What is the history of hypertension (high blood pressure)?

From the Guidelines

Hypertension management should prioritize identifying the underlying cause, whether primary or secondary, to guide treatment and improve patient outcomes, as outlined in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. When considering a patient's history of hypertension, it's crucial to distinguish between primary and secondary hypertension, as the approach to management can differ significantly.

Key Historical Features

• Primary hypertension is often characterized by a gradual increase in blood pressure, lifestyle factors favoring higher BP (such as weight gain, high-sodium diet, decreased physical activity), and a family history of hypertension 1.
• Secondary hypertension, on the other hand, may present with more abrupt changes in blood pressure, symptoms such as BP lability, episodic pallor and dizziness (suggestive of pheochromocytoma), snoring and hypersomnolence (indicative of obstructive sleep apnea), or other specific clinical features that point to an underlying cause like kidney disease, hyperthyroidism, or Cushing's syndrome 1.

Clinical Approach

Given the complexity and variability of presentations, a thorough clinical evaluation is essential. This includes:

• A detailed medical history to identify potential causes or contributing factors.
• Physical examination to look for signs of end-organ damage or clues to secondary causes.
• Laboratory tests as indicated to evaluate for target organ damage or to investigate potential secondary causes.

Management Considerations

The management of hypertension, whether primary or secondary, aims to reduce blood pressure to levels that minimize cardiovascular risk while maintaining quality of life.

• Lifestyle modifications are a cornerstone of treatment for all patients with hypertension, including dietary changes, increased physical activity, weight loss if needed, and limitation of alcohol intake 1.
• Pharmacological therapy is guided by the presence of compelling indications (such as heart failure, chronic kidney disease) and the patient's overall cardiovascular risk profile, with the goal of achieving blood pressure targets that balance efficacy with tolerability 1.

From the FDA Drug Label

Almost all of the patients (96.6%) had a history of hypertension, and the patients entered the trial with a mean serum creatinine of 1. 9 mg/dL and mean proteinuria (urinary albumin/creatinine) of 1808 mg/g at baseline. The presence of a history of hypertension is noted in the study, with 96.6% of patients having this condition.

• The study involved patients with a history of hypertension, with a mean serum creatinine and proteinuria at baseline.
• Losartan was used to treat these patients, with the goal of reducing blood pressure and slowing the progression of renal disease.
• Key points about the study population include:
  • Age: 66.4% of patients were under 65 years old
  • Gender: 63.2% of patients were men
  • Race: diverse population with 16.7% Asian, 15.2% Black, 18.3% Hispanic, and 48.6% White
  • Comorbidities: 13% had diabetes, 14% had isolated systolic hypertension, 16% had coronary heart disease, and 8% had cerebrovascular disease 2

From the Research

History of Hypertension

• Hypertension is defined as persistent systolic blood pressure (SBP) at least 130 mm Hg or diastolic BP (DBP) at least 80 mm Hg, affecting approximately 116 million adults in the US and more than 1 billion adults worldwide 3.
• The condition is associated with increased risk of cardiovascular disease (CVD) events, including coronary heart disease, heart failure, and stroke, and death 3.

Treatment of Hypertension

• First-line therapy for hypertension is lifestyle modification, including weight loss, healthy dietary pattern, physical activity, and moderation or elimination of alcohol consumption 3, 4.
• The decision to initiate antihypertensive medication should be based on the level of BP and the presence of high atherosclerotic CVD risk 3.
• First-line drug therapy for hypertension consists of a thiazide or thiazide-like diuretic, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and a calcium channel blocker 3, 5.

Calcium Channel Blockers

• Calcium channel blockers (CCBs) are often recommended as a first-line drug to treat hypertension, but their effect on the prevention of cardiovascular events compared to other antihypertensive drug classes is still debated 6.
• CCBs have been shown to reduce major cardiovascular events and stroke when compared to beta-blockers and angiotensin-converting enzyme (ACE) inhibitors, but increase congestive heart failure when compared to ACE inhibitors and angiotensin receptor blockers (ARBs) 6.

Combination Therapy

• Dual therapy with calcium channel blockers and beta-blockers is effective in achieving BP control and produces similar outcomes in hypertensive patients with coronary artery disease (CAD) 7.
• Combination treatment with either a CCB/ACE inhibitor or a beta-blocker/diuretic regimen can decrease the risk of primary outcome, including death, nonfatal MI, or nonfatal stroke, in patients with hypertension and CAD 7.