ash ish-guidelines 2013

8/18/2019 ASH ISH-Guidelines 2013

1/69

A S H P A P E R

ClinicalPracticeGuidelines for

theManagement ofHypertension intheCommunity

AStatement by the American Societyof

Hypertension andtheInternationalSocietyofHyperten

sion

Michael A. eber!

M"#$ Ernesto %.

Schiffrin! M"#&

illiam '. hite!

M"#( Samuel

Mann! M"#) %ars

H. %indholm! M"#*

+ohn G.

,enerson! M"#-

+ohn M. lac/!

M"#0 'arry %.

Carter! Pharm "#1

'arry +. Materson!


2/69

M"#2 C. 3en/ata

S. Ram! M"#$4

"ebbie %. Cohen!

M"#$$

+ean5

Claude Cadet!

M"#$&

Roger R.

+ean5Charles!

M"#$(

Sandra

6aler! M"#$)

"a7id

,ount8! M"#$*

Raymond R.6o9nsend! M"#

$-

+ohn Chalmers!

M"#$0

Agustin +.

Ramire8! M"#$1

George %. 'a/ris!

M"#$2

+iguang

ang! M"#&4

Aletta E. Schutte!

M"#&$

+ohn ".

'isognano! M"#&&

Rhian M. 6ouy8!

M"#

&(

"ominicSica! M"#

&)

Stephen '.

Harrap! M"&*

State :ni7ersity of;e9


3/69

"epartment ofMedicine! :ni7ersityof Pennsyl7aniaSchool of Medicine!

Philadelphia! PA#$$

State :ni7ersitySchool of Medicine!Port Au Prince!

Haiti#$&

Hypertension

Center of Haiti! Port

Au Prince! Haiti#$(

"epartment ofMedicine! MayoClinic! Rochester!

M;#$)

+ersey Shore

:ni7ersity MedicalCenter! ;eptune!

;+#$*

Hypertension

Center! :ni7ersity ofPennsyl7ania!

Philadelphia! PA#$-

George Institute forGlobal Health!:ni7ersity of Sydney!Sydney! ;S!

Australia#$0

Arterial

Hypertension andMetabolic :nit!

:ni7ersity Hospital!a7alorooundation! 'uenos

Aires! Argentina#$1

ASH Comprehensi7eHypertensionCenter! :ni7ersity ofChicago Medicine!

Chicago! I%#$2

6he

Shanghai Institute of Hypertension!Shanghai +iaotong:ni7ersity School ofMedicine! Shanghai!

China#&4

Hypertension in Africa Research6eam! ;orth est:ni7ersity!Potchefstroom!

South Africa#&$

"epartment ofMedicine! :ni7ersityof RochesterMedical Center!

Rochester! ;


4/69

have

been

writte

n to

provi

de a

straig

ht-

forwa

rd

approach

to

mana

ging

hyper

tensi

on in

the

com

munit

y. We

have

inten

ded

that

this

brief

curric

ulum

and

set of

reco

mme

ndati

ons be

usefu

l not

only

for

prima

ry

care

physi

cians

and

medi

cal

stude

nts,

but

for

all

profe

ssion

als

who

work

as

hands-on

practi

tioner

s.

We

are

awar

e that

there

is

great

varia bility

in

acces

s to

medi

cal

care

amon

g

com

munit

ies.Even

in so-

calle

d

wealt

hy

count

ries

there

are

sizabl

e

communit

ies in

whic

h

econ

omic,

logist

ic,

and

geogr

aphic

issues put

const

raints

on

medi

cal

care.

And,

at the

same

time,

we

areremin

ded


5/69

that

even

in

count

ries

with

highl

y

limite

d

resources,

medi

cal

leade

rs

have

assig

ned

the

highe

st

priori

ty to

supp

ortin

g

their

colle

agues

in

confr

ontin

g the

growi

ngtoll

of

devas

tating

strok

es,

cardi

ovasc

ular

event

s, and

kidne

y

failur

e

cause

d by

hyper

tensi

on.

ur

goal

has

beento

give

suffic

ient

infor

matio

n to

enabl

e

healt

h

care

practitioner

s,

wher

ever

they

are

locat

ed, to

provi

de

profe

ssion

al

care

for

peopl

e

with

hyper

tensi

on.

All

the

same,

werecog

nize

that it

will

often

not

be

possi

ble to

carry

out

all of

our

sugge

stions

for

clinic

al

evalu

ation,

tests,

and

thera

pies.

!ndeed,

there


6/69

are

situat

ions

wher

e the

most

simpl

e and

empir

-ical

carefor

hyper

tensi

on>simpl

y

distri

butin

g

Address forcorrespondence?Michael A.eber!M"!"i7ision ofCardio7ascularMedicine!State:ni7er

sity of;e9

is

better

than

doing

nothi

ng at

all.

We

hope

that

we

have

allow

ed

suffic

ient

fle"ib

ility

in

this

state

mentto

enabl

e

respo

nsibl

e

clini-

cians

to

devis

e

work

able

plans

for

provi

ding

the

best

possi

ble

care

for

patie

ntswith

hyper


7/69

tensi

on in

their

com

munit

ies.

We

have

divid

edthis

brief

docu

ment

into

the

follo

w-ing

sectio

ns#

!ntroducti

on

Epide

miolo

gy$peci

al

!ssues

With

%lack

&atie

nts

'African

Ance

stry(

)ow

is

)ype

rtensi

on

*efin

ed+

)ow

is

)ype

rtensi

on

lass

ified+

aus

es of

)ype

rtensi

on

aki

ng

the*iag

nosis

of

)ype

rtensi

on

Evalu

ating

the

&atie

nt

&hysi

calE"am

inatio

n

Tests

oals

of

Treati

ng

)ype

rtensi

on

/onp

harm

acolo

gic

Treat

ment

of

)ype

rtensi

on

*rug

treat

ment

for)ype

rtensi

on

%rief

om

ment

s on

*rug

lass

es

Treat

ment-

0esis

tant

)ype

rtensi

on

I;6R=":C6I=;

Abou

t one


8/69

third

of

adult

s in

most

com

munit

ies in

the

devel

opedand

devel

oping

world

have

hyper

tensi

on.

)ype

rtensi

on is

the

most

com

mon

chron

ic

condi

tion

dealt

with

by prima

ry

care

physi

cians

and

other

healt

h

practi

tioner

s.

=fficial +ournal of the American Society ofHypertension! Inc.

6he +ournal

of Clinical Hypertension

$

ASHBISHHypertensionGuidelines Deberet al.

ost

patie

nts

with

hyper

tensi

on

have

other

riskfactor

s as

well,

inclu

ding

lipid

abnor

maliti

es,

gluco

se

intole

rance

, or

diabe

tes1 a

famil

y

histor

y of

early

car-

diova

scula

r

event

s1

obesi

ty1

and

cigar

ette

smok ing.

The

succe

ss of

treati

ng

hyper

tensi

on

has

been

lim-

ited,

and


9/69

despi

te

well-

establ

ished

appro

aches

to

diagn

osis

andtreat

ment,

in

many

com

munit

ies

fewer

than

half

of all

hyper

tensi

ve

patie

nts

have

ade2

uatel

y

contr

olled

blood

press

ure.

EPI"EMI=%=G<

There

is a

close

relati

onshi

p

betw

een

blood

press

ure

levels

and

the

risk

of

cardiovasc

ular

event

s,

strok

es,

and

kidne

y

disea

se.

The

risk

of

these

outco

mes

is

lowes

t at a

blood

press

ure of aroun

d

33456

4 mm

)g

Abov

e

33456

4 mm

)g,

foreach

incre

ase of

78

mm

)g in

systol

ic

blood

press

ure or

38

mm)g in

diast

olic

blood

press

ure,

the

risk

of

ma9or

cardi

o-

vascu


10/69

lar

and

strok

e

event

s

doubl

es.

The

high preva

lence

of

hyper

tensi

on in

the

com

mu-

nity

is

currently

being

drive

n by

two

phen

omen

a# the

incre

ased

age

of

our popul

ation

and

the

growi

ng

preva

lence

of

obesi

ty,

which is

seen

in

devel

oping

as

well

as

devel

oped

count

ries.

!nmany

com

munit

ies,

high

dietar

y salt

intak

e is

also a

ma9or

factor .

The

main

risk

of

event

s is

tied

to an

incre

asedsystol

ic

blood

press

ure1

after

age

48 or

:8

years,

diast

olic

blood

press

ure

may

actua

lly

start

to

decre

ase,

but

systol

ic press

ure

conti

nues

to

rise

throu

ghout

life.

This

incre

ase in

systol

ic

blood


11/69

press

ure

and

decre

ase in

diast

olic

blood

press

ure

withaging

reflec

ts the

pro-

gressi

ve

stiffe

ning

of the

arteri

al

circul

ation.

The

reaso

n for

this

effect

of

aging

is not

well

under

stood

, buthigh

systol

ic

blood

press

ures

in

older

peopl

e

repre

sent a

ma9or

risk

factor

for

cardi

ovasc

ular

and

strok

e

event

s and

kidney

disea

se

progr

essio

n.

SPECIA%ISS

:ESI6H'%AC,PA6IE;6SARIC A; A;C

ES6R


12/69

nts

than

in

white

s.

A

highe

r

propo

rtionof

black

peopl

e are

sensit

ive to

the

blood

press

ure raisin

geffect

s of

salt

in the

diet

than

white

patie

nts,

and

this

>

together

with

obesi

ty,

espec

ially

amon

g

wom

en>may

be part

of the

e"pla

natio

n for

why

youn

g

black

peopl

e

tend

tohave

earlie

r and

more

sever

e

hyper

tensi

on

than

other

groups.

%lack

patie

nts

with

hyper

tensi

on

are

partic

ularlyvulne

rable

to

strok

es

and

hyper

tensi

ve

kidne

y dis-

ease.

They

are ;

to 4

times

as

likely

as

white

s to

have

renal

complicati

ons

and

end-

stage

kidne

y

disea

se.

There

is a

tendency

for

black


13/69

patie

nts to

have

differ

ing

blood

press

ure

respo

nsesto the

avail

able

antih

ypert

ensiv

e

drug

class

es#

they

usually

respo

nd

well

to

treat

ment

withcalci

um

chan

nel

block

ers

and

diuret

ics

but

have

small

er

blood

press

ure

reduc

tions

with

angio

tensi

n-

conv

erting

enzyme

inhibi

tors,

angio

tensi

n

recep

tor

block

ers,

and

b-

block ers.

)ow-

ever,

appro

priate

comb

inatio

n

thera

pies

provi

de

powe

rful

antih

ypert

ensiv

e

respo

nses

that

are

simil

ar in

black and

white

patie

nts.

ost

patie

nts

will

re2ui

re

more

than

one

antih

ypert

ensiv

e

drug

to

maint

ain

blood

press

ure

contr ol.


14/69

H=ISH


15/69

press

ure to

levels

belo

w the

numb

ers

used

for

making

the

diagn

osis.

Thes

e

defini

tions

are

based

onthe

result

s of

ma9or

clinic

al

trials

that

have

show

n the

benef

its of

treati

ng

peopl

e to

these

levels

of

blood

press

ure.

Even

though a

blood

press

ure of

33456

4 mm

)g is

ideal,

as

discu

ssed

earlie

r,

there

is no

evide

nce

to

9ustif

y

treati

ng

hyper

-

tension

down

to

such

a low

level.

We

do

not

have

sufficient

infor

matio

n

about

youn

ger

adult

s

'betw

een

3?

and

44

years

( to

know

whet

her

they

might

benef

it

from

defining

hyper

tensi

on at

a

level

@3=85

>8

mm)

g 'eg,

3;85?

8 mm

)g(

and

treati


16/69

ng

them

more

aggre

ssivel

y

than

older

adult

s.

Thus,guide

lines

tend

to use

3=85>

8 mm

)g

for

all

adult

s 'up

to ?8

years

(.

Even

so, at

a

practi

tioner

8

mm

)g.

H=ISH


17/69

or

patie

nts

with

systol

ic

blood

press

ure

between

378

mm

)g

and

3;>

mm

)g,

or

diast

olic

pressures

betw

een

?8

and

?>

mm

)g,

the

term

prehy

perte

n-sion

can

be

used.

&atie

nts

with

this

condi

tion

shoul

d not be

treate

d

with

blood

press

ure

medi

catio

ns1

howe

ver,

they

shoul

d be

enco

urage

d to

make

lifestyle

chan

ges in

the

hope

of

delay

ing or

even

preve

nting progr

essio

n to

hyper

tensi

on.

$tage

3

hyper

tensi

on#

patie

nts

with

systol

ic

blood

press

ure

3=8

to

34>

mm

)g or diast

olic

blood

press

ure

>8 to

>>

mm

)g.

& 6he +ournalof Clinical Hypertension

=fficial

+ournal of the AmericanSociety of Hypertension!Inc.


18/69

$tage

7

hyper

tensi

on#

systol

ic blood

press

ure

3:8mm

)g or

diast

olic

blood

press

ure 388

mm )g.

CA:SES=H

4B

of

adult

s

with

high

blood

press

ure

have

prima

ry

hyper

tensi

on

'som

etime

s

called

essen

tial

hyper

tensi

on(.

The

cause

of

prima

ry

hyper

tensi

on is

not

know

n,

altho

ugh

genet

ic

and

envir onme

ntal

factor

s that

affect

blood

press

ure

regul

ation

arenow

being

studi

ed.

Envir

onme

ntal

factor

s

inclu

de

e"cess

intak

e of

salt,

obesi

ty,

and

perha

ps

seden

tary

lifestyle.


19/69

$ome

genet

ically

relate

d

factor

s

could

inclu

de

inap- propr

iately

high

activi

ty of

the

renin

-

angio

tensi

n-

aldos

teron

e

syste

m

and

the

symp

atheti

c

nervo

us

syste

mand

susce

ptibil

ity to

the

effect

s of

dietar

y salt

on

blood press

ure.

Anot

her

com

mon

cause

of

hyper

tensi

on is

stiffe

ning

of the

aorta

with

incre

asing

age.

This

cause

s

hyper

-

tension

referr

ed to

as

isolat

ed or

predo

mina

nt

systol

ic

hyper

tensi

on

chara

cteriz

ed by

high

systol

ic

press

ures

'ofte

n

withnorm

al

diast

olic

press

ures(,

whic

h are

found

prima

rily

in

elderl

y

peopl

e.

Secondar yHypertension

This

pertai

ns to


20/69

the

relati

vely

small

numb

er of

cases,

about

4B

of all

hyper tensi

on,

wher

e the

cause

of the

high

blood

press

ure

can

be

identi

fied

and

some

times

treate

d.

The

main

types

of

secon

dary

hyper

tensi

on

are

chron

ic

kidne

y

disea

se,renal

artery

steno

sis,

e"ces

-sive

aldos

teron

e

secret

ion,

pheo

chro

mocy

toma,

and

sleep

apnea

.

A

simpl

e

scree

ning

appro

ach

for

identi

fying

secon

d-ary

hyper

tensi

on is

given

later.

MA,I;G6HE"IAG;=SIS=H


21/69

mate

d

electr

onic

devic

e.

The

electr

onic

devic

e, ifavail

able,

is

prefe

rred

becau

se it

provi

des

more

repro

ducib

le

result

s than

the

older

meth

od

and is

not

influe

nced

by

variations

in

techn

i2ue

or by

the

bias

of the

obser

vers.

!f the

auscu

ltator

y

meth

od is

used,

the

first

and

fifth

Corot

koff

soun

ds'the

appea

rance

and

disap

peara

nce

of

soun

ds(

will

cor-

respo

nd to

the

systol

ic

and

diast

olic

blood

press

ures.

Armcuffs

are

prefe

rred.

uffs

that

fit on

the

finge

r or

wrist

are

ofteninacc

urate

and

shoul

d, in

gener

al,

not

be

used.

!t is

impo

rtant

to

ensur

e that

the

corre

ct

size

of the

armcuff

is

used


22/69

'in

partic

ular,

a

wider

cuff

in

patie

nts

withlarge

arms

D;7

cm

circu

mfere

nceF(.

At

the

initial

evalu

ation, blood

press

ure

shoul

d be

meas

ured

in

both

arms1

if the

readi

ngs

are

differ

ent,


the

armwith

the

highe

r

readi

ng

shoul

d be

used

for

meas

urements

there

after.

The

blood

press

ure

shoul

d be

taken

after

patie

nts

have

empti

ed

their

bladd

ers.

&atie

nts

shoul

d be

seated

with

their

backs

supp

orted

and

with

their

legs

restin

g on

the

groun

d and


23/69

in the

uncro

ssed

positi

on

for 4

minut

es.

The

patie

nt


24/69

after

the

first

meas

urem

ent.

n

both

occa-

sions,

thesystol

ic

blood

press

ure

shoul

d be3=8mm

)g or

the

diast

olic

press

ure

>8mm)

g, or

both,

in

order

to

make

a

diagnosis

of

hyper

tensi

on.

!f the

blood

press

ure is

very

high'for

insta

nce, a

systol

ic

blood

press

ure

3?8mm

)g(,

or if

available

resou

rces

are

not

ade2

uate

to

permi

t a

conv

enien

tsecon

d

visit,

the

diagn

osis

and,

if

appro

priate

,

treat

ment

can

be

starte

d

after

the

first

set of

readi

ngs

thatdemo

nstrat

e

hyper

tensi

on.

or

practi

tioner

s and

theirstaff

not

e"per

ience

d in

meas

uring

blood

press

ures,

it is

neces

sary

to

recei


25/69

ve

appro

priate

traini

ng in

perfo

rmin

g this

impo

rtant

techn

i2ue.

$ome

patie

nts

may

have

blood

press

ures

thatare

high

in the

clinic

or

office

but

are

norm

al

elsew

here.

This

is

often

calle

d

white

-coat

hyper

tensi

on. !f

it is

suspe

cted,consi

der

gettin

g

home

blood

press

ure

readi

ngs

'see

belo

w( to

check

this

possi

bility.

Anot

her

appro

ach is

to use

ambu

latory

blood

pressure

monit

oring,

if it is

avail

able.

!n

this

proce

dure,

the

patie

nt

wears

an

arm

cuff

conn

ected

to a

devic

e that

auto

matic

allymea-

sures

and

recor

ds

blood

press

ures

at

regul

ar

interv

als

usual

ly

over

a 7=-

hour

perio

d.

!t can

be

helpf

ul to

meas


26/69

ure

blood

press

ures

at

home

. !f

avail

able,

the

electr onic

devic

e is

simpl

er to

use

and is

proba

bly

more

reliab

le

than

the

sphy

gmo

ma-

nome

ter.

The

avera

ge of

blood

press

uresmeas

ured

over

4 to 6

days,

if

possi

ble in

dupli

cate

at

each

meas

urem

ent,

can

be a

usefu

l

guide

for

diagn

ostic

and

treatment

decisi

ons.

E3A%:A6I;G6HEPA6I

E;6

ften

, high

blood

press

ure is

only

one

of

sever

al

cardiovasc

ular

risk

factor

s that

re2ui

re

attent

ion.

%efor

e

starti

ng

treat

ment

for

hyper

tensi

on, it

is

usefu

l to

evalu

atethe

patie

nt

more

thoro

ughly

. The

three

meth

ods

are

perso

nal

histor

y,


27/69

physi

cal

e"am

-

inatio

n.

and

select

ive

testin

g.


6he +ournal


(


History

Ask

about

previ

ous

cardi

ovasc

ular

event

s

because

they

often

sugge

st an

incre

ased

proba

bility

of

futur

e

events that

can

influe

nce

the

choic

e of

drugs

for

treati

ng

hyper tensi

on

and

will

also

re2ui

re

more

aggre

ssive

treat

ment

of allcardi

ovasc

ular

risk

factor

s.

Also

ask

patie

nts if

they

have

previously

been

told

that

they

have

hyper

tensi

on

and,

if

relevant,

their

respo

nses

to

any

drugs

they

might

have

been

given

.

!mpo


28/69

rtant

previ

ous

event

s

inclu

de.

$trok

e or

transi

entische

mic

attac

ks or

deme

ntia.

hyisthisinfor

mationimportant or

patie

nts with

these

previ

ous

event

s, it

may be

neces

sary

to

inclu

de

partic

ular

drug

types

in

theirtreat

ment,

for

insta

nce

angio

tensi

n

recep

tor

block

ers or

angioten-

sin-

conv

erting

enzy

me

inhibi

tors,

calci

um

chan

nel

block ers,

and

diuret

ics,

as

well

as

drugs

for

low-

densi

ty

lipop

rotein

'G*G

(

chole

sterol

'stati

ns(

and

antipl

atelet

drugs

.

oro

nary

artery

disea

se,

inclu

ding

myoc

ardial

infarc

tions,angin

a

pecto

ris,

and

coron

ary

revas

cu-

lariza

tions.

hyisthis


29/69

important erta

in

medi-

catio

ns

woul

d be

preferred,

for

insta

nce

b- block

ers,

angio

tensi

n-

conv

erting

enzy

me

inhibi

tors

or

angio

-

tensi

n

recep

tor

block ers,

statin

s, and

antipl

atelet

agent

s

'aspir

in(.

)eart

failur e or

symp

toms

sugge

sting

left

ventri

c-ular

dysfu

nctio

n

'short

ness

of

breat

h,

edem

a(.hy isthisimportanterta

inmedi

catio

ns

woul

d be prefe

rred

in

such

patie

nts,

inclu

ding

angio

tensi

n

recep

tor

block

ers or

angio

tensi

n-

conv

ertingenzy

me

inhibi

tors,

b- block

ers,

diuret

ics,

and

spironolac

-tone.

Also,

certai

n

medi

catio

ns

shoul

d be

avoid

ed,

suchas

nondi


30/69

hydro

pyrid

ine

calci

um

chan

nel

block

-

ers'vera

pamil

,

diltia

zem(,

in

patie

nts

with

systol

ic

heartfailur

e.

!H.

hro

nic

kidne

y

disea

se.

hyisthisimportant erta

in

medi

catio

ns

woul

d be

prefe

rred,inclu

ding

angio

tensi

n-

conv

erting

enzy

me

inhibi

tors

or

angio

-

tensi

n

recep

tor

block

ers

'altho

ugh

these

two

drug

classes

shoul

d not

be

presc

ribed

in

comb

inatio

n

with

each

other

(,

statin

s, and

diuret

ics

'loop

diuret

-ics

may

be

re2ui

red if the

estim

ated

glom

erular

filtrat

ion

rate

is

belo

w ;8(

and

blood

press

ure

treat

ment

target

s

might

be

lower

'3;85

?8

mm)g(

if


31/69

albu

minu

ria is

prese

nt.

/ote#

!n

patie

nts

with

moreadva

nced

kidne

y

disea

se,

the

use

of

some

of

these

drugs

often

re2ui

res

the

e"per

tise

of a

nephr

ologi

st.

&eripheral

artery

disea

se.

hyisthisimportant This

finding

sugge

sts

adva

nced

arteri

al

disea

se

that

may

also

e"istin the

coron

ary or

brain

circul

ation

s,

even

in the

absen

ce of

clinic

alhistor

y. !t

is

vital

that

smok

ing

be

disco

ntinu

ed. !n

most

cases,

antipl

atelet

drugs

shoul

d be

used.

H!.

*iab

etes.

hy

isthisimportant+

This

condi

tion

is

com

monl

y

associated

with

hyper

tensi

on

and

an

incre

ased

risk

of

cardi

ovascular

event


32/69

s.

erta

in

medi

catio

ns

such

as

angio

tensi

nrecep

tor

block

ers

and

angio

tensi

n-conv

erting

enzy

me

inhibi

tors

shoul

d be

used,

partic

ularly

ifthere

is

evide

nce

of

albu

minu

ria or

chron

ic

kidne

y

disease.

ood

blood

press

ure

contr

ol,

often

re2ui

ring

the

addition of

calci

um

chan

nel

block

ers

and

diuret

ics, is

also

impo

rtantin

these

patie

nts.

H!!.

$leep

apnea

.

hyis

thisimportant+

$peci

al

treat-

ment

s are

often

re2ui

red

for

these patie

nts

and

their

use

may

make

it

possi

ble to

impr

ove blood

press

ure

contr

ol as

well

as

other

findi

ngs

of

this

condition.


33/69

Ask

about

other

risk

factor

s.hyisthisimpo

rtant 0isk

factor

s can

affect

blood

press

ure

target

s and

treat

ment

select

ion

for

the

hyper

tensi

on.

Thus,

know

ing

about

age,

dysli pide

mia,

micro

albu

minu

-ria,

gout,

or

famil

y

histor

y of

hyper

tensi

on

and

diabe

tes

can

be

valua

ble.

igar

ette

smok ing is

a risk

factor

that

must

be

identi

fied

so

that

couns

eling

can

be

given

about

stopp

ing

this

dang

erous

habit.

Askabout

conc

urren

t

drugs

.

om

monl

y

used

drugs

'for

indic

ation

s

unrel

ated

to

treati

ng

hyper

tensi

on(

can

increase

blood

press

ure

and

theref

ore

shoul

d be

stopp

ed if

possi

ble.

Thes

e


34/69

inclu

de

nonst

eroid

al

anti-

infla

mmat

ory

drugs

usedfor

arthri

tis

and

pain

relief,

some

tricyc

lic

and

other

types

of

antid

epres

-

sants,

older

high-

dose

oral

contr

acept

ives,

migraine

medi

catio

ns,

and

cold

reme

dies

'eg,

pseud

oeph

e-

drine

(. !n

additi

on,

some

patie

nts

may

be

takin

g

herba

lmedi

catio

ns,

folk

reme

dies,

or

recre

ation

al

drugs

'eg,

cocaine(,

whic

h can

incre

ase

blood

press

ure.

PH<

SIC A%EJAMI; A6I=;

At

the

first

visit

it is

important

to

perfo

rm a

comp

lete

physi

cal

e"am

inatio

n

because

often

gettin

g

care

for

hyper

tensi

on is

the

only

conta

ctthat

patie


35/69

nts

have

with

a

medi

cal

practi

tioner

.

easuring

blood

press

ure

'disc

ussed

earlie

r(.

*ocu

ment

the patie

nt


36/69

d-ing

strok

e,

parad

o"ica

lly

may

be

highe

r in

lean

hyper

tensi

ve

patie

nts

than

in

obese

patie

nts.

Waist

circu

mfere

nce.hyisthisimportant !nde-

pend

ent of

weig

ht,

this

helps

deter

mine

whet

her a

patie

nt has

the

meta bolic

syndr

ome

or is

at

risk

for

type

7

diabe

tes.

0isk

is

high

when

the

meas

urem

ent

is

387

cm in

menor

??

cm in

wom

en.

$igns

of

heart

failur

e.

hyisthisimportant This

diagn

osis

stron

gly

influe

nces

the

choic

e of

hyper

ten-

sion

thera

py.

Geft

ventri

cular

hyper

trophy can

be

suspe

cted

by

chest

palpa

tion,

and

heart

failur

e can


37/69

) 6he +ournalof Clinical Hypertension

=fficial

+ournal of the AmericanSociety of Hypertension!Inc.

beindic

ated

by

diste

nded

9ugul

ar

veins,

rales

on

chest

e"am

ination, an

enlar

ged

liver,

and

perip

heral

edem

a.

/eur

ologic

e"am

inatio

n.

Why

is this

impo

rtant+

This

may

revea

l

signs

of

previ

ous

strok

e and

affect

treat

ment

select

ion.

Eyes#

!f

possi

ble,

the

optic

fundi

should be

check

ed for

hyper

tensi

ve or

diabe

tic

chan

ges

and

the

areas

aroun

d the

eyes

for

findi

ngs

such

as

"anth

omas.

&ulse

# !t is

impo

rtant

to

check

perip

heral

pulse

rates1

if

theyare

dimin

ished

or

absen

t, this

can

indic

ate

perip

heral

artery

disease.


38/69

6ES6S

%loo

d

samp

le

/ote#

This prefe

rably

shoul

d be

a

fastin

g

samp

le so

that a

fastin

g

bloodgluco

se

level

and

more

accur

ate

lipid

profil

es

can

beobtai

ned.

Elect

rolyte

s.

hyisthisimportant There

is a

speci

al

emph

asis

on

potas

sium#

high

levels

can

suggest

renal

disea

se,

partic

ularly

if

creati

nine

is

eleva

ted.

Gowvalue

s can

sugge

st

aldos

teron

e

e"ces

s. !n

additi

on,

illnes

ses

assoc

iated

with

sever

e

diarr

hea

are

com

mon

in

somecom

munit

ies

and

can

cause

hypo

kale

mia

and

other

electr

olyte

chan

ges.

asti

ng

gluco

se

conce

ntrati

on.

hy

isthisimpo


39/69

r5tant!f

eleva

ted,

this

could

be

indic

ative

of impai

red

gluco

se

tolera

nce,

or, if

suffic

iently

high,

of

diabe

tes. !f

avail

able,

glyca

ted

hemo

globi

n

shoul

d be

meas

ured

tofurth

er

asses

s an

eleva

ted

gluco

se

level

and

help

in

maki

ng a

diagn

osis.

$eru

m

creati

nine

and

blood

urea

nitrogen.

hy

aretheseimportant!ncre

ased

creati

nine

levelsare

usual

ly

indic

ative

of

kidne

y

disea

se1

creati

nine

is

also

used

in

form

ulae

for

e

0.

Whe

n

appro-

priate

, use

form

ulae

desig

ned

for

e

0

calcu

la-tions

in

patie

nts of

Afric

an

ances

try.

!H.

Gipid

s.

hyarethes


40/69

eimportant Eleva

ted

G*G

chole

sterol

or

lowvalue

s of

high-

densi

ty

lipop

rotein

chole

sterol

are

assoc

iated

with

incre

ased

cardi

ovas-

cular

risk.

)igh

G*G

chole

sterol

can

typically

be

treate

d

with

avail

able

drugs

,

usual

ly

statin

s.

)em

oglob

in5he

mato

crit.

hyaretheseimpo

r5tantThes

e

meas

urem

ents

can

identi

fy

issue

s beyo

ndhyper

tensi

on

and

cardi

ovasc

ular

disea

se,

inclu

ding

sickle

cell

anem

ia in

vulne

rable

popu-

lation

s and

anem

ia

assoc

iated

withchron

ic

kid-

ney

disea

se.

H!.

Giver

functi

on

tests.hyaretheseimportant erta

in

blood

press

ure

drugscan

affect


41/69

liver

functi

on,

so it

is

usefu

l to

have

baseli

ne

values.

Also,

obese

peopl

e can

have

fatty

liver

disor

ders

that

shoul

d be

identi

fied

and

consi

dered

in

overa

ll

mana

geme

nt.

Irine

samp

le

Albu

minu

ria.hyisthis

important !f

prese

nt,

this

can

be

indic

ative

of

kidne

ydisea

se

and is


also

associated

with

an

incre

ased

risk

of

cardi

o-

vascu

lar

events.

!deall

y, an

albu

min5c

reatin

ine

ratio

shoul

d be

obtai

ned,

buteven

dipsti

ck

evide

nce

of

albu

minu

ria

'J3

or

greater( is

helpf

ul.

0ed

and

white

cells.hyaretheseimportant


42/69

&ositi

ve

findi

ngs

can

be

indic

ative

of

urinary

tract

infect

ions,

kidne

y

stone

s, or

other

poten

tially

serious

urina

ry

tract

condi

tions,

inclu

ding

bladd

er

tumo

rs.

Elect

rocar

diogr

aphy.

hyisthisimportant Elec-

trocar diogr

aphy

'E

( can

help

identi

fy

previ

ous

myoc

ardial

infarc

tions

or

left

atrial

and

ventri

cular

hyper

troph

y

'whic

h is

evide

nceof

target

organ

dama

ge

and

indic

ative

of the

need

for

good

contr

ol of

blood

press

ure(.

E

might

also

identi

fy

cardi

ac

arrhythmia

s

such

as

atrial

fibrill

ation

'whic

h

woul

d

dictat

e the

use

of

certai

n

drugs

( or

condi

tions

such

as

heart

block 'whic

h


43/69

woul

d

contr

aindi

cate

certai

n

drugs

, eg,

b- block

ers,

rate-

slowi

ng

calci

um

chan

nel

block

ers(.

Echocardi

ograp

hy, if

avail

able,

can

also

be

helpf

ul in

diagn

osing

leftventri

cular

hyper

troph

y and

2uant

ifyin

g the

e9ecti

on

fracti

on in patie

nts

with

suspe

cted

heart

failur

e,

altho

ugh

this

test is

notrouti

ne in

hyper

tensi

ve

patie

nts.

=3ERA%%

G= A%S=6RE A6ME;6

!.

The

goal

of

treat

mentis to

mana

ge

hyper

tensi

on

and

to

deal

with

all

the

other

identi

fied

risk

factor

s for

cardi

ovasc

ular

disea

se,

inclu

dinglipid

disor

ders,

glu-

cose

intole

rance

or

diabe

tes,

obesi

ty,and

smok

ing.


44/69

or

hyper

tensi

on,

the

treat

ment

goal

for

systolic

blood

press

ure is

usual

ly

@3=8

mm

)g

and

for

diastolic

blood

press

ure

@>8

mm

)g.

!n the

past,

guide

lines

have

recomme

nded

treat

ment

value

s of

@3;85

?8

mm

)g

for

patients

with

diabe

tes,

chron

ic

kidne

y

disea

se,

and

coron

aryartery

disea

se.

)ow-

ever,

evide

nce

to

supp

ort

this

lower

targetin

patie

nts

with

these

condi

tions

is

lacki

ng,

so the

goal

of

@3=85

>8

mm

)g

shoul

d

gener

ally

be

used,

altho

ughsome

e"per

ts

still

reco

mme

nd

@3;85

?8

mm

)g if

albu-

minu

ria is

prese

nt in

patie

nts

with

chron

ic

kidne

y

disease.


45/69

Are

there

other

e"cep

tions

to

@3=85

>8

mm

)g+

ostevide

nce

linkin

g the

effect

s on

cardi

ovasc

ular

or

renal

outco

mes

to

treate

d

blood

press

ures

have

been

based

on

clinic

altrials

in

middl

e-

aged

to

elderl

y

patie

nts

'typic

ally

betw

een

44

and

?8

years

(.

$ome

recen

t

trials

sugge

stthat

in

peopl

e ?8

or

older,

achie

ving

a

systol

ic

blood

pressure of

@348

mm

)g is

assoc

iated

with

stron

g

cardi

ovasc

ular

and

strok

e

prote

ction

and

so a

target

of

@3485

>8

mm

)g isnow

reco

mme

nded

for

patie

nts in

this

age

group

. We

have

almo

st no

clinic

al

trial

evide

nce

regar

ding

blood

press

ure

targets in

patie


46/69

nts

youn

ger

than

48

years.

*iast

olic

blood

press

uremay

be

impo

rtant

in

this

age

group

, so

achie

ving

a

value

@>8

mm

)g

shoul

d be

a

priori

ty. !n

additi

on, itis

also a

reaso

nable

e"pec

tation

that

target

s

@3=85

>8

mm


6he +ournal


*


)g

'eg, @

3;85?

8 mm

)g(

could

be

appro

priate

inyoun

g

adult

s and

can

be

consi

dered

.

!H.!t

is

impo

rtant

to

infor

m

patie

nts

that

the

treatment

of

hyper

tensio

n is

usuall

y

e"pec

ted to

be a

life-

longcom

mitm

ent

and

that it

can

be

dange

rous

for

them

to

terminate

their


47/69

treat

ment

with

drugs

or

lifest

yle

chan

ges

witho

utfirst

consu

lting

their

practi

tioner

.

;=;PH AR

MAC=%=GIC6RE A6ME;6

$ever

al

lifest

yle

interv

entio

ns

have

been

show

n to

reduc

e

blood

press

ure.

Apartfrom

contri

butin

g to

the

treat

ment

of

hyper

tensi

on,

these

strate

gies

are

benef

icial

in

mana

ging

most

of the

other

cardi

ovasc

ularrisk

factor

s. !n

patie

nts

with

hyper

tensio

n that

is no

more

sever

e

than

stage

3 and

is not

assoc

iated

with

evide

nce

of

abnor

malcardi

ovasc

ular

findin

gs or

other

cardi

ovas-

cular

risks,

: to

37

mont

hs of

lifest

yle

chang

es

can

be

attem

pted

in the

hope

thatthey

may


48/69

be

suffic

iently

effect

ive to

make

it

unne

cessa

ry to

usemedi

cines.

)ow

ever,

it

may

be

prude

nt to

start

treat

ment

with

drugs

soone

r if it

is

clear

that

the

blood

press

ure is

not

responding

to the

lifest

yle

meth

ods

or if

other

risk

factor

s

appea

r.

Also,

in

practi

ce

settin

gs

wher

e

patie

nts

have

logistical

diffic

ulties

in

maki

ng

regul

ar

clinic

visits,

it

might

bemost

practi

cal to

start

drug

thera

py

early.

!n

gener

al,

lifest

yle

chang

es

shoul

d be

regar

ded

as a

comp

leme

nt to

drug

thera py

rather

than

an

altern

ative.

Weig

ht

loss#

!n

patients

who

are

over

weig

ht or

obese

,

weig

ht

loss

is

helpf ul in

treati


49/69

ng

hyper

tensi

on,

diabe

tes,

and

lipid

disor

ders.

$ubstitutin

g

fresh

fruits

and

veget

ables

for

more

tradit

ional

diets

may

have

benef

its

beyo

nd

weig

ht

loss.

Info

rtunat

ely,

thesediets

can

be

relati

vely

e"pe

nsive

and

incon

venie

nt for

patie

nts,

and

can

work

only

if

patie

nts

are

provi

ded

with

astron

g

suppo

rt

syste

m.

Even

mode

st

weig

ht

loss

can be

helpf

ul.

$alt

reduc

tion#

)igh-

salt

diets

are

common

in

many

com

munit

ies.

0edu

ction

of

salt

intak

e is

recom-

mend

ed

becau

se it

can

reduc

e

blood

press

ure

anddecre

ase

the

need

for

medi

catio

ns in

patie

nts

who

are

Ksaltsensit

ive,L


50/69

whic

h

may

be a

fairly

com

mon

findi

ng in

black

communit

ies.

ften

,

patie

nts

are

unaw

are

that

there

is a

large

amou

nt of

salt

in

foods

such

as

bread

,

canne

d

goods, fast

foods

,

pickl

es,

soups

, and

proce

ssed

meats

. This

intak

e can

be

diffic

ult to

chan

ge

becau

se

salty

foods

are

often

partof the

tradit

ional

diets

found

in

many

cultur

es. A

relate

d

probl

em isthat

many

peopl

e eat

diets

that

are

low

in

potas

sium,and

they

shoul

d be

taugh

t

about

availa

ble

sourc

es of

dietar

y potas

sium.

E"erc

ise#

0egul

ar

aerob

ic

e"erc

ise

canhelp

reduc

e

blood

press

ure,

but

oppor

tuniti

es to

follo

w a

struc-

tured

e"erc


51/69

ise

regim

en

are

often

limite

d.

$till,

patie

nts

should be

enco

urage

d to

walk,

use

bicyc

les,

climb

stairs,

and

pursu

e

mean

s of

integr

ating

phys-

ical

activi

ty

into

their

daily

routines.

!H.Al

cohol

consu

mptio

n# Ip

to 7

drink

s a

day

can be

helpf

ul in

prote

cting

again

st

cardi

ovasc

ular

event

s,

but

great

er

amou

nts of

alcoh

ol

can

raise

blood

press

ure

and

shoul

d

theref

ore

be

disco

urage

d. !nwom

en,

alcoh

ol

shoul

d be

limite

d to 3

drink

a day.

igar ette

smok

ing#

$topp

ing

smok

ing

will

not

reduc

e

blood

pressure,

but

since

smok

ing

by

itself

is

such

a

ma9or

cardiovasc

ular

risk


52/69

factor

,

patie

nts

must

be

stron

gly

urged

to

discontinu

e this

habit.

&atie

nts

shoul

d be

warn

ed

that

stopp

ing

smok

ing

may

be

assoc

iated

with

a

mode

st

incre

ase in

bodyweig

ht.

"R:G6RE A6ME;6=H


53/69

not

have

evide

nce

of

abnor

mal

cardi

ovasc

ular

findings

or

other

risk

factor

s. !n

settin

gs

wher

e

healt

hcare

resou

rces

are

highl

y

limite

d,

clinic

ians

can

consi

der

e"tending

the

nondr

ug

obser

vatio

n

perio

d in

unco

mplic

ated

stage

3

hyper

tensi

ve

patie

nts

provi

ded

there

is no

evi-

dencefor an

incre

ase in

blood

press

ure or

the

appea

rance

of

cardi

ovasc

ularor

renal

findin

gs(.

!n

patie

nts

with

stage

7

hyper tensio

n

'bloo

d

press

ure

3:85388

mm

)g(,

drug

treat

mentshoul

d be

starte

d

imme

diatel

y

after

diagn

osis,

usuall

ywith

a 7-

drug

comb

inatio

n,

witho

ut

waiti

ng to

see

the

effects of

lifest


54/69

yle

chan

ges.

*rug

treat

ment

can

also

be

starte

dimme

diatel

y in

all

hyper

tensi

ve

patie

nts in

who

m,

for

logist

ical

or

other

practi

cal

reaso

ns,

the

practi

tioner

belie

ves itis

neces

sary

to

achie

ve

more

rapid

contr

ol of

blood

press

ure.

The

prese

nce

of

other

cardi

ovasc

ular

risk

factor

sshoul

d also

accel

erate

the

start

of

hyper

tensio

n

treat

ment.

or patie

nts

older

than

?8

years,

the

sugge

sted

thres

hold

for

starti

ng

treat

ment

is at

levels

3485>8

mm

)g.

Thus,

the

targetof

treat

ment

shoul

d be

@3=85

>8

mm

)g

for

most

patie

nts

but

@3485

>8

mm

)g

for

older

patie

nts

'unle

ss

these patie

nts


55/69

have

chron

ic

kidne

y

disea

se or

diabe

tes,

when

@3=85>8

mm

)g

can

be

consi

dered

(.

The

treat

ment

regim

en#

ost

patie

nts

will

re2ui

re

more

than

one

drug

toachie

ve

contr

ol of

their

blood

press

ure.

!n

gener

al,incre

ase

the

dose

of

drugs

or

add

new

drugs

at

appro

"imat

ely 7-

to ;-

week

interv

als.

This

fre2u

ency

can

be

faster

or

slower

depen

d-ing

on

the

9udg

ment

of the

practi

tioner

. !n

gener

al,

the

initial

doses

of

drugs

chose

n

shoul

d be

at

least

halfof the

ma"i

mum

dose

so

that

only

one

dose

ad9ust

ment

is

re2uir

ed

there

after.

!t is

gener

ally

antici

pated

that

most

patie

ntsshoul

d


56/69

reach

an

effect

ive

treat

ment

regim

en,

whet

her 3,

7, or;

drugs

,

withi

n : to

?

week

s.

!f the

untre

ated

blood

press

ure is

at

least

785

38mm

)g

above

the

target

blood

press

ure,

- 6he +ournalof Clinical Hypertension

=fficial+ournal of the AmericanSociety of Hypertension!Inc.


57/69

ASHBISH Hypertension Guidelines D eber et al.

IG:RE. 6his algorithm summari8es the main recommendations of these guidelines. At any stage it is entirely appropriate to see/ help from ahypertension e@pert if treatment is pro7ing difficult. In patients 9ith stage $ hypertension in 9hom there is no history of cardio7ascular! stro/e!or renal e7ents or e7idence of abnormal findings and 9ho do not ha7e diabetes or other maor ris/ factors! drug therapy can be delayed forsome months. In all other patients including those 9ith stage & hypertensionF! it is recommended that drug therapy be started 9hen thediagnosis of hypertension is made. CC' indicates calcium channel bloc/er# ACE5i! angiotensin5con7erting en8yme inhibitors# AR'!angiotensin receptor bloc/er# thia8ide! thia8ide or thia8ide5li/e diuretics. 'lood pressure 7alues are in mm Hg.

consider starting treatment immediately with 7 drugs.

!H. hoice of drugs#

This should be influenced by the age, ethnicity5 race, and

other clinical characteristics of the patient 'Table !(.

The choice of drugs will also be influenced by other

conditions 'eg, diabetes and coronary disease(

associated with the hypertension 'Table !!(.

&regnancy also influences drug choice.

Gong-acting drugs that need to be taken only once

daily are preferred to shorter-acting drugs that

re2uire multiple doses because patients are more

likely to follow a simple treatment regi-men. orthe same reason, when more than one drug is

prescribed, the use of a combination product with


58/69

two appropriate medications in a single tablet can simplify

treatment for patients, although these products can

sometimes be more

e"pensive than individual drugs. nce-daily drugs can be

taken at any time during the day, most usually either in the

morning or in the evening before sleep. !f multiple drugs

are needed, it is possible to divide them between the

morning and the evening.

The choice of drugs will further be influenced by their

availability and affordability. !n many cases, it is

necessary to use whichever drugs have been

provided by government or other agencies. or this

reason, we will only make recommendations for

drug classes, not individ-ual agents, recognizing

that there may be a limited selection of drugs that

can be prescribed by a practitioner. Even among

generic drugs there can be a wide variation in cost.

0ecommendations for drug selection are shown inTable ! '&art 3( for patients whose primary problem

is hypertension, and in Table ! '&art 7(

=fficial +ournal of the American Society of Hypertension! Inc. 6he +ournal of Clinical Hypertension 0


59/69


6A'%E I. "rug Selection in Hypertensi7e Patients ith or ithout =ther Maor Conditions

Add Second "rug If

;eeded to Achie7e a

Patient 6ype irst "rug 'P K$)4B24 mm Hg

If 6hird "rug is ;eededto Achie7e a 'P ofK$)4B24 mm Hg

A. hen hypertension is the only or main condition

'lac/ patients African

CC'a or thia8ide diuretic

AR'b or ACE inhibitor

ancestryF? All ages

If una7ailable can add

alternati7e first drug

choiceFhite and other non5blac/

AR'b or ACE inhibitor

CC'a or thia8ide diuretic

Patients?


60/69

cIf eGR K)4 m%Bmin! a loop diuretic eg! furosemide or torsemideF may be needed.

d;ote? If history of myocardial infarction! a b5bloc/er and AR'Bor ACE inhibitor are indicated regardless of blood pressure.

e;ote? If using a diuretic! there is good e7idence for indapamide if a7ailableF.

for patients who have a ma9or comorbidity

associated with their hypertension. The igure

3 displays an algorithm that summarizes the

use of therapy for most patients with

hypertension. The recommendations for particular drug classes are made with the

recognition that sometimes only alternative

drug classes will be available. )owever, most

of the time, the use of any drugs that reduce

blood pressure is more likely to help protect

patients from strokes and other serious events

than giving patients no drug at all.

'RIE C=MME;6S =; "R:GC%ASSES

/ote# There is an assumption, unlessotherwise stated, that all drugs in a class are

similar to each other. We only mention

individual agents if they have an

important property that is not shared by the

others in its class. Table !! provides a list of

commonly used antihypertensive drugs and

their doses.

Angiotensin5con7erting en8yme Inhibitors

These agents reduce blood pressure by

blocking the renin-angiotensin system. They

do this by preventing conversion of

angiotensin ! to the blood pressure-raising

hormone angiotensin !!. They also increase

availability of the vasodilator bradykinin by

block-

ing its breakdown.

Angiotensin-converting enzyme inhibitors arewell tolerated. Their main side effect is cough

'most common in women and in patients of

Asian and African background(. Angioedema

is an uncommon but potentially serious

complication that can threa-

1 6he +ournal of Clinical Hypertension =fficial +ournal of the American Society of Hypertension! Inc.

6A'%E II. "osages of Commonly :sed

Antihypertensi7e "rugs

"aily "osage! mg

%o9 "osage:sual "osage

Calcium channel bloc/ers

;ondihydropyridines

"iltia8em$&4&)4(-4

3erapamil$&4&)4)14"ihydropyridines

Amlodipine&.**$4

elodipine&.**$4Isradipine&.* t9ice*$4 t9ice daily

daily

;ifedipine(4(424;itrendipine$4&4"rugs that target the renin5angiotensin system

Angiotensin5con7erting en8yme inhibitors

'ena8epril*$4)4Captopril$&.* t9ice daily*4$44 t9ice dailyEnalapril*$4)4osinopril$4$4)4%isinopril*$4)4Perindopril))1


61/69

uinapril*$4)4Ramipril&.**$46randolapril$&&1 Angiotensin receptor bloc/ers

A8ilsartan)4

14Candesartan)1(&Eprosartan)44-44144Irbesartan$*4$*4(44%osartan*4*4$44=lmesartan$4&4)46elmisartan)4

)4143alsartan1414(&4"irect renin inhibitor

Alis/iren0*$*4(44"iuretics

6hia8ide and thia8ide5li/e diuretics

'endroflumethia8ide*$4Chlorthalidone$&.*$&.*&*Hydrochlorothia8ide$&.*$&.**4Indapamide$.&*&.*%oop diuretics

'umetanide4.*$urosemide&4 t9ice daily)4 t9ice daily6orsemide*$4Potassium5sparing diuretics

Amiloride**$4Eplerenone&**4$44Spironolactone$&.*&**4

6riamterene$44$44b5'loc/ers

Acebutalol&44&44)44


62/69


6A'%E II. ContinuedF

"aily "osage! mg

%o9 "osage:sual "osage

Atenolol&*$44'isoprolol**$4Car7edilol(.$&* t9ice daily-.&*&* t9ice daily%abetalol$44 t9ice daily$44(44 t9ice dailyMetoprolol succinate&**4$44Metoprolol tartrate&* t9ice daily*4$44 t9ice daily;adolol&4)414;ebi7olol&.*

*$4Propranolol)4 t9ice daily)4$-4 t9ice dailya5Adrenergic receptor bloc/ers

"o@a8osin$$&Pra8osin$ t9ice daily$* t9ice daily6era8osin$$&3asodilators! central a5agonists! and adrenergic depleters3asodilators

Hydrala8ine$4 t9ice daily&*$44 t9ice dailyMino@idil&.**$4Central alpha5agonists

Clonidine

4.$ t9ice daily4.$4.& t9ice dailyClonidine patch66S5$! once 9ee/ly66S5$! &! or (!

once 9ee/lyMethyldopa$&* t9ice daily&*4*44 t9ice daily Adrenergic depleters

Reserpine4.$4.$4.&*

All doses are gi7en once5daily unless other9ise specified.

ten airway function, and it occurs most

fre2uently in black patients.

These drugs can increase serum creatinine by

as much as ;8B, but this is usually because

they reduce pressure within the renal

glomerulus and decrease filtration. This is a

reversible change in function and is not

harmful. An even greater increase in

creatinine sometimes occurs when

angiotensin-converting enzyme inhibitors are

combined with diuretics and produce large

blood pressure reductions. Again, this change

is reversible, although it may be necessary to

reduce doses of one or both drugs. !f

creatinine levels increase substantially this

can be caused by concom-itant treatment withnonsteroidal anti-inflammatory drugs or it

may indicate the presence of renal artery

stenosis.

The side effects associated with angiotensin-

convert-ing enzyme inhibitors are generally

not dose-depen-dent, as they occur as

fre2uently at low doses as at high doses. Thus,

it can be perfectly acceptable when using

these agents to start at medium or even high

doses. The one e"ception to this rule is inhyperkal-emia, which may occur more

fre2uently at higher

angiotensin-converting enzyme inhibitor

doses.

These drugs have established clinical outcome

ben-efits in patients with heart failure, post myocardial

=fficial +ournal of the American Society of Hypertension! Inc. 6he +ournal of Clinical Hypertension 2


infarction, left ventricular systolic


63/69

dysfunction, and diabetic and nondiabetic

chronic kidney disease.

!n general, angiotensin-converting enzyme

inhibitors are more effective as monotherapy

in reducing blood pressure in white patients

than in black patients, possibly because the

renin-angiotensin system is often less active

in black patients. )owever, these drugs are

e2ually effective in reducing blood pressurein all ethnic and racial groups when combined

with

either calcium channel blockers or diuretics.

*o not combine angiotensin-converting

enzyme inhibitors with angiotensin receptor

blockers1 each of these drug types is

beneficial in patients with kidney disease, but

in combination they may actually

have adverse effects on kidney function.

When starting treatment with an angiotensin-

con-verting enzyme inhibitor, there is a risk of

hypoten-sion in patients who are already

taking diuretics or are on very low-salt diets

or are dehydrated 'eg, laborers in hot climates

and patients with diarrhea(. or patients

taking a diuretic, skipping a dose before

starting the angiotensin-converting enzyme

inhibitor

helps prevent this sudden effect on blood pressure. Angiotensin-converting enzyme

inhibitors must not be used in pregnancy,

especially in the second or third trimesters,

since they can compromise the

normal development of the fetus.

Angiotensin Receptor 'loc/ers

Angiotensin receptor blockers, like

angiotensin-con-verting enzyme inhibitors,

antagonize the renin-angiotensin system.They reduce blood pressure by blocking the

action of angiotensin !! on its AT3 receptor

and thus prevent the vasoconstrictor effects

of this receptor.

The angiotensin receptor blockers are well

toler-ated. %ecause they do not cause cough

and only rarely cause angioedema, and have

effects and benefits similar to angiotensin-

converting enzyme inhibitors, they are

generally preferred over angio-tensin-converting enzyme inhibitors if they are

available and affordable. Gike angiotensin-

convert-ing enzyme inhibitors, angiotensin

receptor blockers can increase serum

creatinine 'see comments about angiotensin-

converting enzyme inhibitors(, but usu-ally

this is a functional change that is reversible

and

not harmful.

These drugs do not appear to have dose-dependent side effects, so it is perfectly

reasonable to start treatment

with medium or even ma"imum approved

doses.

These drugs have the same benefits on

cardiovascular and renal outcomes as

angiotensin-converting

enzyme inhibitors.

Gike angiotensin-converting enzyme

inhibitors, they tend to work better in white

and Asian patients than in black patients, but,

when combined with either calcium channel

blockers or diuretics, they become e2ually

effective in all patient groups.

*o not combine angiotensin receptor blockers

with angiotensin-converting enzyme

inhibitors1 each of these drug types is

beneficial in patients with kidney disease, but

in combination they may actually have

adverse effects on renal events.

When starting treatment with an angiotensin

recep-tor blocker in patients already taking

diuretics, it may be beneficial to skip a dose

of the diuretic to

prevent a sudden fall in blood pressure.

Angiotensin receptor blockers must not be

used in pregnancy, especially in the second or

third trimes-ters, since they can compromise

the normal devel-opment of the fetus.

6hia8ide and 6hia8ide5li/e "iuretics

These agents work by increasing e"cretion of

sodium by the kidneys and additionally may

have some

vasodilator effects.


64/69

linical outcome benefits 'reduction of

strokes and ma9or cardiovascular events( have

been best estab-lished with chlorthalidone,

indapamide, and hydro-chlorothiazide,

although evidence for the first two of

these agents has been the strongest.

hlorthalidone has more powerful effects on

blood pressure than hydrochlorothiazide'when the same doses are compared( and has

a longer duration of

action.

The main side effects of these drugs are

metabolic 'hypokalemia, hyperglycemia, and

hyperuricemia(. The likelihood of these

problems can be reduced by using low doses

'eg, 37.4 mg or 74 mg of hydro-

chlorothiazide or chlorthalidone( or by

combining these diuretics with angiotensin-converting enzyme inhibitors or angiotensin

receptor blockers, which have been shown to

reduce these metabolic changes. ombining

diuretics with potassium-sparing agents

also helps prevent hypokalemia.

*iuretics are most effective in reducing blood

pressure when combined with angiotensin-

convert-ing enzyme inhibitors or angiotensin

receptor block-ers, although they are also

effective when combined with calcium

channel blockers.

/ote# Thiazides plus b-blockers are also aneffective combination for reducing blood

pressure, but since both classes can increase blood glucose concentrations this

combination should be used with caution in

patients at risk for developing diabetes.

Calcium Channel 'loc/ers

These agents reduce blood pressure by

blocking the inward flow of calcium ions

through the G channels

of arterial smooth muscle cells.

There are two main types of calcium channel

blockers# dihydropyridines, such as

amlodipine and nifedipine, which work by

dilating arteries1 and nondihydropyridines,

such as diltiazem and verapa-mil, which

dilate arteries somewhat less but also reduce

heart rate and contractility.

$4 6he +ournal of Clinical Hypertension =fficial +ournal of the American Society of Hypertension! Inc.

ost e"perience with these agents has been

with the dihydropyridines, such as amlodipine

and nifedipine, which have been shown to

have beneficial effects on cardiovascular and

stroke outcomes in hypertension

trials.

The main side effect of calcium channel

blockers is peripheral edema, which is most prominent at high doses1 this finding can

often be attenuated by combining these agents

with angiotensin-convert-ing enzyme

inhibitors or angiotensin receptor block-

ers.

/ondihydropyridine calcium channel

blockers are not recommended in patients

with heart failure, but amlodipine appears to

be safe when given to heart failure patients

receiving standard therapy 'includingangiotensin-converting enzyme inhibitors( for

this

condition.

%ecause the nondihydropyridine drugs,

verapamil and diltiazem, can slow heart rate,

they are some-times preferred in patients with

fast heart rates and even for rate control in

patients with atrial fibrilla-

tion who cannot tolerate b-blockers. /ondihydro-pyridine drugs can also reduce

proteinuria.

alcium channel blockers have powerful

blood pressure-reducing effects, particularly

when com-bined with angiotensin-converting

enzyme inhibitors or angiotensin receptor

blockers. They are e2ually

effective in all racial and ethnic groups.

The dihydropyridine, but not the

nondihydropyri-dine, agents can be safely

combined with b-blockers.

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b-blockers reduce cardiac output and alsodecrease the release of renin from the kidney.

They have strong clinical outcome benefits in

patients with histories of myocardial

infarction and heart failure and are effective

in the management of

angina pectoris.

They are less effective in reducing blood

pressure in black patients than in patients of

other ethnic-

ities.

b-blockers may not be as effective as theother ma9or drug classes in preventing strokeor cardiovascular events in hypertensive

patients, but they are the drugs of choice in

patients with histories of myocar-

dial infarction or heart failure.

any of these agents have adverse effects on

glucose metabolism and therefore are not

recommended in patients at risk for diabetes,

especially in combina-tion with diuretics.

They may also be associated with

heart block in susceptible patients.

The main side effects associated with b- blockers are reduced se"ual function, fatigue,

and reduced e"er-

cise tolerance.

The combined a- and b-blocker, labetalol, iswidely used intravenously for hypertensive

emergencies, and is also used orally for

treating hypertension in pregnant and

breastfeeding women.


a5'loc/ers

a-%lockers reduce blood pressure by blockingarte-rial a-adrenergic receptors and thus

preventing the vasoconstrictor actions of

these receptors.

These drugs are less widely used as first-step

agents than other classes because clinical

outcome benefits have not been as well

established as with other agents. )owever,

they can be useful in treating resistant

hypertension when used in combination

with agents such as diuretics, b-blockers, andangio-tensin-converting enzyme inhibitors.

To be ma"imally effective, they shouldusually be combined with a diuretic. $ince a-

blockers can have somewhat beneficial effects

on blood glucose and lipid levels, they can

potentially neutralize some of

the adverse metabolic effects of diuretics.

The a-blockers are effective in treating benign prostatic hypertrophy, and so can be a

valuable part of hypertension treatment

regimens in older men who have this

condition.

Centrally Acting Agents

These drugs, the most well-known of which

are clonidine and a-methyldopa, work primarily by reducing sympathetic outflow

from the central ner-

vous system.

They are effective in reducing blood pressure

in most patient groups.

%othersome side effects such as drowsiness

and dry mouth have reduced their popularity.

Treatment with a clonidine skin patch causes

fewer side effects than the oral agent, but the

patch is not always

available and can be more costly than the

tablets. !n certain countries, including the

Inited $tates,

a-methyldopa is widely employed for treatinghyper-tension in pregnancy.


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"irect 3asodilators

%ecause these agents, specifically hydralazine

and mino"idil, often cause fluid retention and

tachycar-dia, they are most effective in

reducing blood

pressure when combined with diuretics and b-

blockers or sympatholytic agents. or thisreason, they are now usually used only as

fourth-line or later

additions to treatment regimens.

)ydralazine is the more widely used of these

agents. The powerful drug mino"idil is

sometimes used by specialists in patients

whose blood pressures are difficult to control.

luid retention and tachycardia are fre2uent

problems with mino"idil, as well as unwanted

hair growth 'particularly in women(.

urosemide is often re2uired to cope with the

fluid retention.

Mineralocorticoid Receptor Antagonists

The best known of these agents is

spironolactone. Although it was originally

developed for the treat-ment of high

aldosterone states,

ash ish-guidelines 2013

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