Raised blood pressure is a major risk factor for cardiovascular disease. The higher the blood pressure, the higher the risk of stroke, coronary heart disease, kidney disease, heart failure and death. This relationship applies across the whole range of blood pressures usually encountered in clinical practice. Systolic blood pressure is a stronger and more consistent predictor of cardiovascular risk than diastolic blood pressure. Standard procedures and several visits are needed to assess clinic blood pressure and achieve appropriate management. Consideration should also be given to obtaining blood pressure measurements outside the clinic, either by home or ambulatory blood pressure monitoring.
a)Goal of Treatment
The ultimate goal of treatment of hypertension is to reduce the cardiovascular, cerebrovascular and renal morbidity and mortality. The aim must be to achieve targets of below 140/90. However in patients with diabetes or renal disease the goal should be less than 130/80.
b) Coexisting Conditions
1) Angina
The importance of treatment of hypertension in ischemic heart disease is that this itself produces relief of angina in many cases. The added benefit is that the usual antihypertensives used such as beta blockers and calcium channel blockers provide anti anginal effects also.
2)Chronic Obstructive Pulmonary Disease (COPD)
The important precaution to take when treating patients with COPD is the avoidance of beta blockers due to their bronchoconstrictive effects. Selective blockers like bisoprolol and metoprolol may be carefully tried if absolutely indicated. However, even these drugs are dose dependent on their selectivity.
3)Diabetes
In the Indian scenario, in a large proportion of cases, diabetes is part of the Metabolic Syndrome X, of which hypertension is an integral constituent, along with dyslipidemia and central obesity.
4)LV Failure
In cardiac failure the true degree of hypertension may be masked because the BP may be low due to the low cardiac output. The optimum use of ACE inhibitors and some AR Blockers makes substantial contribution in the relief of heart failure. In certain cases of chronic heart failure the addition of Carvedilol and Bisoprolol has been found to decrease the morbidity.
Non-pharmacological Management
Great importance is being given to life style modifications because of definite benefits observed in patients who follow this. Life style changes have advantages not only in the control of hypertension, but also in the management of dyslipidemia and diabetes.
General Measures: Diet, Weight, Alcohol, Smoking
1) While the major effects of tobacco are in the development of atherosclerotic heart disease, its role in management of hypertension cannot be forgotten. The pressure effect of tobacco is so strong that the blood pressure comes down immediately after stoppage of smoking.Tobacco is one of the agents that induces clustering of risk factors.
2) Body weight: Lowering of excess body weight can lower BP. In one of the studies it was found that a decrease of 1 kg of body weight is associated with an average fall of 1.6 mmHg.Indeed in many instances, it would be possible to discontinue medications after effective weight control.
3) Dietary Sodium: Restriction of dietary sodium is one of the most useful methods of controlling hypertension. This fact should be emphasized because of the increasing use of fast foods which have high salt content. It has to be admitted that this cannot be achieved easily. Norman Kaplan gives these practical suggestions:
a)Do not add salt during cooking or at the table
b) If salt is desired, add half sodium and half potassium chloride preparations
c)Avoid fast foods
d) Be careful about the sodium content of some medications
4) Alcohol: Alcohol consumption of more than 1 oz of ethanol is found to increase blood pressure. Hence moderation is recommended. One of the major hazards of drinking is the usual, associated consumption of high salt savouries, which are an unseen source of salt.
5) Regular physical exercise has been found to induce reduction in blood pressure in hypertensives.
6) Relaxation techniques: There have been various reports as to the efficacy of yoga, transcendal meditation, etc., but none of these have been been accepted by on the basis of statistical studies. However, it is widely accepted that relaxation techniques along with other reduction in risk factors do definitely decrease the incidence of cardiovascular complications.
Pharmacological Management
Once the decision to start drug treatment of hypertension is made, the aim should be to provide 24 hour BP control, with agents that would encourage patient adherence. The patient and preferably, his family members must be educated about the disease, complications and treatment.Since the treatment would be long term, great care should be taken to assess the patient’s financial status and to tailor the investigations and the drugs suitably. It has been noted that ver often, the home blood pressure instruments are either inaccurate or not used properly giving false results. So it is advisable to check on these factors if the patients are asked to do home monitoring.
a)Goal of Treatment
The ultimate goal of treatment of hypertension is to reduce the cardiovascular, cerebrovascular and renal morbidity and mortality. The aim must be to achieve targets of below 140/90. However in patients with diabetes or renal disease the goal should be less than 130/80.
b) Coexisting Conditions
1) Angina
The importance of treatment of hypertension in ischemic heart disease is that this itself produces relief of angina in many cases. The added benefit is that the usual antihypertensives used such as beta blockers and calcium channel blockers provide anti anginal effects also.
2)Chronic Obstructive Pulmonary Disease (COPD)
The important precaution to take when treating patients with COPD is the avoidance of beta blockers due to their bronchoconstrictive effects. Selective blockers like bisoprolol and metoprolol may be carefully tried if absolutely indicated. However, even these drugs are dose dependent on their selectivity.
3)Diabetes
In the Indian scenario, in a large proportion of cases, diabetes is part of the Metabolic Syndrome X, of which hypertension is an integral constituent, along with dyslipidemia and central obesity.
4)LV Failure
In cardiac failure the true degree of hypertension may be masked because the BP may be low due to the low cardiac output. The optimum use of ACE inhibitors and some AR Blockers makes substantial contribution in the relief of heart failure. In certain cases of chronic heart failure the addition of Carvedilol and Bisoprolol has been found to decrease the morbidity.
Non-pharmacological Management
Great importance is being given to life style modifications because of definite benefits observed in patients who follow this. Life style changes have advantages not only in the control of hypertension, but also in the management of dyslipidemia and diabetes.
General Measures: Diet, Weight, Alcohol, Smoking
1) While the major effects of tobacco are in the development of atherosclerotic heart disease, its role in management of hypertension cannot be forgotten. The pressure effect of tobacco is so strong that the blood pressure comes down immediately after stoppage of smoking.Tobacco is one of the agents that induces clustering of risk factors.
2) Body weight: Lowering of excess body weight can lower BP. In one of the studies it was found that a decrease of 1 kg of body weight is associated with an average fall of 1.6 mmHg.Indeed in many instances, it would be possible to discontinue medications after effective weight control.
3) Dietary Sodium: Restriction of dietary sodium is one of the most useful methods of controlling hypertension. This fact should be emphasized because of the increasing use of fast foods which have high salt content. It has to be admitted that this cannot be achieved easily. Norman Kaplan gives these practical suggestions:
a)Do not add salt during cooking or at the table
b) If salt is desired, add half sodium and half potassium chloride preparations
c)Avoid fast foods
d) Be careful about the sodium content of some medications
4) Alcohol: Alcohol consumption of more than 1 oz of ethanol is found to increase blood pressure. Hence moderation is recommended. One of the major hazards of drinking is the usual, associated consumption of high salt savouries, which are an unseen source of salt.
5) Regular physical exercise has been found to induce reduction in blood pressure in hypertensives.
6) Relaxation techniques: There have been various reports as to the efficacy of yoga, transcendal meditation, etc., but none of these have been been accepted by on the basis of statistical studies. However, it is widely accepted that relaxation techniques along with other reduction in risk factors do definitely decrease the incidence of cardiovascular complications.
Pharmacological Management
Once the decision to start drug treatment of hypertension is made, the aim should be to provide 24 hour BP control, with agents that would encourage patient adherence. The patient and preferably, his family members must be educated about the disease, complications and treatment.Since the treatment would be long term, great care should be taken to assess the patient’s financial status and to tailor the investigations and the drugs suitably. It has been noted that ver often, the home blood pressure instruments are either inaccurate or not used properly giving false results. So it is advisable to check on these factors if the patients are asked to do home monitoring.
One of the usual statements made by patient is that when checked by another person, he found to have low BP or high BP. He should be asked to make a note of the exact readings obtained at that time.
There are instances when patients claim that they felt that they had “pressure”, when the truth was that he was going through a stressful period. Our practice is to warn the patient that the “pressure” he feels does not necessarily reflect high blood pressure.
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