2 days ago
Management of Hypertension in Primary Care
Hypertension is the most common chronic condition that primary care physicians treat. Knowledge about the causes and effective treatment strategies have evolved over the decades since I attended medical school, and I want to highlight some of the most useful approaches I have found over the years.
What are the most common causes of secondary hypertension?
Most hypertension (90%-95%) is essential hypertension. In medical school, I learned a list of rare diseases to consider as causes of secondary hypertension like pheochromocytoma, coarctation of the aorta, and Cushing syndrome. In the real world, the diagnoses with highest prevalence of secondary hypertension are obstructive sleep apnea (25%-50%), hyperaldosteronism (8%), atherosclerotic renal artery stenosis (5%), and drug or alcohol abuse (4%). The rare diseases listed above account for 0.1% or less of secondary hypertension.
What is the best initial treatment for patients just diagnosed with hypertension?
The biggest change from what I was taught in medical school is that for most patients, we should start with two-drug therapy to achieve the blood pressure (BP) goal if the initial BP is more than 20/10 mm Hg above the target BP goal. Patients with stage 1 hypertension are usually started on one medication if the goal is more modest BP lowering.
What if your initial treatment with a single drug does not achieve its goal?
Douglas S. Paauw, MD
The standard approach for many years was to increase the dose of the single BP medication with the hope that there would be a more pronounced BP response. J.R. Benz and colleagues looked at the BP effect of doubling the dose of valsartan from 80 mg to 160 mg. The difference was an additional BP lowering of only 3 mm Hg/0.8 mm Hg.
Patients who received a second drug (hydrochlorothiazide) in addition to 80 mg of valsartan rather than doubling the valsartan dose had an average reduction in BP of 12 mm Hg/6 mm Hg. In a meta-analysis comparing monotherapy with combination therapy for lowering BP, adding another drug lowered BP five times more than doubling the dose of the initial antihypertensive drug.
What is the best approach to treating resistant hypertension?
According to my training, patients with resistant hypertension needed a workup for secondary hypertension and rarely used drugs like clonidine and minoxidil were in play. De Jager and colleagues evaluated renal denervation in hypertension treatment. As part of the study, stored blood samples collected at study entry were evaluated for adherence to prescribed antihypertensive medications.
In 80% of patients, fewer drugs were detected than prescribed. This high rate of nonadherence emphasizes that the first place to start in treatment of resistant hypertension is to carefully assess adherence. For patients with true resistant hypertension, de Souza et al studied 175 patients taking at least three antihypertensive medications and documented adherence. All patients were then given spironolactone, with a mean decrease in systolic BP of 16 mm Hg and diastolic BP of 9 mm Hg. Adding a mineralocorticoid receptor antagonist is recommended in the American College of Cardiology/American Heart Association guidelines. Recent data collected by Lee and colleagues show that amiloride is equivalent to spironolactone in patients with resistant hypertension, with systolic BP reductions of 13.6 mm Hg.
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