What are the risks and management strategies for hypertension?

Risks of Hypertension and Management Strategies

Hypertension significantly increases the risk of cardiovascular disease, stroke, heart failure, kidney disease, and premature death, making aggressive blood pressure control essential for reducing morbidity and mortality. 1

Health Risks Associated with Hypertension

Cardiovascular Risks

• Coronary heart disease: Hypertension doubles the risk of fatal cardiovascular events with each 20/10 mmHg increase in blood pressure 1
• Heart failure: 40% reduction in risk with proper BP control 1
• Stroke: 35% reduction in risk with proper BP control 1
• Myocardial infarction: 15% reduction in risk with proper BP control 1

Kidney Risks

• Chronic kidney disease progression: Hypertension accelerates kidney function decline 2, 3
• Proteinuria: Increased risk with uncontrolled hypertension 1
• End-stage renal disease: 2-6 fold higher risk in resistant hypertension 1

Other Target Organ Damage

• Brain: Cognitive decline, vascular dementia, and increased stroke risk 4
• Vascular system: Arterial stiffness, atherosclerosis, and peripheral vascular disease 4
• Mortality risk: 20% reduction in cardiovascular mortality and 10% reduction in all-cause mortality with proper BP control 1

Diagnosis and Assessment

Blood Pressure Classification (ACC/AHA 2017) 1

BP Category	SBP	DBP
Normal	<120 mmHg	<80 mmHg
Elevated	120-129 mmHg	<80 mmHg
Stage 1 Hypertension	130-139 mmHg	80-89 mmHg
Stage 2 Hypertension	≥140 mmHg	≥90 mmHg

Risk Assessment

• Evaluate total cardiovascular risk profile, not just blood pressure numbers 1
• Assess for additional risk factors (diabetes, dyslipidemia, smoking, obesity)
• Screen for target organ damage (heart, kidney, brain, blood vessels)
• Calculate 10-year cardiovascular risk score

Management Strategies

Lifestyle Modifications (First-line for all patients) 5

• Weight reduction: Target BMI <25 kg/m²
• DASH diet: Rich in fruits, vegetables, whole grains, low-fat dairy
• Sodium restriction: <2,300 mg/day
• Increased physical activity: 150 minutes/week of moderate-intensity exercise
• Alcohol moderation: ≤2 drinks/day for men, ≤1 drink/day for women

Pharmacological Treatment

When to Initiate Medication 1, 5

• BP ≥140/90 mmHg: All patients
• BP 130-139/80-89 mmHg: Patients with clinical CVD, diabetes, CKD, or 10-year CVD risk ≥10%

First-line Medications 5

• Thiazide or thiazide-like diuretics: Chlorthalidone preferred over hydrochlorothiazide
• ACE inhibitors or ARBs: Especially beneficial in diabetes, CKD, and heart failure
• Calcium channel blockers: Particularly effective in black patients

BP Targets 1

• General population: <130/80 mmHg
• Older adults (≥65 years): <130/80 mmHg (if tolerated)
• Patients with CKD and proteinuria: <130/80 mmHg
• Diabetes: <130/80 mmHg

Management of Resistant Hypertension 1

Resistant hypertension is defined as BP ≥130/80 mmHg despite adherence to 3+ antihypertensive agents (including a diuretic) at optimal doses.

Management approach:

1. Confirm medication adherence
2. Rule out white coat hypertension with home or ambulatory BP monitoring
3. Maximize diuretic therapy (switch to chlorthalidone or indapamide)
4. Add a mineralocorticoid receptor antagonist (spironolactone or eplerenone)
5. Consider loop diuretics in patients with CKD
6. Refer to hypertension specialist if BP remains uncontrolled

Special Populations

Chronic Kidney Disease 1, 2

• BP target: <130/80 mmHg
• First-line therapy: ACE inhibitors or ARBs (reduce proteinuria and slow CKD progression)
• Monitor: eGFR, microalbuminuria, and electrolytes

Diabetes 1

• BP target: <130/80 mmHg
• First-line therapy: RAS inhibitor (ACE inhibitor or ARB) plus CCB and/or thiazide-like diuretic

Older Adults 1, 6

• BP target: <130/80 mmHg if tolerated
• Caution: Monitor for orthostatic hypotension
• Diastolic concerns: Maintain diastolic BP ≥70 mmHg to prevent tissue hypoperfusion 6

Implementation Strategies

Team-Based Approach 1

• Utilize multidisciplinary teams (physicians, nurses, pharmacists)
• Use electronic health records and patient registries to identify uncontrolled hypertension
• Consider telehealth strategies for monitoring and follow-up

Improving Medication Adherence 1

• Once-daily dosing when possible
• Use of combination pills
• Regular follow-up and BP monitoring
• Patient education about hypertension risks and treatment benefits

Common Pitfalls to Avoid

• Underestimating cardiovascular risk: Even mild hypertension increases long-term risk
• Therapeutic inertia: Failure to intensify treatment when BP remains uncontrolled
• Ignoring medication adherence: Up to 25% of patients don't fill their initial prescription
• Inadequate BP measurement technique: Ensure proper cuff size and measurement protocol
• Overlooking secondary causes: Screen for secondary hypertension in resistant cases
• Neglecting diastolic concerns: Avoid excessive lowering of diastolic BP (<60 mmHg) in elderly patients with coronary artery disease 6