Chapter 32: Treatment of Hypertension

ABBREVIATIONS

EPIDEMIOLOGY AND TREATMENT ALGORITHMS

Hypertension is the most common cardiovascular disease. Elevated arterial pressure causes hypertrophy of the left ventricle and pathological changes in the vasculature. As a consequence, hypertension is the principal cause of stroke; a major risk factor for coronary artery disease (CAD) and its associated complications, myocardial infarction (MI) and sudden cardiac death; and a major contributor to heart failure, renal insufficiency, and dissecting aneurysm of the aorta. The prevalence of hypertension increases with age; for example, about 50% of people between the ages of 60 and 69 years old have hypertension, and the prevalence further increases beyond age 70. According to a survey in the U.S., 81.5% of those with hypertension are aware they have it, 74.9% are being treated, yet only 52.5% are considered controlled (Go et al., 2014). The success of hypertension treatment programs, such as one organized in a large integrated healthcare delivery system in the U.S. (Jaffe et al., 2013), shows that these figures can be substantially improved by electronic hypertension registries tracking hypertension control rates, regular feedback to providers, development and frequent updating of an evidence-based treatment guideline, promotion of single-pill combination therapies, and follow-up blood pressure checks. Between 2001 and 2009, this program increased the number of patients with a diagnosis of hypertension by 78%, as well as the proportion of subjects meeting target blood pressure goals from 44% to more than 84% (Jaffe et al., 2013).

The definition of hypertension and treatment goals have evolved over the years according to results of intervention studies. The SPRINT study in nondiabetics with increased cardiovascular risk was prematurely stopped because the group of patients treated with antihypertensives to a systolic blood pressure target of 120 mmHg experienced a 25% lower rate of cardiovascular end points and total mortality than the group targeted to 140 mmHg (SPRINT Research Group, 2015). The rate of adverse effects such as hypotension and worsening of renal function were higher in the intensified treatment group, but this did not translate to a signal for real harm. The consequences of these results on the recent American Heart Association (AHA)/American College of Cardiology (ACC) (Whelton et al., 2018) and European Society of Cardiology (ESC) guidelines (Williams et al., 2018) slightly differ (Bakris et al., 2019; Table ...