High blood pressure (or hypertension) is a serious problem in the United States . Approximately 25% of the population has high blood pressure.¹  High blood pressure puts you at risk for many conditions including heart disease, stroke and kidney damage.

The National Heart, Lung, and Blood Institute (NHLBI) is an organization that publishes guidelines for high blood pressure. These guidelines are based on sound research studies and are meant to be a tool for physicians to use when treating high blood pressure. The guidelines were last updated in May of 2003. It is tragic that while no more than 50% of patients with high blood pressure are controlled on a single blood pressure drug, many doctors will only prescribe one medication at a time instead of using combinations of drugs as the guidelines suggest. Is your doctor following new guidelines?

 The following information is based on these guidelines.

What Should My Blood Pressure Goal Be?

The top number of a blood pressure reading is your ‘systolic’ blood pressure. This number measures the  pressure on the walls of your blood vessels when the heart is contracting. The bottom number is the ‘diastolic’ blood pressure. This number measures the pressure on the walls of your blood vessels when your heart is at rest. The guidelines suggest that as blood pressure increases over normal, the risk of death from heart disease and stroke also increases.

Blood pressure goals for most people should be 140/80 or less.  Patients with diabetes are at a higher risk of heart disease and stroke. Therefore, they have a stricter target of 130/80. Patients with chronic kidney disease also have a goal blood pressure of 130/80. Patients with peripheral arterial disease (PAD) will have a goal of 130/80.

Treatment

Patients with pre-hypertension will generally need to make lifestyle modifications such as eating healthier and exercising to lower their blood pressure and reduce their risk for heart disease and stroke. All other stages of hypertension will usually require medication  therapy to meet their blood pressure goals.  As mentioned above, only 50% of patients with high blood pressure will be controlled on one medication. In fact, if a decrease in blood pressure of more than 20/10 is needed, the guidelines recommend starting with two medications. Your doctor’s choice of blood pressure mediation for you will depend on other conditions you have. This is where the guidelines are helpful. You see, certain medications have been shown to decrease the risk of developing other health problems in patients with certain conditions. Some medications have even been shown to decrease the risk of death in some patients. Read on to find out more. 

Lifestyle Modifications

No matter which medication you are prescribed, if any, adopting a healthier lifestyle is an important part of controlling your blood pressure. Eating healthy, exercising, avoiding too much alcohol and quitting smoking are all part of these lifestyle modifications.  Maintaining a healthy weight and getting at least 30 minutes of moderate exercise on most days is recommended to obtain and keep a healthy blood pressure. The Dietary Approaches to Stop Hypertension (DASH) diet is recommended in the guidelines. DASH is a diet plan that   is rich in veggies, fruits, nonfat dairy and is very low in salt. Adhering to such a diet can lower blood pressure as much as a single drug in many people.

Diuretics

These are often called ‘water pills’. They work by causing the body to loose excess water. Getting rid of this extra fluid in the body can lower blood pressure and decrease the work on the heart. Examples of diuretics are furosemide (Lasix), spironolactone, chlorthalidone and hydrochlorothiazide. Side effects of these medications include changes in sodium, magnesium, calcium and potassium levels. Side effects can also include orthostatic hypotension. This is when you start to feel dizzy when getting up from the seated position. To avoid this, rise slowly when getting up out of a chair or out of bed. 

ACE Inhibitors

These medications work by minimizing blood vessel constriction and reduce sodium and water retention. This helps lower your blood pressure. Examples of these medications include the following:

·         Capoten (captopril)

·         Vasotec (enalapril)

·         Prinivil, Zestril (lisinopril)

·         Lotensin (benazepril)

·         Monopril (fosinopril)

·        Altace (ramipril)

·         Accupril (quinapril)

·         Aceon (perindopril)

·         Mavik (trandolapril)

·         Univasc (moexipril)

These medications are the drug of choice in patients with diabetes or kidney disease. This is because these medications have been shown to help ‘protect’ the kidneys in these patients.  These drugs are also good choices if the patient has a history of heart attack or stroke. Often these medications are not tolerated well because of an often troublesome side effect; cough. These drugs have the ability to produce dry, persistent cough in many patients. It is unclear why this occurs. Some patients are able to tolerate the drug despite this, but others find it too bothersome and choose to switch medications. As with diuretics, you can feel light headed or dizzy when getting up from a seated position. These drugs can also cause disturbances in your potassium level. One potentially serious side effect of these medications is called ‘angioedema’. Symptoms of this condition include swelling of the face, hands and feet. It is serious because it can affect internal organs and can affect your ability to breath. If you notice any facial swelling while taking an ACE inhibitor, talk to a health care professional promptly.

Angiotensin Receptor Blockers

These medications work in a way similar to ACE inhibitors. Examples of these medications include:

·         Cozaar (losartan)

·         Diovan (valsartan)

·         Avapro (irbesartan)

·         Atacand (candesartan)

These medications are generally the second drug of choice in patients with diabetes or kidney disease and are often used when the patient can not tolerate ACE Inhibitors because of side effects. These medications do not generally cause the dry, persistent cough that ACE inhibitors often cause. There is less data that shows if this group of medications has the same ‘kidney-protecting’ properties of the ACE inhibitors in patients with diabetes and kidney disease.

Side effects for these medications are similar to ACE inhibitors in that they too can cause dizziness, potassium disturbances and angioedema.

Beta Blockers

·         Sectral (acebutolol)

·         Zebeta (bisoprolol)

·         Brevibloc (esmolol)

·         Inderal (propanolol)

·         Tenormin (atenolol)

·         Normodyne, Trandate (labetalol)

·         Coreg (carvedilol)

·         Lopressor, Toprol-XL (metoprolol)

These medications are often the first choice if a patient has a history of heart attack. In fact, most patients who have had a heart attack will already be on a beta blocker due to another set of guidelines that tells us that heart attack patients benefit from beta blocker therapy, even if they do not have high blood pressure. This is because research has found that taking a beta blocker after a heart attack can actually decrease your risk of death.

The most common side effect with beta blockers is cold hands and feet. Other common side effects include dizziness, tiredness and sleep disturbances.

Calcium Channerl Blockers

These medications are similar to beta blockers in that they decrease the pumping force of the heart. This lowers blood pressure and lessens the work load on the heart. Examples of these mediations include:

·         Norvasc (amlodipine)

·         Plendil (felodipine)

·         Cardizem, Cardizem CD, Cardizem SR, Dilacor XR, Diltia XT, Tiazac (diltiazem)

·         Calan, Calan SR, Covera-HS, Isoptin, Isoptin SR, Verelan, Verelan PM (verapamil)

·         Adalat, Adalat CC, Procardia, Procardia XL (nifedipine)

·         Cardene, Cardene SR (nicardipine)

·         Sular (nisoldipine)

·         Vascor (bepridil)

Side effects include dizziness and headache. Some like diltiazem and verapamil may cause constipation.

How Can I Expect My Treatment to Progress?

It used to be that ACE inhibitors, beta blockers or calcium channel blockers were prescribed first, then diuretics were prescribed if added control was needed. This has changed in recent years. Recent research shows that thiazide-type diuretics, like chlorthalidone, are at least as effective as ACE inhibitors and calcium channel blockers for preventing heart attacks and decreasing heart disease-related death. It also shows that thiazides are actually more effective for preventing heart failure and stroke than some of these other medications.

For this reason, most doctors will now start with a thiazide-type diuretic and add other medications to it as needed. Evidence suggests that blood pressure medications that are added should be done so according to what other conditions you have. It is important to talk to make sure that your blood pressure regimen follows these guidelines. To recap, patients with a history of heart attack should get a beta blocker and/or ACE inhibitor. Patients with diabetes, kidney disease or history of stroke should get an ACE inhibitor.  If your regimen does not follow these guidelines, you may wan to talk with your doctor.  

Author: Christi Larson, Pharm. D.

REFERENCES:

1. Burt VL, Whelton P, Roccella EJ, et al. Hypertension. 1995 Mar;25(3):305-13.  

    

2. The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002;288:2981-97.

    

3. National Heart, Lung, and Blood Institute. The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. May 2003.