Hypertension is currently the most common cardiovascular disease, there are at least 300 million patients in China, but for the treatment of hypertension, many people still have misconceptions.
Many people believe that hypertension can not be “broken”; many patients also simply do not take drugs, worrying about taking the drugs can not stop, these views are wrong. According to the current level of medicine, most patients with essential hypertension do need to take antihypertensive drugs for a long time or even for life, but not all patients need to take drugs for life. Below we share with you a few common questions about hypertension treatment so that you can have a better understanding of hypertension.
Is my hypertension primary or secondary?
To diagnose hypertension, you must first figure out whether the hypertension is primary or secondary. In secondary hypertension, once the cause is removed, it is possible to completely cure the hypertension. For example, in primary aldosteronism and pheochromocytoma, blood pressure can return to normal when the corresponding adenoma is removed.
Therefore, many secondary hypertensions are potentially curable and do not require lifelong use of antihypertensive medication. For mild hypertension, there are also a significant number of patients who can normalize their blood pressure through non-pharmacological treatment and do not need to take antihypertensive drugs. However, more than 90% of patients with hypertension are clinically classified as primary hypertension, and it is difficult to determine its exact cause. There is no cure for this type of patient, so most patients require lifelong treatment.
How should hypertensive patients manage their blood pressure?
According to the current guidelines for the prevention and treatment of hypertension in China, general hypertensive patients should have their blood pressure controlled to less than 140/90 mmHg within 4 to 12 weeks; patients with combined diabetes, kidney disease, previous history of myocardial infarction or stroke should have their blood pressure controlled to less than 130/80 mmHg if they can tolerate it; elderly hypertensive patients aged ≥65 years can have their systolic blood pressure reduced to less than 150 mmHg and further if tolerated.
Active lifestyle improvement is appropriate for every patient with hypertension and should be considered a cornerstone of hypertension control. Effective lifestyle improvement may reduce blood pressure by 10 to 20 mmHg and may spare some people with mildly elevated blood pressure from taking antihypertensive medications. For patients with significantly elevated blood pressure who must take medication, lifestyle improvements can help improve the efficacy of antihypertensive medications and reduce the dose and type of medication needed.
What factors should be considered when choosing antihypertensive medications?
There are five main classes of antihypertensive drugs in common use: diuretics, angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor antagonists (ARB), calcium channel blockers (CCB), and beta-blockers (BB). Because of the high number of adverse effects and poor target organ protection of alpha-blockers (e.g., prazosin, terazosin, etc.), they are no longer used as first-line antihypertensive drugs, but may still be considered in certain patients (e.g., those with refractory hypertension, hypertension in pregnancy, prostatic hyperplasia).
If the increase in blood pressure is small (<160/100mmHg), one antihypertensive drug may be used for initial treatment. If blood pressure is not satisfactorily controlled after 2-4 weeks of treatment, a combination of drugs may be considered. If the patient's blood pressure is significantly elevated (more than 20/10mmHg above the target value) at the time of consultation, two antihypertensive drugs or a new fixed combination should be selected for initial treatment, because the maximum blood pressure lowering range of monotherapy in general is about 20/10mmHg, and it is difficult to achieve the blood pressure target by applying one drug at this time. Clinical studies confirm that most patients require a combination of antihypertensive drugs.
The basic principles of drug combination are complementary mechanisms of action, additive antihypertensive effects, and offsetting adverse effects. China’s guidelines for the prevention and treatment of hypertension recommend the following six combination regimens as the first choice: ACEI and diuretics, ARB and diuretics, ACEI and dihydropyridine CCB, ARB and dihydropyridine CCB, dihydropyridine CCB and diuretics, and dihydropyridine CCB and BB.
Combinations that are generally inappropriate include: ACEI with ARB, ACEI with BB, ARB with BB, non-dihydropyridine CCB with BB, and central antihypertensive drugs with BB. These combinations either do not provide additive antihypertensive effects or are prone to serious adverse effects and should be avoided. Some patients whose blood pressure still cannot reach the standard after the combination of two drugs can consider the combination of three drugs. At this time, the combination of ACEI/ARB with dihydropyridine CCB and diuretics is suitable for most patients.
Which patients need to be referred to a higher level hospital for treatment?
Is the patient adhering to effective lifestyle interventions? As previously mentioned, weight loss and salt intake restriction are effective measures to lower blood pressure. If patients fail to improve their lifestyle effectively, the effectiveness of antihypertensive medications may be greatly reduced. If the patient’s blood pressure is still not satisfactorily controlled after the above treatment, the patient should be advised to go to a higher level hospital or hypertension specialist for further consultation.
The following patients should be considered for referral if their condition is more complex or critical.
①Refractory hypertension;
②Patients with suspected secondary hypertension often require special tests or therapeutic measures;
③ Hypertension combined with serious disorders of the heart, brain, kidneys, peripheral vasculature (such as unstable angina pectoris, myocardial infarction, heart failure, cerebral infarction or cerebral hemorrhage, renal failure, arterial occlusive vasculitis, etc.);
(iv) Hypertensive emergencies and subacute conditions. Hypertensive emergencies refer to severe elevation of blood pressure (generally >180/120mmHg) with progressive target organ damage, such as hypertensive encephalopathy, intracranial hemorrhage, acute myocardial infarction, acute left heart failure, unstable angina pectoris, aortic coarctation, etc.; hypertensive sub-emergencies refer to severe elevation of blood pressure but not target organ damage.
How to lower blood pressure when hypertension is combined with other diseases?
When a patient with hypertension has diabetes or chronic kidney disease, blood pressure should be controlled more aggressively. The target blood pressure for such patients is <130/80 mmHg, which may be relaxed to <140/90 mmHg for patients of advanced age, poor general health, and significant target organ damage, and the drug of choice is ARB or ACEI, combined with CCB or thiazide diuretics if necessary.
The goal of blood pressure control in stable stroke patients is <140/90 mmHg. Antihypertensive drugs can be chosen from diuretics, CCB, ACEI/ARB alone or in combination. However, patients of advanced age, patients with severe bilateral carotid or intracranial artery stenosis, and patients with severe postural hypotension should be treated with caution in antihypertensive therapy. At this time, antihypertensive drugs should be started in small doses, blood pressure levels and adverse reactions should be closely observed, and antihypertensive drugs and their doses should be adjusted according to patient tolerance.
In case of obvious adverse reactions such as dizziness, the dose should be reduced or the antihypertensive drug should be discontinued. Keep blood pressure within a safe range (within 160/100 mmHg) whenever possible. The strategy of antihypertensive treatment for acute stroke patients is more complex and referral to a higher level hospital is recommended.