Hypertension

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Revision as of 22:21, 22 October 2007 by imported>Robert Badgett (→‎Initial medication)
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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

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).[1]

Treatment goals

Per the JNC7 Guidelines:[1]

  • "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"[1]
Efficacy of different drugs. From Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents.[2]

However, the initial drug may be better selected based on the patient's age, race, and gender.[2][3] The patient's demographic roughly corresponds with their renin profile, but is more predictive than the renin profile.[3] The molecular basis is being determined.[4]

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).[2]

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[5] are also associated with low renin.

Several randomized controlled trials have compared initial medications for hypertension.[6][7][8][2]

  • In the Second Australian National Blood Pressure study (ANBP2),[7] 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,[6] 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.[1]

The race and age demographic may partly predict frequency of adverse drug responses to different anti-hypertensive mediations.[9]

Persistent hypertension

Systolic hypertension

For more information, see: Systolic hypertension.


Prognosis

References

  1. 1.0 1.1 1.2 1.3 Chobanian AV, Bakris GL, Black HR, et al (2003). "The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report". JAMA 289 (19): 2560-72. DOI:10.1001/jama.289.19.2560. PMID 12748199. Research Blogging. http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf
  2. 2.0 2.1 2.2 2.3 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
  3. 3.0 3.1 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]
  4. 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.
  5. 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]
  6. 6.0 6.1 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]
  7. 7.0 7.1 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.
  8. 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]
  9. 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.