Management of hypertension
Blood pressure target
For most people, recommendations are to reduce blood pressure to less than or equal to somewhere between 140/90 mmHg and 160/100 mmHg.[2] In general, for people with elevated blood pressure, attempting to achieve lower levels of blood pressure than the recommended 140/90 mmHg will create more harm than benefits,[3] in particular for older people.[4] In those with diabetes or kidney disease, some recommend levels below 120/80 mmHg;[2][5] however, evidence does not support these lower levels.[6]
The benefit of medications is related to a person's cardiac disease risk.
If the blood pressure goal is not met, a change in treatment should be made as therapeutic inertia is a clear impediment to blood pressure control.[12]
Lifestyle modifications
The first line of treatment for hypertension is identical to the recommended preventive lifestyle changes[13] and includes dietary changes,[14] physical exercise, and weight loss. These have all been shown to significantly reduce blood pressure in people with hypertension.[15] Their potential effectiveness is similar to and at times exceeds a single medication.[11] If hypertension is high enough to justify immediate use of medications, lifestyle changes are still recommended in conjunction with medication.[16]
Dietary change, such as a low sodium diet and a vegetarian diet, are beneficial. A long-term (more than 4-week) low-sodium diet is effective in reducing blood pressure, both in people with hypertension and in people with normal blood pressure.[17] Also, the DASH diet, a diet rich in nuts, whole grains, fish, poultry, fruit and vegetables, lowers blood pressure.[18] A major feature of the plan is limiting intake of sodium, although the diet is also rich in potassium, magnesium, calcium, and protein.[18] A vegetarian diet is associated with a lower blood pressure, and switching to such a diet may be useful for reducing high blood pressure.[19] A review in 2012 found that a diet high in potassium lowers blood pressure in those with high blood pressure and may improve outcomes in those with normal kidney function,[20] while a 2006 review found evidence to be inconsistent; additionally, the review found no significant reduction in blood pressure overall for people with high blood pressure who were given oral potassium supplementation.[21] Meta-analyses conducted by the Cochrane Hypertension group have found no evidence of an appreciable blood pressure reduction from any combination of calcium, magnesium, or potassium supplements; this information stands contrary to prior systematic reviews suggesting that a dietary intake adjustment for each of these may benefit adults with high blood pressure.[22][23][24] While weight loss diets reduce body weight and blood pressure, it is unclear if they reduce negative outcomes.[14]
Some programs aimed to reduce psychological stress, such as
Several exercise regimes—including
Medications
Several classes of medications, collectively referred to as antihypertensive medications, are available for treating hypertension. Use should take into account the person's cardiovascular risk (including risk of myocardial infarction and stroke), as well as blood pressure readings, in order to gain a more accurate picture of the person's risks.[2]
The best first-line medication is disputed,
Medication combinations
The majority of people require more than one medication to control their hypertension. In those with a systolic blood pressure greater than 160 mmHg or a diastolic blood pressure greater than 100 mmHg, the American Heart Association recommends starting both a thiazide and an ACEI, ARB, or CCB.[15] An ACEI and CCB combination can be used as well.[15] In general, medications should be implemented in a stepped care approach when people do not reach target blood pressure levels.[34]
Unacceptable combinations are non-dihydropyridine calcium blockers (such as verapamil or diltiazem) and beta-blockers, dual renin–angiotensin system blockade (e.g., angiotensin converting enzyme inhibitor + angiotensin receptor blocker), renin–angiotensin system blockers and beta-blockers, and beta-blockers and centrally acting medications.
Regular monitoring of blood pressure
The regular measurement of blood pressure is critical in the management of hypertension. The American Heart Association recommends home monitoring for people with elevated readings.[38] Readings taken at predetermined regular intervals are considered by healthcare providers in determining whether a treatment is working and in suggesting alternative treatments.[39] A study published in December 2018 by Clinical Cardiology showed that a home-based program involving a Bluetooth-enabled blood pressure monitoring device reduced hypertension in seven weeks.[40] In the study, patients with hypertension (blood pressure above 140/90 mmHg) measured their blood pressure twice a day, the blood pressure device transmitted the readings to an electronic medical record, and that data was used to adjust participants' medication at biweekly intervals.[40]
Elderly
Treating moderate to severe hypertension decreases death rates and cardiovascular
There are no randomized clinical trials addressing the goal blood pressure of hypertensives over 79 years old. A recent review concluded that antihypertensive treatment reduced cardiovascular deaths and disease, but did not significantly reduce total death rates.[41] Two professional organizations have published guidelines for the management of hypertension in persons over 79 years old.[43][44]
Resistant hypertension
Resistant hypertension is defined as hypertension that remains above goal blood pressure in spite of using, at once, three antihypertensive medications belonging to different drug classes. Guidelines for treating resistant hypertension have been published in the UK[45] and US.[46] It has been proposed that a proportion of resistant hypertension may be the result of chronic high activity of the autonomic nervous system, known as "neurogenic hypertension".[47] Low adherence to treatment is an important cause of resistant hypertension.[48] This low adherence to blood pressure treatment is the result of many patients’ generally poor health literacy, costly antihypertensive medications, and inability to accurately follow complex regimens.[49]
Some common secondary causes of resistant hypertension include obstructive sleep apnea, pheochromocytoma, renal artery stenosis, coarctation of the aorta, and primary aldosteronism.[50]
Research
Non-drug treatment
One avenue of research investigating more effective treatments for severe resistant hypertension has focused on the use of selective
Although considered an experimental treatment in the United States and the United Kingdom, it is an approved treatment in Europe, Australia, and Asia.[55][56]
Pregnancy
Regarding research in hypertension that occurs during pregnancy, it has been recommended that basic research be directed toward increasing understanding of the genetics and pathogenesis of
2017 guidelines
The American Heart Association and the American College of Cardiology issued guidelines on November 13, 2017, based on the findings of the
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