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An in-depth report on the causes, diagnosis, treatment, and prevention of high blood pressure.
Hypertension
Patients with hypertension should work with their doctors to set blood pressure goals based on individual risk factors. Lifestyle changes are important for everyone, and patients should routinely monitor their blood pressure at home. Drug treatment needs to be planned on an individual basis. About 30% of patients with hypertension are not treated at all, and less than 50% have adequately controlled blood pressure.
It is not always clear when drugs should be started, particularly for people with prehypertension or mild high blood pressure. To help make treatment choices, the U.S. National Heart, Lung, and Blood Institute has created categories (groups A, B, and C) according to a patient's risk factors for heart disease. Applying these categories to the severity of hypertension helps determine whether lifestyle changes alone or medications are needed.
Treatment Recommendations by Stage and Risk Groups | |||
Risk Groups | Blood Pressure Stages (Systolic/Diastolic) | ||
Prehypertension (120 - 139/80 - 89) | Mild (Stage 1) Blood Pressure (140 - 159/90 - 99) | Moderate-to-Severe (Stage 2) Blood Pressure (Systolic pressure over 160 or diastolic pressure over 100) | |
Risk Group A Have no risk factors for heart disease. | Lifestyle changes only. (Exercise and dietary program with regular monitoring.) | Year trial of lifestyle changes only. If blood pressure is not lower at 1 year, add drug treatments. | Lifestyle changes and medications. |
Risk Group B Have at least one risk factor for heart disease* (excluding diabetes) but have no target organ damage (such as in the kidneys, eyes, or heart, or existing heart disease). | Lifestyle changes only. | 6-month trial of lifestyle changes only. If blood pressure is not lower at 6 months, add drug treatments. Medications considered for patients with multiple risk factors. | Lifestyle changes and medications. |
Risk Group C Have diabetes with or without target organ damage and existing heart disease (with or without risk factors for heart disease). | Lifestyle changes and medications. | Lifestyle changes and medications. | Lifestyle changes and medications. |
Most anti-hypertensive medications fall into the following categories:
In about half of patients a single-drug regimen can control mild-to-moderate hypertension. More severe hypertension often requires a combination of two or more drugs. Each drug has specific benefits, but their effects may vary depending on the individual patient.
Side Effects and Problems in Compliance. One of the most difficult issues that patients face, is that the treatment may make them feel worse than the disease, which usually has no symptoms. Whatever the difficulties, compliance with a drug and lifestyle program is worth the effort. It is very important that patients discuss medication concerns with their doctors. If current blood pressure drugs are causing uncomfortable side effects, the doctor may adjust dosages or combinations.
Withdrawal from Anti-Hypertensive Medications. Patients whose blood pressure has been well-controlled and who are able to maintain a healthy life style may be able to withdraw from medications. They should do so in a step-down manner (gradual reduction) and be monitored regularly. Stopping too quickly can have adverse effects, including serious effects on the heart. The highest success rates are more likely in those who lose weight and reduce sodium intake, in patients who have been treated with a single drug, and in those who have maintained lower systolic blood pressure during treatment. People over 75 years old may have more trouble than younger adults in maintaining normal blood pressure after withdrawal.
Some patients are unable to meet target blood pressure goals despite consistently following a treatment plan that includes three or more medications. Factors that contribute to resistant hypertension include older age (especially age 75 or older), high baseline blood pressure, and medical conditions such as obesity, sleep apnea, diabetes, and chronic kidney disease. Treating any underlying medical condition is important for helping control blood pressure. Patients should be sure to adhere to lifestyle changes (weight loss and dietary changes) and may require modifications to their drug regimens. Patients with severe resistant hypertension should consider seeking a consultation with a doctor who specializes in treating high blood pressure.
Children with high blood pressure should first be treated with lifestyle changes, including weight reduction, increased physical activity, and diet modification. If blood pressure is not controlled with lifestyle changes, drug treatment may be required. Results of studies evaluating outcomes of children with hypertension suggest that early abnormalities, including enlarged heart and abnormalities in the kidney and eyes, may occur even in children with mild hypertension. Children and adolescents with hypertension should be monitored and evaluated for any early organ damage. Secondary hypertension (high blood pressure due to another disease or drug) is more common in children than adults.
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