Hypertension
Hypertension is a multisystem disease whose hallmark is the elevation of blood pressure.
Classification
| Blood pressure classification | Initial blood pressure mm Hg | Followup recommended | ||
|---|---|---|---|---|
| SBP | DBP | |||
| Normal | <120 | and | <80 | Recheck in 2 years |
| Prehypertension | 120-139 | or | 80-99 | Recheck in 1 year |
| Stage 1 Hypertension | 140-159 | or | 90-99 | Confirm within 2 months |
| Stage 2 Hypertension | >160 | or | >100 | "Evaluate or refer to source of care within 1 month. For those with higher pressures (e.g., >180/110 mmHg), evaluate and treat immediately or within 1 week depending on clinical situation and complications." |
Diagnosis
A systematic review by the Rational Clinical Examination has reviewed the research on measuring the blood pressure.[1]
If the diastolic pressure is below 110 mm Hg, it should be confirmed on two addition visits as some patients will have a lower blood pressure on repeat measurements.[2] A larger cuff should be used for obese patients.[3]
21% of patients with untreated borderline hypertension (diastolic pressure between 90 and 104 mm Hg) may have normal blood pressures outside of the doctor's office.[4]
Some patients may have their blood pressure rise by as much as 25 mm Hg due to an alarm reaction upon seeing a doctor.[5]
Elderly patients may have pseudohypertension due to inability of the blood pressure cuff to compress stiff arteries.[6] Pseudohypertension may be detected by Osler's maneuver.[6]
Excluding secondary hypertension
Listening for an abdominal bruit, especially if it is both systolic and diastolic, may help detect underlying renal artery stenosis.[7]
Treatment
Current clinical practice guidelines are based on The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7).[8]
Treatment goals
Per the JNC7 Guidelines:[8]
- "Treating "most patients" SBP and DBP to targets that are <140/90 mmHg is associated with a decrease in cardiovascular complications.
- In patients with hypertension and diabetes or renal disease, the BP goal is <130/80 mmHg.
Initial medication
In the absence of any comordid medical conditions that would affect the selection of a drug, the JNC7 recommends:
- "Thiazide-type diuretics for most"[8]
However, the initial drug may be better selected based on the patient's age, race, and gender.[9][10] The patient's demographic roughly corresponds with their renin profile, but is more predictive than the renin profile.[10] The molecular basis is being determined.[11]
In the high renin demographic (young whites), diuretics had similar efficacy to placebo; whereas in the low renin demographic (older blacks), the ace-inhibitors had similar efficacy to placebo in the Masterson Veterans Affairs Cooperative Study Group on Antihypertensive Agents (see figure).[9]
| Category name | demographics | Comments | Best anti-hypertensive categories |
|---|---|---|---|
| High renin demographic | less than 50 years old, anglo | salt-sensitive; diuretic responsive | diuretics, calcium channel blockers |
| Low renin demographic | more than 50 years old, non-anglo* | ace-inhibitors, beta-blockers | |
| * Obesity and female[12] are also associated with low renin. | |||
Several randomized controlled trials have compared initial medications for hypertension.[13][14][15][9]
- In the Second Australian National Blood Pressure study (ANBP2),[14] ace-inhibitors were better in a population that was 95% white with a body-mass index of 27. This demographic has features of both high (age) and low (race) renin status.
- In the ALLHAT study,[13] diuretics were better in a population that was 47% white with a body-mass index of 30.
For patients with Stage 2 Hypertension (SBP >160 or DBP>100 mmHg), start with two drugs.[8]
The race and age demographic may partly predict frequency of drug toxicity to different anti-hypertensive medications.[16]
Persistent hypertension
Systolic hypertension
Prognosis
References
- ↑ Reeves RA (1995). "The rational clinical examination. Does this patient have hypertension? How to measure blood pressure". JAMA 273 (15): 1211–8. PMID 7707630. [e]
- ↑ Hartley RM, Velez R, Morris RW, D'Souza MF, Heller RF (1983). "Confirming the diagnosis of mild hypertension". Br Med J (Clin Res Ed) 286 (6361): 287–9. PMID 6402075. [e] PubMed Central
- ↑ Nielsen PE, Larsen B, Holstein P, Poulsen HL (1983). "Accuracy of auscultatory blood pressure measurements in hypertensive and obese subjects". Hypertension 5 (1): 122–7. PMID 6848459. [e]
- ↑ Pickering TG, James GD, Boddie C, Harshfield GA, Blank S, Laragh JH (1988). "How common is white coat hypertension?". JAMA 259 (2): 225–8. PMID 3336140. [e]
- ↑ Mancia G, Parati G, Pomidossi G, Grassi G, Casadei R, Zanchetti A (1987). "Alerting reaction and rise in blood pressure during measurement by physician and nurse". Hypertension 9 (2): 209–15. PMID 3818018. [e]
- ↑ 6.0 6.1 Messerli FH, Ventura HO, Amodeo C (1985). "Osler's maneuver and pseudohypertension". N. Engl. J. Med. 312 (24): 1548–51. PMID 4000185. [e]
- ↑ Turnbull JM (1995). "The rational clinical examination. Is listening for abdominal bruits useful in the evaluation of hypertension?". JAMA 274 (16): 1299–301. PMID 7563536. [e]
- ↑ 8.0 8.1 8.2 8.3 Chobanian AV, Bakris GL, Black HR, et al (2003). "The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report". JAMA 289 (19): 2560-72. DOI:10.1001/jama.289.19.2560. PMID 12748199. Research Blogging. http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf
- ↑ 9.0 9.1 9.2 9.3 Materson BJ, Reda DJ (1994). "Correction: single-drug therapy for hypertension in men". N. Engl. J. Med. 330 (23): 1689. PMID 8177286. [e]
Cite error: Invalid
<ref>tag; name "pmid8177286" defined multiple times with different content - ↑ 10.0 10.1 Preston RA, Materson BJ, Reda DJ, et al (1998). "Age-race subgroup compared with renin profile as predictors of blood pressure response to antihypertensive therapy. Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents". JAMA 280 (13): 1168–72. PMID 9777817. [e]
- ↑ Materson BJ (2007). "Variability in response to antihypertensive drugs". Am. J. Med. 120 (4 Suppl 1): S10–20. DOI:10.1016/j.amjmed.2007.02.003. PMID 17403377. Research Blogging.
- ↑ Cowley AW, Skelton MM, Velasquez MT (1985). "Sex differences in the endocrine predictors of essential hypertension. Vasopressin versus renin". Hypertension 7 (3 Pt 2): I151–60. PMID 3888837. [e]
- ↑ 13.0 13.1 ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (2002). "Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT)". JAMA 288 (23): 2981-97. PMID 12479763. [e]
- ↑ 14.0 14.1 Wing LM, Reid CM, Ryan P, et al (2003). "A comparison of outcomes with angiotensin-converting--enzyme inhibitors and diuretics for hypertension in the elderly". N. Engl. J. Med. 348 (7): 583-92. DOI:10.1056/NEJMoa021716. PMID 12584366. Research Blogging.
- ↑ Materson BJ, Reda DJ, Cushman WC, et al (1993). "Single-drug therapy for hypertension in men. A comparison of six antihypertensive agents with placebo. The Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents". N. Engl. J. Med. 328 (13): 914-21. PMID 8446138. [e]
- ↑ McDowell SE, Coleman JJ, Ferner RE (2006). "Systematic review and meta-analysis of ethnic differences in risks of adverse reactions to drugs used in cardiovascular medicine". BMJ 332 (7551): 1177–81. DOI:10.1136/bmj.38803.528113.55. PMID 16679330. Research Blogging.