Treatment

Therapeutic Approach in Special Conditions

These recommendations are presented in abbreviated form. Readers should refer to the guideline summary² and the complete guideline document¹ for a detailed discussion of each of the following topics.

Antihypertensive therapy in the elderly¹

There is little doubt from randomized controlled trials that older patients with systolic–diastolic or with isolated systolic hypertension benefit from antihypertensive treatment in terms of reduced cardiovascular morbidity and mortality.
Initiation of antihypertensive treatment in elderly patients should follow the general guidelines, but should be particularly gradual, especially in frail individuals.
Blood pressure measurement should also be performed in the erect posture, to exclude patients with marked postural hypotension from treatment and to evaluate postural effects of treatment.
Many elderly patients will have other risk factors, target organ damage and associated cardiovascular conditions, to which the choice of the first drug should be tailored.
Many elderly patients need two or more drugs to control blood pressure, particularly since it is often difficult to lower systolic blood pressure to below 140 mmHg.
In subjects aged 80 years and over, a recent metaanalysis concluded that fatal and non-fatal cardiovascular events, but not mortality, are reduced by antihypertensive therapy.

Antihypertensive therapy in diabetics¹

Non-pharmacological measures (particularly weight loss and reduction in salt intake) should be encouraged in all patients with type 2 diabetes, independently of the existing blood pressure. These measures may suffice to normalize blood pressure in patients with high normal or grade 1 hypertension, and can be expected to facilitate blood pressure control by antihypertensive agents.
The goal blood pressure to aim at during behavioural or pharmacological therapy is below 130/ 80 mmHg.
To reach this goal, most often combination therapy will be required.
It is recommended that all effective and well tolerated antihypertensive agents are used, generally in combination.
Available evidence indicates that renoprotection benefits from the regular inclusion in these combinations of an ACE inhibitor in type 1 diabetes and of an angiotensin receptor antagonist in type 2 diabetes.
In type 2 diabetic patients with high normal blood pressure, who may sometimes achieve blood pressure goal by monotherapy, the first drug to be tested should be a blocker of the renin–angiotensin system.
The finding of microalbuminuria in type 1 or 2 diabetics is an indication for antihypertensive treatment, especially by a blocker of the renin–angiotensin system, irrespective of the blood pressure values.

Patients with previous cardiovascular disease²

Patients who have suffered a previous stroke or transient ischaemic attack have a reduced recurrence of stroke if they receive antihypertensive therapy (diuretics and ACE-inhibitors), even if their BP is in the normal or high normal range only
Whether BP in acute stroke should be lowered is still disputed
Several antihypertensive agents have been proven beneficial post-myocardial infarction
In congestive heart failure, diuretics, anti-aldosterone agents, beta-blockers, ACE-inhibitors, and angiotensin receptor antagonists have been proven beneficial.

Antihypertensive therapy in patients with deranged renal function¹

Before antihypertensive treatment became available, renal involvement was frequent in patients with essential hypertension.
Renal protection in diabetes has two main requirements:
- strict blood pressure control (,130/80 mmHg
  and even lower if proteinuria is .1 g/day);
- lowering proteinuria to values as near to normal as possible.
To reduce proteinuria either an angiotensin receptor blocker or an ACE inhibitor is required.
To achieve the blood pressure goal, combination therapy is usually required, with addition of a diuretic and a calcium antagonist.
To prevent or retard nephrosclerosis in hypertensive non-diabetic patients, blockade of the renin–angiotensin system appears more important than attaining very low blood pressure, but evidence is so far restricted to Afro-American hypertensives, and suitable studies in other ethnic groups are required. It appears prudent, however, to lower blood pressure intensively in all hypertensive patients with deranged renal function.
An integrated therapeutic intervention (antihypertensives, statins, antiplatelet therapy, etc.) frequently has to be considered in patients with renal damage.

Hypertension in pregnancy²

For pregnant women with pre-existing hypertension:
- non-pharmacological treatment when BP is 140–149/90–99 mmHg
- weight reduction contraindicated (associated with reduced neonatal weight)
- low-dose aspirin in women with a history of early pre-eclampsia
Thresholds for initiating antihypertensive treatment are:
- systolic BP 140 mmHg or diastolic BP 90 mmHg in gestational hypertension or pre-existing hypertension with organ damage
- thresholds in other circumstances are 150/95 mmHg
- systolic BP > 170 or diastolic BP > 110 mmHg in pregnancy should be considered an emergency (hospitalization essential)
Methyldopa, labetalol, calcium antagonists and (though less effective) beta-blockers are the drugs of choice.

References:
1. 2003 European Society of Hypertension–European Society of Cardiology guidelines for the management of arterial hypertension. Journal of Hypertension 2003, 21:1011–1053. Available at: http://www.eshonline.org/
2. Practice Guidelines for Primary Care Physicians: 2003 ESH/ESC Hypertension Guidelines. Available at: http://www.eshonline.org/

Hypertension Knowledge Centre

Treatment

Quick Search:

Treatment

Therapeutic Approach in Special Conditions