User:GT67/managementofhypertension

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Lifestyle modifications[edit]

The first line of treatment for hypertension is identical to the recommended preventative lifestyle changes[1] and includes: dietary changes[2] physical exercise, and weight loss. These have all been shown to significantly reduce blood pressure in people with hypertension.[3] If hypertension is high enough to justify immediate use of medications, lifestyle changes are still recommended in conjunction with medication. Different programs aimed to reduce psychological stress such as biofeedback, relaxation or meditation are advertised to reduce hypertension. However, in general claims of efficacy are not supported by scientific studies, which have been in general of low quality.[4][5][6]

Dietary change such as a low sodium diet is beneficial. A long term (more than 4 weeks) low sodium diet in Caucasians is effective in reducing blood pressure, both in people with hypertension and in people with normal blood pressure.[7] Also, the DASH diet, a diet rich in nuts, whole grains, fish, poultry, fruits and vegetables promoted in the USA by the National Heart, Lung, and Blood Institute lowers blood pressure. A major feature of the plan is limiting intake of sodium, although the diet is also rich in potassium, magnesium, calcium, as well as protein.[8]

Medications[edit]

Several classes of medications, collectively referred to as antihypertensive drugs, are currently available for treating hypertension. Prescription should take into account the person's cardiovascular risk (including risk of myocardial infarction and stroke) as well as blood pressure readings, in order to gain a more accurate picture of the person's cardiovascular profile.[9] Evidence in those with mild hypertension (SBP less than 160 mmHg and /or DBP less than 100 mmHg) and no other health problems does not support a reduction in the risk of death or rate of health complications from medication treatment.[10]

If drug treatment is initiated the Joint National Committee on High Blood Pressure (JNC-7)[11] recommends that the physician not only monitor for response to treatment but should also assess for any adverse reactions resulting from the medication. Reduction of the blood pressure by 5 mmHg can decrease the risk of stroke by 34%, of ischaemic heart disease by 21%, and reduce the likelihood of dementia, heart failure, and mortality from cardiovascular disease.[12] The aim of treatment should be to reduce blood pressure to <140/90 mmHg for most individuals, and lower for those with diabetes or kidney disease (some medical professionals recommend keeping levels below 120/80 mmHg).[9][13] If the blood pressure goal is not met, a change in treatment should be made as therapeutic inertia is a clear impediment to blood pressure control.[14]

Guidelines on the choice of agents and how best to step up treatment for various subgroups have changed over time and differ between countries. The best first line agent is disputed.[15] The Cochrane collaboration, World Health Organization and the United States guidelines supports low dose thiazide-based diuretic as first line treatment.[15][16] The UK guidelines emphasise calcium channel blockers (CCB) in preference for people over the age of 55 years or if of African or Caribbean family origin, with angiotensin converting enzyme inhibitors (ACE-I) used first line for younger people.[17] In Japan starting with any one of six classes of medications including: CCB, ACEI/ARB, thiazide diuretics, beta-blockers, and alpha-blockers is deemed reasonable while in Canada all of these but alpha-blockers are recommended as options.[15]

Drug combinations[edit]

The majority of people require more than one drug to control their hypertension. JNC7[11] and ESH-ESC guidelines[18] advocate starting treatment with two drugs when blood pressure is >20 mmHg above systolic or >10 mmHg above diastolic targets. Preferred combinations are renin–angiotensin system inhibitors and calcium channel blockers, or renin–angiotensin system inhibitors and diuretics.[19] Acceptable combinations include calcium channel blockers and diuretics, beta-blockers and diuretics, dihydropyridine calcium channel blockers and beta-blockers, or dihydropyridine calcium channel blockers with either verapamil or diltiazem. Unacceptable combinations are non-dihydropyridine calcium blockers (such as verapamil or diltiazem) and beta-blockers, dual renin–angiotensin system blockade (e.g. angiotensin converting enzyme inhibitor + angiotensin receptor blocker), renin–angiotensin system blockers and beta-blockers, beta-blockers and centrally acting agents.[19] Combinations of an ACE-inhibitor or angiotensin II–receptor antagonist, a diuretic and an NSAID (including selective COX-2 inhibitors and non-prescribed drugs such as ibuprofen) should be avoided whenever possible due to a high documented risk of acute renal failure. The combination is known colloquially as a "triple whammy" in the Australian health industry.[1] Tablets containing fixed combinations of two classes of drugs are available and while convenient for the people, may be best reserved for those who have been established on the individual components.[20]

In the elderly[edit]

Treating moderate to severe hypertension decreases death rates and cardiovascular morbidity and mortality in people aged 60 and older.[21] There are limited studies of people over 80 years old but a recent review concluded that antihypertensive treatment reduced cardiovascular deaths and disease, but did not significantly reduce total death rates.[21] The recommended BP goal is advised as <140/90 mm Hg with thiazide diuretics being the first line medication in America,[22] and in the revised UK guidelines calcium-channel blockers are advocated as first line with targets of clinic readings <150/90, or <145/85 on ambulatory or home blood pressure monitoring.[17]

Resistant hypertension[edit]

Resistant hypertension is defined as hypertension that remains above goal blood pressure in spite of concurrent use of three antihypertensive agents belonging to different antihypertensive drug classes. Guidelines for treating resistant hypertension have been published in the UK[23] and US.[24]

Africa[edit]

Egypt[edit]

Asia[edit]

China[edit]

India[edit]

Japan[edit]

South Korea[edit]

Taiwan[edit]

Turkey[edit]

Europe[edit]

England[edit]

France[edit]

Germany[edit]

Italy[edit]

Scotland[edit]

Medications[edit]

The British Hypertension Society AB/CD algorithm has been widely adopted for deciding drug therapy for an individual.38 The algorithm was substantially ratified by the ASCOT trial and AB/ CD has now been accepted by JBS2 as the best method of defining combination drug therapy. The AB/CD algorithm was designed to improve blood pressure control based on age-related renin levels and appropriate combinations. In June 2006 the National Institute for Clinical Health and Excellence (NICE) and the BHS jointly released a revised guideline that updated the clinical evidence base to include recent meta-analyses and RCTs and included a cost effectiveness analysis comparing the various blood pressure lowering drug classes.270 The results showed that:[25]

  • beta blockers were the least clinically and cost effective drug at preventing major cardiovascular events
  • calcium channel blockers and thiazide-type diuretics were the most clinically and cost effective choice for the majority of cases
  • for people under the age of 55, drugs affecting the renin-angiotensin system are likely to be most effective.

The recommendations based on this evidence are summarized below. It incorporates all classes of antihypertensive drugs. Although not specifically validated by a clinical trial, the recommended drug combinations and sequencing are similar to those used in many clinical trials of blood pressure lowering drugs.[25]

First-line treatment[edit]

First-line therapy for people <55 years of age is an angiotensin converting enzyme inhibitor (ACE-I) or an angiotensin II receptor blocker (ARB) if the patient is intolerant to the ACE-I. People who are ≥55 years of age or black people of African or Caribbean origin of any age, calcium channel blockers or thiazide-type diuretics are the first-line therapy.[25]

Second-line treatment[edit]

If first-line therapy fails, second-line therapy consists of adding a CCB or a thiazide-type diuretic for patient who initially started an ACE-I or ARB as first-line treatment. For patients who were started on a calcium channel blocker or a thiazide-type diuretic should also be given an ACE-I or and ARB.[25]

Third-line treatment[edit]

When blood pressure goal is not reached after introducing a second-line treatment option, patient should be on three medications: an ACE-I or ARB (not both), a CCB, and a thiazide-type diuretic.[25]

Fourth-line treatment[edit]

Patients who fail third-line treatment can further add diuretic therapy, an alpha blocker, or a beta blocker and should consider seeking the advice of a specialist. However, beta blockers are not a preferred initial therapy for hypertension but are an alternative to ACE inhibitors in patients <55 years in whom ACE inhibitors or ARBs are not tolerated, or contraindicated (includes women of childbearing potential). Black patients are only those of African or Caribbean descent. In the absence of evidence, all other patients should be treated according to the algorithm as non-black.[25]

Most Readily Prescribed[edit]

The following table depicts the most readily prescribed medications to treat high blood pressure in Scotland.

Rank Medication Class
1 amlodipine CCB
2
3

Amlodipine was the most dispensed medication used to treat angina and high blood pressure, and the 9th most dispensed medication overall, during the fiscal year of 2011/2012 in Scotland.[26]

Invasive treatments[edit]

Accessibility to treatment[edit]

Treatment programs[edit]

Traditional medicines[edit]

Socioeconomic impact[edit]

The estimated cost burden of high blood pressure in the U.K. has been estimated to be over £7 billion.[27]

Government policies[edit]

The following current national waiting time standards have been developed for patients who have developed cardiac conditions requiring intervention: no patient will wait more than 16 weeks for cardiac intervention following General Practice (GP) referral through a rapid access chest pain clinic (RACPC) and no patient will wait more than 16 weeks for treatment after they have been seen as an outpatient by a heart specialist who has recommended treatment. Currently, the NHS Scotland lacks systems that capture the total patient journey and have relied on an interim solution, which is to monitor the progress of wait times using component parts of the journey.[28]Additionally, practices are required to complete a CVD risk assessment in people who have been diagnosed with hypertension without confirmed CVD, after April 1, 2009. [29]

Challenges ahead[edit]

Spain[edit]

The Americas[edit]

Brazil[edit]

Canada[edit]

Mexico[edit]

United States[edit]

Oceania and the Pacific[edit]

Australia[edit]

New Zealand[edit]

South Pacific Islands[edit]

References[edit]

  1. ^ a b "NPS Prescribing Practice Review 52: Treating hypertension". NPS Medicines Wise. September 1, 2010. Retrieved November 5, 2010.
  2. ^ Siebenhofer, A.; Jeitler, K.; Berghold, A.; Waltering, A.; Hemkens, L. G.; Semlitsch, T.; Pachler, C.; Strametz, R.; Horvath, K. (2011-09-07). Siebenhofer, Andrea (ed.). "Long-term effects of weight-reducing diets in hypertensive patients". Cochrane Database of Systematic Reviews (Online). 9 (9): CD008274. doi:10.1002/14651858.CD008274.pub2. PMID 21901719.
  3. ^ Blumenthal JA; Babyak MA; Hinderliter A; et al. (January 2010). "Effects of the DASH diet alone and in combination with exercise and weight loss on blood pressure and cardiovascular biomarkers in men and women with high blood pressure: the ENCORE study". Arch. Intern. Med. 170 (2): 126–35. doi:10.1001/archinternmed.2009.470. PMC 3633078. PMID 20101007. {{cite journal}}: Unknown parameter |author-separator= ignored (help)CS1 maint: date and year (link)
  4. ^ Greenhalgh J, Dickson R, Dundar Y (October 2009). "The effects of biofeedback for the treatment of essential hypertension: a systematic review". Health Technol Assess. 13 (46): 1–104. doi:10.3310/hta13460. PMID 19822104.{{cite journal}}: CS1 maint: date and year (link) CS1 maint: multiple names: authors list (link)
  5. ^ Rainforth MV, Schneider RH, Nidich SI, Gaylord-King C, Salerno JW, Anderson JW (December 2007). "Stress Reduction Programs in Patients with Elevated Blood Pressure: A Systematic Review and Meta-analysis". Curr. Hypertens. Rep. 9 (6): 520–8. doi:10.1007/s11906-007-0094-3. PMC 2268875. PMID 18350109.{{cite journal}}: CS1 maint: date and year (link) CS1 maint: multiple names: authors list (link)
  6. ^ Ospina MB; Bond K; Karkhaneh M; et al. (June 2007). "Meditation practices for health: state of the research". Evid Rep Technol Assess (Full Rep) (155): 1–263. PMC 4780968. PMID 17764203. {{cite journal}}: Unknown parameter |author-separator= ignored (help)CS1 maint: date and year (link)
  7. ^ He, FJ (2004). MacGregor, Graham A (ed.). "Effect of longer-term modest salt reduction on blood pressure". Cochrane Database of Systematic Reviews (Online) (3): CD004937. doi:10.1002/14651858.CD004937. PMID 15266549. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  8. ^ "Your Guide To Lowering Your Blood Pressure With DASH" (PDF). Retrieved 2009-06-08.
  9. ^ a b Nelson, Mark. "Drug treatment of elevated blood pressure". Australian Prescriber (33): 108–112. Retrieved August 11, 2010.
  10. ^ Diao, Diana (2012). "Pharmacotherapy for mild hypertension". The Cochrane Collaboration. 2014 (8): CD006742. doi:10.1002/14651858.CD006742.pub2. PMC 8985074. PMID 22895954.
  11. ^ a b Cite error: The named reference JNC7 was invoked but never defined (see the help page).
  12. ^ Law M, Wald N, Morris J (2003). "Lowering blood pressure to prevent myocardial infarction and stroke: a new preventive strategy" (PDF). Health Technol Assess. 7 (31): 1–94. doi:10.3310/hta7310. PMID 14604498.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  13. ^ Shaw, Gina (2009-03-07). "Prehypertension: Early-stage High Blood Pressure". WebMD. Retrieved 2009-07-03.
  14. ^ Eni C. Okonofua; Kit N. Simpson; Ammar Jesri; Shakaib U. Rehman; Valerie L. Durkalski; Brent M. Egan (January 23, 2006). "Therapeutic Inertia Is an Impediment to Achieving the Healthy People 2010 Blood Pressure Control Goals". Hypertension. 47 (2006, 47:345): 345–51. doi:10.1161/01.HYP.0000200702.76436.4b. PMID 16432045. S2CID 15729937. Retrieved 2009-11-22.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  15. ^ a b c Klarenbach, SW (2010 May). "Identification of factors driving differences in cost effectiveness of first-line pharmacological therapy for uncomplicated hypertension". The Canadian Journal of Cardiology. 26 (5): e158–63. doi:10.1016/S0828-282X(10)70383-4. PMC 2886561. PMID 20485695. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
  16. ^ Wright JM, Musini VM (2009). Wright, James M (ed.). "First-line drugs for hypertension". Cochrane Database Syst Rev (3): CD001841. doi:10.1002/14651858.CD001841.pub2. PMID 19588327.
  17. ^ a b National Institute Clinical Excellence (August 2011). "1.5 Initiating and monitoring antihypertensive drug treatment, including blood pressure targets". GC127 Hypertension: Clinical management of primary hypertension in adults. Retrieved 2011-12-23.
  18. ^ Cite error: The named reference ESH-ESC was invoked but never defined (see the help page).
  19. ^ a b Sever PS, Messerli FH (October 2011). "Hypertension management 2011: optimal combination therapy". Eur. Heart J. 32 (20): 2499–506. doi:10.1093/eurheartj/ehr177. PMID 21697169.{{cite journal}}: CS1 maint: date and year (link)
  20. ^ "2.5.5.1 Angiotensin-converting enzyme inhibitors". British National Formulary. Vol. No. 62. September 2011. Retrieved 2011-12-22. {{cite book}}: |volume= has extra text (help)
  21. ^ a b Musini VM, Tejani AM, Bassett K, Wright JM (2009). Musini, Vijaya M (ed.). "Pharmacotherapy for hypertension in the elderly". Cochrane Database Syst Rev (4): CD000028. doi:10.1002/14651858.CD000028.pub2. PMID 19821263.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  22. ^ Aronow WS; Fleg JL; Pepine CJ; et al. (May 2011). "ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus documents developed in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension". J. Am. Coll. Cardiol. 57 (20): 2037–114. doi:10.1016/j.jacc.2011.01.008. PMID 21524875. {{cite journal}}: Unknown parameter |author-separator= ignored (help)CS1 maint: date and year (link)
  23. ^ "CG34 Hypertension - quick reference guide" (PDF). National Institute for Health and Clinical Excellence. 28 June 2006. Retrieved 2009-03-04.
  24. ^ Calhoun DA; Jones D; Textor S; et al. (June 2008). "Resistant hypertension: diagnosis, evaluation, and treatment. A scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research". Hypertension. 51 (6): 1403–19. doi:10.1161/HYPERTENSIONAHA.108.189141. PMID 18391085. {{cite journal}}: Unknown parameter |author-separator= ignored (help)CS1 maint: date and year (link)
  25. ^ a b c d e f Scottish Intercollegiate Guidelines Netowrk. Risk estimation and the prevention of cardiovascular disease: A National Clinical Guideline. Edinburgh: SIGN, 2007. (SIGN publication no. 97). http://www.sign.ac.uk/pdf/sign97.pdf Cite error: The named reference "Tx" was defined multiple times with different content (see the help page).
  26. ^ ISD Scotland. Prescribing & Medicines: Prescription Cost Analysis (2012). http://www.isdscotland.org/Health-Topics/Prescribing-and-Medicines/Publications/2012-06-26/2012-06-26-Prescribing-PrescriptionCostAnalysis-Report.pdf
  27. ^ Public Health Information for Scotland (2005). http://www.scotpho.org.uk/clinical-risk-factors/high-blood-pressure/introduction
  28. ^ ISD Scotland. Inpatient, Day case and Outpatient stage of treatment waiting times (2011). http://www.isdscotland.org/Health-Topics/Waiting-Times/Publications/2011-02-22/2011-02-22-WTIPDCOP-Report.pdf
  29. ^ NHS Scotland. Better Heart Disease and Stroke Care Action Plan, (2009). http://www.scotland.gov.uk/Resource/Doc/277650/0083350.pdf
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