Treatment of Hypertension
The primary objective of antihypertensive therapy is to reduce cardiovascular and renal morbidity and mortality. Controlling systolic BP is the major concern because, in patients older than 50 years, systolic BP greater than 140 mm Hg is a more important cardiovascular risk factor than diastolic BP. In addition, diastolic BP is usually controlled when the systolic goal is reached. Maintaining BP at less than 130/80 mm Hg decreases cardiovascular complications. In hypertensive patients with diabetes mellitus or renal disease, the BP goal is less than 120/80 mm Hg. These patients have a higher incidence of proteinuria, which is associated with hyperlipidemia, cardiovascular events, and overall higher morbidity. Effective BP control can be attained in most patients with hypertension, but the majority of these patients require 2 or more medications to achieve this control. It is important for patients to understand that lifelong treatment is usually necessary and that symptoms are not a reliable indicator of the severity of hypertension.
When selecting the appropriate therapy for a patient, the physician should consider multiple factors: stage of hypertension, target-organ disease, cardiovascular risk factors, cost, adherence, adverse effects, and comorbid conditions. In general, the higher the BP, the greater the damage to target organs; and the greater the risk factors for cardiovascular disease, the sooner treatment should be initiated. For example, patients with severe hypertension and encephalopathy require urgent treatment, whereas those with mild hypertension may wish to attempt lifestyle modifications before drug therapy is initiated along with consideration of comorbid conditions such as diabetes mellitus and obesity.
Obesity, sedentary lifestyle, excessive sodium intake, moderate daily alcohol consumption, and inadequate intake of vitamins and minerals, including potassium, calcium, magnesium, and folate, can contribute to the development of hypertension. Smoking is also a major contributor to cardiovascular disease in patients with hypertension. Lifestyle modifications, including reducing weight, adopting the DASH (Dietary Approaches to Stop Hypertension) eating plan, reducing dietary sodium intake, increasing physical activity, and moderating alcohol and caffeine consumption can decrease BP, enhance the effectiveness of antihypertensive drugs, and lower the risk of cardiovascular disease; Table 3-4 presents further details. The PREMIER trial investigated the benefit of adding behavioral modifications such as increased physical activity to the DASH diet. At 18 months, the prevalence of hypertension remained lowest in this group compared with those on the DASH program alone and with those who had only received advice once on dietary and behavioral intervention. Such healthful lifestyle habits are essential for the prevention and control of hypertension.
Excerpted from BCSC 2020-2021 series: Section 1 - Update on General Medicine. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.