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Hypertension

CME credit available from Harvard Medical School through November 2019.

Published Materials

The goal of this program is to update prescribers on the most recent evidence regarding treatment of hypertension, selection of blood pressure goals based on patient characteristics, and management of hypertension with non-pharmacologic and pharmacologic interventions.

Hypertension is common with nearly 1 in 3 Americans receiving this diagnosis. While 77% of hypertensive patients are being treated, only 54% of these patients are controlled.1 Controlling blood pressure is a critical step to prevent stroke, coronary heart disease, heart failure, and cardiovascular death.2 The most recent hypertension guideline was released over a decade ago. With new evidence, and in the absence of an updated consensus guideline, selecting blood pressure targets in the management of hypertension has become more complex.

The first and most important step in managing hypertension is to select the blood pressure target. A new landmark study (SPRINT)3 found intensive blood pressure lowering (BP <120/90 mm Hg) in patients at increased risk of cardiovascular (CV) events prevented more CV events than standard blood pressure control (SBP <140 mm Hg). Combining the findings of SPRINT with earlier studies, the resulting figure below provides guidance to select a blood pressure target based on clinical trial evidence.

Selecting a blood pressure target based on current evidence4-8

For older patients in the SPRINT study, the benefit of intensive blood pressure control was greater than in younger patients.

Intensive BP lowering to a goal of <120/90 mm Hg, prevented more CV events in patients age 75 and over than in younger patients with increased CV risk

In these older patients, side effects were common, but not different between the intensive and standard BP goals.

 
Key considerations for managing hypertension:
  • Counsel patients on a low-salt diet.
  • Ensure patient adherence to prescribed medication.
  • Intensify therapy for patients who are not at goal.

 

Achieving the blood pressure target is more important than the drug class used to get there.9

When selecting an antihypertensive medication, begin with a thiazide-type diuretic, angiotensin converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), or a calcium channel blocker (CCB). When dual therapy is required, the combination of an ACEI + CCB prevented more CV events than an ACEI + thiazide.10 The algorithm below suggests a strategy for managing therapy, continually reassessing treatment effect to achieve the blood pressure goal.

Algorithm of treating patients with hypertension 3,11-10


Additional Resources

Information current at time of publication, November 2016.

The content of this website is educational in nature and includes general recommendations only; specific clinical decisions should only be made by a treating physician based on the individual patient’s clinical condition.


References
  1. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation. 2015;131(4):e29-322.
  2. Sundstrom J, Arima H, Woodward M, et al. Blood pressure-lowering treatment based on cardiovascular risk: a meta-analysis of individual patient data. Lancet. 2014;384(9943):591-598.
  3. SPRINT Research Group, Wright JT, Jr., Williamson JD, et al. A Randomized Trial of Intensive versus Standard Blood-Pressure Control. N Engl J Med. 2015;373(22):2103-2116.
  4. Accord Study Group, Cushman WC, Evans GW, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362(17):1575-1585.
  5. SPS Study Group, Benavente OR, Coffey CS, et al. Blood-pressure targets in patients with recent lacunar stroke: the SPS3 randomised trial. Lancet. 2013;382(9891):507-515.
  6. Jatos Study Group. Principal results of the Japanese trial to assess optimal systolic blood pressure in elderly hypertensive patients (JATOS). Hypertension research : official journal of the Japanese Society of Hypertension. 2008;31(12):2115-2127.
  7. Ogihara T, Saruta T, Rakugi H, et al. Target blood pressure for treatment of isolated systolic hypertension in the elderly: valsartan in elderly isolated systolic hypertension study. Hypertension. 2010;56(2):196-202.
  8. Medical Research Council Working Party. MRC trial of treatment of mild hypertension: principal results. British medical journal (Clinical research ed). 1985;291(6488):97-104.
  9. Law MR, Morris JK, Wald NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. Bmj. 2009;338:b1665.
  10. Jamerson K, Weber MA, Bakris GL, et al. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. N Engl J Med. 2008;359(23):2417-2428.
  11. Yusuf S, Teo KK, Pogue J, et al. Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med. 2008;358(15):1547-1559.