How to manage hypertension and non-Hodgkin's lymphoma?

Management of Hypertension in Patients with Non-Hodgkin's Lymphoma

For patients with both hypertension and non-Hodgkin's lymphoma, a comprehensive approach that includes lifestyle modifications, careful medication selection, and regular monitoring is essential to reduce cardiovascular morbidity and mortality while effectively treating the lymphoma. 1

Hypertension Management Priorities

Lifestyle Modifications

• Dietary interventions:

  • Follow DASH diet: fruits, vegetables, whole grains, low-fat dairy products with reduced saturated and total fat 1
  • Reduce sodium intake to <2,300 mg/day 1
  • Increase potassium intake (3,500-5,000 mg/day) 1
  • Moderate alcohol consumption (≤2 standard drinks/day for men, ≤1 for women) 1

• Physical activity:

  • Aerobic exercise 5-7 times/week (30-60 minutes/session), aiming for at least 150 minutes/week 1
  • Dynamic resistance exercise 2-3 times/week as tolerated 1

• Weight management:

  • Achieve and maintain healthy body weight 1
  • Expect approximately 1 mmHg reduction in SBP for every 1 kg weight loss 1

Pharmacological Management

1. Blood pressure targets:

   • Goal <130/80 mmHg for most patients with hypertension and non-Hodgkin's lymphoma 1
   • Monthly visits until blood pressure target is achieved 1

2. First-line medications:

   • Long-acting amlodipine as first-line calcium channel blocker 1
   • Consider ACE inhibitors or ARBs as they have cardiovascular protective effects 1
   • Long-acting chlorthalidone preferred over hydrochlorothiazide for diuretic therapy 1

3. Medication considerations:

   • Use fixed-dose combinations to improve adherence 1
   • Replace 30-day with 90-day refills when possible 1
   • Consider potential interactions with chemotherapy regimens

Special Considerations for Non-Hodgkin's Lymphoma Patients

Cardiovascular Risk Assessment

• Pre-existing hypertension significantly increases risk of left ventricular systolic dysfunction during chemotherapy (19.7% vs. 6.6% in non-hypertensive patients) 2
• Hypertension is a major risk factor for developing early left ventricular systolic dysfunction after (R)-CHOP chemotherapy 2

Monitoring During Cancer Treatment

• More frequent blood pressure monitoring during chemotherapy cycles
• Regular assessment of cardiac function with echocardiography before and during treatment
• Monitor for signs of heart failure (ankle edema, nycturia) which occur more frequently in hypertensive lymphoma patients (23.9% vs. 9.5%) 2

Treatment Adjustments

• Aggressive blood pressure control before initiating chemotherapy to minimize cardiac complications
• Consider telehealth strategies to augment office-based management 1
• Use multidisciplinary team-based care involving oncology and cardiology 1

Management Algorithm

1. Initial Assessment:

   • Establish baseline blood pressure and cardiovascular risk factors
   • Evaluate for target organ damage
   • Screen for secondary causes of hypertension

2. Pre-Chemotherapy Optimization:

   • Achieve blood pressure control (<130/80 mmHg) before starting lymphoma treatment
   • Implement all appropriate lifestyle modifications
   • Select antihypertensive medications with minimal interaction potential

3. During Chemotherapy:

   • Monitor blood pressure weekly during initial cycles
   • Assess for fluid retention and cardiac symptoms
   • Adjust antihypertensive medications as needed
   • Evaluate for treatment delays or dose reductions if cardiovascular complications occur

4. Long-term Follow-up:

   • Continue regular blood pressure monitoring after completion of cancer therapy
   • Annual assessment of cardiovascular function
   • Maintain lifestyle modifications indefinitely

Common Pitfalls and Caveats

1. Underestimating cardiovascular risk:

   • Hypertensive lymphoma patients have higher rates of chemotherapy delays (26.8% vs. 14.6%), dose reductions (18.3% vs. 8.8%), and premature discontinuations (16.9% vs. 7.3%) 2

2. Medication interactions:

   • Some antihypertensive medications may interact with chemotherapy agents
   • Beta-blockers may mask symptoms of anemia or infection

3. Volume status fluctuations:

   • Chemotherapy and supportive medications can cause fluid retention
   • Nausea/vomiting may lead to volume depletion and hypotension

4. Resistant hypertension:

   • Screen for secondary causes including sleep apnea 1
   • Consider referral to hypertension specialist if BP remains ≥130/80 mmHg despite 3+ medications 1

By implementing this comprehensive approach to managing hypertension in non-Hodgkin's lymphoma patients, clinicians can reduce cardiovascular complications and improve overall outcomes in this high-risk population.