Hypertension is a aloft accident agency for cardiovascular-related ache and afterlife worldwide. Although it is one of the best accepted affidavit for physician visits, hypertension is generally undertreated. To facilitate the administration of hypertension, the Canadian Hypertension Education Program provides recommendations that are adapted yearly. Using a academic case, we altercate the key 2005 recommendations for managing apprehensible hypertension. Apprehensible hypertension refers to hypertension afterwards the attendance of comorbid altitude such as diabetes mellitus, abiding branch ache or cardiac disease, which would crave a specific antihypertensive agent.
CASE: A 64-year-old woman presents in your appointment for aftereffect with claret burden that has been animated over the accomplished 2 months (at 3 antecedent appointment visits, her claret burden was 178/96 mm Hg, 170/94 mm Hg and 168/96 mm Hg), alike admitting she is afterward the DASH diet and accepting 30 annual of aerobic exercise 5 canicule per week. Her medical history includes dyslipidemia and hypertension. She has no ambition agency accident and no added accident factors for cardiovascular disease. She works as an accountant and does not smoke or booze alcohol. Her alone medication is pravastatin for her dyslipidemia. The after-effects of her concrete assay are contrarily unremarkable.
Question: Should I accord this accommodating pharmacotherapy?
Comment: The accommodation to activate antihypertensive biologic analysis charge booty into annual the patient’s approaching cardiovascular risk. “White coat” (or office-induced) hypertension may additionally charge to be afar afore biologic analysis is started. Accustomed this patient’s claret burden and cardiovascular accident factors (age and dyslipidemia), she would account from an antihypertensive agent. The after-effects of abundant analytic studies accept approved that with moderately animated claret burden (≥ 160 mm Hg systolic or ≥100 mm Hg diastolic), antihypertensive analysis leads to 20%–25% reductions in cardiovascular anguish and 5%– 15% reductions in mortality.1 When claret burden is agilely added (140–159 mm Hg systolic or 90–99 mm Hg diastolic), patients with macrovascular ambition agency accident or a cardinal of cardiovascular accident factors would accept abundantly added accident to accreditation initiating biologic therapy.
Question: Which antihypertensive agents should I initiate?
Comment: Variables complex in the best of abettor accommodate the patient’s age, preferences, comorbid conditions, and biologic abhorrence or acuteness profile; whether the accommodating is abundant or lactating; and the bulk of the drugs (Box 1). For this patient, any distinct abettor from the afterward biologic classes would be an adapted first-line option: low-dose thiazide diuretics, angiotensin-converting agitator (ACE) inhibitors, long-acting calcium-channel blockers or angiotensin-receptor blockers (Table 1). A meta–analysis of 192 478 patients accent the accent of claret burden blurred and begin no aberration in cardiovascular anguish or absolute bloodshed amid any of these biologic classes compared with low-dose diuretics.1
Although β-blockers are a reasonable advantage for first-line analysis in adolescent patients and those with absolute cardiovascular disease, they are not recommended as first-line monotherapy in patients 60 years of age or more. In a meta-analysis of patients 60 years and older, β-blocker monotherapy was no added able than placebo in abbreviation the accident of coronary avenue disease, cardiovascular-related afterlife or afterlife due to any cause.2 In the ALLHAT study, α-blockers were associated with a college accident of affection abortion than were thiazide diuretics.3 Thus, α-blockers are not advised first-line agents for managing hypertension.
Question: I’ve absitively to alpha this accommodating with hydrochlorothiazide at 12.5 mg per day. How should I adviser her for adverse effects?
Comment: Metaic disturbances such as hypokalemia, dyslipidemia and hyperglycemia action infrequently with low doses of thiazide diuretic. Despite the accident of these abnormalities, the all-embracing cardiovascular allowances remain. Affirmation is defective on the optimal abundance and timing of ecology for adverse furnishings associated with antihypertensive agents. In our opinion, all patients starting on thiazide diuretics (even at low doses) should be buried afterwards 4–6 weeks for glucose, electrolyte, creatinine and serum absolute cholesterol levels in case metaic disturbances occur. Any abnormalities should alert afterpiece aftereffect and correction. The accident of hypokalemia can be minimized amid patients accepting thiazide diuretic monotherapy through the use of potassium-sparing agents (e.g., triamterene, aldactone, amiloride). For those demography ACE inhibitors or angiotensin-receptor blockers, serum creatinine levels should be monitored 2–4 weeks afterwards analysis starts. Serum potassium and creatinine levels should be monitored at atomic 1–2 times per year thereafter. In general, if there are adverse furnishings with a distinct agent, addition biologic from any of the added adapted first-line agents should be substituted.
Patients accustomed biologic analysis should acknowledgment for aftereffect claret burden ecology every 1–2 months until their ambition akin is reached. Patients with astringent hypertension, bent to antihypertensive drugs or ambition agency accident may charge to be monitored added frequently. Once the ambition akin is reached, claret burden should be monitored at intervals of 3–6 months.
Question: Afterwards accretion hydrochlorothiazide to a accepted dosage (25 mg per day), the patient’s claret burden is 162/92 mm Hg. Since this akin is still aloft the ambition (140/90 mm Hg), what medication should be added?
Comment: For best patients, extensive a ambition of beneath than 140/90 mm Hg requires 2 or added antihypertensive agents at accepted doses. In a meta-analysis of 50 placebo-controlled trials evaluating drugs from 2 altered classes alone and in combination, reductions in claret burden with aggregate biologic analysis were additive, and adverse furnishings were appear beneath generally than expected.4 Thus, if the claret burden ambition has not been accomplished at the accepted dosage (rather than the best dose) of an antihypertensive agent, a added antihypertensive abettor should be started and the dosage added to the accepted bulk until the claret burden ambition is met. Currently, there is little -to-be affirmation acknowledging starting with a aggregate of 2 drugs, although trials are ongoing.
For this patient, and in general, thiazide diuretics can be accumulated with any of the added aloft biologic classes (calcium-channel blockers, β-blockers, ACE inhibitors or angiotensin-receptor blockers). On the base of their commutual physiologic effects, added advantageous combinations accommodate a calcium-channel acquaintance with either an ACE inhibitor or angiotensin-receptor blocker. If claret burden is still not controlled with 2 agents or if there are adverse effects, addition abettor should be added from the actual first-line agents. Added classes of antihypertensive drugs, such as α-blockers and centrally acting agents, may be acclimated if added analysis is bare for claret burden control.
Question: Two months later, the accommodating is demography 3 agents at accepted dosages: hydrochlorothiazide 25 mg per day, enalapril 10 mg alert circadian and amlodipine 10 mg per day. However, her claret burden charcoal aloft ambition at 152/90 mm Hg. What should I accede now?
Comment: The boilerplate abridgement in claret burden with a distinct abettor at accepted dosage is 9.1 (8.8–9.3) mm Hg systolic and 5.5 (5.4–5.7) mm Hg diastolic.4 Using 3 agents, one would apprehend an alike greater abridgement in claret pressure, which is not credible in our patient. When the accommodating is not responding to analysis and suboptimal analysis has been excluded, one charge accede nonadherence, accessible medication adverse effects, or aggressive hypertension (Box 1).
Alternatively, if the accommodating describes affection of hypotension or letters lower claret burden readings alfresco of the appointment setting, accede office-induced hypertension. A 24-hour ambulant claret burden barometer accessory can be acclimated to affirm this diagnosis. If the ambition claret burden charcoal difficult to achieve, barometer to a hypertension specialist should be considered.
On added altercation with this patient, she had chock-full demography the enalapril because of a dry cough. We recommended that the enalapril be replaced with atenolol 50 mg daily. At the aing aftereffect visit, her claret burden was 138/85 mm Hg, the ambition level.
Question: Abounding patients accuse about “having to booty so abounding pills.” What strategies can advice to advance adherence to the ameliorative regimen?
Comment: Nonadherence to the ameliorative dieting may action for a array of reasons. Several strategies that can advice to advance adherence are apparent in Box 2.
McAlister FA, Wooltorton E, Campbell NRC. The Canadian Hypertension Education Program (CHEP) recommendations: ablution a new series. CMAJ 2005;173(5):508-9.
Bolli P, Myers M, McKay D. Applying the 2005 Canadian Hypertension Education Program recommendations: 1. Analysis of hypertension. CMAJ 2005;173(5):480-3.
Hemmelgarn BR, Grover S, Feldman RD. Applying the 2005 Canadian Hypertension Education Program recommendations: 2. Assessing and abbreviation all-around atheroscl accident amid hypertensive patients [published absurdity appears in CMAJ 2005;173(7):738]. CMAJ 2005;173(6):593-5.
Padwal R, Campbell N, Touyz RM. Applying the 2005 Canadian Hypertension Education Program recommendations: 3. Lifestyle modifications to anticipate and amusement hypertension. CMAJ 2005;173(7):749-51.
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