JOURNAL OF

HIGH BLOOD PRESSURE (HYPERTENSION)

BY :
DWIANA WAHYU SETIYOWATI
NIM : 11620554
PSIK 6A
HEALTHY NURSING S!IEN!E
KADIRI UNI"ERSITY
2014
HYPERTENSION
INTRODU!TION
For more than three decades, the National Heart, Lung, and Blood Institute
(NHLBI) has coordinated the National High Blood Pressure Education Program, a coalition
of 39 major rofessional, u!lic, and "oluntar# organi$ations and se"en Federal %gencies&
'ne imortant function is to issue guidelines and ad"isories designed to increase
a(areness, re"ention, treatment, and control of h#ertension (high !lood ressure (BP))&
)ince the u!lication of the *)i+th ,eort of the -oint National .ommittee on the
Pre"ention, /etection, E"aluation, and 0reatment of High Blood Pressure (-N. 1)2
released in 3994, man# large5scale clinical trials ha"e !een u!lished& 0he decision to
aoint a -N. 4 committee (as !ased on four factors6 (3) u!lication of man# ne(
h#ertension o!ser"ational studies and clinical trials7 (8) need for a ne(, clear, and concise
guideline that (ould !e useful for clinicians7 (3) need to simlif# the classification of BP7
and (9) clear recognition that the -N. reorts (ere not !eing used to their ma+imum
!enefit& 0his -N. reort is resented in t(o searate u!lications6 a current, succinct,
ractical guide and a more comrehensi"e reort to !e u!lished searatel#, (hich (ill
ro"ide a !roader discussion and justification for the current recommendations& In
resenting these guidelines, the committee recogni$es that the resonsi!le h#sician:s
judgment is aramount in managing atients&
!LASSIFI!ATION OF BLOOD PRESSURE
0a!le 3 ro"ides a classification of BP for adults ages 3; and older& 0he
classification is !ased on the a"erage of t(o or more roerl# measured, seated BP readings
on each of t(o or more office "isits& In contrast to the classification ro"ided in the -N. 1
reort, a ne( categor# designated reh#ertension has !een added, and stages 8 and 3
h#ertension ha"e !een com!ined& Patients (ith reh#ertension are at increased ris< for
rogression to h#ertension7 those in the 33=>339?;=>;9 mmHg BP range are at t(ice the
ris< to de"elo h#ertension as those (ith lo(er "alues&
!ARDIO"AS!ULAR DISEASE RISK
H#ertension affects aro+imatel# @= million indi"iduals in the Anited )tates and
aro+imatel# 3 !illion (orld(ide& %s the oulation ages, the re"alence of h#ertension
(ill increase e"en further unless !road and effecti"e re"enti"e measures are imlemented&
,ecent data from the Framingham Heart )tud# suggest that indi"idual (ho are
normotensi"e at age @@ ha"e a 9= ercent lifetime ris< for de"eloing h#ertension&
0he relationshi !et(een BP and ris< of .B/ e"ents is continuous, consistent, and
indeendent of other ris< factors& 0he higher the BP, the greater is the chance of heart
attac<, heart failure, stro<e, and <idne# disease& For indi"idu als 9=>4= #ears of age, each
increment of 8= mmHg in s#stolic BP ()BP) or 3= mmHg in diastolic BP (/BP) dou!les
the ris< of .B/ across the entire BP range from 33@?4@ to 3;@?33@ mmHg&
T#$%& 1 !%#''()(*#+(,- #-. /#-#0&/&-+ ,) $%,,. 12&''32& ),2 #.3%+'*
BP
.lassification
)BPC
Dmhg
/BPC
Dmhg
Lifest#le
Dodif
Initial /rug 0hera#
Eithout .omelling
Indication
Eith
.omellingg
Indications
Normal F38= %nd
F;=
Encourage No antih#ertensi"e drug
indicated
/rug(s) for
comelling
indications)
Preh#ertension 38=5339 'r ;=5
9=
Ges
)tage 3
H#ertension
39=53@9 'r
9=599
Ges 0hia$ide5t#e diuretics
for most & ma# consider
%.EI, %,B, BB, ..B,
or com!ination
/rug(s) for the
comelling
indications&
'ther
antih#ertensi"e
drugs (diuretics,
%.EI, %,B,
BB, ..B) as
needed
)tage 8
H#ertension
H31= 'r H3== Ges 0(o5drug com!ination
for most (usuall#
thia$ide5t#e diuretic and
%.EI or%,B or BB or
..B)
Note 6
/BP, diastolic !lood ressure7 )BP, s#stolic !lood ressure&
/rug a!!re"iations6 %.EI, angiotensin con"erting en$#me inhi!itor7 %,B, angiotensin
recetor !loc<er7 BB, !eta5!loc<er7
..B, calcium channel !loc<er&
C 0reatment determined !# highest BP categor#&
I Initial com!ined thera# should !e used cautiousl# in those at ris< for orthostatic
h#otension&
J 0reat atients (ith chronic <idne# disease or dia!etes to BP goal of F33=?;= mmHg&
0he classification reh#ertension introduced in this reort (ta!le 3), recogni$es this
relationshi and signals the need for increased education of health care rofessional and the
u!lic to reduce BP le"els and re"ent the de"eloment of h#ertension in the general
oulation& H#ertension re"ention strategies are a"aila!le to achie"e this goal&
BENEFITS OF LOWERING BLOOD PRESSURE
In clinical trials, antih#ertensi"e thera# has !een associated (ith reductions in
stro<e incidence a"eraging 3@>9= K7 m#ocardial infarction, 8=>8@ K7 and heart failure,
more than @= K& It is estimated that in atients (ith stage 3 h#ertension ()BP 39=>3@9
mmHg and?or /BP 9=>99 mmHg) and additional cardio"ascular ris< factors, achie"ing a
sustained 38 mmHg reduction in )BP o"er 3= #ears (ill re"ent 3 death for e"er# 33
atients treated& In the resence of .B/ or target organ damage, onl# 9 atients (ould
reLuire such BP reduction to re"ent a death&
T#$%& 2 T2&-.' (- #4#2&-&''5 +2&#+/&-+5 #-. *,-+2,% ,) 6(06 BP (- #.3%+' #0&' 17894:
National health and nutrition e+amination sur"e#, ercent
II
(39415;=)
III (PH%)E 3
39;;593)
III (PH%)E 8
3993599) 399958===
%(areness @3 43 1; 4=
0reatment 33 @@ @9 @9
control 3= 89 84 39
Note 6
C High !lood ressure is s#stolic !lood ressure ()BP) H19= mmHg or diastolic !lood
ressure (/BP) H9= mmHg or ta<ing antih#ertensi"e medication&
I )BP <39= mmHg and /BP <9= mmHg&
BLOOD PRESSURE !ONTROL RATES
H#ertension is the most common rimar# diagnosis in %merica (3@ million office
"isits as the rimar# diagnosis)& .urrent control rates ()BP F39= mmHg and /BP F9=
mmHg), though imro"ed, are still far !elo( the Health# Peole 8=3= goal of @= K7 3= K
are still una(are the# ha"e h#ertension& ()ee ta!le 8&) In the majorit# of atients,
controlling s#stolic h#ertension, (hich is a more imortant .B/ ris< factor than /BP
e+cet in atients #ounger than age @=33 and occurs much more commonl# in older
ersons, has !een considera!l# more difficult than controlling diastolic h#ertension&
,ecent clinical trials ha"e demonstrated that effecti"e BP control can !e achie"ed in most
atients (ho are h#ertensi"e, !ut the majorit# (ill reLuire t(o or more antih#ertensi"e
drugs& Ehen clinicians fail to rescri!e lifest#le modifications, adeLuate antih#ertensi"e
drug doses, or aroriate drug com!inations, inadeLuate BP control ma# result&
A!!URATE BLOOD PRESSURE MEASUREMENT IN THE OFFI!E
0he auscultator# method of BP measurement (ith a roerl# cali!rated and
"alidated instrument should !e used& Persons should !e seated Luietl# for at least @ minutes
in a chair (rather than on an e+am ta!le), (ith feet on the floor, and arm suorted at heart
le"el& Deasurement of BP in the standing osition is indicated eriodicall#, eseciall# in
those at ris< for ostural h#otension& %n aroriate5si$ed cuff (cuff !ladder encircling at
least ;= ercent of the arm) should !e used to ensure accurac#& %t least t(o measurements
should !e made& )BP is the oint at (hich the first of t(o or more sounds is heard (hase
3), and /BP is the oint !efore the disaearance of sounds (hase @)& .linicians should
ro"ide to atients, "er!all# and in (riting, their secific BP num!ers and BP goals&
AMBULATORY BLOOD PRESSURE MONITORING
%m!ulator# !lood ressure monitoring (%BPD) ro"ides information a!out BP
during dail# acti"ities and slee& %BPD is (arranted for e"aluation of *(hite5coat2
h#ertension in the a!sence of target organ injur#& It is also helful to assess atients (ith
aarent drug resistance, h#otensi"e s#mtoms (ith antih#ertensi"e medication, eisodic
h#ertension, and autonomic d#sfunction& 0he am!ulator# BP "alues are usuall# lo(er than
clinic readings& %(a<e, indi"iduals (ith h#ertension ha"e an a"erage BP of more than
33@?;@ mmHg and during slee, more than 38=?4@ mmHg& 0he le"el of BP measurement !#
using %BPD correlates !etter than office measurements (ith target organ injur#& %BPD
also ro"ides a measure of the ercentage of BP readings that are ele"ated, the o"erall BP
load, and the e+tent of BP reduction during slee& In most indi"iduals, BP decreases !# 3=5
8= K during the night7 those in (hom such reductions are not resent are at increased ris<
for cardio"ascular&
SELF;MEASUREMENT OF BLOOD PRESSURE
BP self measurements ma# !enefit atients !# ro"iding information on resonse to
antih#ertensi"e medication, imro"ing atient adherence (ith thera#, and in e"aluating
(hite5coat h#ertension& Persons (ith an a"erage BP more than 33@?;@ mmHg measured at
home are generall# considered to !e h#ertensi"e& Home measurement de"ices should !e
chec<ed regularl# for accurac#&
PATIENT E"OLUATION
E"aluation of atients (ith documented h#ertension has three o!jecti"es6
3& to assess lifest#le and identif# other cardio"ascular ris< factors or concomitant disorders
that ma# affect rognosis and guide treatment (ta!le 3)7
8& to re"eal identifia!le causes of high BP (ta!le 9)7 and (3) to assess the resence or
a!sence of target organ damage and .B/& 0he data needed are acLuired through
medical histor#, h#sical e+amination, routine la!orator# tests, and other diagnostic
rocedures& 0he h#sical e+amination should
T#$%& < !#2.(,=#'*3%#2 2('> )#*+,2'
T#$%& 4 I.&-+()(#$%& *#3'&' ,) HT
3& )lee anea
8& /rug5induced or related causes
M#?,2 R('> F#*+,2'
H#ertensionC
.igarette smo<ing
'!esit#C (!od# mass inde+ H3= <g?m8)
Ph#sical inacti"it#
/#sliidemiaC
/ia!etes mellitusC
Dicroal!uminuria or estimated MF, F1= mL?min
%ge (older than @@ for men, 1@ for (omen)
Famil# histor# of remature cardio"ascular disease
(men under age @@ or (omen under age 1@)
3& .hronic <idne# disease
9& Primar# aldosteronism
@& ,eno"ascular disease
1& Pheochromoc#toma
4& .oarctation of the aorta
;& 0h#roid or arath#roid disease
Note 6
MF,, glomerular filtration rate&
C .omonents of the meta!olic s#ndrome&
include an aroriate measurement of BP,
(ith "erification in the contralateral arm7
e+amination of the otic fundi7 calculation
of !od# mass inde+ (BDI) (measurement of
(aist circumference also ma# !e useful)7
auscultation for carotid, a!dominal, and femoral !ruits7 alation of the th#roid gland7
thorough e+amination of the heart and lungs7 e+amination of the a!domen for enlarged
<idne#s, masses, and a!normal aortic ulsation7 alation of the lo(er e+tremities for
edema and ulses7 and neurological assessment&
LABORATORY TESTS AND OTHER DIAGNOSTI! PRO!EDURES
,outine la!orator# tests recommended !efore initiating thera# include an E.M7
urinal#sis7 !lood glucose and hematocrit7 serum otassium, creatinine (or the corres5
onding estimated glomerular filtration rate NMF,O), and calcium78= and a liid rofile,
after 95 to 385hour fast, that includes highdensit# liorotein cholesterol and lo(5densit#
liorotein cholesterol, and trigl#cerides& 'tional tests include measurement of urinar#
al!umin e+cretion or al!umin?creatinine ratio& Dore e+tensi"e testing for identifia!le
causes is not indicated generall# unless BP control is not achie"ed&
TREATMENT
1 G,#%' ,) T6&2#1@
T#20&+ O20#- D#/#0&
Heart
P Left "entricular h#ertroh#
P %ngina or rior m#ocardial infarction
P Prior coronar# re"asculari$ation
P Heart failure
Brain
P )tro<e or transient ischemic attac<
.hronic <idne# disease
Periheral arterial disease and ,etinoath#
0he ultimate u!lic health goal of antih#ertensi"e thera# is the reduction of
cardio and renal mor!idit# and mortalit#& )ince most ersons (ith H0, eseciall# those age
Q@= #ears, (ill reach the /BP goal once )BP is at goal, the rimar# focus should !e on
achie"ing the )BP goal& 0reating )BP and /BP to targets that are F39=?9= mmHg is
associated (ith a decrease in .B/ comlications& In atients (ith h#ertension and
dia!etes or renal disease, the BP goal is F33=?;= mmHg&
2 L()&'+@%& M,.()(*#+(,-'
%dotion of health# lifest#les !# all ersons is critical for the re"ention of high BP
and is an indisensa!le art of the management of those (ith h#ertension& Dajor lifest#le
modifications sho(n to lo(er BP include (eight reduction in those indi"iduals (ho are
o"er(eight or o!ese, adotion of the /ietar# %roaches to )to H0 (/%)H) eating lan
(hich is rich in otassium and calcium, dietar# sodium reduction, h#sical acti"it#, and
moderation of alcohol consumtion& ()ee ta!le @&) Lifest#le modifications reduce BP,
enhance antih#ertensi"e drug efficac#, and decrease cardio"ascular ris<& For e+amle, a
3,1== mg sodium /%)H eating lan has effects similar to single drug thera#&
.om!inations of t(o (or more) lifest#le modifications can achie"e e"en !etter results&
< P6#2/#*,%,0(* T2&#+/&-+
0here are e+cellent clinical outcome trial data ro"ing that lo(ering BP (ith se"eral
classes of drugs, including angiotensin con"erting en$#me inhi!itors (%.EIs), angiotensin
recetor !loc<ers (%,Bs), !eta5!loc<ers (BBs), calcium channel !loc<ers (..Bs), and
thia$ide5t#e diuretics, (ill all reduce the comlications of h#ertension& 0a!les 1 and 4
ro"ide a list of commonl# used antih#ertensi"e agents& 0hia$ide5t#e diuretics ha"e !een
the !asis of antih#ertensi"e thera# in most outcome trials& In these trials, including the
recentl# u!lished %ntih#ertensi"e and Liid Lo(ering 0reatment to Pre"ent Heart %ttac<
0rial (%LLH%0), diuretics ha"e !een "irtuall# unsurassed in re"enting the cardio"ascular
comlications of h#ertension& 0he e+cetion is the )econd %ustralian National Blood
Pressure trial (hich reorted slightl# !etter outcomes in Ehite men (ith a regimen that
!egan (ith an %.EI comared to one starting (ith a diuretic& /iuretics enhance the
antih#ertensi"e efficac#
T#$%& 5 L()&'+@%& /,.()(*#+(,-' +, /#-#0& 6@1&2+&-'(,-:A
M,.()(*#+(,- R&*,//&-.#+(,- A112,B(/#+& SBP
R&.3*+(,- (R#-0&)
Eeight
reduction
Daintain normal !od# (eight (!od# mass inde+
3;&@>89&9 <g?m8)
@>8= mmHg?3= <g
(eight loss83,89
%dot /%)H
eating lan
.onsume a diet rich in fruits, "egeta!les, and lo(fat
dair# roducts (ith a reduced content of saturated
and total fat
,;>39 mmHg8@,81
/ietar# sodium
reduction
,educe dietar# sodium inta<e to no more than 3==
mmol er da# (8&9 g sodium or 1 g sodium chloride)&
8>; mmHg8@>84
Ph#sical acti"it# Engage in regular aero!ic h#sical acti"it# such as
!ris< (al<ing (at least 3= min er da#, most da#s of
the (ee<)&
9>9 mmHg8;,89
Doderation of
alcohol
consumtion
Limit consumtion to no more than consumtion 8
drin<s (3 o$ or 3= mL ethanol7 e&g&, 89 o$ !eer, 3= o$
(ine, or 3 o$ ;=5roof (his<e#) er da# in most men
and to no more than 3 drin< er da# in (omen and
lighter (eight ersons&
8>9 mmHg3=
Note 6
/%)H, /ietar# %roaches to )to H#ertension&
C For o"erall cardio"ascular ris< reduction, sto smo<ing&
I 0he effects of imlementing these modifications are dose and time deendent, and could
!e greater for some indi"iduals&
of multidrug regimens, can !e useful in achie"ing BP control, and are more afforda!le than
other antih#ertensi"e agents& /esite these findings, diuretics remain underutili$ed&
0hia$ide5t#e diuretics should !e used as initial thera# for most atients (ith
h#ertension, either alone or in com!ination (ith one of the other classes (%.EIs, %,Bs,
BBs, ..Bs) demonstrated to !e !eneficial in randomi$ed controlled outcome trials& If a
drug is not tolerated or is contraindicated, then one of the other classes ro"en to reduce
cardio"ascular e"ents should !e used instead&
T#$%& 6 O2#% #-+(6@1&2+&-'(=& .230':
!%#'' D230 (T2#.& N#/&) U'3#% .,'&
2#-0& (/0C.#@)
U'3#% D#(%@
F2&D
0hia$ide diuretics .hlorothia$ide (/iuril)
chlorthalidone (generic)
h#drochlorothia$ide (Dicro$ide,
H#dro/IA,ILI)
ol#thia$ide (,enese)
indaamide (Lo$olI)
metola$one (D#<ro+)
metola$one (Raro+ol#n)
38@5@==
38&@58@
38&@5@=
859
3&8@58&@
=&@53&=
8&@5@
358
3
3
3
3
3
3
Loo diuretics !umetanide (Bume+I)
furosemide (Lasi+I)
torsemide (/emade+I)
=&@58
8=5;=
8&@53=
8
8
3
Potassium5
saring diuretics
amiloride (DidamorI)
triamterene (/#renium)
@53=
@=53==
358
358
%ldosterone
recetor !loc<ers
elerenone (Insra)
sironolactone (%ldactoneI)
@=53==
8@5@=
3
3
BBs atenolol (0enorminI)
!eta+olol (SerloneI)
!isorolol (Re!etaI)
metorolol (LoressorI)
metorolol e+tended release (0orol)
nadolol (.orgardI)
roranolol (InderalI)
roranolol long5acting (Inderal L%I)
timolol (BlocadrenI)
8@53==
@58=
8&@53=
@=53==
@=53==
9=538=
9=531=
1=53;=
8=59=
3
3
3
358
3
3
8
3
8
BBs (ith intrin5
sic s#mathomi5
metic acti"it#
ace!utolol ()ectralI)
en!utolol (Le"atol)
indolol (generic)
8==5;==
3=59=
3=59=
8
3
8
.om!ined alha5
and BBs
car"edilol (.oreg) la!etalol
(Normod#ne, 0randateI)
38&@5@=
8==5;==
8
8
%.EIs !ena$eril (LotensinI)
catoril (.aotenI)
enalaril (BasotecI)
fosinoril (Donoril)
lisinoril (Prini"il, RestrilI)
moe+iril (Ani"asc)
erindoril (%ceon)
Luinaril (%ccuril)
ramiril (%ltace)
trandolaril (Da"i<)
3=59=
8@53==
@59=
3=59=
3=59=
4&@53=
95;
3=5;=
8&@58=
359
3
8
358
3
3
3
3
3
3
3
Note 6
C In some atients treated once dail#, the antih#ertensi"e effect ma# diminish to(ard the
end of the dosing inter"al (trough effect)& BP should !e measured just rior to dosing to
determine if satisfactor# BP control is o!tained& %ccordingl#, an increase in dosage or
freLuenc# ma# need to !e considered& 0hese dosages ma# "ar# from those listed in the
*Ph#sicians /es< ,eference, @4th ed&2
I %"aila!le no( or soon to !ecome a"aila!le in generic rearations&
4 A*6(&=(-0 B%,,. P2&''32& !,-+2,% (- I-.(=(.3#% P#+(&-+'
Dost atients (ho are h#ertensi"e (ill reLuire t(o or more antih#ertensi"e
medications to achie"e their BP goals&39,3@ %ddition of a second drug from a different
class should !e initiated (hen use of a single drug in adeLuate doses fails to achie"e the BP
goal& Ehen BP is more than 8=?3= mmHg a!o"e goal, consideration should !e gi"en to
initiating thera# (ith t(o drugs, either as searate rescritions or in fi+ed5dose
com!inations& 0he initiation of drug thera# (ith more than one agent ma# increase the
li<elihood of achie"ing the BP goal in a more timel# fashion, !ut articular caution is
ad"ised in those at ris< for orthostatic h#otension, such as atients (ith dia!etes,
autonomic d#sfunction, and some older ersons& Ase of generic drugs or com!ination drugs
should !e considered to reduce rescrition costs&
5 F,%%,431 #-. M,-(+,2(-0
'nce antih#ertensi"e drug thera# is initiated, most atients should return for
follo(u and adjustment of medications at aro+imatel# monthl# inter"als until the BP
goal is reached& Dore freLuent "isits (ill !e necessar# for atients (ith stage 8 h#er5
tension or (ith comlicating comor!id conditions& )erum otassium and creatinine should
!e monitored at least 3>8 times?#ear& %fter BP is at goal and sta!le, follo(u "isits can
usuall# !e at 35 to 15month inter"als& .omor!idities, such as heart failure, associated
diseases such as dia!etes, and the need for la!orator# tests influence the freLuenc# of "isits&
'ther cardio"ascular ris< factors should !e treated to their resecti"e goals, and to!acco
a"oidance should !e romoted "igorousl#& Lo(5dose asirin thera# should !e considered
onl# (hen BP is controlled, !ecause the ris< of hemorrhagic stro<e is increased in atients
(ith uncontrolled h#ertension&
SPE!IAL !ONSIDERATIONS
0he atient (ith h#ertension and certain comor!idities reLuires secial attention and
follo(u !# the clinician&
1 I'*6&/(* H&#2+ D('&#'&
Ischemic heart disease (IH/) is the most common form of target organ damage
associated (ith h#ertension& In atients (ith h#ertension and sta!le angina ectoris, the
first drug of choice is usuall# a BB7 alternati"el#, long5acting ..Bs can !e used& In atients
(ith acute coronar# s#ndromes (unsta!le angina or m#ocardial infarction), h#ertension
should !e treated initiall# (ith BBs and %.EIs, (ith addition of other drugs as needed for
BP control& In atients (ith ostm#ocardial infarction, %.EIs, BBs, and aldosterone
antagonists ha"e ro"en to !e most !eneficial& Intensi"e liid management and asirin
thera# are also indicated&
2 H&#2+ F#(%32&
Heart failure (HF), in the form of s#stolic or diastolic "entricular d#sfunction,
results rimaril# from s#stolic h#ertension and IH/& Fastidious BP and cholesterol control
are the rimar# re"enti"e measures for those at high ris< for HF& In as#mtomatic
indi"iduals (ith demonstra!le "entricular d#sfunction, %.EIs and BBs are recommended&
For those (ith s#mtomatic "entricular d#sfunction or end5stage heart disease, %.EIs,
BBs, %,Bs and aldosterone !loc<ers are recommended along (ith loo diuretics&
< D(#$&+(* H@1&2+&-'(,-
.om!inations of t(o or more drugs are usuall# needed to achie"e the target goal of
F33=?;= mmHg& 0hia$ide diuretics, BBs, %.EIs, %,Bs, and ..Bs are !eneficial in
reducing .B/ and stro<e incidence in atients (ith dia!etes& %.EI5 or %,B5!ased
treatments fa"ora!l# affect the rogression of dia!etic nehroath# and reduce
al!uminuria, and %,Bs ha"e !een sho(n to reduce rogression to macroal!uminuria&
4 !62,-(* K(.-&@ D('&#'&
In eole (ith chronic <idne# disease (.S/), as defined !# either (3) reduced
e+cretor# function (ith an estimated MF, !elo( 1= ml?min er 3&43 m8 (corresonding
aro+imatel# to a creatinine of Q3&@ mg?dL in men or Q3&3 mg?dL in (omen), or (8) the
resence of al!uminuria (Q3== mg?da# or 8== mg al!umin?g creatinine), theraeutic goals
are to slo( deterioration of renal function and re"ent .B/& H#ertension aears in the
majorit# of these atients, and the# should recei"e aggressi"e BP management, often (ith
three or more drugs to reach target BP "alues of F33=?;= mmHg& %.EIs and %,Bs ha"e
demonstrated fa"ora!le effects on the rogression of dia!etic and nondia!etic renal disease&
% limited rise in serum creatinine of as much as 3@ ercent a!o"e !aseline (ith %.EIs or
%,Bs is acceta!le and is not a reason to (ithhold treatment unless h#er<alemia
de"elos& Eith ad"anced renal disease (estimated MF, F3= ml?min 3&43 m8, corresonding
to a serum creatinine of 8&@>3 mg?dL), increasing doses of loo diuretics are usuall# needed
in com!ination (ith other drug classes&
5 !&2&$2,=#'*3%#2 D('&#'&
0he ris<s and !enefits of acute lo(ering of BP during an acute stro<e are still
unclear7 control of BP at intermediate le"els (aro+imatel# 31=?3== mmHg) is aroriate
until the condition has sta!ili$ed or imro"ed& ,ecurrent stro<e rates are lo(ered !# the
com!ination of an %.EI and thia$ide5t#e diuretic&
OTHER SPE!IAL SITUATIONS
1 M(-,2(+(&'
BP control rates "ar# in minorit# oulations and are lo(est in De+ican
%mericans and Nati"e %mericans& In general, the treatment of h#ertension is similar for
all demograhic grous, !ut socioeconomic factors and lifest#le ma# !e imortant
!arriers to BP control in some minorit# atients& 0he re"alence, se"erit#, and imact of
h#ertension are increased in %frican %mericans, (ho also demonstrate some(hat
reduced BP resonses to monothera# (ith BBs, %.EIs, or %,Bs comared to diuretics
or ..Bs& 0hese differential resonses are largel# eliminated !# drug com!inations that
include adeLuate doses of a diuretic& %.EI5induced angioedema occurs 8>9 times more
freLuentl# in %frican %merican atients (ith h#ertension than in other grous&
2 O$&'(+@ #-. +6& /&+#$,%(* '@-.2,/&
'!esit# (BDI Q3= <g?m8) is an increasingl# re"alent ris< factor for the
de"eloment of h#ertension and .B/& 0he %dult 0reatment Panel III guideline for
cholesterol management defines the meta!olic s#ndrome as the resence of three or
more of the follo(ing conditions6 a!dominal o!esit# ((aist circumference Q9= inches in
men or Q3@ inches in (omen), glucose intolerance (fasting glucose Q33= mg?dL), BP
Q33=?;@ mmHg, high trigl#cerides (Q3@= mg?dL), or lo( H/L (F9= mg?dL in men or
F@= mg?dL in (omen)& Intensi"e lifest#le modification should !e ursued in all
indi"iduals (ith the meta!olic s#ndrome, and aroriate drug thera# should !e
instituted for each of its comonents as indicated&
< L&)+ =&-+2(*3%#2 6@1&2+2,16@
Left "entricular h#ertroh# (LBH) is an indeendent ris< factor that increases
the ris< of su!seLuent .B/& ,egression of LBH occurs (ith aggressi"e BP
management, including (eight loss, sodium restriction, and treatment (ith all classes of
antih#ertensi"e agents e+cet the direct "asodilators h#drala$ine, and mino+idil&
4 P&2(16&2#% #2+&2(#% .('&#'&
Periheral arterial disease (P%/) is eLui"alent in ris< to IH/& %n# class of anti5
h#ertensi"e drugs can !e used in most P%/ atients& 'ther ris< factors should !e
managed aggressi"el#, and asirin should !e used&
5 H@1&2+&-'(,- (- ,%.&2 1&2',-'
H#ertension occurs in more than t(o5thirds of indi"iduals after age 1@& 0his is
also the oulation (ith the lo(est rates of BP control& 0reatment recommendations for
older eole (ith h#ertension, including those (ho ha"e isolated s#stolic h#ertension,
should follo( the same rinciles outlined for the general care of h#ertension& In man#
indi"iduals, lo(er initial drug doses ma# !e indicated to a"oid s#mtoms7 ho(e"er,
standard doses and multile drugs are needed in the majorit# of older eole to reach
aroriate BP targets&
6 P,'+32#% 6@1,+&-'(,-
% decrease in standing )BP Q3= mmHg, (hen associated (ith di$$iness or faint5
ing, is more freLuent in older atients (ith s#stolic h#ertension, dia!etes, and those
ta<ing diuretics, "enodilators (e&g&, nitrates, alha5!loc<ers, and sildenafilli<e drugs),
and some s#chotroic drugs& BP in these indi"iduals should also !e monitored in the
uright osition& .aution should !e used to a"oid "olume deletion and e+cessi"el#
raid dose titration of antih#ertensi"e drugs&
9 D&/&-+(#
/ementia and cogniti"e imairment occur more commonl# in eole (ith
h#ertension& ,educed rogression of cogniti"e imairment ma# occur (ith effecti"e
antih#ertensi"e thera#&
7 H@1&2+&-'(,- (- 4,/&-
'ral contraceti"es ma# increase BP, and the ris< of h#ertension increase (ith
duration of use& Eomen ta<ing oral contraceti"es should ha"e their BP chec<ed
regularl#& /e"eloment of h#ertension is a reason to consider other forms of
contracetion& In contrast, menoausal hormone thera# does not raise BP&
Eomen (ith h#ertension (ho !ecome regnant should !e follo(ed carefull#
!ecause of increased ris<s to mother and fetus& Deth#ldoa, BBs, and "asodilators are
referred medications for the safet# of the fetus& %.EI and %,Bs should not !e used
during regnanc# !ecause of the otential for fetal defects and should !e a"oided in
(omen (ho are li<el# to !ecome regnant& Preeclamsia, (hich occurs after the 8=th
(ee< of regnanc#, is characteri$ed !# ne(5onset or (orsening h#ertension,
al!uminuria, and h#eruricemia, sometimes (ith coagulation a!normalities& In some
atients, reeclamsia ma# de"elo into a h#ertensi"e urgenc# or emergenc# and ma#
reLuire hositali$ation, intensi"e monitoring, earl# fetal deli"er#, and arenteral
antih#ertensi"e and anticon"ulsant thera#&
E H@1&2+&-'(,- (- *6(%.2&- #-. #.,%&'*&-+'
In children and adolescents, h#ertension is defined as BP that is, on reeated
measurement, at the 9@th ercentile or greater adjusted for age, height, and gender& 0he
fifth Sorot<off sound is used to define /BP& .linicians should !e alert to the ossi!ilit#
of identifia!le causes of h#ertension in #ounger children (i&e&, <idne# disease,
coarctation of the aorta)& Lifest#le inter"entions are strongl# recommended, (ith
harmacologic thera# instituted for higher le"els of BP or if there is insufficient
resonse to lifest#le modifications& .hoices of antih#ertensi"e drugs are similar in
children and adults, !ut effecti"e doses for children are often smaller and should !e
adjusted carefull#& %.EIs and %,Bs should not !e used in regnant or se+uall# acti"e
girls& Ancomlicated h#ertension should not !e a reason to restrict children from
articiating in h#sical acti"ities, articularl# !ecause long5term e+ercise ma# lo(er
BP& Ase of ana!olic steroids should !e strongl# discouraged& Bigorous inter"entions also
should !e conducted for other e+isting modifia!le ris< factors (e&g&, smo<ing)&
10 H@1&2+&-'(=& 320&-*(&' #-. &/&20&-*(&'
Patients (ith mar<ed BP ele"ations and acute target5organ damage (e&g&,
encehaloath#, m#ocardial infarction, unsta!le angina, ulmonar# edema, eclamsia,
stro<e, head trauma, life5threatening arterial !leeding, or aortic dissection) reLuire
hositali$ation and arenteral drug thera#& Patients (ith mar<edl# ele"ated BP !ut
(ithout acute target organ damage usuall# do not reLuire hositali$ation, !ut the# should
recei"e immediate com!ination oral antih#ertensi"e thera#& 0he# should !e carefull#
e"aluated and monitored for h#ertension5induced heart and <idne# damage and for
identifia!le causes of h#ertension& ()ee ta!le 9&)
ADDITIONAL !ONSIDERATIONS IN ANTIHYPERTENSI"E DRUG !HOI!ES
%ntih#ertensi"e drugs can ha"e fa"ora!le or unfa"ora!le effects on other comor!idities&
1 P,+&-+(#% )#=,2#$%& &))&*+'
0hia$ide5t#e diuretics are useful in slo(ing deminerali$ation in osteoorosis&
BBs can !e useful in the treatment of atrial tach#arrh#thmias?fi!rillation, migraine,
th#roto+icosis (short term), essential tremor, or erioerati"e h#ertension& ..Bs ma#
!e useful in ,a#naud:s s#ndrome and certain arrh#thmias, and alha5!loc<ers ma# !e
useful in rostatism&
2 P,+&-+(#% 3-)#=,2#$%& &))&*+'
0hia$ide diuretics should !e used cautiousl# in atients (ho ha"e gout or (ho
ha"e a histor# of significant h#onatremia& BBs should generall# !e a"oided in
indi"iduals (ho ha"e asthma, reacti"e air(a#s disease, or second or third degree heart
!loc<& %.EIs and %,Bs should not !e gi"en to (omen li<el# to !ecome regnant and
are contraindicated in those (ho are& %.EIs should not !e used in indi"iduals (ith a
histor# of angioedema& %ldosterone antagonists and otassium5saring diuretics can
cause h#er<alemia and should generall# !e a"oided in atients (ho ha"e serum
otassium "alues more than @&= mEL?L (hile not ta<ing medications&
IMPRO"ING HYPERTENSION !ONTROL
1 A.6&2&-*& +, R&0(/&-'
Beha"ioral models suggest that the most effecti"e thera# rescri!ed !# the most
careful clinician (ill control h#ertension onl# if the atient is moti"ated to ta<e the
rescri!ed medication and to esta!lish and maintain a health5romoting lifest#le&
Doti"ation imro"es (hen atients ha"e ositi"e e+eriences (ith and trust in their
clinicians& Emath# !oth !uilds trust and is a otent moti"ator&
Patient attitudes are greatl# influenced !# cultural differences, !eliefs, and
re"ious e+eriences (ith the health care s#stem& 0hese attitudes must !e understood if
the clinician is to !uild trust and increase communication (ith atients and families&
Failure to titrate or com!ine medications, desite <no(ing the atient is not at
goal BP, reresents clinical inertia and must !e o"ercome& /ecision suort s#stems
(i&e&, electronic and aer), flo( sheets, feed!ac< reminders, and in"ol"ement of nurse
clinicians and harmacists can !e helful&
0he clinician and the atient must agree uon BP goals& % atient5centered
strateg# to achie"e the goal and an estimation of the time needed to reach goal are
imortant& Ehen BP is a!o"e goal, alterations in the lan should !e documented& BP
self5monitoring can also !e useful&
Patients: nonadherence to thera# is increased !# misunderstanding of the
condition or treatment, denial of illness !ecause of lac< of s#mtoms or ercetion of
drugs as s#m!ols of ill health, lac< of atient in"ol"ement in the care lan, or
une+ected ad"erse effects of medications& 0he atient should !e made to feel
comforta!le in telling the clinician all concerns and fears of une+ected or distur!ing
drug reactions&
0he cost of medications and the comle+it# of care (i&e&, transortation, atient
difficult# (ith ol#harmac#, difficult# in scheduling aointments, and life:s comet5
ing demands) are additional !arriers that must !e o"ercome to achie"e goal BP&
%ll mem!ers of the health care team (e&g&, h#sicians, nurse case managers, and
other nurses, h#sician assistants, harmacists, dentists, registered dietitians,
otometrists, and odiatrists) must (or< together to influence and reinforce instructions
to imro"e atients: lifest#les and BP control&
2 R&'('+#-+ H@1&2+&-'(,-
,esistant h#ertension is the failure to reach goal BP in atients (ho are
adhering to full doses of an aroriate three5drug regimen that includes a diuretic& %fter
e+cluding otential identifia!le h#ertension (see ta!le 9), clinicians should carefull#
e+lore reasons (h# the atient is not at goal BP& Particular attention should !e aid to
diuretic t#e and dose in relation to renal function& ()ee *.hronic Sidne# /isease2
section&) .onsultation (ith a h#ertension secialist should !e considered if goal BP
cannot !e achie"ed&