Management of Blood Pressure Disorders
The most conservative approach is usually the first treatment strategy:
- lifestyle changes
- Low salt diet
- Potassium supplementation
- Quit smoking, if a smoker
- Weight loss via caloric restriction and nutritional counseling
- Exercise to address a sedentary lifestyle, especially in sedentary occupations
- Alcohol restriction (avoid excesses)
- Psychological counseling to identify stressors and to develop coping skills to handle them
- CPAP for obstructive sleep apnea, which is associated with hypertension
When conservative measures fail or when a patient is non-compliant with them, pharmacologic therapy is indicated, which can reduce heart failure by 50%, stroke by 30-40%, and myocardial infarction by 20-25%.
Drug therapy is typically begun when the out-of-office mean BP is ≥130 systolic or ≥80 diastolic. These same criteria apply even when there are no out-of-office data, but the ≥130/≥80 criteria are met with office BP readings in patients who have one or more of the following:
- Age >65
- Any cardiovascular disease
- Type 2 diabetes
- Chronic kidney disease
Depending on age, race, and/or the presence of diabetes (DM), initial therapy begins with one of 4 medications:
- Thiazide diuretics
- Calcium channel blockers
- ACE (angiotensin-converting enzyme) inhibitors
- ARBs (angiotensin II receptor blockers)
When monotherapy fails to achieve a target BP (the “goal” BP), a combination of an ACE inhibitor or ARB with a calcium channel blocker can be tried. (Alternately, the ACE inhibitor or ARB can also be used with a thiazide diuretic). When this fails, an ACE inhibitor or an ARB in combination with both a calcium channel blocker and the diuretic.
If a patient cannot tolerate the typical combination therapeutic choices, a beta blocker, alpha blocker, or arterial vasodilator can be used.
When results are good and a normal BP remains stable for a few years, the dose and number of antihypertensive agents can be reduced as a trial, as many patients maintain their normal BPs off medications for years, especially if they have lost weight.