Chronic hypertension medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]; Assistant Editor-In-Chief: Taylor Palmieri

Overview

There are many classes of medications for treating hypertension, together called antihypertensives, which by varying means act by lowering blood pressure. Evidence suggests that reduction of the blood pressure by 5-6 mmHg can decrease the risk of stroke by 40%, of coronary heart disease by 15-20%, and reduces the likelihood of dementia, heart failure, and mortality from vascular disease.

Medical Therapy

Goals of Therapy

In addition to alleviating symptoms of hypertension, such as headache and blurry vision, the ultimate long term goals of the management of hypertension are to reduce cardiovascular risk, prevent cardiovascular events, and reverse or ameliorate target organ damage. According to “Blood Pressure Lowering Treatment Trialists’ Collaboration” in 2000, lowering blood pressure decreases the incidence of stroke by an average of 30%, MI by an average of 20%, major cardiovascular events by an average of 21%, and heart failure by an average of more than 50%.[1]

JNC 7 has established the goal blood pressure to be < 140/90 mmHg[2], with major focus on reduction of systolic blood pressure due to its role in the consequential reduction of diastolic blood pressure. In special populations such as those with diabetes mellitus or renal disease, the blood pressure goal is < 130/80 mmHg.[3][4]

Approach to Medical Therapy

A lot of debate exists on the optimal approach to the medical management of hypertension. With the multitude of classes and agents that can be used, several questions arise about the single best agent, the optimal combination of agents, and the best step-wise approach to medical management. Although JNC7 tried to address these issues, almost a decade has passed since the release of their recommendations, with a myriad of studies and trials presenting newer compelling evidence to update the current recommendations. The 2013 ESH/ESC guidelines for the management of hypertension have dwelled into these issues and have outlined the rationale behind adopting a new approach. Below are the algorithms for the approach to the medical therapy of hypertension presented by JNC7 in 2004 and ESH/ESC in 2013.


ESH/ESC 2013 Guidelines. Approach to medical therapy of hypertension.
ESH/ESC 2013 Guidelines. Approach to medical therapy of hypertension.


JNC7 Guidelines. Approach to medical therapy of hypertension.
JNC7 Guidelines. Approach to medical therapy of hypertension.

JNC- Seventh Report Recommendations: Medical Management[5]

Table 1:Clinical trial and guideline basis for compelling indications for individual drug classes
Compelling Indication Recommended Drugs Clinical Trial Basis
Heart failure Diuretics, Beta blockers, ACEIs, ARBs, Aldosterone antagonist ACC/AHA Heart Failure Guideline [6]; MERIT-HF [7]; COPERNICUS [8]; CIBIS [9]; SOLVD [10]; AIRE [11]; TRACE [12]; ValHEFT [13]; RALES [14]
Post-Myocardial infarction Beta blockers, ACEIs, Aldosterone antagonist ACC/AHA Post-MI Guideline [15]; BHAT [16]; SAVE [17]; Capricorn [18]; EPHESUS [19]
High coronary disease risk Diuretics, Beta blockers, ACEIs, CCBs, ALLHAT [20]; HOPE [21]; ANBP2 [22]; LIFE [23]; CONVINCE [24]
Diabetes Diuretics, Beta blockers, ACEIs, ARBs, CCBs NKF-ADA Guideline [3][4]; UKPDS [25]; ALLHAT [20]
Chronic kidney disease ACEIs, ARBs NFK Guideline [4]; Captopril Trial [26]; RENAAL [27]; IDNT [28]; REIN [29]; AASK [30]
Recurrent stroke prevention Diuretics, ACEIs PROGRESS [31]

References

  1. ↑ Neal B, MacMahon S, Chapman N, Blood Pressure Lowering Treatment Trialists' Collaboration (2000). "Effects of ACE inhibitors, calcium antagonists, and other blood-pressure-lowering drugs: results of prospectively designed overviews of randomised trials. Blood Pressure Lowering Treatment Trialists' Collaboration". Lancet. 356 (9246): 1955–64. PMID 11130523.
  2. ↑ Maldonado J (1998). "[Recommended article of the month: Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the hypertension optimal treatment (HOT) randomised trial]". Rev Port Cardiol. 17 (10): 843–4. PMID 9865094.
  3. ↑ 3.0 3.1 Arauz-Pacheco C, Parrott MA, Raskin P, American Diabetes Association (2003). "Treatment of hypertension in adults with diabetes". Diabetes Care. 26 Suppl 1: S80–2. PMID 12502624.
  4. ↑ 4.0 4.1 4.2 National Kidney Foundation (2002). "K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification". Am J Kidney Dis. 39 (2 Suppl 1): S1–266. PMID 11904577.
  5. ↑ Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL et al. (2003) Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 42 (6):1206-52. DOI:10.1161/01.HYP.0000107251.49515.c2 PMID: 14656957
  6. ↑ Hunt SA, Baker DW, Chin MH, Cinquegrani MP, Feldman AM, Francis GS et al. (2001) ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1995 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol 38 (7):2101-13. PMID: 11738322
  7. ↑ Tepper D (1999) Frontiers in congestive heart failure: Effect of Metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Congest Heart Fail 5 (4):184-185. PMID: 12189311
  8. ↑ Packer M, Coats AJ, Fowler MB, Katus HA, Krum H, Mohacsi P et al. (2001) Effect of carvedilol on survival in severe chronic heart failure. N Engl J Med 344 (22):1651-8. DOI:10.1056/NEJM200105313442201 PMID: 11386263
  9. ↑ (1994) A randomized trial of beta-blockade in heart failure. The Cardiac Insufficiency Bisoprolol Study (CIBIS). CIBIS Investigators and Committees. Circulation 90 (4):1765-73. PMID: 7923660
  10. ↑ (1991) Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. The SOLVD Investigators. N Engl J Med 325 (5):293-302. DOI:10.1056/NEJM199108013250501 PMID: 2057034
  11. ↑ (1993) Effect of ramipril on mortality and morbidity of survivors of acute myocardial infarction with clinical evidence of heart failure. The Acute Infarction Ramipril Efficacy (AIRE) Study Investigators. Lancet 342 (8875):821-8. PMID: 8104270
  12. ↑ Køber L, Torp-Pedersen C, Carlsen JE, Bagger H, Eliasen P, Lyngborg K et al. (1995) A clinical trial of the angiotensin-converting-enzyme inhibitor trandolapril in patients with left ventricular dysfunction after myocardial infarction. Trandolapril Cardiac Evaluation (TRACE) Study Group. N Engl J Med 333 (25):1670-6. DOI:10.1056/NEJM199512213332503 PMID: 7477219
  13. ↑ Cohn JN, Tognoni G, Valsartan Heart Failure Trial Investigators (2001) A randomized trial of the angiotensin-receptor blocker valsartan in chronic heart failure. N Engl J Med 345 (23):1667-75. DOI:10.1056/NEJMoa010713 PMID: 11759645
  14. ↑ Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A et al. (1999) The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med 341 (10):709-17. DOI:10.1056/NEJM199909023411001 PMID: 10471456
  15. ↑ Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS et al. (2002) ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction--summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol 40 (7):1366-74. PMID: 12383588
  16. ↑ (1982) A randomized trial of propranolol in patients with acute myocardial infarction. I. Mortality results. JAMA 247 (12):1707-14. PMID: 7038157
  17. ↑ Hager WD, Davis BR, Riba A, Moye LA, Wun CC, Rouleau JL et al. (1998) Absence of a deleterious effect of calcium channel blockers in patients with left ventricular dysfunction after myocardial infarction: The SAVE Study Experience. SAVE Investigators. Survival and Ventricular Enlargement. Am Heart J 135 (3):406-13. PMID: 9506325
  18. ↑ Dargie HJ (2001) Effect of carvedilol on outcome after myocardial infarction in patients with left-ventricular dysfunction: the CAPRICORN randomised trial. Lancet 357 (9266):1385-90. PMID: 11356434
  19. ↑ Pitt B, Remme W, Zannad F, Neaton J, Martinez F, Roniker B et al. (2003) Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med 348 (14):1309-21. DOI:10.1056/NEJMoa030207 PMID: 12668699
  20. ↑ 20.0 20.1 ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (2002) Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 288 (23):2981-97. PMID: 12479763
  21. ↑ Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G (2000) Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med 342 (3):145-53. DOI:10.1056/NEJM200001203420301 PMID: 10639539
  22. ↑ Wing LM, Reid CM, Ryan P, Beilin LJ, Brown MA, Jennings GL et al. (2003) A comparison of outcomes with angiotensin-converting--enzyme inhibitors and diuretics for hypertension in the elderly. N Engl J Med 348 (7):583-92. DOI:10.1056/NEJMoa021716 PMID: 12584366
  23. ↑ Dahlöf B, Devereux RB, Kjeldsen SE, Julius S, Beevers G, de Faire U et al. (2002) Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet 359 (9311):995-1003. DOI:10.1016/S0140-6736(02)08089-3 PMID: 11937178
  24. ↑ Black HR, Elliott WJ, Grandits G, Grambsch P, Lucente T, White WB et al. (2003) Principal results of the Controlled Onset Verapamil Investigation of Cardiovascular End Points (CONVINCE) trial. JAMA 289 (16):2073-82. DOI:10.1001/jama.289.16.2073 PMID: 12709465
  25. ↑ (1998) Efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 39. UK Prospective Diabetes Study Group. BMJ 317 (7160):713-20. PMID: 9732338
  26. ↑ Lewis EJ, Hunsicker LG, Bain RP, Rohde RD (1993) The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. The Collaborative Study Group. N Engl J Med 329 (20):1456-62. DOI:10.1056/NEJM199311113292004 PMID: 8413456
  27. ↑ Brenner BM, Cooper ME, de Zeeuw D, Keane WF, Mitch WE, Parving HH et al. (2001) Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med 345 (12):861-9. DOI:10.1056/NEJMoa011161 PMID: 11565518
  28. ↑ Lewis EJ, Hunsicker LG, Clarke WR, Berl T, Pohl MA, Lewis JB et al. (2001) Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med 345 (12):851-60. DOI:10.1056/NEJMoa011303 PMID: 11565517
  29. ↑ (1997) Randomised placebo-controlled trial of effect of ramipril on decline in glomerular filtration rate and risk of terminal renal failure in proteinuric, non-diabetic nephropathy. The GISEN Group (Gruppo Italiano di Studi Epidemiologici in Nefrologia) Lancet 349 (9069):1857-63. PMID: 9217756
  30. ↑ Wright JT, Agodoa L, Contreras G, Greene T, Douglas JG, Lash J et al. (2002) Successful blood pressure control in the African American Study of Kidney Disease and Hypertension. Arch Intern Med 162 (14):1636-43. PMID: 12123409
  31. ↑ PROGRESS Collaborative Group (2001) Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack. Lancet 358 (9287):1033-41. DOI:10.1016/S0140-6736(01)06178-5 PMID: 11589932

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