II. Management: General Guidelines
- See Hypertension General Measures (includes DASH Diet)
- See Antihypertensive Selection
- See patients back at one month after starting agent
- Significantly improves compliance
- BP requires 1 month on agent to equilibrate
- Maximize compliance
- Work with patients to reduce adverse effects
- Switch to other agents if adverse effects significant
- Do not be overzealous
- Risk of overcorrection of Blood Pressure
- Avoid lowering diastolic pressure <70 mmHg
- Greater tolerance for elevated BP with increased age
- Study of 484 Swedish men over 70 from 1982-1992
- Risk if Diastolic Blood Pressure lowered below 90
- Increased cardiac event risk 3.9x
- Controlled for confounding factors
- Reference
- Consider nighttime dosing
- Advantages
- Variable data on cardiovascular events
- Studies showing decreased cardiovascular events and improve Blood Pressure control
- Studies showing no difference in cardiovascular outcomes compared with morning dosing
- Benefit may best in patients who do not dip their Blood Pressure overnight
- Non-dippers: Older, Diabetes Mellitus, Chronic Kidney Disease, Resistant Hypertension
- Consider 24 hour ambulatory monitoring to define unclear cases
- Variable data on cardiovascular events
- Disadvantages
- Risk of Orthostatic Hypotension and Fall Risk at night
- Risk of non-compliance
- Do not switch to nighttime dose if patient can not remember that dose
- The best time to dose is when the medication can be remembered (missed pills are useless)
- Indications to switch at least one medication to nighttime dosing
- Three or more Antihypertensives used
- Best medications for nighttime dosing
- References
- (2012) Prescr Lett 19(1): 4
- Hermida (2011) J Am Soc Nephrol 22: 2313-21 [PubMed]
- Advantages
III. Management: Choose Agents with Best Outcome Data
- See Antihypertensive Selection
- Medications that prevent Hypertension vascular sequelae
- Thiazide Diuretics
- ACE Inhibitors or Angiotensin Receptor Blockers (ARB)
- Long-acting Dihydropyridine Calcium Channel Blocker (e.g. Amlodipine)
- Beta-Blockers
- Indicated in patients with known Coronary Artery Disease or chronic, stable Systolic Dysfunction
- Not recommended as a first-line agent outside of specific cardiovascular indications
- Medications that prevent Left Ventricular Hypertrophy
- Most effective at reducing LVH risk
- ACE Inhibitors (e.g. Lisinopril) or Angiotensin Receptor Blockers (ARB)
- Diuretics (e.g. Chlorthalidone)
- Beta-Blockers (e.g. Metoprolol)
- Least effective at reduced LVH risk
- References
- Most effective at reducing LVH risk
IV. Management: Tailor Therapy to the Patient
- Assess patient risk factors and target Blood Pressures
- Management should include non-pharmacologic therapy for all patients
- Target medications to the patient
- Ongoing Blood Pressure Monitoring
- See Home Blood Pressure Monitoring
- Follow-up monthly until systolic Blood Pressure controlled (then every 3 to 6 months)
- Continue to review and encourage Nonpharmacologic Management of Hypertension
- Most patients require at least 2 medications for adequate Blood Pressure reduction to goal
- See Hypertension Combination Therapy
- Early combination therapy is most effective
- Lab monitoring
- Serum Creatinine and Electrolytes (e.g. chem8, basic metabolic panel) every 6 to 12 months
- Urine Microalbumin every 1 to 2 years (esp. for those not yet on an ACE Inhibitor or ARB)
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Related Studies
| Definition (MEDLINEPLUS) |
High blood pressure, also called hypertension, usually has no symptoms. But it can cause serious problems such as stroke, heart failure, heart attack and kidney failure. If you cannot control your high blood pressure through lifestyle changes such as losing weight and reducing sodium in your diet, you may need medicines. Blood pressure medicines work in different ways to lower blood pressure. Some remove extra fluid and salt from the body. Others slow down the heartbeat or relax and widen blood vessels. Often, two or more medicines work better than one. NIH: National Heart, Lung, and Blood Institute |
| Definition (NCI) | Any substance used in the treatment of acute or chronic hypertension regardless of pharmacological mechanism. Antihypertensive agents include diuretics, alpha-adrenergic and beta-adrenergic antagonists, angiotensin-converting enzyme inhibitors, calcium channel blockers, ganglionic blockers, and vasodilator agents. |
| Definition (CSP) | agent that reduces high blood pressure. |
| Definition (MSH) | Drugs used in the treatment of acute or chronic vascular HYPERTENSION regardless of pharmacological mechanism. Among the antihypertensive agents are DIURETICS; (especially DIURETICS, THIAZIDE); ADRENERGIC BETA-ANTAGONISTS; ADRENERGIC ALPHA-ANTAGONISTS; ANGIOTENSIN-CONVERTING ENZYME INHIBITORS; CALCIUM CHANNEL BLOCKERS; GANGLIONIC BLOCKERS; and VASODILATOR AGENTS. |
| Concepts | Pharmacologic Substance (T121) |
| MSH | D000959 |
| SnomedCT | 1182007, 372586001 |
| LNC | LP31453-1 |
| English | Agents, Antihypertensive, antihypertensive agent, Antihypertensive Drugs, Agents, Anti-Hypertensive, Anti Hypertensive Agents, Anti Hypertensive Drugs, Anti Hypertensives, Anti-Hypertensive Agents, Anti-Hypertensive Drugs, Anti-Hypertensives, Antihypertensives, Drugs, Anti-Hypertensive, Drugs, Antihypertensive, antihypertensives (medication), antihypertensives, anti hypertensive, antihypertensives drugs, anti hypertensive drug, anti-hypertensive drugs, hypotensive agent, antihypertensive drug, antihypertensive drugs, anti hypertensives, antihypertensive, antihypertensive agents, hypotensive agents, anti-hypertensives, anti hypertensive drugs, blood pressure lowering drug, Antihypertensive Agents, Antihypertensive medicines, Antihypertensive Medicines, High Blood Pressure Medicines, High blood pressure medicines, Blood Pressure Medicines, ANTIHYPERTENSIVES, Hypotensive agents, Antihypertensive drug, Antihypertensive, Hypotensive agent (product), Hypotensive agent (substance), Hypotensive agent, Antihypertensive agent, Antihypertensive agent, NOS, Antihypertensive drug, NOS, Hypotensive agent, NOS, Hypotensive Agents, Hypotensive Drugs, Hypotensives, Antihypertensive Agent |
| French | Agents antihypertenseurs, Médicaments antihypertenseurs, Anti-hypertenseurs, Antihypertenseurs |
| Swedish | Blodtryckssänkande medel |
| Czech | hypotenzíva, antihypertenzíva, hypotonika |
| Finnish | Verenpainelääkkeet |
| Italian | Farmaci antiipertensivi, Antiipertensivi |
| Russian | GIPOTENZIVNYE SREDSTVA, ANTIGIPERTENZIVNYE SREDSTVA, АНТИГИПЕРТЕНЗИВНЫЕ СРЕДСТВА, ГИПОТЕНЗИВНЫЕ СРЕДСТВА |
| Croatian | ANTIHIPERTENZIVI |
| Polish | Leki obniżające ciśnienie, Leki hipotensyjne, Leki przeciwnadciśnieniowe |
| Japanese | 血圧下降剤, 降圧剤, 抗高血圧症薬, 抗高血圧薬, 血圧降下剤, 血圧降下薬, 降圧物質, 降圧薬 |
| Spanish | Antihipertensivos, Fármacos Antihipertensivos, Agentes Antihipertensivos, agente antihipertensivo, agente hipotensor (producto), agente hipotensor (sustancia), agente hipotensor, droga antihipertensiva |
| Norwegian | Blodtrykkssenkende midler |
| Portuguese | Agentes Anti-Hipertensivos, Fármacos Anti-Hipertensivos, Anti-Hipertensivos |
| German | Antihypertonika, Blutdrucksenkende Mittel, Antihypertensiva |
Ontology: Hypertensive disease (C0020538)
| Definition (MEDLINEPLUS) |
Blood pressure is the force of your blood pushing against the walls of your arteries. Each time your heart beats, it pumps out blood into the arteries. Your blood pressure is highest when your heart beats, pumping the blood. This is called systolic pressure. When your heart is at rest, between beats, your blood pressure falls. This is the diastolic pressure. Your blood pressure reading uses these two numbers, the systolic and diastolic pressures. Usually they are written one above or before the other. A reading of
High blood pressure usually has no symptoms, but it can cause serious problems such as stroke, heart failure, heart attack and kidney failure. You can control high blood pressure through healthy lifestyle habits and taking medicines, if needed. NIH: National Heart, Lung, and Blood Institute |
| Definition (NCI_CDISC) | Pathological increase in blood pressure defined as one of the following: History of hypertension diagnosed and treated with medication, diet, and/or exercise; On at least 2 separate occasions, documented blood pressure greater than 140 mm Hg systolic and/or 90 mm Hg diastolic in patients without diabetes or chronic kidney disease, or blood pressure greater than 130 mm Hg systolic or 80 mm Hg diastolic in patients with diabetes or chronic kidney disease; Currently on pharmacological therapy for the treatment of hypertension. |
| Definition (NCI) | Blood pressure that is abnormally high. |
| Definition (NCI_CTCAE) | A disorder characterized by a pathological increase in blood pressure; a repeatedly elevation in the blood pressure exceeding 140 over 90 mm Hg. |
| Definition (NCI_NCI-GLOSS) | A blood pressure of 140/90 or higher. High blood pressure usually has no symptoms. It can harm the arteries and cause an increase in the risk of stroke, heart attack, kidney failure, and blindness. |
| Definition (CSP) | persistantly high arterial blood pressure. |
| Definition (MSH) | Persistently high systemic arterial BLOOD PRESSURE. Based on multiple readings (BLOOD PRESSURE DETERMINATION), hypertension is currently defined as when SYSTOLIC PRESSURE is consistently greater than 140 mm Hg or when DIASTOLIC PRESSURE is consistently 90 mm Hg or more. |
| Concepts | Disease or Syndrome (T047) |
| MSH | D006973 |
| ICD9 | 997.91, 401-405.99 |
| ICD10 | I10-I15.9 , I10, I10-I15 |
| SnomedCT | 38341003, 155302005, 194757006, 194760004, 155295004, 194756002, 266287006, 194794002, 195537001 |
| LNC | MTHU020789, LA14293-7, LA7444-8 |
| English | Hypertension, BLOOD PRESSURE HIGH, HYPERTENSION ARTERIAL, Hypertensive disease NOS, Hypertensive diseases, [X]Hypertensive diseases, Systemic hypertension, Hypertensive disorder, systemic arterial, hyperpiesia, hyperpiesis, systemic HTN, systemic hypertension (diagnosis), systemic hypertension, Hypertension arterial, Blood pressure high, HBP, HT, Hypertension NOS, Surg comp - hypertension, HTN, Hypertension [Disease/Finding], high blood pressure, hypertensive disorder, hypertensive vascular disease, arterial hypertension, arterial hypertension systemic, vascular hypertension, blood high pressure, high blood pressure disorder, systemic arterial hypertension, hypertensive disease, Hypertensive diseases (I10-I15), Complications affecting other specified body systems, not elsewhere classified, hypertension, High Blood Pressure, Hypertensive disease NOS (disorder), Hypertensive disease (disorder), (Hypertensive disease) or (hypertension), (Hypertensive disease) or (hypertension) (disorder), [X]Hypertensive diseases (disorder), hypertension, BLOOD PRESSURE, INCREASED, BLOOD PRESSURE, HIGH, Hypertensive Disorder, HIGH BLOOD PRESSURE, INCREASED BLOOD PRESSURE, HYPERTENSION, PRESSURE, HIGH BLOOD, High blood pressure, Hyperpiesia, Hyperpiesis, Hypertensive vascular degeneration, Hypertensive vascular disease, BP - High blood pressure, High blood pressure disorder, Systemic arterial hypertension, HBP - High blood pressure, BP+ - Hypertension, HT - Hypertension, Hypertensive disorder, systemic arterial (disorder), Hypertensive disorder, HTN - Hypertension, blood pressure; high, high; arterial tension, high; blood pressure, Hypertension, NOS, Hypertensive disease, NOS, Raised blood pressure (disorder), Blood Pressure, High, Blood Pressures, High, High Blood Pressures, Vascular Hypertensive Disorder, Hypertensive disease, HYPERTENSIVE DISEASE |
| French | HYPERTENSION ARTERIELLE, Pression artérielle élevée, PAH, Hypertension SAI, TH, HYPERTENSION, TENSION ARTERIELLE E, Hypertension chronique, Hypertension permanente, Hypertension artérielle, Hypertension |
| Portuguese | HIPERTENSAO, Hipertensão arterial NE, Hipertensão arterial, Pressão arterial alta, HYPERTENSAO ARTERIAL, PRESSAO SANGUINEA ELEVADA, Pressão Arterial Alta, Pressão Sanguínea Alta, Hipertensão |
| Spanish | HIPERTENSION, PRESION SANGUINEA ALTA, Presión sanguínea alta, HTA, Hipertensión NEOM, Hipertensión arterial, HT, HIPERTENSION ARTERIAL, enfermedad hipertensiva, SAI, [X]enfermedades hipertensivas (trastorno), enfermedad hipertensiva, SAI (trastorno), [X]enfermedades hipertensivas, Hypertensive disease NOS, degeneración vascular hipertensiva, enfermedad hipertensiva, enfermedad vascular hipertensiva, hiperpiesia, hiperpiesis, hipertensión arterial (trastorno), hipertensión arterial, presión arterial alta, tensión arterial alta, tensión arterial elevada, Hipertensión, Presión Sanguínea Alta |
| German | HYPERTONIE, Hypertonie, arteriell, Blutdruck, hoch, HBP, HT, Hypertonie NNB, BLUTDRUCK HOCH, HYPERTONIE ARTERIELL, Hypertension, Hypertonie |
| Dutch | hypertensie NAO, hoge bloeddruk, arteriële hypertensie, bloeddruk; hoog, hoog; arteriële druk, hoog; bloeddruk, hypertensie, Bloeddruk, hoge, Hypertensie |
| Italian | Ipertensione (HT), Ipertensione NAS, Pressione del sangue elevata, Ipertensione, Pressione sanguigna alta, Ipertensione arteriosa |
| Japanese | 動脈性高血圧, 高血圧ＮＯＳ, ｺｳｹﾂｱﾂ, ｺｳｹﾂｱﾂNOS, ﾄﾞｳﾐｬｸｾｲｺｳｹﾂｱﾂ, 高血圧, 高血圧症 |
| Swedish | Högt blodtryck |
| Czech | hypertenze, Arteriální hypertenze, Vysoký krevní tlak, Hypertenze NOS, Hypertenze, vysoký krevní tlak, hypertonie |
| Finnish | Kohonnut verenpaine |
| Russian | GIPERTENZIIA, GIPERTONICHESKAIA BOLEZN', KROVIANOE DAVLENIE VYSOKOE, ГИПЕРТЕНЗИЯ, ГИПЕРТОНИЧЕСКАЯ БОЛЕЗНЬ, КРОВЯНОЕ ДАВЛЕНИЕ ВЫСОКОЕ |
| Croatian | HIPERTENZIJA |
| Polish | Nadciśnienie |
| Hungarian | Arteriás hypertonia, Hypertensio, HT, RR magas, Hypertonia k.m.n., Magas vérnyomás |
| Norwegian | Høyt blodtrykk, Hypertensjon, Hypertoni |
