Chronic hypertension medical therapy
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Medical Therapy
Medications
There are many classes of medications for treating hypertension, together called antihypertensives, which — by varying means — act by lowering blood pressure. Evidence suggests that reduction of the blood pressure by 5-6 mmHg can decrease the risk of stroke by 40%, of coronary heart disease by 15-20%, and reduces the likelihood of dementia, heart failure, and mortality from vascular disease.
The aim of treatment should be blood pressure control to <140/90 mmHg for most patients, and lower in certain contexts such as diabetes or kidney disease (some medical professionals recommend keeping levels below 120/80 mmHg).[3] Each added drug may reduce the systolic blood pressure by 5-10 mmHg, so often multiple drugs are necessary to achieve blood pressure control.
Commonly used drugs include:
- ACE inhibitors such as captopril, enalapril, fosinopril (Monopril), lisinopril (Zestril), quinapril, ramipril (Altace)
- Angiotensin II receptor antagonists: eg, telmisartan (Micardis, Pritor), irbesartan (Avapro), losartan (Cozaar), valsartan (Diovan), candesartan (Atacand)
- Alpha blockers such as doxazosin, prazosin, or terazosin
- Beta blockers such as atenolol, labetalol, metoprolol (Lopressor, Toprol-XL), propranolol.
- Calcium channel blockers such as nifedipine (Adalat®)[1] amlodipine (Norvasc), diltiazem, verapamil
- Direct renin inhibitors such as aliskiren (Tekturna)
- Diuretics: eg, bendroflumethiazide, chlortalidone, hydrochlorothiazide (also called HCTZ)
- Combination products (which usually contain HCTZ and one other drug)
Influence of age and race on medication efficacy
A randomized controlled trial by the Veterans Affairs Cooperative Study Group on Antihypertensive Agents reported the influence of patient age and race on the proportion of patients whose blood pressure was controlled by different agents.[2][3] For example:
- Less than 7% of young white patients responded to a diuretic (hydrochlorothiazide)
- Only 6% of older black patients responded to an ACE inhibitor (captopril)
The effect of age and race are in part due to differences in plasma renin activity.[4][5]
Choice of initial medication
Which type of many medications should be used initially for hypertension has been the subject of several large studies and various national guidelines.
Regarding cardiovascular outcomes, the ALLHAT study showed a slightly better outcome and cost-effectiveness for the thiazide diuretic chlortalidone compared to other anti-hypertensives in an ethnically mixed population.[6] Whilst a subsequent smaller study (ANBP2) did not show this small difference in outcome and actually showed a slightly better outcome for ACE-inhibitors in older white male patients.[7]
Whilst thiazides are cheap, effective, and recommended as the best first-line drug for hypertension by many experts, they are not prescribed as often as some newer drugs. Arguably, this is because they are off-patent and thus rarely promoted by the drug industry.[8]
Due to their metabolic impact (hypercholesterinemia, impairment of glucose tolerance, increased risk of developing Diabetes mellitus type 2), the use of thiazides as first line treatment for essential hypertension has been repeatedly questioned and strongly disencouraged.[9] [10] [11]
Physicians may start with non-thiazide antihypertensive medications if there is a compelling reason to do so. An example is the use of ACE-inhibitors in diabetic patients who have evidence of kidney disease, as they have been shown to both reduce blood pressure and slow the progression of diabetic nephropathy.[12] In patients with coronary artery disease or a history of a heart attack, beta blockers and ACE-inhibitors both lower blood pressure and protect heart muscle over a lifetime, leading to reduced mortality.
Advice in the United Kingdom
The risk of beta-blockers provoking type 2 diabetes led to their downgrading to fourth-line therapy in the United Kingdom in June 2006[13], in the revised national guidelines.[14]
Advice in the United States
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) in the United States recommends starting with a thiazide diuretic if single therapy is being initiated and another medication is not indicated.[15]
References
- ↑ Kragten JA, Dunselman PHJM. Nifedipine gastrointestinal therapeutic system (GITS) in the treatment of coronary heart disease and hypertension. Expert Rev Cardiovasc Ther 5 (2007):643-653. FULL TEXT!
- ↑ Materson BJ, Reda DJ, Cushman WC; et al. (1993). "Single-drug therapy for hypertension in men. A comparison of six antihypertensive agents with placebo. The Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents". N. Engl. J. Med. 328 (13): 914–21. PMID 8446138.
- ↑ Materson BJ, Reda DJ (1994). "Correction: single-drug therapy for hypertension in men". N. Engl. J. Med. 330 (23): 1689. PMID 8177286. Summary
- ↑ Blaufox MD, Lee HB, Davis B, Oberman A, Wassertheil-Smoller S, Langford H (1992). "Renin predicts diastolic blood pressure response to nonpharmacologic and pharmacologic therapy". JAMA. 267 (9): 1221–5. PMID 1538559.
- ↑ Preston RA, Materson BJ, Reda DJ; et al. (1998). "Age-race subgroup compared with renin profile as predictors of blood pressure response to antihypertensive therapy. Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents". JAMA. 280 (13): 1168–72. PMID 9777817.
- ↑ ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group (2002). "Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT)". JAMA. 288 (23): 2981–97. PMID 12479763. Unknown parameter
|month=ignored (help) - ↑ Wing LM, Reid CM, Ryan P; et al. (2003). "A comparison of outcomes with angiotensin-converting--enzyme inhibitors and diuretics for hypertension in the elderly". NEJM. 348 (7): 583–92. PMID 12584366. Unknown parameter
|month=ignored (help) - ↑ Wang TJ, Ausiello JC, Stafford RS (1999). "Trends in Antihypertensive Drug Advertising, 1985–1996". Circulation. 99: 2055–2057. PMID 10209012.
- ↑ Lewis PJ, Kohner EM, Petrie A, Dollery CT (1976). "Deterioration of glucose tolerance in hypertensive patients on prolonged diuretic treatment". Lancet. 307 (7959): 564–566. PMID 55840.
- ↑ Murphy MB, Lewis PJ, Kohner E, Schumer B, Dollery CT (1982). "Glucose intolerance in hypertensive patients treated with diuretics; a fourteen-year follow-up". Lancet. 320 (8311): 1293–1295. PMID 6128594.
- ↑ Messerli FH, Williams B,Ritz E (2007). "Essential hypertension". Lancet. 370 (9587): 591–603. PMID.
- ↑ Ruggenenti P, Perna A, Gherardi G, Gaspari F, Benini R, Remuzzi G. (1998). "Renal function and requirement for dialysis in chronic nephropathy patients on long-term ramipril: REIN follow-up trial. Gruppo Italiano di Studi Epidemiologici in Nefrologia (GISEN). Ramipril Efficacy in Nephropathy". Lancet. 352: 1252–6. PMID 9788454.
- ↑ Sheetal Ladva (28/06/2006). "NICE and BHS launch updated hypertension guideline". National Institute for Health and Clinical Excellence. Check date values in:
|date=(help) - ↑ "Hypertension: management of hypertension in adults in primary care" (PDF). National Institute for Health and Clinical Excellence.
- ↑