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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2866_Библиотеки_им_академика_М_И_Перельмана.pdf
316
J. Barmecha
Treatment
The treatment of high blood pressure requires a multipronged approach, which includes lifestyle management,
non-pharmacological, and pharmacological interventions.
Lifestyle Management
A healthy lifestyle is essential in the management of high
blood pressure [8]. Healthy lifestyle choices can prevent or
delay the onset of high BP and can reduce both cardiovascular risk and hypertension-mediated organ damage (HMOD).
Diet, nutrient intake, and physical activity can play an important role in the prevention and treatment of blood pressure
and its associated complications. Dietary modifications
include weight loss, reduced salt intake, increased potassium
intake, moderation of alcohol consumption, and consumption
of an overall healthy dietary pattern, similar to a DASH
(Dietary Approaches to Stop Hypertension) diet.
Diet: Emphasis on intake of vegetables (8–10 servings/
day), fruits and whole grains, low-fat dairy products (2–3 servings/day), poultry, fish, legumes, nontropical vegetables oils
and nuts, limited intake of sweets, sugar-sweetened beverages,
and red meat is recommended. The following forms of diet to
control hypertension are recommended:
• DASH (www.dashforhealth.com) [9] or its variant diet
• US Department of Agriculture (USDA) diet
• American Heart Association (AHA) diet
Diet counseling should take into account personal and
cultural food preferences, appropriate calorie intake, and
other medical conditions.
Dietary supplements: Garlic has been shown to have blood
pressure-lowering property and therefore has been used as a
dietary supplement to lower blood pressure.
Cocoa has a small blood pressure-lowering effect (average
of 2–3 mmHg) in adults with hypertension, but there is no
evidence that it improves cardiovascular events.
Chapter 16. Hypertension
Although vitamin C, coenzyme Q10, omega-3 fatty acids,
and magnesium are used for lowering blood pressure, there is
no clear evidence to support their use in the prevention or
treatment of hypertension.
Sodium can be reduced to 2400 mg/day or less if the
desired BP goal is not achieved.
Potassium intake can be increased potassium intake to
4.7gm/day.
Physical activity: Engaging in aerobic physical activity for
3–4 sessions a week lasting on average of 40min per session
(moderate to vigorous intensity) or at least 150min per week
of moderate intensity is shown to be beneficial in reducing
blood pressure.
Weight loss: The target body mass index is ≤25. Alternatively,
a waist-to-height ratio<0.5 is recommended.
Smoking cessation: Smoking cessation lowers blood pres-
sure and heart rate, reducing overall cardiovascular morbidity
and mortality.
Alcohol use: Limit to ≤2 alcoholic drinks per day for men
and ≤1 alcoholic drink per day for women. One alcoholic
drink is defined as 12 ounces of regular beer, 5 ounces of
wine, or 1.5 ounces of 80-proof distilled spirits (10 g
alcohol).
Other healthy drinks: Moderate consumption of coffee
and green and black tea. Others include hibiscus tea, pomegranate juice, beetroot juice, and cocoa.
Relaxation techniques: There is sporadic evidence for yoga,
transcendental meditation, acupuncture, and biofeedback
techniques in lowering blood pressure.
317
Pharmacological Interventions
Pharmacological agents, in addition to lifestyle management,
provide the primary basis for treatment of high blood pressure (Fig.16.1). Based on the recent guidelines [7], pharmacotherapy should be initiated for persons with stage 1
318
J. Barmecha
Established Diagnosis of
Hypertension
(BP 130-139/80-89 mm Hg)
NO
Non-
Pharmacological
Therapy
Reassess in 3 – 6
months
STAGE 1
Clinical
ASCVD or
estimated 10 yr
CVD risk > 10%
YES
Non
Pharmacological
Therapy and BP
lowering meds
Reassess in 1 month
STAGE 2
(BP > 140/90 mmHg)
BP goal met
YES
NO
Reassess in
3-6 months
Assess for adherence
and or consider
intensification of
therapy
F . Algorithm for blood pressure thresholds, treatment
recommendation and reassessments
hypertension with ASCVD or 10-year CVD risk ≥10% and
stage 2 hypertension as mentioned in Table16.3.
Current evidence demonstrates that antihypertensive
pharmacotherapy not only lowers blood pressure but reduces
the risk of cardiovascular disease, cerebrovascular events, and
death [4]. Various classes of antihypertensive agents are available to treat high blood pressure. The primary agents used in
the treatment of hypertension include thiazide diuretics, ACE
Inhibitors, ARBs, and CCBs (Table16.4). Drug combinations
that have similar mechanisms of action or clinical effects
Chapter 16. Hypertension
T . AHA/ACC (2020) guideline recommendations by blood
pressure category
Pressure
ranges
BP category
Normal BP <120/<80 Promote healthy lifestyle; reassess
Elevated BP 120–
Stage 1
hypertension
Stage 2
hypertension
(mmHg) Recommendations
BP annually
Start with non-pharmacologic
129/<80
130–
139/80–89
≥140/≥90
therapy; reassess BP in 3–6months
ASCVD or 10-year CVD risk≥10%
Start with both nonpharmacologic and
pharmacologic therapy. Reassess
BP in 1month. If at goal,
reassess every 3–6months. If
not at goal, assess for adherence
and consider intensification of
therapy
No ASCVD and 10-year CVD
risk<10%
Start with non-pharmacologic
therapy; reassess BP in
3–6months. If not at goal,
consider initiation of
pharmacologic therapy
Start with both non-pharmacologic
and pharmacologic therapy.
Reassess BP in 1month. If at goal,
reassess every 3–6months. If not
at goal, assess for adherence and
consider intensification of therapy
319
J. Barmecha
320
T . Choice and indications of antihypertensive medications
Initial drugs
of choice for
hypertension
• ACE inhibitor
(ACEI)
• Angiotensin
receptor
blocker (ARB)
• Thiazide
diuretic
• Calcium
channel blocker
(CCB)
Recommended indications
Indication Treatment choice
Heart failure ACEI/
Post-MI/clinical
CAD
CAD ACEI, BB, diuretic, CCB
Diabetes ACEI/ARB, CCB, diuretic
CKD ACEI/ARB
Recurrent stroke
prevention
Pregnancy Labetalol (first line), nifedipine,
Source: Modified with permission from a card developed by Cole
Glenn, Pharm D and James Taylor, Pharm D. www.nmhs.net/docum
ents/27JNC8HTNGuidelinesBookBooklet.pdf [10]
Beta-1 selective beta-blockers (BB)
Safer in patients with COPD, asthma,
diabetes, and peripheral vascular disease
• Metoprolol
• Bisoprolol
• Betaxolol
• Atenolol
ARB+BB+diuretic+spironolactone
ACEI/ARB and BB
ACEI, diuretic
methyldopa
should be avoided. Many patients started on a single pharmacological agent will subsequently require more than two
drugs from different pharmacological classes to control blood
pressure (Table 16.5). Initiation of antihypertensive drug
therapy with a single drug is reasonable with stage 1 hyper-
Chapter 16. Hypertension
T . Summary of oral antihypertensive drugs
Class Choice of medications Comments
Diuretics HCTZ 12.5–50mg
Chlorthalidone 12.5–
25mg
Indapamide 1.25–
2.5mg
Spironolactone
25–50mg
Eplerenone 50–100mg
Amiloride 5–10mg
Triamterene 100mg
Furosemide 20–80mg
Torsemide 10–40mg
Metolazone 2.5–5mg
Bumetanide 0.5–2mg
Monitor for
hypokalemia
Most side effects are
metabolic in nature
Most effective when
combined w/ACEI
Stronger clinical
evidence with
chlorthalidone
Spironolactonegynecomastia and
hyperkalemia
Loop diuretics may
be needed when
GFR<40mL/min
ACEI/ARB ACEI
Lisinopril 10–40mg
Benazepril 10–40mg
Fosinopril 10–40mg
Quinapril 10–40mg
Ramipril 5–10mg
Trandolapril 2–8mg
Perindopril 4–16mg
Side effects: Cough
(ACEI only),
angioedema (more with
ACEI), hyperkalemia
Losartan lowers uric
acid levels; candesartan
may prevent migraine
headaches
ARB
Candesartan 8–32mg
Valsartan 80–320mg
Losartan 50–100mg
Olmesartan 20–40mg
Telmisartan 20–80mg
Azilsartan 40–80mg
Eprosartan 600–
800mg
321
(continued)
322
J. Barmecha
T . (continued)
Class Choice of medications Comments
Betablockers
Calcium
channel
blockers
Atenolol 25–100mg
Betaxolol 5–20mg
Nadolol 40–120mg
Acebutolol 200–
800mg
Penbutolol 10–40mg
Pindolol 10–60mg
Labetalol 200–800mg
Metoprolol succinate
50–100mg and tartrate
50–100mg, twice daily
Nebivolol 5–10mg
Propranolol 40–120mg
twice daily carvedilol
6.25–25mg twice daily
Bisoprolol 5–10mg
Labetalol 100–300mg
twice daily
Dihydropyridines
Amlodipine 5–10mg
Nifedipine ER
30–90mg
Nicardipine SR
60–120mg
Isradipine 5–10mg
Nisoldipine 17–34mg
Felodipine 2.5–10mg
Non-dihydropyridine
Diltiazem ER 180–
360mg
Verapamil 80–120mg
three times daily or
ER 240–480mg
Not first-line agents;
reserve for post-MI/
CHF
Cause fatigue and
decreased heart rate
Adversely affect
glucose, mask
hypoglycemic awareness
Cause edema;
dihydropyridines may
be safely combined w/B- blocker
Non-dihydropyridines
reduce heart rate and
proteinuria
Chapter 16. Hypertension
T . (continued)
Class Choice of medications Comments
Direct
vasodilators
Alpha-1
blockers
Centrallyacting agents
Direct renin
inhibitors
Hydralazine
25–100mg twice daily,
Minoxidil 5–10mg
Terazosin 1–20mg
Doxazosin 1–16mg
Prazosin 2–20mg
Clonidine 0.1–0.2mg
twice daily methyldopa
250–500mg twice daily
Guanfacine 0.5–2mg
Aliskiren 150–300mg Very long acting, do not
Hydralazine and
minoxidil may cause
reflex tachycardia and
fluid detention–usually
require diuretic+BB
Alpha-blockers may
cause orthostatic
hypotension
Clonidine available
in weekly patch
formulation for resistant
hypertension
use with ACEI or ARB
Avoid in pregnancy and
CKD
323
tension with dosage titration and sequential addition of other
agents to achieve the BP target. Initiation of antihypertensive
drug therapy with two first-line agents of different classes,
either as separate agents or in a fixed-dose combination, is
recommended with stage 2 hypertension and an average BP
more than 20/10mmHg above their BP target.
Various substances, including prescriptions medications,
over-the-counter medications, illicit drugs, herbals, and food
substances, may affect BP [4]. In the clinical assessment of
hypertension, a careful history should be taken with regard to
medications and substances (Table16.6) that impair BP control. When feasible, any medications or substances associated
with increased BP should be reduced or discontinued, and an
alternative agent(s) should be used [4].
J. Barmecha
324
T . Medications and substances that may cause high BP
Alcohol Herbals (Ma Huang, St. John’s Wort)
Amphetamines Immunosuppressant (cyclosporine)
Antidepressants (MAOI,
SNRIs)
Atypical antipsychotics
(clozapine, olanzapine)
Caffeine Systemic corticosteroids
Decongestants
(pseudoephedrine)
Oral contraceptives
Angiogenesis inhibitor
(bevacizumab) and tyrosine kinase
inhibitors (sunitinib)
Recreational drugs (Cocaine, bath
salts)
Office, Home Blood Pressure Monitoring
(HBPM), andAmbulatory Blood Pressure
Monitoring (ABPM)
Outpatient office measurements continue to be the most
common means of diagnosing hypertension. The home and
ambulatory readings are more consistent and better reflect
hypertension-mediated organ damage (HMOD) risk and better differentiate white coat hypertension with elevated office
measurements and masked hypertension, where measurements are lower in the office.
The office blood pressure measurement can vary by
20–25mmHg between visits due to various factors and limitations such as poor technique, masked effect, white coat effect,
and a small number of readings. Moreover, the traditional
office blood pressure (BP) may not provide accurate estimates of blood pressure status. There are currently two methods of out of office blood pressure monitoring modalities that
Chapter 16. Hypertension
T . Blood pressure patterns that can be determined by
ofce BP, ambulatory blood pressure monitoring ABPM and HBPM
measurements
Blood pressure Office BP ABPM HBPM
Predict events + + +
Diagnostic utility + + +
White coat hypertension − + +/−
Masked hypertension − + −
Measures diurnal variation of BP − + −
Cost Low High Low
Duration of drug effects − + +
Reimbursement Ye s Partial No
325
have been recommended such as self or home monitoring
(HBPM) and ambulatory blood pressure monitoring
(Table16.7). The blood pressure measured over 24h by an
ambulatory recording (ABPM) is the best method for estimating an individual’s cardiovascular risk related to hypertension and response to antihypertension therapies [11]. The
ABPM is also the most effective means to determine white
coat or masked hypertension, and the BP values during sleep
when nocturnal hypertension or non-dipping profiles are
suspected (Fig.16.2). For both self- and ambulatory blood
pressure monitoring, the use of the upper arm is better than
the wrist monitors, except in very obese individuals. Finger
devices are not reliable. An up-to-date list of monitors can be
retrieved from www.validatebp.org [12]. Currently, ABPM is
being widely used in clinical practice, and the expenses are
often reimbursed by most of the payors.