Pharmacological therapy

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Pharmacological therapy is initiated in individuals in whom lifestyle changes are not accomplished or are inadequate to control hypertension and in those individuals who have sustained blood pressure readings greater than 160 mmHg systolic and/or 100 mmHg diastolic.9 In individuals with diabetes or who have evidence of end-stage target organ damage, treatment should be started if blood pressure is higher than 140/90 mmHg.3

Recent studies have found that the most important factor is getting the blood pressure controlled, and "this is more important than the means."10 Similarly, most patients will need more than one medication. Several commissions have suggested that the first-line drugs should be low-dose thiazide diuretics or beta-blockers, in the absence of other factors. Beta-blockers, especially the cardioselective types, are good medications for many individuals. Data suggest that use of beta-blockers may reduce the incidence of strokes but not total mortality.11 They are especially good choices in patients with tachycardia, anxiety, migraine headaches, and angina. They should be avoided in asthmatics, patients with bradycardia or atrioventricular blocks, and diabetic patients using insulin who may become hypoglycemic. Beta-blockers can make the individual feel slow, tired, or depressed. Their effects on women's sexual function are not known.

Diuretics are effective antihypertensive medications, but they may worsen incontinence and glycemic and lipid control, and theymay cause hypokalemia.

Angiotensin-converting enzyme inhibitors (ACEIs) are effective treatment and have many other effects, some of which are not understood. They protect renal function in diabetics, and one study found recently that ramipril decreased the risk of stroke, even in diabetic individuals who were not overtly hypertensive.12 However, up to 49% ofwomenon, ACEIs may develop a cough. The angiotensin II inhibitors are another good choice and have been found to be as effective in reducing blood pressure and microalbuminuria in diabetic hypertensive patients.13

The short-acting calcium-channel blocker nifedipine has been implicated in increasing heart failure and in increasing the risk of breast cancer. However, sustained-release forms are effective and a good choice in treating hypertension, especially in individuals with angina, atrial tachycardias, or migraines.

Comparison of different classes of drugs has produced a variety of results. One study of more than 6000 patients aged 70-84 found no difference in control of blood pressure or morbidity or mortality between use of diuretics, beta-blockers, calcium-channel blockers, and ACEIs.14 A meta-analysis found that ACEIs and calcium-channel blockers reduced cardiovascular mortality and morbidity as well as beta-blockers and thiazide diuretics.15 The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) study, a randomized, double-blind, controlled clinical trial examining 42 418 patients with mild to moderate hypertension and aged 55 years

Table 13.1 Medications that can interfere with blood pressure medications or worsen hypertension

Dietary: alcohol, caffeine, licorice Appetite suppressants Anesthetics

Analgesics: non-steroidal anti-inflammatory drugs Medications containing sodium: antacids, antibiotics

Hormones: adrenal steroids, chronic steroid use, erythropoietin; oral contraceptives Illegal substances: cocaine, amphetamines, androgen steroids or older, examined the results of one of four antihypertensive treatments: the diuretic chlortalidone (12.5-25 mg daily), the ACEI lisinopril (10-40 mg daily), the calcium-channel blocker amlodipine (2.5-10 mg daily), and the alpha-blocker doxazosin (1-8 mg daily). More than 15 000 participants were women, and more than 10 000 were African-American. The effects of all drugs except doxazosin were similar in reduction of mortality and heart disease. However, lisinopril was significantly less effective than the diuretic at reducing stroke and combined cardiovascular disease, and chlortalidone use reduced the incidence of heart failure.16 A recent editorial from the British Medical Journal states: "What matters most is getting blood pressure controlled, and this is overwhelmingly more important than the means."17

Concomitant illnesses may indicate the need for different first-line drugs. Diabetics should be given ACEIs, whereas patients with cardiac disease may need medications that are also anti-anginal, such as calcium-channel blockers.

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