Applied Evidence
Is your patient on target? Optimizing diabetes management
As new evidence emerges and guidelines are frequently revised, optimizing diabetes treatment with an eye toward HbA1c, blood pressure, and lipid...
Method 1. Initiate one medication from any of the 4 classes of antihypertensives recommended for initial treatment, and titrate to the maximum effective dose. If the BP goal is not achieved at maximum dose, add a medication from a second class and titrate that drug to the maximum effective dose, as well. If the goal is still not reached, add a medication from a third class and titrate up as needed.
Method 2. Initiate one medication, then add a second agent from a different drug class, if necessary, and titrate until both are at the maximum effective dose. If the goal still has not been reached, add a third agent and titrate that until BP is well controlled.
Method 3. Initiate 2 medications from 2 different classes of drugs simultaneously. If BP is not at goal after a reasonable trial, add a third agent and titrate to maximum effective dose. (Use this approach for patients who have systolic BP >160 mm Hg and/or diastolic BP >100 mm Hg or systolic BP >20 mm Hg above goal and/or diastolic BP >10 mm Hg above goal.)
As a general rule, a trial with monotherapy should be considered if BP is ≤160/100; a 2-agent combination is recommended as first-line therapy for pressure that exceeds that threshold. If a patient’s BP target is not reached even with the above strategies, a consultation with a hypertension specialist may be needed.
Treating patients with cardiovascular comorbidities
As noted earlier, JNC 8 offers no guidance in treating patients with HF or CAD and multiple comorbidities. In such cases, we turn to the American College of Cardiology (ACC) and American Heart Association (AHA).24
Recent ACC/AHA guidelines recommend a beta-blocker and ACEI for patients with a history of symptomatic stable HF and a left ventricular ejection fraction (EF) ≤40%, unless contraindications exist.24 Beta-blockers and an ACEI or an ARB should be used to prevent HF in patients with a history of myocardial infarction (MI) or acute coronary syndrome and a reduced EF. Beta-blockers with evidence to support their use in such cases include carvedilol, bisoprolol, and sustained-release metoprolol succinate.24
For symptomatic patients with dyspnea or other mild fluid retention, a loop diuretic or a thiazide diuretic can be used. Nondihydropyridine CCBs should be avoided in post-MI patients with low left ventricular EF due to the medication’s negative inotropic effects.24 The optimal drug regimen for secondary stroke prevention is not clear due to a lack of studies comparing drug regimens, but data suggest that a diuretic or a diuretic-ACEI combination is beneficial.25
Evaluating treatment-resistant hypertension
When a patient presents with treatment-resistant hypertension—elevated BP that is not controlled with a 3-drug regimen, all at maximum doses—start by asking several questions.26 Is the patient:
- having difficulty following a drug regimen that calls for multiple daily doses?
- drinking excessive amounts of alcohol?
- failing to adhere to a low-salt dietary regimen?
- taking any other medications or supplements that might elevate BP (eg, nonsteroidal anti-inflammatory agents, pseudoephedrine, ephedra, or licorice)?
- unable to afford all the drugs prescribed?
If no such issues are identified, consider a referral to a specialist for further evaluation and to rule out disorders associated with treatment-resistant hypertension, including CKD, renal artery stenosis, hyperaldosteronemia, sleep apnea, and coarctation of the aorta.26
Controlling hypertension starts with lifestyle modification
For most people, cardiovascular health is dependent on exercise and weight control. That’s particularly true for those with hypertension, for whom limiting alcohol and salt consumption is crucial, as well.
JNC 8 calls for lifestyle management,1 but specific recommendations come from the American College of Cardiology (ACC)/American Heart Association (AHA)’s 2013 Lifestyle Work Group.17 The guidelines call for patients with elevated blood pressure (BP) to follow a diet rich in vegetables, fruits, and whole grains, including low-fat dairy, poultry, fish, legumes, nuts, and nontropical vegetable oils, such as the DASH (Dietary Approaches to Stop Hypertension) or AHA diet. Salt consumption should not exceed 2400 mg/d—and, ideally, be limited to 1500 mg/d or reflect a reduction of at least 1000 mg/d.17
Stress the importance of regular physical activity in controlling BP, as well. The ACC/AHA call for adults to engage in moderate to vigorous aerobic activity 3 to 4 times a week, averaging about 40 minutes per session.17
CASE › When Ms. S returns 3 months later, her BP is 140/70 mm Hg, her fasting glucose is 94 mg/dL, and her HbA1c is 5.7%. You encourage her to continue her new dietary and exercise regimen and schedule a follow-up visit in 6 months.
CORRESPONDENCE
Tracy D. Mahvan, PharmD, University of Wyoming, School of Pharmacy, Health Sciences Center, Room 292, 1000 East University Avenue, Department 3375, Laramie, WY 82071; tbaher@uwyo.edu