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Management of the Spectrum of Essential Hypertension: A 2013 Perspective

Cristian Riella and Theodore I Steinman

Management of hypertension: The association of hypertension with cardiovascular and renal disease is continuous and independent of other risk factors. Despite the increase in awareness and treatment of hypertension in the past decade, less than 50% of adults in the U.S have adequate blood pressure control. Every 10% increase in the treatment of patients with hypertension could prevent an additional 14,000 deaths. This article reviews the latest evidence guiding current hypertension management.

The main classes of drugs used to treat hypertension are diuretics (thiazides, loop and aldosterone antagonists), angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, beta-blockers. Alpha-adrenergic blockers and direct renin inhibitors are used infrequently and are mostly used as the 4th or 5th added agent.
No consensus has been established on initial drug choice. In patients with compelling indications, such as ischemic heart disease, diabetes, chronic kidney disease and stroke, some classes have shown greater benefits. Widely accepted is that blood pressure reduction is the most important determinant in lowering cardiovascular risk when there is no indication for a particular class of drugs. Hypertensive patients with central and peripheral vascular disease, chronic kidney disease and diabetes should have a lower target blood pressure.

In patients with mild primary hypertension undergoing monotherapy, with inadequate blood pressure control, sequential monotherapy may be attempted prior to adding another drug. Combination therapy should be considered from the onset in individuals with blood pressures that exceed 20/10 mmHg above the set target range.
The combination of angiotensin-converting enzyme inhibitor plus a calcium channel blocker has been proven to be superior to other combinations. Considering the impact that adequate treatment can make in preventing deaths, the challenge is to improve access to care of patients with hypertension.