5. MONITOR, MOTIVATE, AND FOLLOW UP
An interval of at least 4 weeks should be allowed for observation after pharmacotherapy is started, unless BP needs to be lowered more urgently.9 Medications should be titrated as needed and other drugs added for synergistic effect. After BP is under control, patients at low risk for CVD or who have grade 1 hypertension may have follow-up visits every 6 months. High-risk patients should be followed up more frequently.6
Hypertension treatment should continue for the rest of the patient's life. A cautious downward titration of medication may be attempted in patients at low risk of CVD after 1 year of good BP control, particularly if healthy lifestyle changes have been successfully implemented.16
Only 35% of people with hypertension have good BP control.4 JNC 7 emphasizes that even the most effective therapy requires patient motivation to successfully control hypertension.6 In a recent study, researchers found that among persons who were prescribed a once-a-day antihypertensive, approximately 50% stopped taking the medication within 1 year; on any given day, approximately 10% of scheduled doses were omitted; almost 50% of patients taking antihypertensive medications took at least one drug “holiday” a year; and alternative therapies were frequently added to prescribed medications.22
Organizational support, especially from health-promotion personnel dedicated to identifying and following up with high-risk patients, has been shown to improve all quality improvement strategies by 3.3%.1 Recommending and following up on home-based BP self-monitoring increases adherence and can also improve patient self-efficacy regarding medication effects and benefits of lifestyle changes.23
CONCLUSION
Hypertension is asymptomatic and requires lifelong management, which makes the disease difficult to treat. Therapeutic recommendations change periodically, and patients require individualized treatment. This is often burdensome for clinicians. Furthermore, fewer than 40% of persons with hypertension achieve target BP goals, regardless of receiving treatment.1
Treatment goals emphasize maximum possible reduction in total cardiovascular risk. A decrease of as little as 2 mm Hg can produce a significant reduction in risk.18 Health care providers should take every opportunity to check patients' BP and initiate treatment when appropriate. Lifestyle modification and fastidious BP control are the primary preventive measures for persons with hypertension who are at risk for cardiovascular events. Clinicians who assess BP properly, evaluate CVD risks and comorbidities accurately, and treat early and appropriately can save lives and ensure better quality of life for their patients. JAAPA
Margaret Allen practices in family medicine at Ravenswood Family Health Center, East Palo Alto, California. She has indicated no relationships to disclose relating to the content of this article.
DRUGS MENTIONED
Aliskiren (Tekturna)
Amlodipine (Norvasc, generics)
Amlodipine/valsartan (Exforge)
Aspirin
Diltiazem
Eplerenone (Inspra)
Hydralazine
Minoxidil (Loniten, generics)
Nifedipine
Valsartan/hydrochlorothiazide (Diovan HCT)
Verapamil
REFERENCES
1. Walsh J, McDonald KM, Shojania KG. Hypertension care. In: Shojania KG, McDonald KM, Wachter RM, Owens DK, eds. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Vol 3. Rockville, MD: Agency for Healthcare Research and Quality; 2005. AHRQ Publication No. 04-0051-3.
2. Beevers DG, Lip GY, O'Brien E. ABC of Hypertension. 5th ed. Oxford, England: Blackwell Publishing; 2007.
3. Kearney PM, Whelton M, Reynolds K, et al. Global burden of hypertension: analysis of worldwide data. Lancet. 2005;365(9455):217-223.
4. American Heart Association. Heart Disease and Stroke Statistics—2009 Update (At-A-Glance). Dallas, TX: American Heart Association; 2009.
5. Williams B, Lindholm LH, Sever P. Systolic pressure is all that matters. Lancet. 2008;371(9631): 2219-2221.
6. Chobanian AV, Bakris GL, Black HR, et al; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289(19):2560-2572.
7. Blood Pressure Lowering Treatment Trialists' Collaboration, Turnbull F, Neal B, et al. Effects of different regimens to lower blood pressure on major cardiovascular events in older and younger adults: meta-analysis of randomised trials. BMJ. 2008;336(7653):1121-1123.
8. Peralta CA, Hicks LS, Chertow GM, et al. Control of hypertension in adults with chronic kidney disease in the United States. Hypertension. 2005;45(6):1119-1124.
9. Williams B, Poulter NR, Brown MJ, et al; BHS guidelines working party, for the British Hypertension Society. British Hypertension Society guidelines for hypertension management 2004 (BHS-IV): summary. BMJ. 2004;328(7440):634-640.
10. Mancia G, De Backer G, Dominiczak A, et al; Management of Arterial Hypertension of the European Society of Hypertension; European Society of Cardiology. 2007 Guidelines for the Management of Arterial Hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2007;25(6):1105-1187.
11. American Diabetes Association. Standards of medical care in diabetes—2008. Diabetes Care. 2008;31(suppl 1):S12-S54.
12. Kidney Disease Outcomes Quality Initiative (K/DOQI). K/DOQI clinical practice guidelines on hypertension and antihypertensive agents in chronic kidney disease. Am J Kidney Dis. 2004; 43(5 suppl 1):S1-S290.
13. Huntzinger A. AHA releases guidelines for hypertension management in adults with or at risk of CAD. Am Fam Physician. 2008;78(2):July 15.
14. US Preventive Services Task Force. Screening for high blood pressure: US Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med. 2007;147(11):783-786.
15. Meert RL, Grim CE. Inaccurate blood pressure measurement in the clinical setting: causes and control. Am J Hypertens. 2000;13(4 suppl 1):24A.
16. Sica DA. Management of hypertension in the outpatient setting. Primary Care. 2008;35(3): 451-473, vi.
17. National Institutes of Health, National Heart, Lung, and Blood Institute, US Department of Health and Human Services. ATP III Guidelines At-A-Glance Quick Desk Reference. Bethesda, MD: National Institutes of Health, US Dept of Health and Human Services; 2001. NIH Publication 01-3305. http://www.nhlbi.nih.gov/guidelines/cholesterol/atglance.pdf. Accessed August 4, 2009.
18. Lewington S, Clarke R, Qizilbash N, et al; Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360(9349);1903-1913.
19. Jamerson K, Weber MA, Bakris GL, et al; AccoMPLISH Trial investigators. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. N Engl J Med. 2008; 359(23):2417-2428.
20. Watts G. What happened to the polypill? BMJ. 2008;337:a1822. doi:10.1136/bmj.a1822.
21. Pedelty L, Gorelick P. Management of hypertension and cerebrovascular disease in the elderly. Am J Med. 2008;121(8 suppl):S23-S31.
22. Vrijens B, Vincze G, Kristanto P, et al. Adherence to prescribed anti-hypertensive drug treatments: longitudinal study of electronically compiled dosing histories. BMJ. 2008; 336(7653):1114-1117.
23. Pickering TG, Miller NH, Ogedegbe G, et al; American Heart Association; American Society of Hypertension; Preventive Cardiovascular Nurses Association. Call to action on use and reimbursement for home blood pressure monitoring: a joint scientific statement from the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association. Hypertension. 2008;52(1):10-29.