HYPERTENSION

HYPERTENSION

  1. 1
    Current Diagnosis

    • Identification of individuals with hypertension is the first step.

    • Screening should begin at 18 years of age for the general population.

    • Adults with risk factors should be screened annually beginning at 40 years of age.

    • Stage I hypertension is established at blood pressures of 140 mm Hg systolic and 90 mm Hg diastolic.

    • Stage 2 hypertension is established at blood pressures of 160 mm Hg systolic and 100 mm Hg diastolic.

    • Secondary causes of hypertension should be explored and identified to optimize treatment.

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  2. 2
    Current Therapy

    • Initial interventions, regardless of stage, should include lifestyle modifications, including diet and exercise.

    • Optimal pharmacologic therapy should be tailored to take into account age, race, and the presence or absence of chronic kidney disease.

    • For individuals 60 years of age or older, consider initiation of pharmacotherapy when systolic blood pressure is 150 mm Hg and diastolic blood pressure is 90 mm Hg.

    • For individuals younger than 60 years of age but at least 18 years of age, pharmacotherapy should be initiated when systolic blood pressure is 140 mm Hg and diastolic blood pressure is 90 mm Hg.

    • First-line agents for nonblack individuals should include thiazide- type diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers.

    • First-line agents for black individuals should include thiazide-type diuretics or calcium channel blockers.

    • Individuals with chronic kidney disease should have therapy that includes angiotensin-converting enzyme inhibitors or angiotensin receptor blockers.

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  3. 3
    Epidemiology

    Hypertension is one of the most common conditions encountered in primary care offices. It affects 33% of individuals over the age of 20 in the United States, which translates to more than 78 million Americans. The most commonly affected individuals are black adults, making up 44% of the total.

    In the pediatric population the prevalence of hypertension in the United States is between 1% and 5%, with obese children having the highest prevalence at 11%.

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  4. 4
    Risk Factors

    Diet and Sodium Intake

    Diet is a clear target for nonpharmacologic management of hypertension. Diets that are high in sodium and fat can put individuals at risk for suboptimal blood pressure control. Limiting sodium to less than 2400 mg per day confers some health benefit to individuals at risk for hypertension. Limiting even further to 1500 mg or less is more ideal and results in a significant improvement in both systolic and diastolic blood pressure typically. Additionally, putting limits on the consumption of sweets, red meat, and soda, as well as other sugar-sweetened beverages, can help weight reduction and overall health.

    Sedentary Lifestyle and Obesity

    Lack of physical activity is another important risk factor contributing to poor overall health and obesity. Current recommendations endorse engaging in at least 150 minutes of moderate-intensity activity per week. If patients are unable or unwilling to commit to that level of physical activity, then encouraging any physical activity is prudent, as it will convey at least some health benefit. Participation in physical activity results in absolute reduction in chronic comorbidities including hypertension, stroke, heart disease, diabetes, and metabolic syndrome. Resultant weight loss also results in significant improvement in blood pressure. It is noted that a weight loss of 22 pounds has the potential to reduce systolic blood pressure by 5 to 20 mm Hg.

    For children and adolescents, elevated body mass index is the greatest risk factor for the development of hypertension.

    Alcohol Intake

    Although moderate alcohol intake is thought to actually reduce cardiovascular risk, heavier consumption is a risk factor for hypertension. Limiting alcohol intake to no more than two drinks per day (with “drink” defined as 12 oz. of beer, 5 oz. of wine, or 1 oz. of liquor) for men and no more than one drink per day for women (or lightweight men) is beneficial for overall health.

    Smoking

    Along with the myriad other reasons that smoking is not a good choice (cancer risk, chronic obstructive pulmonary disease, stroke, coronary artery disease, etc.), it is also a risk factor for hypertension. This is believed to be at least in part due to a resultant increase in sympathetic nervous system activity, which leads to an increase in myocardial oxygen demand. Additionally, smoking is the leading modifiable cause of death in the United States.

    Sleep Apnea

    Obstructive sleep apnea is a well-known secondary cause of and independent risk factor for hypertension. Statistically, at least half of individuals with sleep apnea also have hypertension.

    Age

    Age is a nonmodifiable risk factor for cardiovascular disease. Risk is higher in men 55 years of age or older and women 65 years of age or older.

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    Gender

    Gender is another nonmodifiable risk factor. Men are at greater risk for hypertension prior to age 45. After age 45 and until age 64, the risk for men and women is approximately equivalent. At 65 years of age or older, women have a higher hypertensive risk than men.

    Race

    Black individuals have a higher risk of hypertension than nonblack individuals. Statistics from 2015 demonstrated that in the general population aged 18 and older, approximately 34% of black individuals had hypertension, compared to approximately 24% of white individuals. Native Americans had a slightly higher risk than white individuals at 28%, and Asians had the lowest prevalence at approximately 20%. Hispanic/Latino individuals had a slightly lower prevalence than white individuals at 23%.

    Family History

    Family history is another nonmodifiable risk factor for cardiovascular disease. Individuals with family history of premature cardiovascular disease (men younger than 45 years of age and women younger than 55 years of age) are at increased risk themselves.

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  6. 6
    Pathophysiology

    The pathophysiology of hypertension is a matter of debate. Essential hypertension, which is defined as hypertension without a clear secondary cause, makes up the majority of cases. Two primary mechanisms have been proposed for essential hypertension: neurogenic and renogenic (or nephrogenic). The neurogenic model suggests that hypertension is the result of a chronic increase in sympathetic nervous system activity. This is in contrast to the renogenic model, which attributes blood pressure increase to renal origins either through decreased renal blood flow or through renal parenchymal disease.

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  7. 7
    Prevention

    Prevention of hypertension involves optimization of modifiable risk factors. Maintaining a healthy body weight, avoiding smoking, and moderating alcohol use are all key factors in minimizing risk.

    Additionally, engaging in regular, moderate-intensity cardiovascular exercise and eating a healthy diet without excessive sodium or fat can help significantly reduce cardiovascular risk and optimize health.

    These risk factors were discussed in detail in the preceding section.

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  8. 8
    Clinical Manifestations

    Hypertension may have very few symptoms or none at all. If symptoms are present, they can include headaches, visual changes, dizziness, nausea, or chest pain. Oftentimes, however, there are no symptoms and individuals can function for years without being diagnosed.

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  9. 9
    Diagnosis

    Screening

    As noted previously, hypertension is oftentimes an asymptomatic condition. As such, screening plays a critical role in early detection to minimize the end-organ damage that could result from untreated, long-standing hypertension. The U.S. Preventative Services Task Force (USPSTF) recommends screening for hypertension in adults who are 18 years or older (grade A recommendation). Adults 40 years and older and those with increased risk of hypertension should be screened annually. A review of the existing evidence demonstrated minimal harm in screening and a significant resultant benefit in the form of a reduction in cardiovascular events. Adults 18 to 39 years of age with no additional risk factors should be screened every 3 to 5 years. Recommended screening techniques include measurement of blood pressure in the office setting with either a manual or automatic cuff and ambulatory or home blood pressure measurement. Office measurement should be done with the patient seated and after at least 5 minutes of the patient arriving in the room. Home measurement may be beneficial after the initial screening for confirmation purposes. For children and adolescents, the USPSTF indicates that the current evidence is insufficient to assess the risk versus benefit of screening in asymptomatic individuals (grade I evidence). The predictive value of childhood hypertension for adult hypertension is modest, with a risk for false-positive readings.

    Clinical Diagnosis

    Hypertension is classified in two stages based on degree of elevation. In stage 1 hypertension, systolic blood pressure is greater than or equal to 140 mm Hg to 159 mm Hg and diastolic blood pressure is greater than or equal to 90 mm Hg to 99 mm Hg. Stage 2 hypertension is reached when systolic blood pressure is 160 mm Hg or greater and diastolic blood pressure is 100 mm Hg or greater. This classification is important as the approach to treatment differs for each category, as will be discussed later.

    Primary (Essential) Hypertension

    Primary hypertension encompasses persistent blood pressure elevation without a discernable cause (idiopathic or of unknown cause). The majority of cases of hypertension will have no discernable cause and fall into this category.

    Secondary Hypertension

    Secondary hypertension is persistent blood pressure elevation that is the result of some other underlying cause. About 10% of all cases of hypertension will fall into this category. If another cause can be identified, in many cases it may be correctable.

    Looking for Secondary Causes

    Identifying these underlying causes can be a challenge. Using a systematic method of investigating potential etiologies can simplify this process and improve the chances of identifying a source that with treatment can improve outcomes. One such approach is the ABCDE mnemonic. The A in this mnemonic stands for accuracy (making sure the reading is correct—such as checking the cuff for appropriate sizing and measurement technique—and repeating readings that are obtained on automatic cuffs manually), apnea (considering the presence of obstructive sleep apnea, which is a known contributor to difficult-to-control hypertension), and aldosteronism (investigating for the presence of primary hyperaldosteronism through urinary potassium excretion and an elevation in plasma aldosterone level to plasma renin activity). B stands for bruits (looking for renovascular sources of hypertension/renal artery stenosis, which would often present with renal bruits upon auscultation) and bad kidneys (hypertension resulting from renal parenchymal disease). C stands for catecholamines (elevation that can contribute to “white coat” hypertension, as well as overproduction with pheochromocytoma or associated with other conditions such as obstructive sleep apnea and acute stress reactions), coarctation (of the aorta), and Cushing syndrome (with mineralocorticoid effects of excess glucocorticoids in this setting). D represents both drugs (including nonsteroidal antiinflammatory drugs, decongestants, estrogens, and immunosuppressive agents, as well as nicotine and alcohol) and diet (particularly excess sodium intake). The final letter in the mnemonic, E, stands for erythropoietin (high endogenous levels—such as in chronic obstructive pulmonary disease—or exogenous levels) and endocrine disorders (hypothyroidism or hyperparathyroidism).

    Utilizing a methodical and organized approach to considering potential causes of hypertension can assist with maximizing the chances of optimally controlling blood pressure.

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  10. 10
    Differential Diagnosis

    The differential diagnosis for hypertension coincides with the array of potential secondary causes that were noted earlier (see Looking for Secondary Causes section). It is important to rule out potentially treatable secondary causes in the initial phases of hypertension management.

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  11. 11
    Treatment Approaches

    Approaching treatment of a patient with hypertension can be challenging. Many factors need to be considered when making these decisions, including reflection on patient age, race, gender, and comorbidities. Each of these factors can influence what the optimal treatment strategy might be. Figure 1 provides a stepwise strategy to blood pressure management.

    FIGURE 1   Algorithm for management of hypertension.  Abbreviations: ACE = angiotensin-converting enzyme; ARB = angiotensin receptor blocker; DASH = dietary approaches to stop hypertension. (Reprinted with permission from Chobanian AV. Shattuck Lecture. The hypertension paradox—More uncontrolled disease despite improved therapy. N Engl J Med 2009;361:878–887.)

    Initial treatment should always include lifestyle modification as discussed previously, and this modification needs to be continued throughout the remainder of any management strategies.

    In 2014, the Eighth Joint National Committee (JNC 8) released new recommendations regarding the treatment of hypertension. These guidelines were a divergence from the prior JNC 7 recommendations, effectively loosening the goals and the levels at which treatment is initiated. The following is a summary of the eight treatment recommendations from JNC 8. (Please note that the strength of recommendation that is referenced corresponds to the following: grade A—strong recommendation based on evidence; grade B— moderate recommendation based on evidence; grade C—weak recommendation with moderate certainty of a small benefit; grade D—recommendation against; grade E—expert opinion with insufficient or conflicting evidence; grade N—no recommendation for or against).

    Recommendation 1

    Individuals aged 60 years or older in the general population should have pharmacologic treatment initiated at a systolic blood pressure level of 150 mm Hg or a diastolic blood pressure of 90 mm Hg with treatment goals of less than 150 mm Hg systolic and less than 90 mm Hg diastolic. (Strength of recommendation: grade A.)

    An additional aspect of this recommendation is that if the pharmacologic treatment results in adequate blood pressure reduction and there is no adverse effect on quality of life or patient health, then the treatment can be continued without alteration. (Strength of recommendation: grade E.)

    Recommendation 2

    Individuals younger than 60 years in the general population should have pharmacologic treatment initiated at a diastolic blood pressure of 90 mm Hg with a treatment goal of less than 90 mm Hg. (Strength of recommendation: grade A for ages 30–59 years, grade E for ages 18– 29 years.)

    Recommendation 3

    Individuals younger than 60 years in the general population should have pharmacologic treatment initiated at a systolic blood pressure of 140 mm Hg with a treatment goal of less than 140 mm Hg. (Strength of recommendation: grade E.)

    Recommendation 4

    Individuals aged 18 years or older with chronic kidney disease should have pharmacologic treatment initiated at a systolic blood pressure of 140 mm Hg or a diastolic blood pressure of 90 mm Hg with a treatment goal of less than 140 mm Hg systolic and less than 90 mm Hg diastolic. (Strength of recommendation: grade E.)

    Recommendation 5

    Individuals older than 18 years with diabetes should have pharmacologic treatment initiated at a systolic blood pressure of 140 mm Hg or a diastolic blood pressure of 90 mm Hg with a treatment goal of less than 140 mm Hg systolic and less than 90 mm Hg diastolic. (Strength of recommendation: grade E.)

    Recommendation 6

    The treatment of nonblack individuals in the general population (including those with diabetes) who require pharmacologic treatment should include thiazide-type diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers. (Strength of recommendation: grade B.)

    Recommendation 7

    The treatment of black individuals (including those with diabetes) should include thiazide-type diuretics or calcium channel blockers. (Strength of recommendation: grade B for general population, grade C for patients with diabetes.)

    Recommendation 8

    The treatment of individuals older than 18 years with chronic kidney disease should include, either as initial or add-on treatment, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers to improve renal outcomes. (Strength of recommendation: grade B.)

    Recommendation 9

    The goal of hypertension treatment is to reach and maintain blood pressure goals consistent with the previous recommendations. If goals are not reached within a month of starting pharmacologic treatment, the dose of the initial agent should be increased or a second agent from recommendation 6 should be added. Blood pressure should continue to be assessed until the goal blood pressure is achieved. If blood pressure goals are not achieved with two agents, a third agent should be added.

    •   Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) should not be used together.

    •   If necessary, other classes of agents can be used if more than three agents are required or if there are contraindications to the agents in recommendation 6.

    •   Referral to a hypertension specialist should be considered for patients whose blood pressure goals cannot be met with the previous strategies or who are more complicated. (Strength of recommendation: grade E.)

    Nonpharmacologic

    For stage I hypertension (140–159/90–99 mm Hg), the first treatment step is to aggressively modify lifestyle. This includes targeting both diet and exercise. These nonpharmacologic strategies should continue even if pharmacologic treatment is found to be necessary. The relative effects of lifestyle modification on blood pressure reduction are noted in Table 1.

    Table 1

    Effect of Lifestyle and Diet Modifications on Systolic Blood Pressure

    Abbreviations: DASH = dietary approaches to stop hypertension; SBP = systolic blood pressure.

    Diet

    Dietary modifications include salt restriction to a level of less than 2400 mg per day but ideally less than 1500 mg per day. Suggested dietary interventions also include the use of the DASH (dietary approaches to stop hypertension) framework. This nutritional framework includes recommendations such as increased consumption of fruits and vegetables, preferential use of complex carbohydrates, and consumption of low-fat dairy products. The DASH diet emphasizes the intake of whole grains, fish, poultry, legumes, nuts, and nontropical vegetable oils. This diet also endorses decreasing higher-fat foods.

    Exercise

    Current exercise recommendations suggest that engaging in a minimum of 150 minutes of moderate-intensity exercise on a weekly basis confers the greatest health benefits. Exercise at this level of intensity reduces the risk of multiple chronic conditions including cardiovascular disease and type 2 diabetes, as well as overall all-cause mortality.

    Other Lifestyle Modifications

    In addition to diet and exercise, other lifestyle interventions can optimize health. Smoking cessation is an important modifiable risk factor and is the single leading cause of preventable death in the United States. Smoking increases the risk of cardiovascular morbidity and mortality, including myocardial infarction.

    Alcohol consumption is another important lifestyle modification that can have a significant impact on overall health. The effects of alcohol consumption, unlike smoking, depend on quantity. It has been shown that at moderate levels of consumption, alcohol can actually decrease blood pressure (defined as no more than two drinks per day for males and no more than one drink per day for females). However, when consumed in greater quantity, alcohol can increase blood pressure, contributing to hypertension. It is emphasized that alcohol consumption should not be promoted in nondrinkers simply for the purpose of decreasing blood pressure.

    Stress reduction is another lifestyle change that can have effects on blood pressure control. The mechanism of this reduction is not clear, but it is hypothesized that it may be related to decreasing autonomic nervous system output. Studies suggest that activities such as transcendental meditation can lead to modest blood pressure reduction. As such, inclusion of these activities in patient treatment plans may provide additional nonpharmacologic options.

    Patients frequently ask about the utility of dietary supplements or other natural alternatives for blood pressure management. There is some evidence for select supplements in the management of hypertension, although such effects appear to be small. Examples of natural substances that may convey a small benefit include garlic and cocoa. Evidence is lacking for other agents including vitamin C, coenzyme Q10, omega-3 fatty acids, and magnesium.

    Pharmacologic

    In cases where hypertension is more significant or nonpharmacologic methods have failed to adequately reduce blood pressure, initiation of medications is indicated (Table 2). The selection of an agent or agents is based on a number of factors including race and comorbidities. As noted earlier, JNC 8 provides a stepwise, evidence-based approach to blood pressure management including recommended cut points where pharmacologic intervention is appropriate.

    Table 2

    Antihypertensive Classes

    Adapted from Medscape. Hypertension Medication. Available at: http://www.emedicine.medscape.com/article/241381-medication. Accessed May 5,   2017.

    Exceeds dosage recommended by the manufacturer.

    One of the points of emphasis of JNC 8 is that the point of intervention for individuals age 60 years or older is higher than those younger than that age. One should also balance the side effects or risks of medications with the benefits of intervention in this age group. The cut points for individuals with chronic kidney disease and

    diabetes do not differ from the general population. The choice of agent according to JNC 8 does not differ based on the presence or absence of diabetes, but does differ based on race (see recommendations 6 and 7 earlier). Individuals with chronic kidney disease also should have an ACEI or an ARB included in their treatment regimen (either as a lone agent or an add-on). In practice, decisions will need to be tailored to individual patient needs and also should consider other factors including whether or not the patient is a reproductive-age female (as ACEIs and ARBs are contraindicated in pregnancy). This is where our role as family physicians becomes increasingly important—embracing our ability to look at the whole patient when making treatment decisions.

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    Monitoring

    Clinical practice guidelines vary in their recommendations regarding optimal monitoring. It is clear that monitoring in the early stage or during periods of treatment change should be more frequent than during times of stability, somewhere between monthly and every 6 weeks. Once the patient is stabilized, periodic monitoring can occur either every 3 to 6 months for everyone or in a more risk-stratified manner, with lower-risk patients being seen every 6 months and higher-risk patients every 3 months.

    JNC 8 recommendations, as previously discussed, suggest that patients with hypertension be monitored on at least a monthly basis until goal blood pressure is achieved, with any necessary adjustments being made at these visits.

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    Complications

    Hypertension is often referred to as “the silent killer.” This menacing name refers to the fact that this condition often presents without any discernable symptoms, which at times can make treatment compliance challenging. One of the greatest concerns with uncontrolled hypertension is the risk of end-organ damage, which is far-reaching.

    Uncontrolled hypertension can lead to serious complications including myocardial infarction, stroke, peripheral artery disease, retinopathy, and renal failure. Given that hypertension is at the same time the most common condition we treat as primary care physicians, the opportunities to circumvent these sources of morbidity and mortality present themselves on a daily basis.

     

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