Hypertension Management Part 4
Special Situations
Hypertension treatment is similar for all demographic groups, but socioeconomic factors and lifestyle can constitute barriers to blood pressure control. African-Americans experience hypertension with increased prevalence, severity, and impact — and respond less well to monotherapy with BBs, angiotensin receptor blockers (ARBs), or ARBs than to diuretics (particularly in combination therapy) or calcium channel blockers (CCBs). Black patients are two to four times more likely to experience ACEI-induced angioedema than are other patients.
Obesity and the metabolic syndrome, left ventricular hypertrophy, peripheral arterial disease, age greater than 65, postural hypotension, and dementia increase health risks associated with hypertension.
For women, oral contraceptives (especially used long-term) may increase blood pressure (BP), but hormone replacement therapy does not. Hypertensive women who become pregnant must be monitored closely because of the potential for harm to both mother and fetus; methyldopa, BBs, and vasodilators are safest for the fetus. Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) should not be used by women who are pregnant or who may become pregnant.
In children and adolescents, hypertension is defined as blood pressure consistently at the 95th percentile or greater when adjusted for age, height, and gender. Lifestyle changes are recommended first, with pharmacologic treatment for those who do not respond or who have higher BP.
The Role of the Health Care Professional
Even when patients receive the most effective treatment from the most careful health care professional, they may not achieve adequate blood pressure (BP) control unless they are motivated. The JNC acknowledges the importance of the health care provider’s judgment in managing each patient and calls for empathy that builds trust and leads to positive experiences for the hypertensive patient.
The JNC writers urge health care professionals to overcome the “clinical inertia” demonstrated by those who “[fail] to titrate or combine medication, despite knowing the patient is not at goal blood pressure (BP).”
In a editorial in JAMA (where the JNC 7 Express was also published), Kottke et al cite numerous projects and medical practices that have “redesigned hypertension detection and treatment” — resulting in BP control rates that often exceeded 50%. They anticipate “dire” societal consequences of what they call a “lifestyle syndrome” of conditions and diseases that result from ingesting too much saturated fat, sodium, and alcohol; consuming too many calories and expending too few; and active or passive smoking. “Clearly,” they conclude, “action to control blood pressure is needed now and is a challenge that all must accept.”
This post has been viewed 4012 times.
Comments are closed.
