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The Treatment of Adults with Essential Hypertension

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APPLIED EVIDENCE The Treatment of Adults with Essential Hypertension STEVEN A. DOSH, MD, MS Escanaba, Michigan ypertension is arbitrarily defined as diastolic KEY POINTS FOR CLINICIANS Hblood pressure (DBP) of 90 mm Hg or higher, ● Only 53% of hypertensive patients are being systolic blood pressure (SBP) of 140 mm Hg or high- treated, and only 24% have their hypertension er, or both, on 3 separate occasions. Essential hyper- under control. tension is hypertension without an identifiable ● The first step in planning the treatment of a cause. Essential hypertension, also known as pri- patient with essential hypertension is to catego- mary or idiopathic hypertension, accounts for at least rize the patient's risk status. 95% of all cases of hypertension. ● The target blood pressure of patients who have According to the third National Health and diabetes or renal failure should be less than Nutrition Examination Survey (NHANES III), approx- 130/85. imately 60% of the 50 million Americans with hyper- ● Diuretics are safe, well tolerated, effective, rela- tension are at increased risk for cardiovascular dis- tively inexpensive, and convenient for initial ease resulting from uncontrolled hypertension. This drug treatment of hypertension in patients who is because only 53% of hypertensive patients are do not have concomitant illness. being treated and only 24% have their hypertension ● Alpha-adrenergic blockers should be used with under control.1 Physicians must play an active role in caution in the treatment of hypertension. identifying and treating hypertension. ● Ambulatory blood pressure measurements pre- In an earlier Applied Evidence article2 an dict cardiovascular events more closely than clin- approach to the diagnosis of hypertension was pre- ic blood pressure measurements. sented. This article reviews the treatment of essential hypertension in adults and the prognosis of untreat- ed hypertension. Risk stratification, alternative thera- category, cardiovascular risk factors, and evidence of pies, lifestyle modification, drug therapy, and prog- end-organ damage found during the initial evalua- nosis will each be reviewed sequentially. tion (Table 1). Once the treatment category is iden- ■ KEY WORDS Blood pressure; hypertension; tified, initial treatment should begin (Figure 1). prognosis; therapy; acupuncture; alternative therapy; Subsequent treatment depends on the patient's biofeedback; herbal medicine; transcendental medi- response to initial treatment (Figure 2). tation; yoga.(J Fam Pract 2002; 51:74-79) Patients should be monitored regularly to be sure they do not develop signs and symptoms that would RISK STRATIFICATION place them in a different category and mandate more The decision to treat hypertension and the choice of aggressive treatment. After a patient's blood pressure treatment is affected by the patient's risk of morbid- has been controlled for 1 year, it may be possible to ity and mortality if the blood pressure remains decrease the dose or the number of antihypertensive untreated or under-treated. According to the recom- drugs—especially among patients who make signifi- mendations of the sixth report of the Joint National cant lifestyle changes.4 Committee on the Prevention, Diagnosis, Evaluation, The effectiveness of therapy varies depending on and Treatment of High Blood Pressure (JNC-VI), the the patient's cardiovascular risk. The New Zealand first step in planning treatment of a patient with •Submitted, revised, September 4, 2001. essential hypertension is to categorize the patient's From the OSF Medical Group. Reprint requests should be risk status.3 The patient is placed in 1 of 9 treatment addressed to Steven A. Dosh, MD, MS, OSF Medical Group, 3409 categories according to his or her blood pressure Ludington, Escanaba, MI 49837. E-mail: [email protected]. 74 ■ The Journal of Family Practice • JANUARY 2002 • VOL. 51, NO. 1 TREATMENT OF ESSENTIAL HYPERTENSION Guidelines Group has developed a helpful risk cal- TREATMENT culator based on the Framingham Heart Study for Drug Therapy estimating a patient's cardiovascular risk. This calcu- Patients who require drug treatment for hyperten- lator incorporates sex, age, systolic blood pressure, sion should begin with a low dose of the initial med- smoking status, total cholesterol, high-density ication, and that dose should be slowly titrated lipoprotein cholesterol, presence or absence of dia- upward every 1 to 2 months (Figure 2). The JNC-VI betes, and presence or absence of electrocardiogram recommends a diuretic or a ß-blocker with once evidence of left ventricular hypertrophy. This helpful daily dosing and 24-hour efficacy as the initial treat- risk calculator may be downloaded from the Web ment for most hypertensive patients. However, the site of the New Zealand Guidelines Group at choice of initial medication will be affected by con- http://www.nzgg.org.nz/library/gl_complete/blood- comitant illnesses: (1) ß-blockers are recommended pressure/appendix.cfm#app3. Alternatively, the for the initial treatment of patients with hypertension University of Sheffield Medical School has developed and a history of coronary artery disease; (2) diuretics tables to estimate an individual's risk of heart disease are suggested for the initial treatment of isolated sys- based on cardiovascular risk factors including age, tolic hypertension; (3) and angiotensin-converting sex, cholesterol level, and presence or absence of enzyme (ACE) inhibitors are recommended for smoking, hypertension, and diabetes—Sheffield hypertensive patients who have systolic dysfunction tables.5 Software for handheld computers (Palm and after myocardial infarction, diabetic nephropathy, or PocketPC) that helps you estimate risk is available at congestive heart failure. Angiotensin II receptor www.jfponline.com. blockers may be used in patients who cannot toler- Regardless of the method used, the benefit of ate ACE inhibitors because of cough or rash. Alpha- treatment increases steadily as the patient's current adrenergic blockers should be used with caution in cardiovascular risk increases. With a 5-year cardio- light of evidence that they may increase the risk of vascular risk of less than 2.5%, more than 120 cardiovascular events (especially congestive heart patients have to be treated for 5 years to prevent 1 failure).7 cardiovascular event; this number decreases to 25 Among patients who do not have concomitant ill- patients with a risk of between 5% and 10%, and ness, the choice of drug therapy is controversial. A only 13 with a risk of between 20% and 24%.6 It is case-control study and a meta-analysis suggested tempting to assume that the benefit of hypertension that short-acting calcium channel blockers (CCBs) treatment is related to reduction in blood pressure increase cardiovascular mortality.8,9 Unfortunately, whether achieved by drug therapy, lifestyle modifi- these studies were not designed to establish a causal cation, or alternative therapy. However, this has not relationship. A recent nonsystematic review suggest- been established and it is important to consider the ed that short-acting CCBs should be avoided and evidence supporting the benefit of each of these that conventional therapies were more effective than therapeutic options (Table 2). long-acting CCBs.10 An earlier non-systematic review suggested that short- and inter- TABLE 1 mediate-acting CCBs were HYPERTENSION RISK STRATIFICATION AND TREATMENT CATEGORIES associated with increased car- diovascular mortality and mor- Blood Pressure bidity. However, a well- Category Risk Group A* Risk Group B* Risk Group C* designed cohort study of patients with coronary artery High-normal Lifestyle Lifestyle modification Lifestyle modification (130 – 139/85 – 89) modification† and drug therapy disease failed to reveal an increase in adverse effects Stage 1 Lifestyle modification Lifestyle modification Lifestyle modification among patients taking short- (140 – 159/0 – 99) (12-month trial) (6-month trial) and drug therapy acting CCBs.11 Furthermore, Stage 2 or 3 Lifestyle modification Lifestyle modification Lifestyle modification randomized controlled trials ( ≥160 / ≥100) and drug therapy and drug therapy and drug therapy suggest that diuretics, ß-block- ers, and long-acting CCBs are equally effective in preventing *Risk groups: A = no risk factors, end-organ damage, or clinical cardiovascular disease; B = ≥ 1 risk factor other than diabetes, no end-organ damage, and no clinical cardiovascular disease; C = Diabetes, end-organ cardiovascular mortality and damage, or clinic cardiovascular disease. morbidity.12,13 Physicians who † Lifestyle modification should be included in the treatment plan of all patients receiving drug therapy. treat hypertension must choose the best initial treat- The Journal of Family Practice • JANUARY 2002 • VOL. 51, NO. 1 ■ 75 TREATMENT OF ESSENTIAL HYPERTENSION TABLE 2 mortality for all stages of NUMBER NEEDED TO TREAT (NNT) FOR SPECIFIC ANTIHYPERTENSIVE TREATMENTS hypertension, but peo- ple with the greatest Level of baseline cardiovascular Medication Evidence NNT (95% CI)* Comment risk (eg, older patients Low-Dose 1a 18 (14-23) Adults with systolic blood pressure and patients with higher Thiazide ≥160 or diastolic blood pressure ≥ 90 regardless of age or comorbidities. levels of blood pressure) have the most to gain High-Dose Thiazide 1a 67 (48-111) 17,18 Beta-Blocker 1a 142 (71-1000) Drug vs no treatment from treatment. comparison.14 There is no conclusive Calcium-Channel Blockers 1b 45 (30-102) Isolated systolic
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