HIGH BLOOD PRESSURE
From the American Academy of Family Physicians’ 2008 Scientific Assembly, San Diego
Robert F. Raspa, MD, Faculty, St. Vincent’s Medical Center, Department of Family Practice, Jacksonville, FL
Educational Objectives
| The goal of this program is to improve the management of hypertension. After hearing and assimilating this program,
the clinician will be better able to:
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 | 1. Identify patients at risk of developing hypertension.
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| 2. Counsel patients about lifestyle interventions to reduce blood pressure or prevent the development of hypertension.
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| 3. Diagnose hypertension and establish goals for management.
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| 4. Customize management plans, based on risk factors, comorbid conditions, and severity of hypertension.
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| 5. Improve adherence to medical regimens for managing hypertension.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest.
Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary
business or commercial interest. For this program, Dr. Raspa and the planning committee reported nothing to disclose.
Acknowledgments
Dr. Raspa was recorded at the American Academy of Family Physicians’ 2008 Scientific Assembly, held September
17-21, 2008, in San Diego, CA. The Audio-Digest Foundation thanks Dr. Raspa and the AAFP for their support in the
production of this program.
| General guidelines: United States Preventive Services Task Force (USPSTF) strongly recommends screening for
hypertension; home monitoring of blood pressure (BP) important for some patients; hypertension diagnosed when
BP measurement elevated on ≥2 successive visits; treatment—first-line medical options include diuretics, angiotensin-converting
enzyme (ACE) inhibitors, and β-blockers; after myocardial infarction (MI), patients should take
aspirin, β-blockers, and ACE inhibitors (if no contraindications) to prevent recurrent MI and cardiovascular-related
death; approach to screening and management—hypertension often not presenting complaint, but should be addressed
when present
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| Example case: black woman, 67 yr of age, weighs 364 lb, and complains of knee pain; medical history includes diabetes
and hypercholesterolemia, but no renal disease; management—patient primarily concerned about knee pain;
opportunity for intervention and education
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| Diagnosis: hypertension—BP ≥140/90 mm Hg; normal—BP <120/<80 mm Hg; prehypertension—systolic BP of
120 to 139 mm Hg or diastolic BP of 80 to 89 mm Hg; patients at risk of developing hypertension
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| Classification: stage 1—systolic BP of 140 to 159 mm Hg; diastolic BP of 90 to 99 mm Hg; stage 2—BP ≥160/
≥100 mm Hg
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| Adverse events: risk doubles with each 20-mm Hg increase in BP (above normal); treatment goals—prevent adverse
outcomes (eg, MI, stroke) and end organ damage
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| Risk factors: smoking; obesity; physical inactivity; dyslipidemia; diabetes; older age (men \>55 yr of age; women
\>65 yr of age); history of heart disease in first-degree relative (male relative <55 yr of age, female relative <65 yr of
age); microalbuminuria; glomerular filtration rate (GFR) <60 mL/min
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| Target organ damage: left ventricular hypertrophy (LVH; electrocardiography [ECG] recommended for all patients
with hypertension); angina; coronary artery disease (CAD); congestive heart failure (CHF); nephropathy (evidenced
by, eg, presence of protein in urine); peripheral arterial disease (eg, claudication); retinopathy
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| Management basics: prehypertension—emphasize lifestyle interventions; address risk factors; stage 1—begin
with lifestyle interventions; initiate medical therapy when lifestyle interventions insufficient (avoid delay); stage
2—2-drug therapy recommended (but consider initiating sequentially to identify source of adverse reactions, if
any); in Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), most patients
required 2 to 3 medications to control BP; patients with diabetes or renal disease—BP goal of <130/<80 mm Hg
(National Kidney Foundation recommends <120/<80 mm Hg; goals to reduce morbidity and mortality and preserve
renal function; patients with CHF—consider more aggressive management (eg, BP <130/<80 mm Hg)
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| Prevention: Framingham study showed age-related hypertension common in United States; diet rich in fresh fruits
and vegetables and low-fat dairy products (eg, Dietary Approaches to Stop Hypertension [DASH] diet) lowers BP
and risk for hypertension; sodium—high in all processed foods; low-sodium diet rich in fresh food recommended;
patients with prehypertension—treating with diuretic for 1 yr delayed, but did not prevent, development of hypertension;
lifestyle interventions key
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Lifestyle Interventions
| Efficacy: decrease BP; reduce number or dose of antihypertensive medications; may prevent hypertension; associated
with minimal cost and risk
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| Weight loss: approach—caloric restriction and exercise; case example—patient reduced daily caloric intake by 500
kcal; initiated water aerobics twice weekly (later increased to 4 times/wk); patient lost 60 lb in first 6 mo; 70-lb
weight loss maintained for ≥1.5 yr; BP decreased; 2 antihypertensive agents discontinued; knee pain resolved;
weight-loss drugs—generally avoid; compliance (eg, with orlistat) difficult in some patients
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| Alcohol restriction: high daily intake common; reducing intake decreases hemoglobin A1c (HbA1c ) level and
weight; problems include resistance to antihypertensive agents and increased caloric intake; maximum daily intake of
alcohol—2 drinks for men and 1 drink for women
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| Physical activity: aerobic exercise associated with cardiovascular benefit, regardless of weight loss; goal—≥30 min
of aerobic exercise (to achieve target heart rate [HR]) ≥3 days/week; note—helpful to calculate target HR for patients
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| Diet: sodium—restriction important (decreases BP and edema, especially in salt-sensitive patients); presence of
edema indicates excessive intake of salt; some antihypertensive agents (eg, diuretics, calcium-channel blockers
[CCBs]) more effective when sodium restricted; decreasing dietary sodium decreases LVH; DASH diet restricts sodium
intake, increases potassium and calcium intake, and results in BP decrease of 8 to 14 mm Hg (better than
medical monotherapy); potassium—avoid potassium supplements in patients taking potassium-sparing agents;
caffeine—no effect on BP; fat—high intake of dietary fat increases cardiovascular risk, but reducing dietary fat
has little effect on BP; increasing intake of omega-3 fatty acids may lower BP
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| Relaxation: unlikely to reduce BP in absence of other lifestyle modifications; one study showed benefit in blacks
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| Smoking: BP transiently increases with smoking (avoid measuring BP within 5-10 min after smoking); smoking
cessation may not significantly lower BP, but prolongs life (eliminates risk factor for CV disease); most nicotine-
cessation aids (eg, patch, gum) do not raise BP
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Medical Therapy
| Efficacy: recommended when lifestyle interventions insufficient; drug therapy shown to reduce CV mortality and
morbidity and risk for stroke, CHF, renal disease, and all-cause mortality
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| General approach: begin with low dose, given once daily; when necessary, add second agent (use diuretic if not
used as initial therapy), beginning with low dose
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| Initial therapy: diuretic recommended for most patients with uncomplicated hypertension; ALLHAT showed diuretic
(chlorthalidone) as effective as β-blockers, CCBs, and ACE inhibitors; Australian study found ACE inhibitors superior to
hydrochlorothiazide in white men; problems with diuretics—adverse effects (eg, frequent urination; but frequency
should decrease if diuretics taken consistently); if adverse effects intolerable, consider switching patient to ACE inhibitor
(but, causes cough in some patients); if potassium levels fall precipitously after initiation of diuretic, measure aldosterone
level (high level suggests aldosteronoma; switch to spironolactone [potassium-sparing]); adding agents—add agent
from different class of antihypertensives
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| Choice of agents: β-blockers—recommended as first-line therapy only for patients with hypertension and CAD or
CHF (less effective in other patients); ACE inhibitors—first-line therapy for patients with diabetes and hypertension;
angiotensin receptor blockers (ARBs)—as effective as ACE inhibitors; recommended for patients intolerant
of ACE inhibitors
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| Special cases: patients with HF—ACE inhibitor and β-blocker recommended; aldosterone antagonist (eg, spironolactone)
and loop diuretic added for symptom control in patients with New York Heart Association (NYHA)
class-III HF; patients at risk for postural hypotension—long-acting CCB suggested; β-blockers reduce risk for
stroke, but less effective for managing BP in these patients; post-MI— β-blocker plus ACE inhibitor; add aldosterone
antagonist when appropriate (eg, to decrease cardiac preload); angina—CCB or β-blocker; atrial tachycardia
or fibrillation— β-blocker or nondihydropyridine CCB to control HR; avoid using drugs together, because
additive effect may cause heart block; patients taking cyclosporine—CCBs control drug-induced hypertension;
essential tremor— β-blockers (eg, propranolol [Inderal] or metoprolol) work well; HF—studies showed
carvedilol superior to metoprolol, and losartan superior to other ARBs and ACE inhibitors (but all acceptable);
hyperthyroidism— β-blocker controls tachycardia and other symptoms; migraine—propranolol commonly used
to control headache with hypertension; non dihydropyridine CCB also used; osteoporosis—thiazide diuretics
cause calcium retention; preoperative hypertension—some studies suggest importance of controlling with
atenolol before surgery; other studies stress importance of intraoperative and perioperative control by anesthesiologist;
Raynaud syndrome—CCB suggested
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| Potential problems: asthma—avoid β-blockers in patients with true asthma (induce bronchospasm); safe to use in
most patients with chronic obstructive pulmonary disease (airways do not react to β-blockers); depression—central
α-agonists and reserpine may exacerbate; gout—avoid thiazide diuretics, but other diuretics (eg, indapamide, furosemide
[Lasix]) safe; heart block or CHF—avoid combining β-blocker and nondihydropyridine CCB;
dyslipidemia—some studies suggest β-blockers raise cholesterol, but proven benefit after MI; diabetes— β-blockers
mask symptoms of hypoglycemia; use clinical judgment before prescribing to diabetic patient; high-dose diuretics—
doses \>25 mg may increase adverse effects, decrease potassium levels, and raise levels of glucose and low-density
lipoprotein (LDL) cholesterol; liver disease—avoid drugs heavily metabolized by liver (eg, metoprolol, α-methyldopa);
peripheral vascular disease—use of β-blockers leads to unopposed α-signaling, which can worsen claudication;
options include CCBs or agents that cause α- and β-blockade (eg, labetalol); pregnancy—avoid ACE inhibitors
and ARBs in women of childbearing age; angioedema—may worsen with ACE inhibitors but not ARBs; renal
insufficiency—caution required when using potassium-sparing agents; renovascular disease—ACE inhibitors and
ARBs may cause elevations in creatinine (≈30%); agents often discontinued when patient admitted for acute renal
insufficiency; if warranted, reinitiate therapy after acute insufficiency resolved
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| Combination therapy: 6.25 mg hydrochlorothiazide plus β-blocker or ACE inhibitor, good options; ACE inhibitor
plus nondihydropyridine CCB reduces proteinuria and edema; metolazone plus loop diuretic useful in patients
with renal failure with persistent edema (may increase creatinine level but helps off-load fluid); adding ACE inhibitor
to CCB results in less pedal edema, compared to CCB alone
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| Newer agents: eplerenone—selective aldosterone-receptor antagonist does not block testosterone (as does spironolactone),
so does not cause gynecomastia in men; both agents raise potassium levels and interfere with lithium; aliskiren
(Tecturna)—renin blocker that effectively lowers BP; targets same pathway as ACE inhibitors and ARBs;
role not established, but likely useful in patients with HF or diabetes; not suitable for patients prone to hypotension
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| Other agents and combinations: statins for BP reduction—decrease BP by ≈2 mm Hg; good add-on therapy for
patients with indications; combination of ACE inhibitor and ARB—no benefit over monotherapy in patients with diabetes;
small benefit in patients with CHF, but questionable cost-effectiveness
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| Discontinuing medication: consider trial discontinuation after 1 yr; emphasize lifestyle modifications (discontinuation
often possible in highly motivated patients)
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| Adherence: poor adherence contributes to insufficient control of hypertension in most patients; assessing
adherence—ask about “forgetting medication” during each visit (be empathetic); ask pharmacist to monitor refills;
use electronic notification when available; implement system for follow-up calls; improving adherence—involve patients
in their treatment (eg, monitor BP at home); maintain contact; reduce cost and complexity of medical regimen;
counsel patient about integration into daily routine; encourage lifestyle modifications; use long-acting drugs;
schedule follow-up appointments; stop unsuccessful therapy; advise patients about adverse effects; adjust therapy
to reduce adverse effects; add effective and tolerated drugs stepwise; maintain positive attitude about goals and
good relationship with patient
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| Reasons for inadequate response: white coat hypertension—patient has transiently elevated BP in office (ie, not
true hypertension); have patient monitor BP at home; volume overload—excess salt intake; inadequate diuresis; need
for exercise; drug issues—wrong agent or combination; insufficient dose; other factors—smoking; increasing obesity;
sleep apnea (ask about snoring); insulin resistance or hyperinsulinemia; ethanol excess; anxiety; true secondary
cause—consider when BP goal not met with 3 agents (and patient adherent to therapy); secondary causes of hypertension
include sleep apnea, renovascular disease, other medications, primary aldosteronism, renal disease, Cushing’s
disease, pheochromocytoma (rare), coarctation of aorta, and hyperthyroidism or hyperparathyroidism; cocaine-related
chest pain—BP increases with β-blocker; treat acutely with benzodiazepine (eg, lorazepam); CCB or nitroglycerine
also acceptable
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| Issues in women: respond similarly to men to antihypertensive agents; hormone replacement therapy uses low-dose
estrogen, so does not raise BP; ACE inhibitors contraindicated in women of childbearing age; pregnancy—
methyldopa (eg, Aldomet) commonly used; some β-blockers (eg, metoprolol) safe in second and third trimesters, but
avoid atenolol (stunts growth of fetus); nifedipine acceptable, but blocks calcium (BP may drop precipitously if patient
requires magnesium infusion; treat with calcium); note, chronic hypertension during pregnancy (even if treated)
increases risk for poor fetal outcomes; diuretics acceptable; methyldopa and CCB considered first-line therapy; little
evidence for aspirin and calcium (may benefit patients with history of preeclampsia); labor and delivery—
hydralazine (intravenous administration preferred) is drug of choice
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Suggested Reading
Bavikati VV et al: Effect of comprehensive therapeutic lifestyle changes on prehypertension. Am J Cardiol 102:1677, 2008;
Chrysant SG et al: Current and future status of beta-blockers in the treatment of hypertension. Clin Cardiol 31:249, 2008;
Cushman WC et al: Blood pressure control by drug group in the Antihypertensive and Lipid-Lowering Treatment to Prevent
Heart Attack Trial (ALLHAT). J Clin Hypertens (Greenwich) 10:751, 2008; Fodor GJ et al: Lifestyle changes and blood
pressure control: a community-based cross-sectional survey (2006 Ontario survey on the prevalence and control of hypertension).
J Clin Hypertens (Greenwich) 11:31, 2009; Fung TT et al: Adherence to DASH-style diet and risk of coronary heart disease
and stroke in women. Arch Intern Med 168:713, 2008; Holland N et al: Identifying barriers to hypertension care: implications
for quality improvement initiatives. Dis Manag 11:71, 2008; Levy D: Hypertension from Framingham to ALLHAT: translating
clinical trials into practice. Cleve Clin J Med 74:672, 2007; Mendoza MD, Stevermer JJ: Hypertension with metabolic
syndrome: think thiazides are old hat? ALLHAT says think again. J Fam Pract 57:306, 2008; Messerli FH et al: Impact of
systemic hypertension on the cardiovascular benefits of statin therapy—a meta-analysis. Am J Cardiol 101:319, 2008; Okcay
A et al: Obstructive sleep apnea and hypertension. J Clin Hypertens (Greenwich) 10:549, 2008; Rosendorff C: Hypertension
and coronary artery disease: a summary of the American Heart Association scientific statement. J Clin Hypertens (Greenwich)
9:790, 2007; Sear JW: Perioperative control of hypertension: when will it adversely affect perioperative outcome? Curr
Hypertens Rep 10:480, 2008; Welch V, Tang SS: Treatment and control of BP and lipids in patients with hypertension and
additional risk factors. Am J Cardiovasc Drugs 7:381, 2007; Wojciechowski D et al: Evaluation and treatment of resistant
or difficult-to-control hypertension. J Clin Hypertens (Greenwich) 10:837, 2008; Wright JT Jr et al: Clinical outcomes by
race in hypertensive patients with and without the metabolic syndrome: Antihypertensive and Lipid-Lowering Treatment to Prevent
Heart Attack Trail (ALLHAT). Arch Intern Med 168:207, 2008.
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