General population: <60 years old-initiate pharmacological therapy to lower diastolic pressure :;90 mm Hg and systolic pressuren:;140 mm Hg Diabetics: lower pressure to < 140/90 mm Hg
Chronic kidney disease: lower pressure to < 140/90 mm Hg. Also add ACE-lnor ARB to improve outcomes
General non black population: initial therapy should include thiazide-type diuretic, calcium-channel blocker, ACE-I, or ARB General black population: primary antihypertensive therapy should include thiazide-type diuretic or calcium-channel blocker Assess monthly, and after 1 month, if goals not met, then increase primary drug dose or add second drug. If no response, increase either or add third drug; then if no response, refer to hypertension specialist
Summarized from James, 201a4.
TABLE 50-2. Lifestyle Modifications for Hypertensive Patients
Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils, and nuts; limits sweets and red meats. Examples are DASH, USDA Food Pattern, or the AHA Diet
Engage in aerobic physical activity three to four sessions per week, lasting on average 40 minutes per session, and involving moderate-to-vigorous intensity physical activity
Moderation of alcohol consumption
AHA = American Heart Association; DASH = Dietary Approaches to Stop Hypertension; USDA = United States Department of Agriculture.
Summarized from Eckel, 2013; Kotchen, 2015.
a urine spot protein/creatinine ratio is abnormally high (>0.3), proteinuria is further quantified with a 24-hour urine collection (Hladunewich, 2011; Kuper, 2016; Morgan, 2016a). The Working Group Report on High Blood Pressure in Pregnancy (2000) of the National Heart, Lung, and Blood Institute concluded that the risks of fetal loss and accelerated renal disease deterioration are increased if the serum creatinine level is above 1.4 mg/dL (Chap. 53, p. 1034).
Although pregnancy is considered by many to be contraindicated in women with severe, poorly controlled hypertension, there is no consensus. Certainly, women who maintain persistent diastolic pressures ::110 mm Hg despite therapy; require multiple antihypertensives; have a serum creatinine level > 2 mg/ dL; or have a history of prior stroke, MI, or cardiac failure must be counseled as to the marked risks to themselves and to their pregnancy outcome.
he hypertensive disorders that uniquely complicate pregnancy are discussed in Chapter 40 (p. 710). Women are diagnosed with chronic hypertension if it is documented to precede pregnancy or ifhypertension is identified before 20 weeks' gestation. Evidence also supports that prehypertension may herald adverse outcomes similar to those in women with chronic hypertension (Rosner, 2017). In some women without overt chronic hypertension, a history of repeated pregnancies complicated by gestational hypertension, with or without the preeclampsia syndrome, may be elicited. Each is a risk marker for latent chronic hypertension, and this is especially so for preeclampsia, and in particular early-onset preeclampsia. In many ways, gestational hypertension is analogous to gestational diabetes in that such women have a chronic hypertensive diathesis, in which heredity and environment playaa major role.