From the Guidelines
Hypertension management should prioritize lifestyle modifications and pharmacological treatment, with a focus on reducing morbidity, mortality, and improving quality of life, as recommended by the 2021 WHO Guidelines for the Pharmacological Treatment of Hypertension in Adults 1.
Etiologies of Hypertension
Hypertension has multiple etiologies, including primary (essential) hypertension and secondary causes. Essential hypertension accounts for about 90-95% of cases and develops gradually without an identifiable cause, likely due to genetic factors, lifestyle choices, and aging. Secondary hypertension results from underlying conditions such as renal disease, endocrine disorders, obstructive sleep apnea, coarctation of the aorta, and medications.
Diagnostic Tests
Diagnostic evaluation begins with proper blood pressure measurement, confirming elevated readings on multiple occasions. Basic workup includes:
- Complete blood count
- Metabolic panel
- Lipid profile
- Urinalysis
- Electrocardiogram For suspected secondary causes, specific tests include:
- Plasma renin and aldosterone levels
- 24-hour urinary metanephrines (pheochromocytoma)
- Cortisol levels (Cushing's)
- Renal ultrasound or CT angiography (renal artery stenosis)
- Polysomnography (sleep apnea)
- Thyroid function tests
Treatment
Treatment starts with lifestyle modifications, including:
- Weight reduction
- DASH diet
- Sodium restriction
- Physical activity
- Limiting alcohol First-line medications include:
- Thiazide diuretics (hydrochlorothiazide 12.5-25mg daily)
- Calcium channel blockers (amlodipine 5-10mg daily)
- ACE inhibitors (lisinopril 10-40mg daily)
- Angiotensin receptor blockers (losartan 50-100mg daily) Beta-blockers (metoprolol 25-100mg twice daily) are often second-line agents. For resistant hypertension, aldosterone antagonists like spironolactone 25-50mg daily may be added. Secondary hypertension requires treating the underlying cause alongside blood pressure management. The treatment goal should aim for blood pressure <130/80 mmHg for most adults, though targets may be individualized based on comorbidities and age, as recommended by the 2020 U.S. Department of Veterans Affairs/U.S. Department of Defense clinical practice guideline 2.
From the FDA Drug Label
When pregnancy is detected, discontinue aliskiren tablets as soon as possible. (5.1, 8.1) Drugs that act directly on the renin-angiotensin system can cause injury and death to the developing fetus. (5.1, 8.1) Aliskiren tablets are indicated for the treatment of hypertension in adults and in pediatric patients weighing 50 kg or greater who are at least 6 years of age and older to lower blood pressure. Lowering blood pressure reduces the risk of fatal and nonfatal cardiovascular events, primarily strokes and myocardial infarctions Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake. Numerous antihypertensive drugs, from a variety of pharmacologic classes and with different mechanisms of action, have been shown in randomized controlled trials to reduce cardiovascular morbidity and mortality, and it can be concluded that it is blood pressure reduction, and not some other pharmacologic property of the drugs, that is largely responsible for those benefits
The various etiologies of hypertension are not directly discussed in the provided drug label. The diagnostic tests for hypertension are not mentioned in the label. The treatments for hypertension are discussed, including the use of aliskiren tablets to lower blood pressure in adults and pediatric patients weighing 50 kg or greater who are at least 6 years of age and older. Comprehensive cardiovascular risk management is recommended, including lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake 3. Blood pressure reduction is largely responsible for the reduction in cardiovascular morbidity and mortality. The label does not provide a detailed discussion of the various etiologies of hypertension or their diagnostic tests.
From the Research
Etiologies of Hypertension
- Hypertension is a complex condition with multiple etiologies, including genetic, environmental, and lifestyle factors 4, 5, 6, 7, 8
- The exact cause of hypertension is often unknown, but it is associated with an increased risk of cardiovascular disease, heart failure, and stroke 4, 5
Diagnostic Tests for Hypertension
- Diagnosis of hypertension is typically based on blood pressure measurements, with a systolic blood pressure of at least 130 mm Hg or a diastolic blood pressure of at least 80 mm Hg 4, 5
- Other diagnostic tests, such as urine tests and blood tests, may be used to rule out underlying conditions that may be contributing to hypertension 5
Treatments for Hypertension
- Lifestyle modifications, such as weight loss, healthy dietary patterns, physical activity, and moderation of alcohol consumption, are recommended as first-line therapy for hypertension 4, 5, 6, 8
- Pharmacologic therapy, including thiazide diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and calcium channel blockers, may be used in conjunction with lifestyle modifications to lower blood pressure 4, 5, 7
- Combination therapy with multiple antihypertensive agents may be necessary to achieve optimal blood pressure control 7
Lifestyle Interventions for Hypertension
- Regular physical exercise, body weight management, and healthy dietary patterns have been shown to have preventive and antihypertensive effects 8
- Stress management, adequate sleep patterns, and circadian entrainment may also be beneficial for preventing and treating hypertension 8
- Lifestyle interventions can help to improve vascular health, reduce sympathetic overactivation, and increase secretion of myokines, all of which can help to lower blood pressure 8