Health care providers often encounter patients with high blood pressure, especially systolic, who come and go without proper treatment and eventually end up in the hospital with a heart attack, kidney failure, or a stroke.
Health care providers often encounter patients with high blood pressure (BP), especially systolic, who come and go without proper treatment and eventually end up in the hospital with a heart attack, kidney failure, or a stroke. Below is a summary of the most recent national guidelines for evaluating these patients, and the Figure shows the BP classification by The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8)1 and 2017 American College of Cardiology/American Heart Association (AHA) hypertension guidelines:
The Canadian guidelines, which are more advanced and clear, are3:
Health care providers should make sure that patients first make lifestyle changes. The AHA recommends no more than 2300 mg of sodium per day and ideally no more than 1500 mg per day for most adults. Because the average American eats so much excess sodium, cutting back by even 1000 mg per day can significantly improve BP and heart health. In Canada, the recommended daily sodium maximum intake is 2000 mg.
In addition, those with normal renal function should have 3.5 g or more of potassium per day, according to AHA guidelines.
Patients should aim for a body mass index of about 25, and their diets should include more fish, fruits, low-fat dairy, legumes, poultry, vegetables, and whole grains. They should eat less red meat, saturated and trans fats, and sweets. Alcohol intake should be limited. Patients should also engage in an aerobic exercise program of 150 to 250 minutes per week.4
Angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers, and thiazide diuretics should be used as first-line options, single or in combination. A β-blocker can be used in patients who have any of the following: coronary artery disease, postmyocardial infarction, dysrhythmia, and heart failure. Those older than 60 years, however, should not use a β-blocker as the initial agent.5 Finally, atenolol should not be used for hypertension treatment, as it has been shown to be less effective in the prevention of events compared with all other agents.
A suggested treatment protocol for moderate hypertension of >20 mm Hg above goal is:
If hypertension is not controlled, the following may be added in stepwise order:
The Table shows treatment recommendations for specific patient populations.
The BP goal for all US patients, including those with diabetes, should be <130/80 mm Hg. Patients over 80 years should have <150 mm Hg systolic, according to the American Society of Hypertension.8 Those with difficulty controlling BP despite the above recommendations should be investigated for outside factors that may worsen BP, such as β agonists, dietary changes, excessive alcohol consumption, and use of NSAIDs. Use of ARB and ACE inhibitors together or with a renin blocker is usually not indicated because of the risk of increased potassium and renal insufficiency.9
Above all, practitioners need to individualize treatment based on multiple parameters, such as age, atherosclerotic cardiovascular disease risk, concomitant diseases, and patient preference.
Roger On, MD, FACC is a cardiologist at Lakeside Community Healthcare in Burbank, California.Saro Arakelians, PharmD, is the general manager and pharmacist in charge at BioScrip Infusion in Burbank.