Hypertension Management

Aka: Hypertension Management, Medical Management of Hypertension, Antihypertensive

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II. Management: General Guidelines

  1. See Hypertension General Measures (includes DASH Diet)
  2. See Antihypertensive Selection
  3. See patients back at one month after starting agent
    1. Significantly improves compliance
    2. BP requires 1 month on agent to equilibrate
  4. Maximize compliance
    1. Work with patients to reduce adverse effects
    2. Switch to other agents if adverse effects significant
  5. Do not be overzealous
    1. Risk of overcorrection of Blood Pressure
    2. Avoid lowering diastolic pressure <70 mmHg
    3. Greater tolerance for elevated BP with increased age
      1. Study of 484 Swedish men over 70 from 1982-1992
      2. Risk if Diastolic Blood Pressure lowered below 90
        1. Increased cardiac event risk 3.9x
        2. Controlled for confounding factors
      3. Reference
        1. Merlo (1996) BMJ 313:457-61 [PubMed]
  6. Consider nighttime dosing
    1. Advantages
      1. Variable data on cardiovascular events
        1. Studies showing decreased cardiovascular events and improve Blood Pressure control
          1. Hermida (2019) Eur Heart J +PMID:31641769 [PubMed]
        2. Studies showing no difference in cardiovascular outcomes compared with morning dosing
          1. Mackenzie (2022) Lancet 400(10361):1417-25 +PMID: 36240838 [PubMed]
      2. Benefit may best in patients who do not dip their Blood Pressure overnight
        1. Non-dippers: Older, Diabetes Mellitus, Chronic Kidney Disease, Resistant Hypertension
        2. Consider 24 hour ambulatory monitoring to define unclear cases
    2. Disadvantages
      1. Risk of Orthostatic Hypotension and Fall Risk at night
      2. Risk of non-compliance
        1. Do not switch to nighttime dose if patient can not remember that dose
        2. The best time to dose is when the medication can be remembered (missed pills are useless)
    3. Indications to switch at least one medication to nighttime dosing
      1. Three or more Antihypertensives used
      2. Best medications for nighttime dosing
        1. Angiotensin Converting Enzyme Inhibitors (ACE Inhibitors)
        2. Angiotensin Receptor Blockers
        3. Calcium Channel Blockers
        4. Alpha Adrenergic Antagonists
        5. Beta Blockers
        6. Avoid Diuretics over night
    4. References
      1. (2012) Prescr Lett 19(1): 4
      2. Hermida (2011) J Am Soc Nephrol 22: 2313-21 [PubMed]

III. Management: Choose Agents with Best Outcome Data

  1. See Antihypertensive Selection
  2. Medications that prevent Hypertension vascular sequelae
    1. Thiazide Diuretics
    2. ACE Inhibitors or Angiotensin Receptor Blockers (ARB)
    3. Long-acting Dihydropyridine Calcium Channel Blocker (e.g. Amlodipine)
    4. Beta-Blockers
      1. Indicated in patients with known Coronary Artery Disease or chronic, stable Systolic Dysfunction
      2. Not recommended as a first-line agent outside of specific cardiovascular indications
  3. Medications that prevent Left Ventricular Hypertrophy
    1. Most effective at reducing LVH risk
      1. ACE Inhibitors (e.g. Lisinopril) or Angiotensin Receptor Blockers (ARB)
      2. Diuretics (e.g. Chlorthalidone)
      3. Beta-Blockers (e.g. Metoprolol)
    2. Least effective at reduced LVH risk
      1. Prazosin
      2. Clonidine
      3. Diltiazem
    3. References
      1. Gottdiener (1997) Circulation 95:2007-14 [PubMed]

IV. Management: Tailor Therapy to the Patient

  1. Assess patient risk factors and target Blood Pressures
    1. See Hypertension Risk Stratification
    2. See Hypertension Reduction Goal
  2. Management should include non-pharmacologic therapy for all patients
    1. See Hypertension General Measures
  3. Target medications to the patient
    1. Antihypertensive Selection
    2. Hypertension Combination Therapy
    3. Hypertension Management for Specific Comorbid Diseases
    4. Hypertension Management for Specific Populations
    5. Hypertension Management for Specific Emergencies
  4. Ongoing Blood Pressure Monitoring
    1. See Home Blood Pressure Monitoring
    2. Follow-up monthly until systolic Blood Pressure controlled (then every 3 to 6 months)
    3. Continue to review and encourage Nonpharmacologic Management of Hypertension
    4. Most patients require at least 2 medications for adequate Blood Pressure reduction to goal
      1. See Hypertension Combination Therapy
      2. Early combination therapy is most effective
  5. Lab monitoring
    1. Serum Creatinine and Electrolytes (e.g. chem8, basic metabolic panel) every 6 to 12 months
    2. Urine Microalbumin every 1 to 2 years (esp. for those not yet on an ACE Inhibitor or ARB)

V. References

  1. (2000) Lancet 356:1955-64 [PubMed]
  2. Clarke (2023) Am Fam Physician 108(3): 352-9 [PubMed]

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