The management of hypertension includes:
assessment:
of blood pressure
of secondary causes of hypertension
of risk factors for essential hypertension
of the complications of hypertension
treatment:
general advice and lifestyle changes
pharmacological treatment
involve the patient:
emphasize that therapy is long term
emphasize that drugs should not be stopped or omitted without prior discussion with the doctor
any side effects should be reported
consider the need to refer
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BHS guidelines - summary recommendations
use of non-pharmacological measures - these should be used in all hypertensive and borderline hypertensive people
antihypertensive drug therapy should be initiated if sustained systolic blood pressure 160 mm Hg or sustained diastolic blood pressure 100 mm Hg
if sustained systolic blood pressure is 140-159 mm Hg or sustained diastolic blood pressure 90-99 mm Hg
consider initiating treatment if cardiovascular disease or other target organ damage present, or if estimated 10 year risk of cardiovascular disease (CVD) * is 20%
in non-diabetic people:
optimal goals for blood pressure treatment are: systolic blood pressure = 20% is equivalent to a CHD risk of approximately >=15% over 10 years
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combination AB/CD drug therapy in hypertension
The guidance regarding combination treatment of systemic hypertension has been updated (1):
this guidance suggests that essential hypertension and its treatment fall into two main categories:
younger caucasians usually have renin-dependent hypertension that responds well to angiotensin-converting-enzyme inhibition or angiotensin receptor blockade (A) or beta blockade (B) - A and B inhibitor specifically block the renin-angiotensin system
younger white hypertensive patients tend to have higher levels of renin and angiotensin II
older patients (>= 55years old) and black patients - these patients, in general, have low-renin hypertension that responds better to calcium channel blockade (C) or diuretics (D). These drugs lower blood pressure independent of the renin-angiotensin system, and cause a reflex activation of this system - thus rendering patients responsive to the addition of renin suppressive therapy
the majority of patients require a combination of drugs in order to achieve a blood pressure target of 140/85 mmHg (140/80 mmHg in diabetics)
coincidence of the initials of these main drug classes with the first four letters of the alphabet permits an AB/CD rule, according to which recommended combinations are one drug from each of the "AB" and "CD" categories of drugs
changes in treatment depend on the tolerability and efficacy of the first drug:
if the first drug is ineffective (e.g. systolic fall in BP = 55 years) or black
Step 1 A or B C or D
Step 2 A (or B*) plus C or D C or D plus A (or B*)
Step 3 A (or B*) + C + D A (or B*) + C +D
Step 4: Resistant Hypertension
Add either alpha-blocker or spironolactone or other diuretic
*Combination therapy involving B and D may induce more new onset type 2 diabetes compared other combinations of drug therapy.
Note that B has been re-included in step three. This is to avoid people who on were moving on to third-line combination therapy having their beta-blockers dropped from their treatment (even if it was effective) (2).
Notes about add-on therapy:
spironolactone is an effective treatment for primary hyperaldosteronism (defined as an elevated plasma aldosterone-to-renin ratio) - thus if a patient is uncontrolled despite triple therapy then a plasma renin should be measured off beta-blockade (which suppresses renin) as part of consideration of secondary causes of hypertension
alpha blocker may be effective in some patients
often the last resort in terms of treatment options is minoxidil (a powerful vasodilator) - this however requires careful titration in combination with a loop diuretic and beta-blocker - also side effects include hirsutism and coarsening of facial features; the difficulties with using minoxidil lead some specialists to try additional diuretic therapy before initiating minoxidil treatment
in high renin patients who are not controlled despite maximal dose of ACE inhibitor, or spironolactone + angiotensin receptor blocker then some specialists may use atypical combinations such as beta-blockade + angiotensin receptor blocker (+/- ACE inhibitor) - in order to take out the whole renin-angiotensin-aldosterone system
The guidance encouraged, given specified conditions, the prescribing of fixed dose combinations of optimal drugs in order to improve concordance with multiple drug therapy .
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