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Algorithm for Treatment of Hypertension

Algorithm for Treatment of Hypertension - In most patients, hypertension results from an unknown pathophysiologic etiology (essential or primary hypertension). This form of hypertension cannot be cured, but it can be controlled. A small percentage of patients have a specific cause of their hypertension (secondary hypertension). There are many potential secondary causes that are either concurrent medical conditions or are endogenously induced. If the cause can be identified, hypertension in these patients has the potential to be cured.

Essential Hypertension

More than 90% of individuals with hypertension have essential hypertension. Numerous mechanisms have been identified that may contribute to the pathogenesis of this form of hypertension, so identifying the exact underlying abnormality is not possible. Genetic factors may play an important role in the development of essential hypertension. There are monogenic and polygenic forms of BP dysregulation that may be responsible for essential hypertension. Many of these genetic traits feature genes that affect sodium balance, but genetic mutations altering urinary kallikrein excretion, nitric oxide release, and excretion of aldosterone, other adrenal steroids, and angiotensinogen are also documented. In the future, identifying individuals with these genetic traits could lead to alternative approaches to preventing or treating hypertension; however, this is not currently recommended.

Secondary Hypertension

Fewer than 10% of patients have secondary hypertension where either a comorbid disease or drug is responsible for elevating BP (Figure 15–1), In most of these cases, renal dysfunction resulting from severe chronic kidney disease or renovascular disease is the most common secondary cause. Certain drugs, either directly or indirectly, can cause hypertension or exacerbate hypertension by increasing BP. When a secondary cause is identified, removing the offending agent (when feasible) or treating/correcting the underlying comorbid condition should be the first step in management.

Classification

The JNC7 classification of BP in adults (age ≥18 years) is based on the average of two or more properly measured BP readings from two or more clinical encounters (Table 15–3). It includes four categories: normal, prehypertension, stage 1 hypertension, and stage 2 hypertension. Prehypertension is not considered a disease category, but identifies patients whose BP is likely to increase into the classification of hypertension in the future. Hypertensive crises are clinical situations where BP values are very elevated, typically greater than 180/120 mm Hg. They are categorized as either a hypertensive emergency or hypertensive urgency.
Hypertensive emergencies are extreme elevations in BP that are accompanied by acute or progressing target-organ damage. Hypertensive urgencies are high elevations in BP without acute or progressing target-organ injury.

Treatment

After a definitive diagnosis of hypertension is made, most patients should be placed on both lifestyle modifications and drug therapy concurrently. Lifestyle modification alone is considered appropriate therapy for patients with prehypertension. However, lifestyle modi fications alone are not considered adequate for patients with hypertension and additional Cardiovascular (CV) risk factors, especially patients with BP goals of less than 130/80 mm Hg (e.g., diabetes, coronary artery disease, chronic kidney disease) or less than 120/80 mm Hg (i.e., left ventricular dysfunction), who have not attained this goal BP.

The choice of initial drug therapy depends on the degree of BP elevation and presence of compelling indications (see Patients with Compelling Indications section). Most patients with stage 1 hypertension should be initially treated with a thiazide-type diuretic, ACE inhibitor, ARB, or CCB. For patients with more severe BP elevation (stage 2 hypertension), combination drug therapy, with one of the agents being preferably a thiazide type-diuretic, is recommended. Figure 15–2 outlines this general approach. There are six compelling indications where specific antihypertensive drug classes have evidence showing unique benefits in patients with the compelling indication (Fig. 15–3).

Nonpharmacologic Therapy

All patients with prehypertension and hypertension should be prescribed lifestyle modifications. Table 15–4 lists modifications that lower BP. These approaches are recommended by the JNC7 (Seventh report of Joint Nasional of committe of Prevention ) and the AHA (American Heart Association). They can provide small to moderate reductions in SBP. Aside from lowering BP in patients with known hypertension, lifestyle modification can decrease the progression to hypertension in patients with prehypertension BP values. In a portion of patients with hypertension that have relatively good BP control while on single antihypertensive drug therapy, sodium reduction and weight loss may allow withdrawal of drug therapy. A sensible dietary program is one that is designed to reduce weight gradually, for overweight and obese patients, and one that restricts sodium intake with only moderate alcohol consumption.

Successful implementation of dietary lifestyle modifications by clinicians requires aggressive promotion through reasonable patient education, encouragement, and continued reinforcement. Patients may better understand the rationale for dietary intervention in hypertension if they are provided the following observations and facts :
1. Hypertension is two to three times more likely in overweight than in lean persons.
2. More than 60% of patients with hypertension are overweight.
3. As little as 10 pounds of weight loss can decrease BP significantly in overweight patients.
4. Abdominal obesity is associated with the metabolic syndrome, which is a precursor to diabetes, dyslipidemia, and, ultimately, CV disease.
5. Diets rich in fruits and vegetables and low in saturated fat lower BP in patients with hypertension.
6. Most people experience some degree of SBP reduction with sodium restriction.

Salam

by Umaee

Algorithm for Treatment of Hypertension

Source: Pharmacotherapy 7th

Image: ayushveda.com

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