Hypertension: Difference between revisions

Latest revision as of 11:01, 30 August 2024

Classification

Classification of blood pressure for adults^[1]
Blood pressure classification	Initial blood pressure mm Hg			Followup recommended
	SBP		DBP
Normal	<120	and	<80	Recheck in 2 years
Prehypertension	120-139	or	80-99	Recheck in 1 year
Stage 1 Hypertension	140-159	or	90-99	Confirm within 2 months
Stage 2 Hypertension	≥ 160	or	≥100	"Evaluate or refer to source of care within 1 month. For those with higher pressures (e.g., >180/110 mmHg), evaluate and treat immediately or within 1 week depending on clinical situation and complications... 2 drug combination for most."
Hypertensive urgency	≥ ~ 180	or	≥ ~ 120 ("without acute target-organ damage"^[1])	"usually do not require hospitalization, but they should receive immediate combination oral antihypertensive therapy"^[1]
Hypertensive emergency	≥ ~ 180	or	≥ ~ 120 (with "acute target-organ damage"^[1])	"require hospitalization and parenteral drug therapy"^[1]

Diagnosis

A systematic review by the Rational Clinical Examination has reviewed the research on blood pressure determination.^[2]

Ambulatory blood pressure monitoring

Clinical practice guidelines by National Institute for Health and Care Excellence (NICE) recommend routine use of ambulatory monitoring for patients newly found to have high blood pressure readings in clinic.^[3]^[4] This approach may reduce the cost of care.^[5]

Ambulatory may better predict future complications than monitoring the office blood pressure.^[6]

Regarding whether the ambulatory pressure should guide treatment, the office pressure may be better.^[7]

A randomized controlled trial of comparing ambulatory versus office monitoring was announced but never completed.^[8]

Confirmation

If the diastolic pressure is below 110 mm Hg, it should be confirmed on two addition visits as some patients will have a lower blood pressure on repeat measurements.^[9] A larger cuff should be used for obese patients.^[10]

White coat hypertension

For more information, see: White coat hypertension.

White coat hypertension is a temporary increase in the blood pressure caused by being examined by a medical professional in a clinical environment. If the only measurements being taken are in medical offices, white coat hypertension may cause the appearance of sustained hypertension.^[11]

White coast hypertension may not be as important to treat.^[12]

Pseudohypertension

Elderly patients may have pseudohypertension due to inability of the blood pressure cuff to compress stiff arteries.^[13] Pseudohypertension may be detected by Osler's maneuver.^[13]

Excluding secondary hypertension

Causes of secondary hypertension^[14]
Cause	Prevalence or effect
Oral contraceptives	1%
Alcohol	6-7 drinks/day may increase BP by 5 mm Hg^[15]
Renal artery stenosis	< 1%
Hyperaldosteronism	?
Pheochromocytoma	?
Coarctation of the aorta	?

Since secondary hypertension may be curable, ruling it out is essential. A starting point is listening for an abdominal bruit, especially if it is both systolic and diastolic, may help detect underlying renal artery stenosis.^[16]

Among patients with resistant hypertension (blood pressure >140/90 mm Hg despite a three drug regimen, 20% of patients had serum aldosterone and plasma renin activity ratio of more than 65:16 with a aldosterone concentration above 416 pmol/L. However, only 10% of all patients had primary aldosteronism. Half of these patients have a normal serum potassium.^[17]

Treatment

Current clinical practice guidelines are:

2001 guidelines by National Institute for Health and Clinical Excellence^[3]
2003 guidelines by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)^[1]
2007 guidelines by the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC).^[18]

In addition, drugs for hypertension (antihypertensives) have been reviewed by the Medical Letter.^[19]

A systematic review by the Cochrane Collaboration has summarized the benefits of treatment.^[20]

Several randomized controlled trials have shown that treating hypertension can reduce morbidity or mortality. These trials include:

MRC trial^[21]
Hypertension Detection and Follow-up Program^[22]
Treatment of Mild Hypertension Study (TOMHS) ^[23]
Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).^[24]
Veterans Affairs Cooperative trial^[25]^[26]
Losartan Intervention For Endpoint reduction in hypertension study (LIFE)^[27]

Treatment goals

Per the JNC7 Guidelines:^[1]

"Treating "most patients" SBP and DBP to targets that are <140/90 mmHg is associated with a decrease in cardiovascular complications.
In patients with hypertension and diabetes or chronic kidney disease, the BP goal is <130/80 mmHg.

The European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) 2007 guidelines add to diabetes and chronic kidney disease that tight control (<130/80 mmHg) is needed for patients with:^[18]

Mild hypertension may not warrant treatment. "Antihypertensive drugs used in the treatment of adults (primary prevention) with mild hypertension (systolic BP 140-159 mmHg and/or diastolic BP 90-99 mmHg) have not been shown to reduce mortality or morbidity in RCTs" according to a meta-analysis by the Cochrane Collaboration. ^[28] In a meta-analysis of randomized controlled trials of patients with mild hypertension, the relative risk ratio of pharmacotherapy, as compared to placebo, for mortality was 0.85 and the relative risk reduction was 15.0%. This finding did not reach statistical significance^[28] Similarly, intensive blood-pressure control ("a mean arterial pressure of 92 is lower than the traditional blood-pressure target of 130/80 mm Hg") had no effect on progression of chronic kidney disease according to a randomized controlled trial. ^[29]

Recent trials present alternative evidence:

An industry-sponsored, unblinded randomized controlled trial suggests benefit from treating any patient with a cardiac risk to a goal systolic pressure of 130 mm Hg.^[30] The HOPE trial reported similar results.^[31] Although 39% of HOPE patients had diabetes, the benefit occurred in patients with and without diabetes.

J-curve

Overly aggressive treatment of hypertension may be harmful due to the "j-curve" effect.^[32]^[33] It is not clear if this is due to excessive reduction in systolic pressure^[34] or low diastolic pressure after treatment^[33] or due to general bad health rather than treatment^[35].

According to the HOT randomized controlled trial, the nadir of the j-curve must be below 80 mm Hg.^[36]

Non-drug treatment

Initial medication

Clinical practice guidelines have tried to make blanket recommendations for all patients:

"Thiazide-type diuretics for most" patients are recommended by the JNC7 clinical practice guidelines.^[1] Chlorthalidone may be the best choice based on the Multiple Risk Factor Intervention Trial^[37] and other studies.^[38]^[39]^[40] In the MRFIT trial, the clinics that predominantly used chlorthalidone reported lower mortality than the clinics using hydrochlorothiazide (5% versus 7%).
"First-line low-dose thiazides reduce all morbidity and mortality outcomes. First-line ACE inhibitors and calcium channel blockers may be similarly effective but the evidence is less robust. First-line high-dose thiazides and first-line beta-blockers are inferior to first-line low-dose thiazides" according to the Cochrane Collaboration.^[41]
ß-blockers
- ß-blockers are the preferred initial medication for patients with coronary heart disease according to a systematic review.^[42]
- "ß-blockers, especially in combination with a thiazide diuretic, should not be used in patients with the metabolic syndrome or at high risk of incident diabetes" is noted by the European ESH/ESC clinical practice guidelines.^[18] The ESH/ESC guidelines cite the LIFE^[27] and ASCOT^[43] trials. Unlike the ALLHAT study^[44], both of these trials were in largely anglo populations, supported by industry, and at the same institution. All patients in the LIFE trial had left ventricular hypertrophy (LVH). Based on these two trials, a meta-analysis has concluded that beta blockers should not be the first choice treatment.^[45]
For Stage 2 Hypertension (SBP ≥ 160 or DBP≥100) consider starting two medications for more effect.^[46]^[1]

Refinements in selection

Selected trials comparing initial medications
Trial	Patients			Intervention	Result
Trial	Race	BMI	Age (mean)	Intervention
ALLHAT^[24] 2002	47% anglo	30	70	Chlorthalidone	Diuretics (chlorthalidone) better than calcium channel blockers and angiotensin-converting enzyme inhibitors
ANBP2^[47] 2003	95% anglo	27	72	Hydrochlorothiazide	Diuretics (hydrochlorothiazide) not as good angiotensin-converting enzyme inhibitors
ACCOMPLISH^[48] 2008	84% anglo	31	68	Hydrochlorothiazide	Diuretics (hydrochlorothiazide) not as good as calcium channel blockers

Several randomized controlled trials have compared initial medications for hypertension. As summarized in the table, the disparate results may be due to racial and gender differences in responses to medications.^[24]^[47]^[49]^[25]^[48]

Should renin levels guide decisions?

Predicting response to anti-hypertensives based on demographics
Category name	demographics	Comments	Best anti-hypertensive categories
High renin demographic	less than 50 years old, anglo	salt-sensitive; diuretic responsive	diuretics, calcium channel blockers
Low renin demographic	more than 50 years old, non-anglo*		ace-inhibitors, ß-blockers
* Obesity and female^[50] are also associated with low renin.

Some authors have proposed that either the renin level or the renin level indexed to urinary sodium excretion in 24 hours.^[51]^[52]

Efficacy of different drugs. From Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents.^[25]

However, the Veterans Affairs Cooperative trial suggests the initial drug may be better selected based on the patient's age, race, and gender.^[25]^[26] The patient's demographic roughly corresponds with their renin profile, but is more predictive than the renin profile.^[26] The molecular basis is being determined.^[53] In the Veterans Affairs Cooperative, among the high renin demographic (young whites), diuretics had similar efficacy to placebo; whereas in the low renin demographic (older blacks), the ace-inhibitors had similar efficacy to placebo in the Veterans Affairs Cooperative Study Group on Antihypertensive Agents (see figure).^[25] Similarly, a meta-analysis has concluded that beta-blockers are a good first choice for younger patients, but not for older patients.^[54]

More recently, plasma renin activity was found to predict response to adrenergic beta-antagonists versus diuretics better than using demographic predictors.^[55]

Race, gender, and age demographic may partly predict frequency of drug toxicity to different anti-hypertensive medications.^[56]

Contraindications

There are contraindications to each of the four major classes, even when other indicators suggest a particular class might be best for the hypertensive patients:

Beta-blockers: asthma, bradycardia and heart block
Diuretics: metabolic syndrome, hypokalemia
ACE inhibitors: pregnancy
Calcium channel blockers: constipation, irritable bowel syndrome

Comorbidities

Given that the antihypertensive is likely to be a lifelong treatment, selection also may be guided by other chronic diseases of the patient.

Beta-blockers: reduce benign essential tremor; may prevent migraine
Diuretics: heart failure
ACE inhibitors: protective of the kidneys, as in diabetes
Calcium channel blockers: also may prevent migraine; may relieve neuropathic pain

Labile hypertension

While labile hypertension may be due to a pheochromocytoma, it may be due to baroreflex failure. This can be treated with clonidine 0.3 to 2.4 mg orally total per day.^[57]

Resistant hypertension

Blood pressure may be difficult to treat, especially in older patients.^[58]^[59] A third of cases may be due to white coat hypertension.^[60] Clinical practice guidelines from the American Heart Association (AHA) address the management of resistant hypertension.^[61]

Physiology

Resistant hypertension is characterized by volume expansion and abnormalities of the renin-angiotensin system with high aldosterone and cortisol with low renin levels in the plasma^[62]^[63] in spite of many patients taking thiazide diuretics.^[63]{ This suggests that high corticotropin may contribute^[63], in some cases due to an abnormal cytochrome P-450 3A5 allele that may reduce metabolism of cortisol and corticosterone (a precursor of aldosterone).^[64] Resistant hypertension is also associated with insulin resistance.^[65]

Evaluation

The AHA defines resistant hypertension as "blood pressure that remains above goal in spite of the concurrent use of 3 antihypertensive agents of different classes."

First, 'pseudoresistance' should be considered:^[61]

Medication noncompliance
Inadequate prescribing by the health care provider^[66] may be the most common cause of persistent hypertension.^[67]^[68]
White coat hypertension, pseudohypertension and other problems of measurement.^[69]

Next, secondary hypertension should be considered:^[61]

Renal artery stenosis may be the cause of as much as 30% of cases of truly resistant hypertension.^[70]
Primary aldosteronism underlies about 10% of cases of resistant hypertension.^[17]
Obstructive sleep apnea

Treatment

A low sodium (50 mmol or 1150 mg of sodium) diet may help.^[71]

The AHA recommends that one of the three medicines use for hypertension should be a diuretic.^[61]

"Three drugs at half standard dose in combination" may be better than one drug at standard dose according to a systematic review.^[42]

In an unblinded, uncontrolled extension of the ASCOT randomized controlled trial, spironolactone 25-50 mg per day as a fourth medication reduced the blood pressure by 21.9/9.5. This result was not affected by whether one of the first three medications included a diuretic.^[72] A second study study, also uncontrolled, corroborated the role of spironolactone.^[73] In this study, 54% of patients were African-American, 45% had primary hyperaldosteronism.

Catheter-based renal sympathetic denervation has been studied for resistant hypertension.^[74]

Hypertensive emergency

Treatment must be from a critical care perspective. While the blood pressure must be lowered quickly to avoid end-stage organ failure or crises such as cerebral hemorrhage, lowering it too quickly may create a different end-stage organ failure through decreased perfusion. "Treat the patient, not the number".

Systolic hypertension

For more information, see: Systolic hypertension.

Diabetes

Randomized controlled trials of treating hypertension in patients with diabetes mellitus type 2^[75]^[76]
Trial	Population	Intervention	Comparison	Outcome	Comments
ACCORD^[75] 2010	4,733 patients	Systolic pressure goal of less than 120 mm Hg for 4.7 years	Systolic pressure goal of less than 140 mm Hg	Mortality	Insignificantly increased
ADVANCE^[76] 2007	11,140 patients	Fixed combination of perindopril and indapamide that achieved blood pressure of 136/73 for 4.3 years	Achieved blood pressure of 130/73	Mortality	Significantly reduced

Geriatrics

Treatment of hypertension in the geriatrics is effective.^[20]

However, treatment of patients over age 80 is not clear.^[20]^[34] A randomized controlled trial included in this meta-analysis found that treating patients aged 80 years or older for two years who have a systolic pressure over 160 mm hg (the average entry pressure was 173/91 mm Hg) and treating to 150/80 mm Hg reduced morbidity.^[77] In this trial, the average seated blood pressure at the end of the study in the treatment group was 143/78.

The Cochrane Collaboration has also performed a meta-analysis of this topic and concluded "treating healthy persons (60 years or older) with moderate to severe systolic and/or diastolic hypertension reduces all cause mortality and cardiovascular morbidity and mortality. The decrease in all cause mortality was limited to persons 60 to 80 years of age."^[20]

Prognosis

References

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↑ Laragh JH, Baer L, Brunner HR, Buhler FR, Sealey JE, Vaughan ED (1972). "Renin, angiotensin and aldosterone system in pathogenesis and management of hypertensive vascular disease.". Am J Med 52 (5): 633-52. PMID 4337477. ^[e]
↑ Materson BJ (2007). "Variability in response to antihypertensive drugs". Am. J. Med. 120 (4 Suppl 1): S10–20. DOI:10.1016/j.amjmed.2007.02.003. PMID 17403377. Research Blogging.
↑ Khan N, McAlister FA (June 2006). "Re-examining the efficacy of beta-blockers for the treatment of hypertension: a meta-analysis". CMAJ 174 (12): 1737–42. DOI:10.1503/cmaj.060110. PMID 16754904. Research Blogging.
↑ Turner ST, Schwartz GL, Chapman AB, Beitelshees AL, Gums JG, Cooper-DeHoff RM et al. (2010). "Plasma renin activity predicts blood pressure responses to beta-blocker and thiazide diuretic as monotherapy and add-on therapy for hypertension.". Am J Hypertens 23 (9): 1014-22. DOI:10.1038/ajh.2010.98. PMID 20725057. PMC PMC2941699. Research Blogging. Commentary at JournalWatch
↑ McDowell SE, Coleman JJ, Ferner RE (2006). "Systematic review and meta-analysis of ethnic differences in risks of adverse reactions to drugs used in cardiovascular medicine". BMJ 332 (7551): 1177–81. DOI:10.1136/bmj.38803.528113.55. PMID 16679330. Research Blogging.
↑ Robertson D, Hollister AS, Biaggioni I, Netterville JL, Mosqueda-Garcia R, Robertson RM (1993). "The diagnosis and treatment of baroreflex failure.". N Engl J Med 329 (20): 1449-55. PMID 8413455.
↑ Moser M, Setaro JF (July 2006). "Clinical practice. Resistant or difficult-to-control hypertension". N. Engl. J. Med. 355 (4): 385–92. DOI:10.1056/NEJMcp041698. PMID 16870917. Research Blogging.
↑ Setaro JF, Black HR (August 1992). "Refractory hypertension". N. Engl. J. Med. 327 (8): 543–7. PMID 1635569. ^[e]
↑ de la Sierra A, Segura J, Banegas JR, Gorostidi M, de la Cruz JJ, Armario P et al. (2011). "Clinical features of 8295 patients with resistant hypertension classified on the basis of ambulatory blood pressure monitoring.". Hypertension 57 (5): 898-902. DOI:10.1161/HYPERTENSIONAHA.110.168948. PMID 21444835. Research Blogging.
↑ ^61.0 ^61.1 ^61.2 ^61.3 Calhoun, D. A., Jones, D., Textor, S., Goff, D. C., Murphy, T. P., Toto, R. D., et al. (2008). Resistant Hypertension: Diagnosis, Evaluation, and Treatment. A Scientific Statement From the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Hypertension, HYPERTENSIONAHA.108.189141. DOI:10.1161/HYPERTENSIONAHA.108.189141.
↑ Sowers JR, Whaley-Connell A, Epstein M (June 2009). "Narrative review: the emerging clinical implications of the role of aldosterone in the metabolic syndrome and resistant hypertension". Ann. Intern. Med. 150 (11): 776–83. PMID 19487712. ^[e]
↑ ^63.0 ^63.1 ^63.2 Gaddam KK, Nishizaka MK, Pratt-Ubunama MN, et al (June 2008). "Characterization of resistant hypertension: association between resistant hypertension, aldosterone, and persistent intravascular volume expansion". Arch. Intern. Med. 168 (11): 1159–64. DOI:10.1001/archinte.168.11.1159. PMID 18541823. Research Blogging.
↑ Givens RC, Lin YS, Dowling AL, et al (September 2003). "CYP3A5 genotype predicts renal CYP3A activity and blood pressure in healthy adults". J. Appl. Physiol. 95 (3): 1297–300. DOI:10.1152/japplphysiol.00322.2003. PMID 12754175. Research Blogging.
↑ Ferrannini E, Buzzigoli G, Bonadonna R, et al (August 1987). "Insulin resistance in essential hypertension". N. Engl. J. Med. 317 (6): 350–7. PMID 3299096. ^[e]
↑ Bolen SD, Samuels TA, Yeh HC, et al (May 2008). "Failure to intensify antihypertensive treatment by primary care providers: a cohort study in adults with diabetes mellitus and hypertension". J Gen Intern Med 23 (5): 543–50. DOI:10.1007/s11606-008-0507-2. PMID 18219539. Research Blogging.
↑ Yakovlevitch M, Black HR (September 1991). "Resistant hypertension in a tertiary care clinic". Arch. Intern. Med. 151 (9): 1786–92. PMID 1888244. ^[e]
↑ Berlowitz DR, Ash AS, Hickey EC, et al (December 1998). "Inadequate management of blood pressure in a hypertensive population". N. Engl. J. Med. 339 (27): 1957–63. PMID 9869666. ^[e]
↑ Mejia AD, Egan BM, Schork NJ, Zweifler AJ (February 1990). "Artefacts in measurement of blood pressure and lack of target organ involvement in the assessment of patients with treatment-resistant hypertension". Ann. Intern. Med. 112 (4): 270–7. PMID 2297205. ^[e]
↑ Isaksson H, Danielsson M, Rosenhamer G, Konarski-Svensson JC, Ostergren J (May 1991). "Characteristics of patients resistant to antihypertensive drug therapy". J. Intern. Med. 229 (5): 421–6. PMID 2040868. ^[e]
↑ Pimenta E, Gaddam KK, Oparil S, Aban I, Husain S, Dell'Italia LJ et al. (2009). "Effects of dietary sodium reduction on blood pressure in subjects with resistant hypertension: results from a randomized trial.". Hypertension 54 (3): 475-81. DOI:10.1161/HYPERTENSIONAHA.109.131235. PMID 19620517. Research Blogging.
↑ Chapman N, Dobson J, Wilson S, et al (April 2007). "Effect of spironolactone on blood pressure in subjects with resistant hypertension". Hypertension 49 (4): 839–45. DOI:10.1161/01.HYP.0000259805.18468.8c. PMID 17309946. Research Blogging.
↑ Nishizaka MK, Zaman MA, Calhoun DA (November 2003). "Efficacy of low-dose spironolactone in subjects with resistant hypertension". Am. J. Hypertens. 16 (11 Pt 1): 925–30. DOI:10.1016/S0895-7061(03)01032-X. PMID 14573330. Research Blogging.
↑ Krum H, Schlaich M, Whitbourn R, et al (April 2009). "Catheter-based renal sympathetic denervation for resistant hypertension: a multicentre safety and proof-of-principle cohort study". Lancet 373 (9671): 1275–81. DOI:10.1016/S0140-6736(09)60566-3. PMID 19332353. Research Blogging.
↑ ^75.0 ^75.1 The ACCORD Study Group (2010). "Effects of Intensive Blood-Pressure Control in Type 2 Diabetes Mellitus.". N Engl J Med. DOI:10.1056/NEJMoa1001286. PMID 20228401. Research Blogging.
↑ ^76.0 ^76.1 Patel A, ADVANCE Collaborative Group. MacMahon S, Chalmers J, Neal B, Woodward M et al. (2007). "Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomised controlled trial.". Lancet 370 (9590): 829-40. DOI:10.1016/S0140-6736(07)61303-8. PMID 17765963. Research Blogging. Review in: Evid Based Med. 2008 Apr;13(2):49
↑ Beckett, N. S., Peters, R., Fletcher, A. E., Staessen, J. A., Liu, L., Dumitrascu, D., et al. (2008). Treatment of Hypertension in Patients 80 Years of Age or Older. N Engl J Med, NEJMoa0801369. DOI:10.1056/NEJMoa0801369

@@ Line 1: / Line 1: @@
 {{subpages}}
 {{TOC|right}}
 '''Hypertension''' is a multisystem [[disease]] whose hallmark is the elevation of [[blood pressure]].  Primary hypertension has no apparent cause, constitutes the majority of cases, and is treated with measures to reduce blood pressure. Secondary hypertension does have an abnormality that is causing the elevation in blood pressure, such as a [[pheochromocytoma|tumor that secretes hormones]] that raise blood pressure; removing the cause may be curative. Primary hypertension is generally not curable and needs to be managed as a chronic disease.
 ==Classification==
 {| class="wikitable"
 |+ Classification of blood pressure for adults<ref name="pmid12748199">{{cite journal |author=Chobanian AV, Bakris GL, Black HR, ''et al'' |title=The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report |journal=JAMA |volume=289 |issue=19 |pages=2560-72 |year=2003 |pmid=12748199 |url=http://jama.ama-assn.org/cgi/content/full/289/19/2560|doi=10.1001/jama.289.19.2560}}http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf</ref>
@@ Line 19: / Line 18: @@
 |-
 | '''Stage 2 Hypertension''' || ≥ 160 ||''or''||≥100 || "Evaluate or refer to source of care within 1 month. For those with higher pressures (e.g., >180/110 mmHg), evaluate and treat immediately or within 1 week depending on clinical situation and complications... 2 drug combination for most."
+|-
+| '''[[Hypertensive urgency]]''' || ≥ ~ 180||''or''||≥ ~ 120 <br/>("''without'' acute target-organ damage"<ref name="pmid12748199"/>)|| "usually do not require hospitalization, but they should receive immediate combination oral antihypertensive therapy"<ref name="pmid12748199"/>
+|-
+| '''[[Hypertensive emergency]]''' || ≥ ~  180||''or''||≥ ~ 120 <br/>(''with'' "acute target-organ damage"<ref name="pmid12748199"/>)|| "require hospitalization and parenteral drug therapy"<ref name="pmid12748199"/>
 |}
-===White coat hypertension===
+==Diagnosis==
-White coat hypertension may lead to sustained hypertension.<ref name="pubmed-19564548">19564548</ref>
+A [[systematic review]] by the [http://www.sgim.org/clinexam-rce.cfm Rational Clinical Examination] has reviewed the research on [[blood pressure determination]].<ref name="pmid7707630">{{cite journal |author=Reeves RA |title=The rational clinical examination. Does this patient have hypertension? How to measure blood pressure |journal=JAMA |volume=273 |issue=15 |pages=1211–8 |year=1995 |pmid=7707630 |doi=}}</ref>
+===Ambulatory blood pressure monitoring===
+[[Clinical practice guideline]]s by [[National Institute for Health and Care Excellence]] (NICE) recommend routine use of ambulatory monitoring for patients newly found to have high blood pressure readings in clinic.<ref name="pmid21868454">{{cite journal| author=Krause T, Lovibond K, Caulfield M, McCormack T, Williams B, Guideline Development Group| title=Management of hypertension: summary of NICE guidance. | journal=BMJ | year= 2011 | volume= 343 | issue=  | pages= d4891 | pmid=21868454 | doi=10.1136/bmj.d4891 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21868454  }} </ref><ref>National Institute for Health and Care Excellence [http://guidance.nice.org.uk/CG127/ CG127 Hypertension]. 2011</ref> This approach may reduce the cost of care.<ref name="pmid21868086">{{cite journal| author=Lovibond K, Jowett S, Barton P, Caulfield M, Heneghan C, Hobbs FD et al.| title=Cost-effectiveness of options for the diagnosis of high blood pressure in primary care: a modelling study. | journal=Lancet | year= 2011 | volume= 378 | issue= 9798 | pages= 1219-30 | pmid=21868086 | doi=10.1016/S0140-6736(11)61184-7 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21868086  }} </ref>
+Ambulatory may better predict future complications than monitoring the office blood pressure.<ref name="pmid10450715">{{cite journal| author=Staessen JA, Thijs L, Fagard R, O'Brien ET, Clement D, de Leeuw PW et al.| title=Predicting cardiovascular risk using conventional vs ambulatory blood pressure in older patients with systolic hypertension. Systolic Hypertension in Europe Trial Investigators. | journal=JAMA | year= 1999 | volume= 282 | issue= 6 | pages= 539-46 | pmid=10450715 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10450715  }} </ref>
+Regarding whether the ambulatory pressure should guide treatment, the office pressure may be better.<ref name="pmid14982911">{{cite journal| author=Staessen JA, Den Hond E, Celis H, Fagard R, Keary L, Vandenhoven G et al.| title=Antihypertensive treatment based on blood pressure measurement at home or in the physician's office: a randomized controlled trial. | journal=JAMA | year= 2004 | volume= 291 | issue= 8 | pages= 955-64 | pmid=14982911 | doi=10.1001/jama.291.8.955 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14982911  }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15252908 Review in: Evid Based Nurs. 2004 Jul;7(3):80] </ref>
-==Diagnosis==
+A [[randomized controlled trial]] of comparing ambulatory versus office monitoring was announced but never completed.<ref name="pmid2150533">{{cite journal| author=Clement DL| title=Office versus ambulatory recordings of blood pressure (OvA): a European multicenter study. The Steering Committee. | journal=J Hypertens Suppl | year= 1990 | volume= 8 | issue= 6 | pages= S39-41 | pmid=2150533 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2150533  }} </ref>
-A [[systematic review]] by the [http://www.sgim.org/clinexam-rce.cfm Rational Clinical Examination] has reviewed the research on measuring the blood pressure.<ref name="pmid7707630">{{cite journal |author=Reeves RA |title=The rational clinical examination. Does this patient have hypertension? How to measure blood pressure |journal=JAMA |volume=273 |issue=15 |pages=1211–8 |year=1995 |pmid=7707630 |doi=}}</ref>
+===Confirmation===
 If the diastolic pressure is below 110  mm Hg, it should be confirmed on two addition visits as some patients will have a lower blood pressure on repeat measurements.<ref name="pmid6402075">{{cite journal |author=Hartley RM, Velez R, Morris RW, D'Souza MF, Heller RF |title=Confirming the diagnosis of mild hypertension |journal=Br Med J (Clin Res Ed) |volume=286 |issue=6361 |pages=287–9 |year=1983 |pmid=6402075 |doi=}} [http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=citizendium&pubmedid=6402075 PubMed Central]</ref> A larger cuff should be used for obese patients.<ref name="pmid6848459">{{cite journal |author=Nielsen PE, Larsen B, Holstein P, Poulsen HL |title=Accuracy of auscultatory blood pressure measurements in hypertensive and obese subjects |journal=Hypertension |volume=5 |issue=1 |pages=122–7 |year=1983 |pmid=6848459 |doi=}}</ref>
-% of patients with untreated borderline hypertension (diastolic pressure between 90 and 104 mm Hg) may have normal blood pressures outside of the doctor's office.<ref name="pmid3336140">{{cite journal |author=Pickering TG, James GD, Boddie C, Harshfield GA, Blank S, Laragh JH |title=How common is white coat hypertension? |journal=JAMA |volume=259 |issue=2 |pages=225–8 |year=1988 |pmid=3336140 |doi=}}</ref>
+===White coat hypertension===
+{{main|White coat hypertension}}
+[[White coat hypertension]] is a temporary increase in the [[blood pressure]] caused by being examined by a medical professional in a clinical environment. If the only measurements being taken are in medical offices, white coat hypertension  may cause the appearance of sustained hypertension.<ref name="pmid19564548">{{cite journal| author=Mancia G, Bombelli M, Facchetti R, Madotto F, Quarti-Trevano F, Polo Friz H et al.| title=Long-term risk of sustained hypertension in white-coat or masked hypertension. | journal=Hypertension | year= 2009 | volume= 54 | issue= 2 | pages= 226-32 | pmid=19564548 | doi=10.1161/HYPERTENSIONAHA.109.129882 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19564548  }} </ref>
-Some patients may have their blood pressure rise by as much as 25 mm Hg due to an alarm reaction upon seeing a doctor.<ref name="pmid3818018">{{cite journal |author=Mancia G, Parati G, Pomidossi G, Grassi G, Casadei R, Zanchetti A |title=Alerting reaction and rise in blood pressure during measurement by physician and nurse |journal=Hypertension |volume=9 |issue=2 |pages=209–15 |year=1987 |pmid=3818018 |doi=}}</ref>
+White coast hypertension may not be as important to treat.<ref name="pmid10973843">{{cite journal| author=Fagard RH, Staessen JA, Thijs L, Gasowski J, Bulpitt CJ, Clement D et al.| title=Response to antihypertensive therapy in older patients with sustained and nonsustained systolic hypertension. Systolic Hypertension in Europe (Syst-Eur) Trial Investigators. | journal=Circulation | year= 2000 | volume= 102 | issue= 10 | pages= 1139-44 | pmid=10973843 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10973843  }} </ref>
+===Pseudohypertension===
 Elderly patients may have pseudohypertension due to inability of the blood pressure cuff to compress stiff arteries.<ref name="pmid4000185">{{cite journal |author=Messerli FH, Ventura HO, Amodeo C |title=Osler's maneuver and pseudohypertension |journal=N. Engl. J. Med. |volume=312 |issue=24 |pages=1548–51 |year=1985 |pmid=4000185 |doi=}}</ref> Pseudohypertension may be detected by Osler's maneuver.<ref name="pmid4000185"/>
 ===Excluding secondary hypertension===
-Listening for an abdominal bruit, especially if it is both systolic and diastolic, may help detect underlying [[renal artery stenosis]].<ref name="pmid7563536">{{cite journal |author=Turnbull JM |title=The rational clinical examination. Is listening for abdominal bruits useful in the evaluation of hypertension? |journal=JAMA |volume=274 |issue=16 |pages=1299–301 |year=1995 |pmid=7563536 |doi=|url=http://jama.ama-assn.org/cgi/reprint/274/16/1299}}</ref>
+{| class="wikitable" align="right"
+|+ Causes of secondary hypertension<ref name="pmid3872106">{{cite journal| author=Lewin A, Blaufox MD, Castle H, Entwisle G, Langford H| title=Apparent prevalence of curable hypertension in the Hypertension Detection and Follow-up Program. | journal=Arch Intern Med | year= 1985 | volume= 145 | issue= 3 | pages= 424-7 | pmid=3872106 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3872106  }} </ref>
+! Cause!! Prevalence or effect
+|-
+| [[Oral contraceptive]]s|| 1%
+|-
+| Alcohol|| 6-7 drinks/day may increase BP by 5 mm Hg<ref name="pmid2210807">{{cite journal| author=Parker M, Puddey IB, Beilin LJ, Vandongen R| title=Two-way factorial study of alcohol and salt restriction in treated hypertensive men. | journal=Hypertension | year= 1990 | volume= 16 | issue= 4 | pages= 398-406 | pmid=2210807 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2210807  }} </ref>
+|-
+| [[Renal artery stenosis]]|| < 1%
+|-
+| [[Hyperaldosteronism]]|| ?
+|-
+| [[Pheochromocytoma]]|| ?
+|-
+| [[Coarctation of the aorta]]|| ?
+|}
+Since secondary hypertension may be curable, ruling it out is essential. A starting point is listening for an abdominal bruit, especially if it is both systolic and diastolic, may help detect underlying [[renal artery stenosis]].<ref name="pmid7563536">{{cite journal |author=Turnbull JM |title=The rational clinical examination. Is listening for abdominal bruits useful in the evaluation of hypertension? |journal=JAMA |volume=274 |issue=16 |pages=1299–301 |year=1995 |pmid=7563536 |doi=|url=http://jama.ama-assn.org/cgi/reprint/274/16/1299}}</ref>
 Among patients with resistant hypertension (blood pressure >140/90 mm Hg despite a three drug regimen, 20% of patients had serum [[aldosterone]] and plasma [[renin]] activity ratio of more than 65:16 with a [[aldosterone]] concentration above 416 pmol/L. However, only 10% of all patients had primary aldosteronism. Half of these patients have a normal serum potassium.<ref name="pmid18539224">{{cite journal |author=Douma S, Petidis K, Doumas M, ''et al'' |title=Prevalence of primary hyperaldosteronism in resistant hypertension: a retrospective observational study |journal=Lancet |volume=371 |issue=9628 |pages=1921–6 |year=2008 |month=June |pmid=18539224 |doi=10.1016/S0140-6736(08)60834-X |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(08)60834-X |issn=}}</ref>
@@ Line 42: / Line 72: @@
 ==Treatment==
 Current [[clinical practice guideline]]s are:
+* 2001 guidelines by [[National Institute for Health and Clinical Excellence]]<ref name="pmid21868454" />
 * 2003 guidelines by  the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)<ref name="pmid12748199">{{cite journal |author=Chobanian AV, Bakris GL, Black HR, ''et al'' |title=The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report |journal=JAMA |volume=289 |issue=19 |pages=2560-72 |year=2003 |pmid=12748199 |url=http://jama.ama-assn.org/cgi/content/full/289/19/2560|doi=10.1001/jama.289.19.2560}}http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf</ref>
 * 2007 guidelines by the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC).<ref name="pmid17562668">{{cite journal |author=Mancia G, De Backer G, Dominiczak A, ''et al'' |title=2007 Guidelines for the management of arterial hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC) |journal=Eur. Heart J. |volume=28 |issue=12 |pages=1462–536 |year=2007 |month=June |pmid=17562668 |doi=10.1093/eurheartj/ehm236 |url=http://eurheartj.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=17562668 |issn=}}</ref>
 In addition, drugs for hypertension ([[antihypertensive]]s) have been reviewed by the Medical Letter.<ref name="pmid15912125">{{cite journal |author= |title=Drugs for hypertension |journal=Treat Guidel Med Lett |volume=3 |issue=34 |pages=39–48 |year=2005 |month=June |pmid=15912125 |doi= |url=http://www.medicalletter.org/scripts/articlefind.cgi?issue=34&page=39 |issn=}}</ref>
+A [[systematic review]] by the [[Cochrane Collaboration]] has summarized the benefits of treatment.<ref name="pmid19821263">{{cite journal| author=Musini VM, Tejani AM, Bassett K, Wright JM| title=Pharmacotherapy for hypertension in the elderly. | journal=Cochrane Database Syst Rev | year= 2009 | volume=  | issue= 4 | pages= CD000028 | pmid=19821263 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&retmode=ref&cmd=prlinks&id=19821263 | doi=10.1002/14651858.CD000028.pub2 }} </ref>
 Several [[randomized controlled trial]]s have shown that treating hypertension can reduce morbidity or mortality. These trials include:
@@ Line 64: / Line 97: @@
 * [[proteinuria]]
-The [[Cochrane Collaboration]] concludes in a [[meta-analysis]] that for patients without comorbidities, there is no value in treating below 140/90.<ref>Arguedas JA, Perez MI, Wright JM.  Treatment blood pressure targets for hypertension.  Cochrane Database Syst Rev. 2009 Jul 8;(3):CD004349. PMID 19588353</ref>
+Mild hypertension may not warrant treatment. "Antihypertensive drugs used in the treatment of adults (primary prevention) with mild hypertension (systolic BP 140-159 mmHg and/or diastolic BP 90-99 mmHg) have not been shown to reduce mortality or morbidity in RCTs" according to a [[meta-analysis]] by the [[Cochrane Collaboration]]. <ref name="pmid22895954">{{cite journal| author=Diao D, Wright JM, Cundiff DK, Gueyffier F| title=Pharmacotherapy for mild hypertension. | journal=Cochrane Database Syst Rev | year= 2012 | volume= 8 | issue= | pages= CD006742 | pmid=22895954 | doi=10.1002/14651858.CD006742.pub2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22895954 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23247955 Review in: Ann Intern Med. 2012 Dec 18;157(12):JC6-6] </ref> In a [[meta-analysis]] of [[randomized controlled trial]]s of patients with mild hypertension, the [[relative risk ratio]] of [[pharmacotherapy]], as compared to [[placebo]], for mortality was 0.85 and the [[relative risk reduction]] was 15.0%. This finding did not reach [[statistical significance]]<ref name="pmid22895954"/> Similarly, intensive blood-pressure control ("a [[mean arterial pressure]] of 92 is lower than the traditional blood-pressure target of 130/80 mm Hg") had no effect on progression of [[chronic kidney disease]] according to a [[randomized controlled trial]]. <ref name="pmid20818902">{{cite journal| author=Appel LJ, Wright JT, Greene T, Agodoa LY, Astor BC, Bakris GL et al.| title=Intensive blood-pressure control in hypertensive chronic kidney disease. | journal=N Engl J Med | year= 2010 | volume= 363 | issue= 10 | pages= 918-29 | pmid=20818902 | doi=10.1056/NEJMoa0910975 }} </ref>
 Recent trials present alternative evidence:
-* An industry-sponsored, [[randomized controlled trial]] suggests benefit from treating any patient with a cardiac risk to a goal systolic pressure of 130 mm Hg.<ref>{{Cite journal | doi = 10.1016/S0140-6736(09)61340-4
+* An industry-sponsored, unblinded [[randomized controlled trial]] suggests benefit from treating any patient with a cardiac risk to a goal systolic pressure of 130 mm Hg.<ref>{{Cite journal | doi = 10.1016/S0140-6736(09)61340-4
 | issn = 0140-6736 | volume = 374 | issue = 9689 | pages = 525-533 | last = Verdecchia
 | first = Paolo | coauthors = Jan A Staessen, Fabio Angeli, Giovanni de Simone, Augusto Achilli, Antonello Ganau, Gianfrancesco Mureddu, Sergio Pede, Aldo P Maggioni, Donata Lucci, Gianpaolo Reboldi | title = Usual versus tight control of systolic blood pressure in non-diabetic patients with hypertension (Cardio-Sis): an open-label randomised trial
-| journal = The Lancet | accessdate = 2009-08-14 | date = 2009-08-15 | url = http://www.sciencedirect.com/science/article/B6T1B-4X0FFDH-P/2/7ea67283aa10eed88d849c2bb9eac72d }}</ref> * The HOPE trial reported similar results.<ref name="pmid10639539">{{cite journal |author=Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G |title=Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators |journal=N. Engl. J. Med. |volume=342 |issue=3 |pages=145–53 |year=2000 |month=January |pmid=10639539 |doi= |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=10639539&promo=ONFLNS19 |issn=}}</ref> Although 39% of HOPE patients had [[Diabetes mellitus type 2|diabetes]], the benefit occurred in patients with and without diabetes.
+| journal = The Lancet | accessdate = 2009-08-14 | date = 2009-08-15 | url = http://www.sciencedirect.com/science/article/B6T1B-4X0FFDH-P/2/7ea67283aa10eed88d849c2bb9eac72d }}</ref> The HOPE trial reported similar results.<ref name="pmid10639539">{{cite journal |author=Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G |title=Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators |journal=N. Engl. J. Med. |volume=342 |issue=3 |pages=145–53 |year=2000 |month=January |pmid=10639539 |doi= |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=10639539&promo=ONFLNS19 |issn=}}</ref> Although 39% of HOPE patients had [[Diabetes mellitus type 2|diabetes]], the benefit occurred in patients with and without diabetes.
+====J-curve====
+Overly aggressive treatment of hypertension may be harmful due to the "j-curve" effect.<ref name="pmid19892233">{{cite journal| author=Messerli FH, Panjrath GS| title=The J-curve between blood pressure and coronary artery disease or essential hypertension: exactly how essential? | journal=J Am Coll Cardiol | year= 2009 | volume= 54 | issue= 20 | pages= 1827-34 | pmid=19892233 | doi=10.1016/j.jacc.2009.05.073 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19892233  }} </ref><ref name="pmid1824642">{{cite journal|  author=Farnett L, Mulrow CD, Linn WD, Lucey CR, Tuley MR| title=The  J-curve phenomenon and the treatment of hypertension. Is there a point  beyond which pressure reduction is dangerous? | journal=JAMA | year=  1991 | volume= 265 | issue= 4 | pages= 489-95 | pmid=1824642 |  doi=10.1001/jama.1991.03460040065031 | pmc= | url=http://jama.ama-assn.org/content/265/4/489.abstract }} </ref> It is not clear if this is due to excessive reduction in systolic pressure<ref name="pmid20574244">{{cite journal| author=Bejan-Angoulvant T, Saadatian-Elahi M, Wright JM, Schron EB, Lindholm LH, Fagard R et al.| title=Treatment of hypertension in patients 80 years and older: the lower the better? A meta-analysis of randomized controlled trials. | journal=J Hypertens | year= 2010 | volume= 28 | issue= 7 | pages= 1366-72 | pmid=20574244 | doi=10.1097/HJH.0b013e328339f9c5 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20574244  }} </ref> or low diastolic pressure after treatment<ref name="pmid1824642"/> or due to general bad health rather than treatment<ref name="pmid11900496">{{cite journal| author=Boutitie F, Gueyffier F, Pocock S, Fagard R, Boissel JP, INDANA Project Steering Committee. INdividual Data ANalysis of Antihypertensive intervention| title=J-shaped relationship between blood pressure and mortality in hypertensive patients: new insights from a meta-analysis of individual-patient data. | journal=Ann Intern Med | year= 2002 | volume= 136 | issue= 6 | pages= 438-48 | pmid=11900496 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11900496  }} </ref>.
+According to the HOT [[randomized controlled trial]], the nadir of the j-curve must be below 80 mm Hg.<ref name="pmid9635947">{{cite journal| author=Hansson L, Zanchetti A, Carruthers SG, Dahlöf B, Elmfeldt D, Julius S et al.| title=Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. | journal=Lancet | year= 1998 | volume= 351 | issue= 9118 | pages= 1755-62 | pmid=9635947 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9635947  }} </ref>
 ===Non-drug treatment===
@@ Line 79: / Line 117: @@
 ===Initial medication===
 [[Clinical practice guideline]]s have tried to make blanket recommendations for all patients:
-* "Thiazide-type [[diuretic]]s for most" patients are recommended by the JNC7 [[clinical practice guideline]]s.<ref name="pmid12748199"/> [[Chlorthalidone]] may be the best choice.<ref name="pmid2225366">{{cite journal |author= |title=Mortality after 10 1/2 years for hypertensive participants in the Multiple Risk Factor Intervention Trial |journal=Circulation |volume=82 |issue=5 |pages=1616–28 |year=1990 |month=November |pmid=2225366 |doi= |url= |issn=}}</ref><ref name="pmid16432050">{{cite journal |author=Ernst ME, Carter BL, Goerdt CJ, ''et al'' |title=Comparative antihypertensive effects of hydrochlorothiazide and chlorthalidone on ambulatory and office blood pressure |journal=Hypertension |volume=47 |issue=3 |pages=352–8 |year=2006 |month=March |pmid=16432050 |doi=10.1161/01.HYP.0000203309.07140.d3 |url=http://hyper.ahajournals.org/cgi/pmidlookup?view=long&pmid=16432050 |issn=}}</ref><ref name="pmid14638621">{{cite journal |author=Carter BL, Ernst ME, Cohen JD |title=Hydrochlorothiazide versus chlorthalidone: evidence supporting their interchangeability |journal=Hypertension |volume=43 |issue=1 |pages=4–9 |year=2004 |month=January |pmid=14638621 |doi=10.1161/01.HYP.0000103632.19915.0E |url=http://hyper.ahajournals.org/cgi/pmidlookup?view=long&pmid=14638621 |issn=}}</ref><ref name="pmid19107095">{{cite journal |author= |title=Drugs for hypertension |journal=Treat Guidel Med Lett |volume=7 |issue=77 |pages=1–10 |year=2009 |month=January |pmid=19107095 |doi= |url=http://www.medicalletter.org/scripts/articlefind.cgi?issue=77&page=1 |issn=}}</ref>
+* "Thiazide-type [[diuretic]]s for most" patients are recommended by the JNC7 [[clinical practice guideline]]s.<ref name="pmid12748199"/> [[Chlorthalidone]] may be the best choice based on the Multiple Risk Factor Intervention Trial<ref name="pmid2225366">{{cite journal |author= |title=Mortality after 10 1/2 years for hypertensive participants in the Multiple Risk Factor Intervention Trial |journal=Circulation |volume=82 |issue=5 |pages=1616–28 |year=1990 |month=November |pmid=2225366 |doi= |url= |issn=}}</ref> and other studies.<ref name="pmid16432050">{{cite journal |author=Ernst ME, Carter BL, Goerdt CJ, ''et al'' |title=Comparative antihypertensive effects of hydrochlorothiazide and chlorthalidone on ambulatory and office blood pressure |journal=Hypertension |volume=47 |issue=3 |pages=352–8 |year=2006 |month=March |pmid=16432050 |doi=10.1161/01.HYP.0000203309.07140.d3 |url=http://hyper.ahajournals.org/cgi/pmidlookup?view=long&pmid=16432050 |issn=}}</ref><ref name="pmid14638621">{{cite journal |author=Carter BL, Ernst ME, Cohen JD |title=Hydrochlorothiazide versus chlorthalidone: evidence supporting their interchangeability |journal=Hypertension |volume=43 |issue=1 |pages=4–9 |year=2004 |month=January |pmid=14638621 |doi=10.1161/01.HYP.0000103632.19915.0E |url=http://hyper.ahajournals.org/cgi/pmidlookup?view=long&pmid=14638621 |issn=}}</ref><ref name="pmid19107095">{{cite journal |author= |title=Drugs for hypertension |journal=Treat Guidel Med Lett |volume=7 |issue=77 |pages=1–10 |year=2009 |month=January |pmid=19107095 |doi= |url=http://www.medicalletter.org/scripts/articlefind.cgi?issue=77&page=1 |issn=}}</ref> In the MRFIT trial, the clinics that predominantly used chlorthalidone reported lower mortality than the clinics using hydrochlorothiazide (5% versus 7%).
 * "First-line low-dose thiazides reduce all morbidity and mortality outcomes. First-line ACE inhibitors and calcium channel blockers may be similarly effective but the evidence is less robust. First-line high-dose thiazides and first-line beta-blockers are inferior to first-line low-dose thiazides" according to the [[Cochrane Collaboration]].<ref>Wright JM, Musini VM. (2009) First-line drugs for hypertension. Cochrane Database Syst Rev. 2009 Jul 8;(3):CD001841. PMID 19588327</ref>
 *[[Adrenergic beta-antagonist|ß-blockers]]
 ** ß-blockers are the preferred initial medication for patients with coronary heart disease according to a  [[systematic review]].<ref name="pmid19454737">{{cite journal |author=Law MR, Morris JK, Wald NJ |title=Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies |journal=BMJ |volume=338 |issue= |pages=b1665 |year=2009 |pmid=19454737 |pmc=2684577 |doi= |url=http://bmj.com/cgi/pmidlookup?view=long&pmid=19454737 |issn=}}</ref>
-**"[[Adrenergic beta-antagonist|ß-blockers]], especially in combination with a thiazide [[diuretic]], should not be used in patients with the metabolic syndrome or at high risk of incident diabetes" is noted by the European ESH/ESC [[clinical practice guideline]]s.<ref name="pmid17562668"/> The ESH/ESC guidelines cite the LIFE<ref name="pmid11937178">{{cite journal |author=Dahlöf B, Devereux RB, Kjeldsen SE, ''et al'' |title=Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol |journal=Lancet |volume=359 |issue=9311 |pages=995–1003 |year=2002 |month=March |pmid=11937178 |doi=10.1016/S0140-6736(02)08089-3 |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(02)08089-3 |issn=}}</ref> and ASCOT<ref name="pmid16154016">{{cite journal |author=Dahlöf B, Sever PS, Poulter NR, ''et al'' |title=Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial |journal=Lancet |volume=366 |issue=9489 |pages=895–906 |year=2005 |pmid=16154016 |doi=10.1016/S0140-6736(05)67185-1 |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(05)67185-1 |issn=}}</ref> trials. Unlike the ALLHAT study<ref name="pmid12479770">{{cite journal |author=Appel LJ |title=The verdict from ALLHAT--thiazide diuretics are the preferred initial therapy for hypertension |journal=JAMA |volume=288 |issue=23 |pages=3039–42 |year=2002 |month=December |pmid=12479770 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=12479770 |issn=}}</ref>, both of these trials were in largely anglo populations, supported by industry, and at the same institution. All patients in the LIFE trial had [[left ventricular hypertension]] (LVH). Based on these two trials, a [[meta-analysis]] has concluded that [[adrenergic beta-antagonist|beta blockers]] should not be the first choice treatment.<ref name="pmid16257341">{{cite journal |author=Lindholm LH, Carlberg B, Samuelsson O |title=Should beta blockers remain first choice in the treatment of primary hypertension? A meta-analysis |journal=Lancet |volume=366 |issue=9496 |pages=1545–53 |year=2005 |pmid=16257341 |doi=10.1016/S0140-6736(05)67573-3 |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(05)67573-3 |issn=}} [http://www.acpjc.org/Content/144/3/issue/ACPJC-2006-144-3-067.htm ACP Journal Club review]</ref>
+**"[[Adrenergic beta-antagonist|ß-blockers]], especially in combination with a thiazide [[diuretic]], should not be used in patients with the metabolic syndrome or at high risk of incident diabetes" is noted by the European ESH/ESC [[clinical practice guideline]]s.<ref name="pmid17562668"/> The ESH/ESC guidelines cite the LIFE<ref name="pmid11937178">{{cite journal |author=Dahlöf B, Devereux RB, Kjeldsen SE, ''et al'' |title=Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol |journal=Lancet |volume=359 |issue=9311 |pages=995–1003 |year=2002 |month=March |pmid=11937178 |doi=10.1016/S0140-6736(02)08089-3 |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(02)08089-3 |issn=}}</ref> and ASCOT<ref name="pmid16154016">{{cite journal |author=Dahlöf B, Sever PS, Poulter NR, ''et al'' |title=Prevention of cardiovascular events with an antihypertensive regimen of amlodipine adding perindopril as required versus atenolol adding bendroflumethiazide as required, in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA): a multicentre randomised controlled trial |journal=Lancet |volume=366 |issue=9489 |pages=895–906 |year=2005 |pmid=16154016 |doi=10.1016/S0140-6736(05)67185-1 |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(05)67185-1 |issn=}}</ref> trials. Unlike the ALLHAT study<ref name="pmid12479770">{{cite journal |author=Appel LJ |title=The verdict from ALLHAT--thiazide diuretics are the preferred initial therapy for hypertension |journal=JAMA |volume=288 |issue=23 |pages=3039–42 |year=2002 |month=December |pmid=12479770 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=12479770 |issn=}}</ref>, both of these trials were in largely anglo populations, supported by industry, and at the same institution. All patients in the LIFE trial had [[left ventricular hypertrophy]] (LVH). Based on these two trials, a [[meta-analysis]] has concluded that [[adrenergic beta-antagonist|beta blockers]] should not be the first choice treatment.<ref name="pmid16257341">{{cite journal |author=Lindholm LH, Carlberg B, Samuelsson O |title=Should beta blockers remain first choice in the treatment of primary hypertension? A meta-analysis |journal=Lancet |volume=366 |issue=9496 |pages=1545–53 |year=2005 |pmid=16257341 |doi=10.1016/S0140-6736(05)67573-3 |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(05)67573-3 |issn=}} [http://www.acpjc.org/Content/144/3/issue/ACPJC-2006-144-3-067.htm ACP Journal Club review]</ref>
-* For Stage 2 Hypertension''' (SBP ≥ 160 ''or'' DBP≥100) consider starting two medications for more effect.<ref name="pmid19272490">{{cite journal |author=Wald DS, Law M, Morris JK, Bestwick JP, Wald NJ |title=Combination therapy versus monotherapy in reducing blood pressure: meta-analysis on 11,000 participants from 42 trials |journal=Am. J. Med. |volume=122 |issue=3 |pages=290–300 |year=2009 |month=March |pmid=19272490 |doi=10.1016/j.amjmed.2008.09.038 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9343(08)00992-3 |issn=}}</ref>
+* For Stage 2 Hypertension''' (SBP ≥ 160 ''or'' DBP≥100) consider starting two medications for more effect.<ref name="pmid19272490">{{cite journal |author=Wald DS, Law M, Morris JK, Bestwick JP, Wald NJ |title=Combination therapy versus monotherapy in reducing blood pressure: meta-analysis on 11,000 participants from 42 trials |journal=Am. J. Med. |volume=122 |issue=3 |pages=290–300 |year=2009 |month=March |pmid=19272490 |doi=10.1016/j.amjmed.2008.09.038 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9343(08)00992-3 |issn=}}</ref><ref name="pmid12748199"/>
-[[Image:Materson et al. NEJM 1994. PMID 8177286.jpg|right|thumb|350px|Efficacy of different drugs. From Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents.<ref name="pmid8177286">{{cite journal |author=Materson BJ, Reda DJ |title=Correction: single-drug therapy for hypertension in men |journal=N. Engl. J. Med. |volume=330 |issue=23 |pages=1689 |year=1994 |pmid=8177286 |doi=}}</ref>]]
 ====Refinements in selection====
-However, the Veterans Affairs Cooperative trial suggests the initial drug may be better selected based on the patient's age, race, and gender.<ref name="pmid8177286">{{cite journal |author=Materson BJ, Reda DJ |title=Correction: single-drug therapy for hypertension in men |journal=N. Engl. J. Med. |volume=330 |issue=23 |pages=1689 |year=1994 |pmid=8177286 |doi=}}</ref><ref name="pmid9777817">{{cite journal |author=Preston RA, Materson BJ, Reda DJ, ''et al'' |title=Age-race subgroup compared with renin profile as predictors of blood pressure response to antihypertensive therapy. Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents |journal=JAMA |volume=280 |issue=13 |pages=1168–72 |year=1998 |pmid=9777817 |doi=}}</ref> The patient's demographic roughly corresponds with their [[renin]] profile, but is more predictive than the renin profile.<ref name="pmid9777817"/> The molecular basis is being determined.<ref name="pmid17403377">{{cite journal |author=Materson BJ |title=Variability in response to antihypertensive drugs |journal=Am. J. Med. |volume=120 |issue=4 Suppl 1 |pages=S10–20 |year=2007 |pmid=17403377 |doi=10.1016/j.amjmed.2007.02.003}}</ref>
+{| class="wikitable" align="right"
+|+ Selected [[randomized controlled trial|trial]]s comparing initial medications
+! rowspan="2"|Trial!! colspan="3"|Patients ||rowspan="2"| Intervention ||Result
+|-
+! Race !! [[Body mass index|BMI]]||Age<br/>(mean)
+|-
+| ALLHAT<ref name="pmid12479763"/><br/>2002 || 47% anglo|| 30||70||[[Chlorthalidone]]||[[Diuretic]]s (chlorthalidone) ''better'' than [[calcium channel blocker]]s and [[angiotensin-converting enzyme inhibitor]]s
+|-
+| ANBP2<ref name="pmid12584366"/><br/>2003 || 95% anglo||27||72|| Hydrochlorothiazide||[[Diuretic]]s (hydrochlorothiazide) ''not'' as good [[angiotensin-converting enzyme inhibitor]]s
+|-
+| ACCOMPLISH<ref name="pmid19052124"/><br/>2008|| 84% anglo||31||68||Hydrochlorothiazide|| [[Diuretic]]s (hydrochlorothiazide) ''not'' as good as [[calcium channel blocker]]s
+|}
-In the Veterans Affairs Cooperative, among the the high renin demographic (young whites), diuretics had similar efficacy to placebo; whereas in the low renin demographic (older blacks), the [[Angiotensin-converting enzyme inhibitor|ace-inhibitors]] had similar efficacy to placebo in the Veterans Affairs Cooperative Study Group on Antihypertensive Agents (see figure).<ref name="pmid8177286"/> Similarly, a meta-analysis has concluded that [[adrenergic beta-antagonist|beta-blockers]] are a good first choice for younger patients, but not for older patients.<ref name="pmid16754904">{{cite journal |author=Khan N, McAlister FA |title=Re-examining the efficacy of beta-blockers for the treatment of hypertension: a meta-analysis |journal=CMAJ |volume=174 |issue=12 |pages=1737–42 |year=2006 |month=June |pmid=16754904 |doi=10.1503/cmaj.060110 |url=http://www.cmaj.ca/cgi/pmidlookup?view=long&pmid=16754904 |issn=}}</ref>
+Several [[randomized controlled trial]]s have compared initial medications for hypertension. As summarized in the table, the disparate results may be due to racial and gender differences in responses to medications.<ref name="pmid12479763" /><ref name="pmid12584366">{{cite journal |author=Wing LM, Reid CM, Ryan P, ''et al'' |title=A comparison of outcomes with angiotensin-converting--enzyme inhibitors and diuretics for hypertension in the elderly |journal=N. Engl. J. Med. |volume=348 |issue=7 |pages=583-92 |year=2003 |pmid=12584366 |doi=10.1056/NEJMoa021716}}</ref><ref name="pmid8446138">{{cite journal |author=Materson BJ, Reda DJ, Cushman WC, ''et al'' |title=Single-drug therapy for hypertension in men. A comparison of six antihypertensive agents with placebo. The Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents |journal=N. Engl. J. Med. |volume=328 |issue=13 |pages=914-21 |year=1993 |pmid=8446138 |doi=|url=http://content.nejm.org/cgi/content/full/328/13/914}}</ref><ref name="pmid8177286" /><ref name="pmid19052124">{{cite journal |author=Jamerson K, Weber MA, Bakris GL, ''et al'' |title=Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients |journal=N. Engl. J. Med. |volume=359 |issue=23 |pages=2417–28 |year=2008 |month=December |pmid=19052124 |doi=10.1056/NEJMoa0806182 |url=http://content.nejm.org/cgi/content/full/359/23/2417 |issn=}}</ref>
+=====Should renin levels guide decisions?=====
 {| class="wikitable"
 |+ Predicting response to anti-hypertensives based on demographics
@@ Line 103: / Line 152: @@
 |}
-Several randomized controlled trials have compared initial medications for hypertension. As summarized in the table, the disparate results may be due to racial and gender differences in responses to medications.<ref name="pmid12479763">{{cite journal |author=ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial |title=Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) |journal=JAMA |volume=288 |issue=23 |pages=2981-97 |year=2002 |pmid=12479763 |doi=|url=http://jama.ama-assn.org/cgi/content/full/288/23/2981}}</ref><ref name="pmid12584366">{{cite journal |author=Wing LM, Reid CM, Ryan P, ''et al'' |title=A comparison of outcomes with angiotensin-converting--enzyme inhibitors and diuretics for hypertension in the elderly |journal=N. Engl. J. Med. |volume=348 |issue=7 |pages=583-92 |year=2003 |pmid=12584366 |doi=10.1056/NEJMoa021716}}</ref><ref name="pmid8446138">{{cite journal |author=Materson BJ, Reda DJ, Cushman WC, ''et al'' |title=Single-drug therapy for hypertension in men. A comparison of six antihypertensive agents with placebo. The Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents |journal=N. Engl. J. Med. |volume=328 |issue=13 |pages=914-21 |year=1993 |pmid=8446138 |doi=|url=http://content.nejm.org/cgi/content/full/328/13/914}}</ref><ref name="pmid8177286">{{cite journal |author=Materson BJ, Reda DJ |title=Correction: single-drug therapy for hypertension in men |journal=N. Engl. J. Med. |volume=330 |issue=23 |pages=1689 |year=1994 |pmid=8177286 |doi=|url=http://content.nejm.org/cgi/content/full/330/23/1689}}</ref><ref name="pmid19052124">{{cite journal |author=Jamerson K, Weber MA, Bakris GL, ''et al'' |title=Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients |journal=N. Engl. J. Med. |volume=359 |issue=23 |pages=2417–28 |year=2008 |month=December |pmid=19052124 |doi=10.1056/NEJMoa0806182 |url=http://content.nejm.org/cgi/content/full/359/23/2417 |issn=}}</ref> Race, gender, and age demographic may partly predict frequency of [[drug toxicity]] to different anti-hypertensive medications.<ref name="pmid16679330">{{cite journal |author=McDowell SE, Coleman JJ, Ferner RE |title=Systematic review and meta-analysis of ethnic differences in risks of adverse reactions to drugs used in cardiovascular medicine |journal=BMJ |volume=332 |issue=7551 |pages=1177–81 |year=2006 |pmid=16679330 |doi=10.1136/bmj.38803.528113.55}}</ref>
+Some authors have proposed that either the renin level or the renin level indexed to urinary sodium excretion in 24 hours.<ref name="pmid4355699">{{cite journal| author=Laragh JH| title=Vasoconstriction-volume analysis for understanding and treating hypertension: the use of renin and aldosterone profiles. | journal=Am J Med | year= 1973 | volume= 55 | issue= 3 | pages= 261-74 | pmid=4355699 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4355699  }} </ref><ref name="pmid4337477">{{cite journal| author=Laragh JH, Baer L, Brunner HR, Buhler FR, Sealey JE, Vaughan ED| title=Renin, angiotensin and aldosterone system in pathogenesis and management of hypertensive vascular disease. | journal=Am J Med | year= 1972 | volume= 52 | issue= 5 | pages= 633-52 | pmid=4337477 | doi= | pmc= | url= }} </ref>
+[[Image:Materson et al. NEJM 1994. PMID 8177286.jpg|right|thumb|350px|Efficacy of different drugs. From Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents.<ref name="pmid8177286" />]]
+However, the Veterans Affairs Cooperative trial suggests the initial drug may be better selected based on the patient's age, race, and gender.<ref name="pmid8177286" /><ref name="pmid9777817">{{cite journal |author=Preston RA, Materson BJ, Reda DJ, ''et al'' |title=Age-race subgroup compared with renin profile as predictors of blood pressure response to antihypertensive therapy. Department of Veterans Affairs Cooperative Study Group on Antihypertensive Agents |journal=JAMA |volume=280 |issue=13 |pages=1168–72 |year=1998 |pmid=9777817 |doi=}}</ref> The patient's demographic roughly corresponds with their [[renin]] profile, but is more predictive than the renin profile.<ref name="pmid9777817"/> The molecular basis is being determined.<ref name="pmid17403377">{{cite journal |author=Materson BJ |title=Variability in response to antihypertensive drugs |journal=Am. J. Med. |volume=120 |issue=4 Suppl 1 |pages=S10–20 |year=2007 |pmid=17403377 |doi=10.1016/j.amjmed.2007.02.003}}</ref> In the Veterans Affairs Cooperative, among the high renin demographic (young whites), diuretics had similar efficacy to placebo; whereas in the low renin demographic (older blacks), the [[Angiotensin-converting enzyme inhibitor|ace-inhibitors]] had similar efficacy to placebo in the Veterans Affairs Cooperative Study Group on Antihypertensive Agents (see figure).<ref name="pmid8177286"/> Similarly, a meta-analysis has concluded that [[adrenergic beta-antagonist|beta-blockers]] are a good first choice for younger patients, but not for older patients.<ref name="pmid16754904">{{cite journal |author=Khan N, McAlister FA |title=Re-examining the efficacy of beta-blockers for the treatment of hypertension: a meta-analysis |journal=CMAJ |volume=174 |issue=12 |pages=1737–42 |year=2006 |month=June |pmid=16754904 |doi=10.1503/cmaj.060110 |url=http://www.cmaj.ca/cgi/pmidlookup?view=long&pmid=16754904 |issn=}}</ref>
+More recently, plasma renin activity was found to predict response to [[adrenergic beta-antagonist]]s versus [[diuretic]]s better than using demographic predictors.<ref name="pmid20725057">{{cite journal| author=Turner ST, Schwartz GL, Chapman AB, Beitelshees AL, Gums JG, Cooper-DeHoff RM et al.| title=Plasma renin activity predicts blood pressure responses to beta-blocker and thiazide diuretic as monotherapy and add-on therapy for hypertension. | journal=Am J Hypertens | year= 2010 | volume= 23 | issue= 9 | pages= 1014-22 | pmid=20725057 | doi=10.1038/ajh.2010.98 | pmc=PMC2941699 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20725057  }} [http://cardiology.jwatch.org/cgi/content/full/2010/1103/4 Commentary at JournalWatch]</ref>
-{| class="wikitable" align="right"
+Race, gender, and age demographic may partly predict frequency of [[drug toxicity]] to different anti-hypertensive medications.<ref name="pmid16679330">{{cite journal |author=McDowell SE, Coleman JJ, Ferner RE |title=Systematic review and meta-analysis of ethnic differences in risks of adverse reactions to drugs used in cardiovascular medicine |journal=BMJ |volume=332 |issue=7551 |pages=1177–81 |year=2006 |pmid=16679330 |doi=10.1136/bmj.38803.528113.55}}</ref>
-|+ Selected [[randomized controlled trial|trial]]s comparing initial medications
-! rowspan="2"|Trial!! colspan="3"|Patients ||rowspan="2"| Intervention ||Result
-|-
-! Race !! [[Body mass index|BMI]]||Age<br/>(mean)
-|-
-| ALLHAT<ref name="pmid12479763"/><br/>2002 || 47% anglo|| 30||70||[[Chlorthalidone]]||[[Diuretic]]s (chlorthalidone) ''better'' than [[calcium channel blocker]]s and [[angiotensin-converting enzyme inhibitor]]s
-|-
-| ANBP2<ref name="pmid12584366"/><br/>2003 || 95% anglo||27||72|| Hydrochlorothiazide||[[Diuretic]]s (hydrochlorothiazide) ''not'' as good [[angiotensin-converting enzyme inhibitor]]s
-|-
-| ACCOMPLISH<ref name="pmid19052124"/><br/>2008|| 84% anglo||31||68||Hydrochlorothiazide|| [[Diuretic]]s (hydrochlorothiazide) ''not'' as good as [[calcium channel blocker]]s
-|}
-For patients with Stage 2 Hypertension (SBP <u>></u>160 or DBP<u>></u>100 mmHg), start with two drugs.<ref name="pmid12748199"/>
 ====Contraindications====
 There are contraindications to each of the four major classes, even when other indicators suggest a particular class might be best for the hypertensive patients:
@@ Line 132: / Line 174: @@
 *ACE inhibitors: protective of the kidneys, as in [[diabetes]]
 *Calcium channel blockers: also may prevent [[migraine]]; may relieve neuropathic pain
+===Labile hypertension===
+While labile hypertension may be due to a pheochromocytoma, it may be due to baroreflex failure. This can be treated with clonidine  0.3 to 2.4 mg orally total per day.<ref name="pmid8413455">{{cite journal| author=Robertson D, Hollister AS, Biaggioni I, Netterville JL, Mosqueda-Garcia R, Robertson RM| title=The diagnosis and treatment of baroreflex failure. | journal=N Engl J Med | year= 1993 | volume= 329 | issue= 20 | pages= 1449-55 | pmid=8413455
+| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=8413455 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref>
 ===Resistant hypertension===
-Blood pressure may be difficult to treat, especially in older patients.<ref name="pmid16870917">{{cite journal |author=Moser M, Setaro JF |title=Clinical practice. Resistant or difficult-to-control hypertension |journal=N. Engl. J. Med. |volume=355 |issue=4 |pages=385–92 |year=2006 |month=July |pmid=16870917 |doi=10.1056/NEJMcp041698 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=16870917&promo=ONFLNS19 |issn=}}</ref><ref name="pmid1635569">{{cite journal |author=Setaro JF, Black HR |title=Refractory hypertension |journal=N. Engl. J. Med. |volume=327 |issue=8 |pages=543–7 |year=1992 |month=August |pmid=1635569 |doi= |url= |issn=}}</ref> [[Clinical practice guideline]]s from the [[American Heart Association]] (AHA) address the management of resistant hypertension.<ref name="doiHYPERTENSIONAHA.108.189141">Calhoun, D. A., Jones, D., Textor, S., Goff, D. C., Murphy, T. P., Toto, R. D., et al. (2008). Resistant Hypertension: Diagnosis, Evaluation, and Treatment. A Scientific Statement From the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Hypertension, HYPERTENSIONAHA.108.189141. {{doi|10.1161/HYPERTENSIONAHA.108.189141}}.</ref>
+Blood pressure may be difficult to treat, especially in older patients.<ref name="pmid16870917">{{cite journal |author=Moser M, Setaro JF |title=Clinical practice. Resistant or difficult-to-control hypertension |journal=N. Engl. J. Med. |volume=355 |issue=4 |pages=385–92 |year=2006 |month=July |pmid=16870917 |doi=10.1056/NEJMcp041698 |url=http://content.nejm.org/cgi/pmidlookup?view=short&pmid=16870917&promo=ONFLNS19 |issn=}}</ref><ref name="pmid1635569">{{cite journal |author=Setaro JF, Black HR |title=Refractory hypertension |journal=N. Engl. J. Med. |volume=327 |issue=8 |pages=543–7 |year=1992 |month=August |pmid=1635569 |doi= |url= |issn=}}</ref> A third of cases may be due to [[white coat hypertension]].<ref name="pmid21444835">{{cite journal| author=de la Sierra A, Segura J, Banegas JR, Gorostidi M, de la Cruz JJ, Armario P et al.| title=Clinical features of 8295 patients with resistant hypertension classified on the basis of ambulatory blood pressure monitoring. | journal=Hypertension | year= 2011 | volume= 57 | issue= 5 | pages= 898-902 | pmid=21444835 | doi=10.1161/HYPERTENSIONAHA.110.168948 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21444835  }} </ref> [[Clinical practice guideline]]s from the [[American Heart Association]] (AHA) address the management of resistant hypertension.<ref name="doiHYPERTENSIONAHA.108.189141">Calhoun, D. A., Jones, D., Textor, S., Goff, D. C., Murphy, T. P., Toto, R. D., et al. (2008). Resistant Hypertension: Diagnosis, Evaluation, and Treatment. A Scientific Statement From the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Hypertension, HYPERTENSIONAHA.108.189141. {{doi|10.1161/HYPERTENSIONAHA.108.189141}}.</ref>
 ;Physiology
@@ Line 163: / Line 209: @@
 Catheter-based renal sympathetic [[denervation]] has been studied for resistant [[hypertension]].<ref name="pmid19332353">{{cite journal |author=Krum H, Schlaich M, Whitbourn R, ''et al'' |title=Catheter-based renal sympathetic denervation for resistant hypertension: a multicentre safety and proof-of-principle cohort study |journal=Lancet |volume=373 |issue=9671 |pages=1275–81 |year=2009 |month=April |pmid=19332353 |doi=10.1016/S0140-6736(09)60566-3 |url=http://linkinghub.elsevier.com/retrieve/pii/S0140-6736(09)60566-3 |issn=}}</ref>
+===Hypertensive emergency===
+Treatment must be from a [[critical care]] perspective. While the blood pressure must be lowered quickly to avoid end-stage organ failure or crises such as [[cerebral hemorrhage]], lowering it too quickly may create a different end-stage organ failure through decreased perfusion. "Treat the patient, not the number".
 ===Systolic hypertension===
 {{main | Systolic hypertension}}
-===Elderly patients===
+===Diabetes===
-Treating patients aged 80 years or older for two years who have a systolic pressure over 160 mm hg (the average entry pressure was 173/91 mm Hg) and treating to 150/80 mm Hg may reduce morbidity.<ref> Beckett, N. S., Peters, R., Fletcher, A. E., Staessen, J. A., Liu, L., Dumitrascu, D., et al. (2008). Treatment of Hypertension in Patients 80 Years of Age or Older. N Engl J Med, NEJMoa0801369. {{doi|10.1056/NEJMoa0801369}}</ref> In this trial, the average seated blood pressure at the end of the study in the treatment group was 143/78.
+{| class="wikitable" border="1"
+|+ [[Randomized controlled trial]]s of treating [[hypertension]] in patients with [[diabetes mellitus type 2]]<ref name="pmid20228401">{{cite journal| author=The ACCORD Study Group| title=Effects of Intensive Blood-Pressure Control in Type 2 Diabetes Mellitus. | journal=N Engl J Med | year= 2010 | volume=  | issue=  | pages=  | pmid=20228401
+| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&retmode=ref&cmd=prlinks&id=20228401 | doi=10.1056/NEJMoa1001286 }} </ref><ref name="pmid17765963">{{cite journal| author=Patel A, ADVANCE Collaborative Group. MacMahon S, Chalmers J, Neal B, Woodward M et al.| title=Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomised controlled trial. | journal=Lancet | year= 2007 | volume= 370 | issue= 9590 | pages= 829-40 | pmid=17765963 | doi=10.1016/S0140-6736(07)61303-8 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17765963  }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18375702 Review in: Evid Based Med. 2008 Apr;13(2):49] </ref>
+! Trial!! Population!!Intervention!!Comparison!!Outcome!!Comments
+|-
+| ACCORD<ref name="pmid20228401"/><br/>2010|| 4,733 patients||Systolic pressure goal of less than 120 mm Hg for  4.7 years||Systolic pressure goal of less than 140 mm Hg||Mortality||Insignificantly increased
+|-
+| ADVANCE<ref name="pmid17765963"/><br/>2007|| 11,140 patients|| Fixed combination of perindopril and indapamide that achieved blood pressure of 136/73 for 4.3 years|| Achieved blood pressure of 130/73||Mortality||Significantly reduced
+|}
+===Geriatrics===
+Treatment of hypertension in the [[geriatrics]] is effective.<ref name="pmid19821263" />
+However, treatment of patients over age 80 is not clear.<ref name="pmid19821263" /><ref name="pmid20574244">{{cite journal| author=Bejan-Angoulvant T, Saadatian-Elahi M, Wright JM, Schron EB, Lindholm LH, Fagard R et al.| title=Treatment of hypertension in patients 80 years and older: the lower the better? A meta-analysis of randomized controlled trials. | journal=J Hypertens | year= 2010 | volume= 28 | issue= 7 | pages= 1366-72 | pmid=20574244 | doi=10.1097/HJH.0b013e328339f9c5 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20574244  }} </ref> A randomized controlled trial included in this meta-analysis found that treating patients aged 80 years or older for two years who have a systolic pressure over 160 mm hg (the average entry pressure was 173/91 mm Hg) and treating to 150/80 mm Hg reduced morbidity.<ref> Beckett, N. S., Peters, R., Fletcher, A. E., Staessen, J. A., Liu, L., Dumitrascu, D., et al. (2008). Treatment of Hypertension in Patients 80 Years of Age or Older. N Engl J Med, NEJMoa0801369. {{doi|10.1056/NEJMoa0801369}}</ref> In this trial, the average seated blood pressure at the end of the study in the treatment group was 143/78.
+The [[Cochrane Collaboration]] has also performed a [[meta-analysis]] of this topic and concluded "treating healthy persons (60 years or older) with moderate to severe systolic and/or diastolic hypertension reduces all cause mortality and cardiovascular morbidity and mortality. The decrease in all cause mortality was limited to persons 60 to 80 years of age."<ref name="pmid19821263" />
 ==Prognosis==
 ==References==
-<references/>
+{{reflist|2}}
 == See also ==
-* [[Salt and health]]
+* [[Salt and health]][[Category:Suggestion Bot Tag]]

Hypertension: Difference between revisions

Latest revision as of 11:01, 30 August 2024

Contents

Classification

Diagnosis

Ambulatory blood pressure monitoring

Confirmation

White coat hypertension

Pseudohypertension

Excluding secondary hypertension

Treatment

Treatment goals

J-curve

Non-drug treatment

Initial medication

Refinements in selection

Should renin levels guide decisions?

Contraindications

Comorbidities

Labile hypertension

Resistant hypertension

Hypertensive emergency

Systolic hypertension

Diabetes

Geriatrics

Prognosis

References

See also

Navigation menu

Hypertension: Difference between revisions

Latest revision as of 11:01, 30 August 2024

Classification

Diagnosis

Ambulatory blood pressure monitoring

Confirmation

White coat hypertension

Pseudohypertension

Excluding secondary hypertension

Treatment

Treatment goals

J-curve

Non-drug treatment

Initial medication

Refinements in selection

Should renin levels guide decisions?

Contraindications

Comorbidities

Labile hypertension

Resistant hypertension

Hypertensive emergency

Systolic hypertension

Diabetes

Geriatrics

Prognosis

References

See also

Navigation menu

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