Cardiovascular disease is today the largest single contributor to global mortality. Hypertension is the main risk factor for cardiovascular disease, prevalent in both developed and developing countries.
Lifestyle modification (including diet, physical activity and weight control), antihypertensive drugs and renal denervation are used for managing of hypertension. Most new guidelines recommend initial treatment of hypertension with one or more of the following three classes of firs line BP lowering agents including calcium channel blockers (CCBs), renin angiotensin system inhibitors (ACEIs or ARBs) and thiazide type diuretics.
CCBs are generally well tolerated, do not require monitoring with blood tests, amlodipine can protect against nonfatal coronary events, stroke and death but provides less protection against heart failure. Unlike diuretics and RAS inhibitors they are not compromised by high salt diet or NSAID therapy.
Renin-Angiotensin Inhibitors reduce CV events and prevent deterioration of renal function in high-risk hypertensive patients.
Diuretics were the first line drugs for treating hypertension but Joint National Committee members in 2014 (JNC8) listed them as one of three first line choices. In ALLHAT study, the diuretic was equally effective as the ACE and CCB in preventing coronary events and strokes, more effective than CCBs in preventing heart failure.
ACCOMPLISH trial showed that the combination of an ACEI with a CCB yield better outcomes than did combination with HCTZ. Diuretic has more side effects than ACEI and CCB.
Add-On Drugs include aldosterone antagonists, beta-adrenergic blockers, alpha-adrenergic blockers (prazosin), central sympatholytics (clonidine), direct vasodilators (minoxidil, hydralazine).
RCTs have shown that most hypertensive patients will require at least two and often three or more medications of different drug classes plus lifestyle modification to control their hypertension.
Combining any two drugs at their starting doses is five times more effective in lowering BP than doubling the dose of any single drug, it has synergistic effects and permits the use of lower doses to minimize dose dependent side effects.
Optimal target level of BP: target of below 140/90 for most hypertensive patients, target of below 130/80 for those with DM or CKD(especially in those with proteinuria) or suspected coronary disease or peripheral arterial disease or those with high global CV risk and target of below 150 mm Hg in elderly patients. In gestational hypertension antihypertensive medication is reserved only for stage 2 hypertension (BP>160/110).
In elderly patients even modest reduction in SBP can confer great benefit, however the intensity of the BP reduction must be weighed against increased risk for hypotension which can precipitate falls and ischemic events. Because white coat (office only) hypertension and masked (out of office only) hypertension are common, ambulatory and home BP monitoring should be considered in hypertensive patients.