Management of Hypertension
Whether or not antihypertensives are used, the best results come from alterations in lifestyle that favorably impact the blood pressure: weight loss, healthy diet, smoking cessation, nutritional counseling for glycemic control and management of lipids, and exercise.
Setting a Blood Pressure (BP) Goal
It is important that the patient and physician set a BP goal for therapy, based on the recommendations of the physician, and follow a timeline along which other therapeutic approaches are to be used if the goal is not met.
When lifestyle alteration fails or when a patient is simply non-compliant in attempting it, a pharmacologic approach to hypertension is indicated. This involves the following types of medications, initially only one, in what is called monotherapy:
- Calcium channel blockers (dihydropyridines)
- ACE (angiotensin-converting enzyme inhibitors)
- ARBs (angiotensin II receptor blockers)
- Beta blockers: Beta blockers block the beta-sympathetic receptors which when filled cause vasoconstriction and increased cardiac contractility.
- Alpha blockers: These block the alpha-sympathetic receptors but are not recommended.
The choice of which single agent to use can be influenced by a number of things, including race, diabetes, pregnancy, side effects, allergies, previous monotherapy failure with one of the others, and physician preference. For example, for African-Americans, a thiazide diuretic or long-acting calcium channel blocker should be used first. For those with renal disease, including diabetic kidney disease, an ACE inhibitor or ARB should be used. Younger patients do best with ACE inhibitors or ARBs and beta blockers.
When there is severe heart disease, myocardial infarction, or heart failure, a beta blocker can be added to the monotherapy to decrease the strain on the heart by blocking the adrenalin receptors that increase vasoconstriction and heart contractility.
Some diuretics can create a renal loss of potassium, so potassium levels can be monitored via blood tests (e.g., a complete metabolic profile–CMP). The CMP can also monitor sodium and calcium whose elevations are warning signals for kidney disease, a common co-morbidity with hypertension.
Sequential monotherapy: when one agent fails, depending on the urgency of bringing the pressure down, another monotherapy choice can be tried.
When a BP goal is not met with monotherapy, meaning the systolic and the diastolic pressures remain more than 20 mmHg and 10 mmHg above the target goal, respectively, a combination therapy can be used, e.g., a long-acting dihydropyridine calcium channel blocker + a long-acting ACE inhibitor or ARB.
Treatment for Dyslipidemia
Those with abnormal cholesterol or triglyceride levels treated with antihypertensives may show improvement in their lipid profile; also, those treated with statins for dyslipidemia may show improvement in their blood pressures. Thus, when a patient has both hypertension and abnormal lipids, both should be treated, but this is true for each of the conditions, anyway, regardless of the presence of the other. This benefit falls away when thiazide diuretics are higher dosed than usual or with the addition of beta blockers.