Hypertension: Treatment

Most patients with hypertension will require drugs (medications) to lower their level of blood pressure to a safe range. Importantly, medications lose part of their effect in patients who cannot adequately control their salt intake. Thus, if the blood pressure does not respond to one or more drugs, it is important to reevaluate salt intake and, if excessive, to make long term plans to reduce dietary salt. Otherwise, more and more drugs are added in what is often a futile effort to control hypertension. Please see link: Dietary Salt Restriction.

There are some principles related to drug therapy:

A. For patients with borderline or modest hypertension, initiation of treatment is usually not urgent and can await investigations and institutions of lifestyle modifications, after which drug therapy may not necessarily be required. However, where the systolic blood pressure is greater than 160 – 170 mmHg, most physicians recommend immediate antihypertensive treatment.

B. It is important to establish that the patient has high blood pressure. This may require return office visits, or, preferably, regular home blood pressure recordings or, most accurately, a 24-hour ambulatory blood pressure monitor. Please see link: Ambulatory Blood Pressure Monitoring.

C. What is important, is not so much the highest blood pressures, but rather the average blood pressure over time. Some patients have an artificial elevation of blood pressure in the doctors office, termed “white coat or office hypertension.” That is why home or ambulatory blood pressure monitoring is so important.

D. Cardiovascular risk declines progressively in subjects with hypertension if their blood pressure can be reduced to a normal level and maintained. Therefore, the dangers of heart attack, stroke, heart failure, will diminish or disappear with effective management of the hypertension.

E. Drug therapy should normally be started once lifestyle modifications are in place and the new baseline blood pressure level is established.

F. There are a wide variety of classes of drugs to treat high blood pressure (antihypertensive drugs). Usually, it is preferable to use one agent initially, then to add another agent from a different class, until the blood pressure is controlled.

G. It is preferable to use modest doses of more than one agent rather than maximal doses of a single or few agents, since the latter strategy can be complicated by adverse effects.

H. In almost all subjects except those with a contraindication, a diuretic should be part of the initial therapy, or, if the another primary drug is not fully effective, should be the second drugs added. This is because diuretics and salt restriction make other drugs more effective and therefore reduce the need, expense and adverse effects of multiple drug therapy.

I. It is important to realize that hypertension, once establish, almost never goes away. Therefore, antihypertensive therapy should be considered as treatment for life. Occasionally, after substantial lifestyle changes, for example big reductions in salt intake and body weight with increased exercise, it may be possible, in those with mild hypertension, to discontinue treatment. However, once present, hypertension frequently recurs. Therefore, even in this situation, blood pressure should be checked regularly (two to four times per year) and if hypertension recurs, it should be managed appropriately.

J. The need for antihypertensive therapy varies over time. Unfortunately, blood pressure increases with age. Moreover, any hypertensive kidney damage further increases the level of blood pressure. Thus, the need for antihypertensive therapy, and the dosage or the number of drugs required to control it, frequently increases over time. Therefore, patients should make plans for regular followup with their primary physician to modify therapy in response to changing circumstance.

K. Modern drugs are generally effective in controlling hypertension especially when the patient is fully cooperative with lifestyle modifications and adequate doses of diuretics are included. However, some patients remain hypertensive despite a three drug treatment and are termed “resistant hypertensive”. This category is particularly common in those with diabetes, obesity and chronic kidney disease. It requires careful management with the help of a specialist in hypertension and kidney disease.

L. Most, but not all, patients can be managed with a regimen that provides proper blood pressure control without unacceptable side effects. Some adverse effects can be encountered during the first few weeks of treatment, but often wane over time. Patient with side effects should discuss these with their physician who may be able to change therapy to correct the problem. Patients should not discontinue therapy on their own since that puts them at risk of an increase in blood pressure and the adverse consequences thereof.

M. This is a lifelong problem and requires that patients form a professional relationship with a primary care physician and, when necessary, a specialist in hypertension and kidney disease for management over the long term.

These fall into several major classes: diuretics, angiotensin converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), renin inhibitor (RIs), alpha-and beta-blockers and central sympatholytic drugs, calcium channel blockers and vasodilators.