Abstract
Hypertension, defined as persistent systolic blood pressure (SBP) at least 130 mm Hg or diastolic BP (DBP) at least 80 mm Hg, affects approximately 116 million adults in the US and more than 1 billion adults worldwide. Hypertension is associated with increased risk of cardiovascular disease (CVD) events (coronary heart disease, heart failure, and stroke) and death. OBSERVATIONS First-line therapy for hypertension is lifestyle modification, including weight loss, healthy dietary pattern that includes low sodium and high potassium intake, physical activity, and moderation or elimination of alcohol consumption. The BP-lowering effects of individual lifestyle components are partially additive and enhance the efficacy of pharmacologic therapy. The decision to initiate antihypertensive medication should be based on the level of BP and the presence of high atherosclerotic CVD risk. First-line drug therapy for hypertension consists of a thiazide or thiazidelike diuretic such as hydrochlorothiazide or chlorthalidone, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker such as enalapril or candesartan, and a calcium channel blocker such as amlodipine and should be titrated according to office and home SBP/DBP levels to achieve in most people an SBP/DBP target (<130/80 mm Hg for adults <65 years and SBP <130 mm Hg in adults ≥65 years). Randomized clinical trials have established the efficacy of BP lowering to reduce the risk of CVD morbidity and mortality. An SBP reduction of 10 mm Hg decreases risk of CVD events by approximately 20% to 30%. Despite the benefits of BP control, only 44% of US adults with hypertension have their SBP/DBP controlled to less than 140/90 mm Hg. CONCLUSIONS AND RELEVANCE Hypertension affects approximately 116 million adults in the US and more than 1 billion adults worldwide and is a leading cause of CVD morbidity and mortality. First-line therapy for hypertension is lifestyle modification, consisting of weight loss, dietary sodium reduction and potassium supplementation, healthy dietary pattern, physical activity, and limited alcohol consumption. When drug therapy is required, first-line therapies are thiazide or thiazidelike diuretics, angiotensin-converting enzyme inhibitor or angiotensin receptor blockers, and calcium channel blockers.
Generated Summary
This document is a review article focusing on the treatment of hypertension. It synthesizes evidence from randomized clinical trials, systematic reviews, meta-analyses, clinical practice guidelines, and scientific statements. The review primarily emphasizes the 2017 ACC/AHA high BP guideline recommendations. The article delves into both nonpharmacologic and pharmacologic interventions, assessing their impact on blood pressure (BP) reduction and the associated cardiovascular disease (CVD) risk. The methodology involved a PubMed database search for studies in English published since the release of the 2017 ACC/AHA BP guideline from January 2018 to September 2022. Key aspects include lifestyle modifications like weight loss, dietary sodium reduction, increased potassium intake, heart-healthy diets, physical activity, and reduced alcohol consumption. The article also examines the use of various drug classes, including thiazide diuretics, ACE inhibitors, ARBs, and calcium channel blockers, and evaluates their effectiveness and safety profiles. The review provides a comprehensive overview of current evidence regarding hypertension treatment, providing insights into achieving and maintaining optimal BP levels.
Key Findings & Statistics
- Hypertension affects approximately 116 million adults in the US and over 1 billion adults worldwide.
- Hypertension is associated with an increased risk of CVD events (coronary heart disease, heart failure, and stroke) and death.
- Based on self-reported data from a survey of hypertension prevalence in 533,306 adults, it was estimated that eliminating hypertension in women would reduce population mortality by approximately 7.3%, compared with 0.1% for hyperlipidemia, 4.1% for diabetes, 4.4% for cigarette smoking, and 1.7% for obesity.
- Eliminating hypertension in men would reduce population mortality by approximately 3.8% compared with 2.0% for hyperlipidemia, 1.7% for diabetes, 5.1% for cigarette smoking, and 2.6% for obesity.
- Only 44% of US adults with hypertension have their SBP/DBP controlled to less than 140/90 mm Hg.
- An SBP reduction of 10 mm Hg decreases the risk of CVD events by approximately 20% to 30%.
- An SBP reduction of approximately 1 mm Hg is expected for every kilogram of weight lost.
- A 1000-mg sodium reduction results in SBP lowering of approximately 3 mm Hg.
- In a clinical trial, 459 people with mean BP at baseline of 132/85 mm Hg were randomized to different diets.
- In the subgroup with hypertension, the SBP/DBP changes were -7.3/-2.9 mm Hg in the DASH group compared with the control group.
- According to clinical trial evidence, an exercise duration of 40 to 60 minutes at least 3 times per week may be optimal for BP lowering.
- Mean SBP was directly associated with risk of ASCVD across SBP ranging from 90 to 180 mm Hg.
- The risk ratio of hypertension in adults with overweight and obesity compared with normal weight was 1.52 and 2.17, respectively (meta-analysis of 10 prospective cohort studies, N = 173,828).
- In a 2005-2010 NHANES analysis, SBP was 2.4 mm Hg higher for a sodium intake that was higher by 2300 mg.
- A potassium intake of 3500-5000 mg/d, preferably through diet, is the optimal approach but any increase is good.
- In a meta-analysis of 25 randomized clinical trials, SBP and DBP were reduced by an average of 4.5 and 3.0 mm Hg, respectively.
- In a 6-mo behavioral intervention trial, the DASH diet reduced SBP/DBP by 4.3/2.6 mm Hg compared with advice only.
- In a meta-analysis of 29 longitudinal cohort studies (330,222 adults with 67,698 cases of incident hypertension during follow-up), both leisure time and total physical activity demonstrated an inverse linear association with the risk of incident hypertension.
- In a meta-analysis of 31 alcohol reduction trials, average SBP/DBP was reduced by 5.5/3.97 mm Hg in individuals consuming ≥2 drinks/d.
- In the SPRINT randomized trial, adults aged 75 years or older, even those who were frail or with slow gait, significantly benefited from treatment to an SBP target of less than 120 mm Hg compared with one of less than 140 mm Hg.
- The STEP randomized clinical trial of 8511 patients aged 60 to 80 years demonstrated that intensive antihypertensive treatment to an SBP target of 110 to less than 130 mm Hg reduced CVD events.
- During a median follow-up period of 3.34 years, primary outcome events occurred in 3.5% of the intensive treatment group and 4.6% of the standard treatment group (hazard ratio for intensive vs standard treatment, 0.74; 95% CI, 0.60-0.92; P < .007).
- The ACC/AHA BP guideline recommends estimating 10-year ASCVD risk in adults aged 40 to 79 years who have not had a CVD event.
- For adults with stage 1 hypertension, no history of CVD, and a 10-year ASCVD risk less than 10%, a 6-month trial of intensive lifestyle modification is recommended.
- The optimal BP goal for adults with hypertension is less than 130/80 mm Hg except in adults aged 65 years or older when the goal is SBP less than 130 mm Hg without regard to DBP.
- In a meta-analysis of 119 randomized trials and 920 participants, compared with usual care, team-based hypertension care led by trained nonphysician health care professionals was associated with a mean decrease in SBP of 7.1 mm Hg in patients with hypertension, and team-based care increased the proportion of patients with controlled BP by a median of 8.5%.
- Pharmacy claims data from the US suggest an antihypertensive medicine nonadherence rate (defined as proportion of days an individual had prescription medication available <80%) of 31.0%.
Other Important Findings
- First-line therapy for hypertension is lifestyle modification, including weight loss, a healthy dietary pattern (low sodium, high potassium), physical activity, and alcohol moderation.
- First-line drug therapy includes thiazide or thiazide-like diuretics, ACE inhibitors or ARBs, and calcium channel blockers.
- In prospective observational studies, mean SBP was directly associated with risk of atherosclerotic cardiovascular disease (ASCVD) across SBP ranging from 90 to 180 mm Hg.
- For adults with diabetes and hypertension, clinical practice guidelines support an SBP goal of less than 130 mm Hg.
- For adults with chronic kidney disease who are not undergoing dialysis, the most recent Kidney Disease: Improving Global Outcomes guidelines recommended an SBP goal of less than 120 mm Hg when tolerated, but other guidelines recommend less than 130 mm Hg.
- The BP goal for patients with other comorbidities (eg, stroke, ischemic heart disease, peripheral artery disease, heart failure) is less than 130/80 mm Hg.
- Successful attainment of the ideal BP level requires continuous accurate BP monitoring, appropriate pharmacologic dose titration, and assessment of adherence to the antihypertensive regimen.
- Resistant hypertension is defined by lack of adequate BP control during treatment with 3 antihypertensive agents of different classes, prescribed at optimal doses and dosing intervals, in patients with good adherence.
- The review emphasizes the 2017 ACC/AHA high BP guideline recommendations.
Limitations Noted in the Document
- The literature search excluded articles not published in English.
- The review may have missed some relevant publications.
- Not all aspects of hypertension treatment were covered.
- Some of the included literature consisted of clinical practice guidelines and scientific statements, which are based in part on expert opinion.
Conclusion
The review article underscores the critical importance of managing hypertension effectively to reduce the global burden of cardiovascular disease. As the document highlights, “Hypertension affects approximately 116 million adults in the US and more than 1 billion adults worldwide and is a leading cause of CVD morbidity and mortality.” The primary approach to treatment, as the article states, “First-line therapy for hypertension is lifestyle modification…” This includes weight loss, a healthy dietary pattern, physical activity, and limited alcohol consumption. Drug therapy should be used when lifestyle modifications are insufficient and may be used in combination with lifestyle modification. The article points out, “When drug therapy is required, first-line therapies are thiazide or thiazidelike diuretics, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and calcium channel blockers.” The importance of regular monitoring and medication adherence is also emphasized, as the article states, “Successful attainment of the ideal BP level requires continuous accurate BP monitoring…and assessment of adherence to the antihypertensive regimen.” The authors also highlight the need for a team-based approach to care and the importance of addressing social determinants of health to improve hypertension control. In conclusion, the review reaffirms the need for a comprehensive and individualized approach to hypertension management, combining lifestyle modifications, appropriate pharmacologic therapy, and patient-centered care to effectively reduce the risk of CVD and improve patient outcomes. The authors underscore this: “In prospective observational studies, mean SBP was directly associated with risk of atherosclerotic cardiovascular disease (ASCVD) across SBP ranging from 90 to 180 mm Hg.”