have pseudohypertension due to inability of the blood pressure cuff to compress stiff arteries.[6] Pseudohypertension may be detected by Osler's maneuver.[6]

Excluding secondary hypertension

Listening for an abdominal bruit, especially if it is both systolic and diastolic, may help detect underlying renal artery stenosis.[7]

Treatment

Current clinical practice guidelines are based on The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)Cite error: Closing </ref> missing for <ref> tag http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf</ref> Drugs for hypertension have been reviewed by the Medical Letter.[8]

Treatment goals

Per the JNC7 Guidelines:[9]

  • "Treating "most patients" SBP and DBP to targets that are <140/90 mmHg is associated with a decrease in cardiovascular complications.
  • In patients with hypertension and diabetes or renal disease, the BP goal is <130/80 mmHg.

Initial medication

In the absence of any comordid medical conditions that would affect the selection of a drug, the JNC7 recommends:

  • "Thiazide-type diuretics for most"[9]
Efficacy of different drugs. From Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents.[10]

However, the initial drug may be better selected based on the patient's age, race, and gender.[10][11] The patient's demographic roughly corresponds with their renin profile, but is more predictive than the renin profile.[11] The molecular basis is being determined.[12]

In the high renin demographic (young whites), diuretics had similar efficacy to placebo; whereas in the low renin demographic (older blacks), the ace-inhibitors had similar efficacy to placebo in the Masterson Veterans Affairs Cooperative Study Group on Antihypertensive Agents (see figure).[10]

Predicting response to anti-hypertensives based on demographics
Category name demographics Comments Best anti-hypertensive categories
High renin demographic less than 50 years old, anglo salt-sensitive; diuretic responsive diuretics, calcium channel blockers
Low renin demographic more than 50 years old, non-anglo* ace-inhibitors, beta-blockers
* Obesity and female[13] are also associated with low renin.

Several randomized controlled trials have compared initial medications for hypertension.[14][15][16][10]

  • In the Second Australian National Blood Pressure study (ANBP2),[15] ace-inhibitors were better in a population that was 95% white with a body-mass index of 27. This demographic has features of both high (age) and low (race) renin status.
  • In the ALLHAT study,[14] diuretics were better in a population that was 47% white with a body-mass index of 30.

For patients with Stage 2 Hypertension (SBP >160 or DBP>100 mmHg), start with two drugs.[9]

The race and age demographic may partly predict frequency of drug toxicity to different anti-hypertensive medications.[17]

Resistant hypertension

Clinical practice guidelines from the American Heart Association (AHA) address resistant hypertension.[18] The AHA defines resistant hypertension as "blood pressure that remains above goal in spite of the concurrent use of 3 antihypertensive agents of different classes."

First, 'pseudoresitance' should be considered:[18]

Next, secondary hypertension should be considered:[18]

Lastly, the AHA recommends that one of the three medicines use for hypertension should be a diuretic.[18]

Systolic hypertension

For more information, see: Systolic hypertension.


Elderly patients

Treating patients aged 80 years or older for two years who have a systolic pressure over 160 mm hg (the average entry pressure was 173/91 mm Hg) and treating to 150/80 mm Hg may reduce morbidity.[19] In this trial, the average seated blood pressure at the end of the study in the treatment group was 143/78.

See also

Prognosis

References

  1. ↑ Reeves RA (1995). "The rational clinical examination. Does this patient have hypertension? How to measure blood pressure". JAMA 273 (15): 1211–8. PMID 7707630. [e]
  2. ↑ Hartley RM, Velez R, Morris RW, D'Souza MF, Heller RF (1983). "Confirming the diagnosis of mild hypertension". Br Med J (Clin Res Ed) 286 (6361): 287–9. PMID 6402075. [e] PubMed Central
  3. ↑ Nielsen PE, Larsen B, Holstein P, Poulsen HL (1983). "Accuracy of auscultatory blood pressure measurements in hypertensive and obese subjects". Hypertension 5 (1): 122–7. PMID 6848459. [e]
  4. ↑ Pickering TG, James GD, Boddie C, Harshfield GA, Blank S, Laragh JH (1988). "How common is white coat hypertension?". JAMA 259 (2): 225–8. PMID 3336140. [e]
  5. ↑ Mancia G, Parati G, Pomidossi G, Grassi G, Casadei R, Zanchetti A (1987). "Alerting reaction and rise in blood pressure during measurement by physician and nurse". Hypertension 9 (2): 209–15. PMID 3818018. [e]
  6. ↑ 6.0 6.1 Messerli FH, Ventura HO, Amodeo C (1985). "Osler's maneuver and pseudohypertension". N. Engl. J. Med. 312 (24): 1548–51. PMID 4000185. [e]
  7. ↑ Turnbull JM (1995). "The rational clinical examination. Is listening for abdominal bruits useful in the evaluation of hypertension?". JAMA 274 (16): 1299–301. PMID 7563536. [e]
  8. ↑ (June 2005) "Drugs for hypertension". Treat Guidel Med Lett 3 (34): 39–48. PMID 15912125. [e]
  9. ↑ 9.0 9.1 9.2 Cite error: Invalid <ref> tag; no text was provided for refs named pmid12748199
  10. ↑ 10.0 10.1 10.2 10.3 Materson BJ, Reda DJ (1994). "Correction: single-drug therapy for hypertension in men". N. Engl. J. Med. 330 (23): 1689. PMID 8177286. [e] Cite error: Invalid <ref> tag; name "pmid8177286" defined multiple times with different content
  11. ↑ 11.0 11.1 Preston RA, Materson BJ, Reda DJ, et al (1998). "Age-race subgroup compared with renin profile as predictors of blood pressure response to antihypertensive therapy. Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents". JAMA 280 (13): 1168–72. PMID 9777817. [e]
  12. ↑ Materson BJ (2007). "Variability in response to antihypertensive drugs". Am. J. Med. 120 (4 Suppl 1): S10–20. DOI:10.1016/j.amjmed.2007.02.003. PMID 17403377. Research Blogging.
  13. ↑ Cowley AW, Skelton MM, Velasquez MT (1985). "Sex differences in the endocrine predictors of essential hypertension. Vasopressin versus renin". Hypertension 7 (3 Pt 2): I151–60. PMID 3888837. [e]
  14. ↑ 14.0 14.1 ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (2002). "Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT)". JAMA 288 (23): 2981-97. PMID 12479763. [e]
  15. ↑ 15.0 15.1 Wing LM, Reid CM, Ryan P, et al (2003). "A comparison of outcomes with angiotensin-converting--enzyme inhibitors and diuretics for hypertension in the elderly". N. Engl. J. Med. 348 (7): 583-92. DOI:10.1056/NEJMoa021716. PMID 12584366. Research Blogging.
  16. ↑ Materson BJ, Reda DJ, Cushman WC, et al (1993). "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". N. Engl. J. Med. 328 (13): 914-21. PMID 8446138. [e]
  17. ↑ McDowell SE, Coleman JJ, Ferner RE (2006). "Systematic review and meta-analysis of ethnic differences in risks of adverse reactions to drugs used in cardiovascular medicine". BMJ 332 (7551): 1177–81. DOI:10.1136/bmj.38803.528113.55. PMID 16679330. Research Blogging.
  18. ↑ 18.0 18.1 18.2 18.3 Calhoun, D. A., Jones, D., Textor, S., Goff, D. C., Murphy, T. P., Toto, R. D., et al. (2008). Resistant Hypertension: Diagnosis, Evaluation, and Treatment. A Scientific Statement From the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Hypertension, HYPERTENSIONAHA.108.189141. DOI:10.1161/HYPERTENSIONAHA.108.189141.
  19. ↑ Beckett, N. S., Peters, R., Fletcher, A. E., Staessen, J. A., Liu, L., Dumitrascu, D., et al. (2008). Treatment of Hypertension in Patients 80 Years of Age or Older. N Engl J Med, NEJMoa0801369. DOI:10.1056/NEJMoa0801369
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