Hypertension is a serious, chronic, and ubiquitous disease that, when left untreated, progresses to cardiovascular disease (CVD). Current recommendations suggest that primary care clinicians evaluate not only the severity of disease but also risk factors for CVD and the willingness of patients to adhere to treatment regimens before initiating pharmacotherapy. Lifestyle modifications are the cornerstone of overall BP management but are often inadequate to achieve control. Thiazide diuretics are recommended for initial treatment of uncomplicated hypertension; however, recent studies suggest clinicians can use greater prescribing flexibility based on patient profile. ACE inhibitors continue to be the first choice for patients with diabetes. Systolic BP (SBP) is the target of most therapies, and many patients will need two or more drugs to bring BP levels to goal. Combination drugs can reduce expense and polypharmacy. An empathetic approach regarding need for lifelong treatment, proper choice of drugs, and regular assessment and titration is important.
Although untreated hypertension inevitably leads to CVD (a diagnostic category that includes stroke, heart disease, and vascular disease) and target organ damage, such as kidney disease and retinopathy, the disease is not optimally managed in millions of people with elevated BP. Inconsistent clinical practices contribute to an avoidable loss of thousands of lives every year and enormous personal and societal burden.1 This article presents five essential steps to better management of hypertension in nonpregnant adults.
1. RECOGNIZE THE SIGNIFICANCE OF HIGH BP
Hypertension was once defined as BP above which investigation and treatment do more good than harm.2 Hyper tension is now usually defined as SBP consistently higher than 140 mm Hg and/or diastolic BP (DBP) consistently higher than 90 mm Hg, or use of antihypertensive medication. The disease affected 972 million people worldwide in 2000. This number is predicted to increase to 1.56 billion by 2025.3
At least one in three (73 million) adults in the United States has hypertension, making it the most common primary care diagnosis in the country. Prevalence of hypertension in African-Americans (more than 42%) is among the highest in the world,4 and 75% of people with hypertension are older than 50 years.5
Elevated BP is a significant risk factor for CVD, which kills more than 1 million people in the United States every year; this equates to one death every 37 seconds. Even a minimally elevated BP, as low as 115/75 mm Hg, increases CVD risks. Furthermore, mortality doubles for every 20/10 mm Hg BP increment.1 CVD usually exhibits no clinical manifestations until the onset of organ damage. Screening and control are, therefore, critical.
Failure to adequately treat hypertension has significant economic as well as public health implications. The cost of untreated high BP is estimated to reach $73.4 billion.4 Treating patients with SBP higher than 140 mm Hg would reduce stroke prevalence by 35% to 40%6 and as much as 62% in those younger than 60 years.7 In addition, acute MI would be reduced by 20% to 25% and heart failure by more than 50% if SBP was treated to goal.6
Eighty percent to 85% of patients with chronic kidney disease (CKD) are also hypertensive. Tight BP control is vital to protect against progressive renal failure. Target BP for patients with CKD is less than 130/80 mm Hg, but only 37% of patients with CKD currently reach this goal.8
2. REVIEW TREATMENT GUIDELINES
An evidence-based approach to managing hypertension is recommended. A number of clinical trials and meta-analyses of treatment recommendations fuel the intense debate on what constitutes optimal therapy. Authoritative international guidelines include The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7),6 the British Hypertension Society guidelines for hypertension management,9 and the European Society of Hypertension/European Society of Cardiology (ESH/ESC) guidelines for the treatment of hypertension.10 These guidelines are frequently reviewed and updated. Other useful guidelines are issued by the American Diabetes Association,11 the National Kidney Foundation,12 and the American Heart Association.13
3. PROFILE YOUR PATIENT
US Preventive Services Task Force guidelines, along with those of the JNC 7, recommend screening healthy people with SBP lower than 120 mm Hg every 2 years. Those with SBP 120 to 139 mm Hg should be screened annually.14 Several important assessments should be made before treating a person with hypertension.
BP measurement and classification Despite the critical importance of measuring BP, it is one of the most inaccurately performed procedures in clinical medicine.15 Frequent observer (re-)training and review of equipment, patient positioning, and cuff size selection is recommended. Use of home BP monitors can complement office-based readings, record diurnal variations, reduce the number of office visits, and facilitate treatment adjustments.16
Classification of BP level is usually based on the average of two or more seated BP readings taken at each of two office visits (Table 1). JNC 7 classifies an SBP of 120 to 139 mm Hg and/or a DBP of 80 to 89 mm Hg as prehypertension;6 however, the European guidelines divide this into two categories: normal (SBP, 120-129 mm Hg; DBP, 80-84 mm Hg) and high normal (SBP, 130-139 mm Hg; DBP 85-89 mm Hg).10 Optimal BP for all adults is less than 120/80 mm Hg. Goal BP for people with heart disease, CKD, diabetes, or multiple CVD risk factors is less than 130/80 mm Hg. Current recommendations suggest a target BP of less than 140/90 mm Hg for persons with uncomplicated hypertension and the elderly.6
Particular hypertensive conditions are categorized to guide treatment and help with patient education (Table 2). In the United States, 37% of the population has prehypertension.4
In persons younger than 50 years, elevated DBP is a strong predictor of CVD and should be treated. However, DBP tends to decrease with age, primarily as a result of large artery stiffness, and the burden of disease lies mainly on an elevated SBP. Vigorous treatment of systolic hypertension concomitantly lowers DBP; therefore, SBP generally remains the main target for treatment.5 If pulse pressure is wide (DBP decreases to less than 60 mm Hg), clinicians should carefully assess the patient for signs or symptoms of cerebral or myocardial hypoperfusion.
Assessment of CVD risk Targeting those at risk for CVD enables effective prevention. Prediction tools based on risk factors, such as BP, age, sex, family and personal history, comorbidities (such as diabetes, dyslipidemia, and obesity), activity levels, and smoking history, can estimate 10-year CVD risk in apparently healthy people and are easily accessed on the Internet. A commonly used tool is the Framingham Risk Model/Adult Treatment Panel III.17 Judicious use of prediction tools is suggested, however, as some people may be falsely reassured and delay taking steps to reduce risk factors.