How can we provide practical and effective interventions for our large hypertensive population? You need to focus on these 6 special groups of people.
Antihypertensive treatment for elderly hypertensive patients
The antihypertensive treatment for elderly patients should emphasize the achievement of systolic blood pressure, while excessive lowering of blood pressure should be avoided; on the premise that antihypertensive treatment can be tolerated, the blood pressure should be lowered gradually to achieve the standard, and too rapid lowering of blood pressure should be avoided; for patients with good tolerance of blood pressure lowering, antihypertensive treatment should be actively carried out.
The blood pressure of elderly hypertensive patients should be lowered to below 150/90 mmHg, or to below 140/90 mmHg if tolerated. The target value for lowering blood pressure in older adults over 80 years of age is <150/90 mmHg. However, it is unclear whether there is a greater benefit to lowering hypertension in the elderly to less than 140/90 mmHg.
The ideal antihypertensive drug for the treatment of geriatric hypertension should meet the following criteria: smooth and effective; safe with few adverse effects; easy to take and good compliance.
For simple systolic hypertension in the elderly, it is troublesome to deal with, and reference recommendations: when diastolic blood pressure (DBP) is <60 mmHg, such as systolic blood pressure (SBP) <150 mmHg, observe, and no drugs can be used; if SBP 150-179 mmHg, use small doses of antihypertensive drugs carefully; if SBP ≥180
mmHg, then use small doses of antihypertensive drugs. Antihypertensive drugs can be low-dose diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor antagonists (ARB). In addition, close observation of changes in the condition is required during the administration of medication.
Antihypertensive management of hypertensive disorders in pregnancy
For hypertensive disorders in pregnancy, the first thing to clarify is the concept of gestational hypertension. Only hypertension that first appears after 20 weeks of gestation is called gestational hypertension, while hypertension that occurs before 20 weeks of gestation (including when not pregnant) is called gestational combined chronic hypertension. The pathogenesis of these two diseases is different, but the clinical management principles are similar. Generally, a more lenient blood pressure lowering principle is adopted, and the target level of blood pressure lowering can be kept below 150/90 mmHg.
In general, pregnant women with mildly elevated blood pressure (blood pressure <150/100 mmHg) do not need antihypertensive treatment for the time being and can be closely observed. When SBP ≥ 150 mmHg and/or DBP ≥ 100 mmHg or target organ damage occurs, drug therapy should be considered.
Regarding drug treatment, both domestic and international guidelines recommend methyldopa as the first choice, but this drug is not easy to find in China; the second recommendation is labetalol, which has a definite and stable antihypertensive effect. The second recommendation is labetalol, which has a definite and stable hypotensive effect. In addition, propranolol and atenolol may also asphyxiate the fetus and care must be taken in their use. Table 1 below shows the recommended medications for hypertension in pregnancy and when the medications should be started.
Table 1. Drug selection for hypertension in pregnancy
Antihypertensive management of hypertension with stroke
For hypertensive patients with stroke, if they have a recent onset of stroke, in principle, antihypertensive therapy should not be administered first, unless the patient’s blood pressure is very high, with SBP exceeding 200 mmHg, and should be moderately controlled. 1 week later, aggressive conventional antihypertensive therapy is recommended to control blood pressure to 140/90 mmHg as recommended by our current guidelines. CCB), ACEI, ARB alone or in combination. It should be noted that beta-blockers are not used as a routine drug in principle for patients with hypertension with stroke.
In addition, for patients of advanced age, patients with severe bilateral carotid or intracranial artery stenosis, and patients with severe postural hypotension, caution is needed in antihypertensive treatment. If obvious adverse reactions such as dizziness occur, the dose should be reduced or the antihypertensive drug should be discontinued, and the blood pressure should be controlled within the safe range (within 160/100 mmHg) as much as possible.
Antihypertensive treatment of hypertension with coronary artery disease
The target blood pressure level for hypertension with stable coronary artery disease, unstable angina, non-ST-segment elevation and ST-segment elevation myocardial infarction is 130/80 mmHg.
The first choice of drugs for hypertension with coronary artery disease is β-blockers, on top of which ACEI or ARB can be considered if the blood pressure does not reach the target, and diuretics can be added if the target is not reached. Table 2 below shows the choice of medication for hypertension with coronary artery disease for reference.
Table 2 Medication selection for hypertension with coronary artery disease
Antihypertensive management of hypertension with heart failure
Hypertension with heart failure is similar to the treatment of hypertension with coronary artery disease described above, and the target level of blood pressure lowering is also 130/80 mmHg, and the drug of choice is also β-blocker plus ACEI or ARB.
Antihypertensive management of hypertension with diabetes mellitus or chronic kidney disease
The target value for hypertension with diabetes or chronic kidney disease is also <130/80 mmHg. ACEI or ARB is the drug of choice for patients with hypertension with renal disease, especially proteinuria, and hypertension with diabetes, especially microalbuminuria, both of which have a stable antihypertensive effect and a beneficial effect on the kidney and glucose metabolism. If the antihypertensive effect of ACEI or ARB alone cannot be achieved, CCB can be combined with ACEI or ARB, and diuretics can be added if the standard cannot be achieved.
Table 3: Hypertension target values and drug selection in special populations