Therapy Nonpharmacologic interventions or lifestyle modifications should be attempted before initiation of medication unless the systolic blood pressure exceeds 139 mm Hg or the diastolic blood pressure exceeds 89 mm Hg. Drug therapy should be initiated for systolic blood pressure greater than 130 mm Hg or diastolic blood pressure greater than 80 mm Hg in those with diabetes or chronic renal failure. An important element in lifestyle modifications is to modify all contributors to cardiovascular disease. In obese patients, weight loss, especially in individuals with truncal and abdominal obesity, can play a significant role in the prevention of atherosclerosis (14,21). A loss of just 10 pounds was reported to lower blood pressure (22). Inquiries into dietary practices should be made to eliminate excess salt in the diet, specifically certain food groups that are high in sodium, such as canned goods, snack food, pork products, and soy sauce (23). Cholesterol and fat intake in the diet should be limited. Dietary interventions that use calcium, magnesium, and potassium supplementation did not make a clinically significant reduction in pressure (24). An exercise program, weight loss, and moderating alcohol intake (to no more than two alcoholic beverages per day) contribute to overall cardiovascular health. Aerobic exercise alone may prevent hypertension in 20% to 50% of normotensive individuals (14).
The goal of therapy is for the patient to lower blood pressure into the “normal range”: a systolic reading less than or equal to 120 mm Hg and a diastolic reading less than or equal to 80 mm Hg. If lifestyle modifications are not sufficient to control blood pressure, then pharmacologic intervention is indicated (Fig. 9.2).
Hypertension without compelling indications Hypertension with compelling indications (See Table 9.7) • If not at goal BP, optimize dosages or add additional drugs until goal is achieved. • Consider consultation with hypertension specialist. Stage I hypertension Stage II hypertensionSystolic BP 140–159 mm Hg or Diastolic BP 90–99 mm Hg • Thiazide-type diuretics for most • May consider ACE inhibitor, ARB, beta-blocker, CCB, or combination Systolic BP ≥160 mm Hg or Diastolic BP ≥100 mm Hg • Two-drug combination for most (usually thiazide-type diuretic and ACE inhibitor, ARB, beta-blocker, or CCB)
Figure 9.2 Algorithm for the drug choices for hypertensive patients unresponsive to lifestyle changes. Goal blood pressure (BP) is <140/90 mm Hg, or <130/80 mm Hg for those with diabetes or chronic kidney disease, respectively. ACE, angiotensin-converting enzyme; ARB, angiotensin-receptor blocker; CCB, calcium channel blocker. (Modified from Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VII). JAMA 2003;289:2560– 2572, with permission.)