Treatment of hypertension

Treatment Goals

The disease generally can be clinically diagnosed. If there are complex situations, it must be determined by the clinician based on the individual patient's situation.

The fundamental goal of hypertension treatment is to reduce the overall risk of cardiovascular, cerebrovascular, renal, and vascular complications and death. The benefits of antihypertensive treatment mainly come from lowering blood pressure. For ordinary hypertensive patients, it is recommended to decide whether to give antihypertensive drugs and drug treatment plans based on the overall risk level of hypertensive patients based on improving their lifestyle. For patients with gestational hypertension, the main purpose of treatment is to ensure the safety of mother and child and the smooth progress of pregnancy and delivery, reduce complications, and reduce mortality. For patients with mild hypertension, non-drug treatment should be emphasized, blood pressure should be actively monitored, and urine routine and other related examinations should be regularly conducted.

Treatment During Acute Phase

The acute phase of hypertension is different from other diseases. It specifically refers to the occurrence of hypertensive crisis (≥180/120 mmHg) under certain inducements. It is necessary to immediately lower blood pressure and control the blood pressure level to "slowly" drop. The treatment of hypertensive crisis is very complicated, and multiple systemic factors must be considered. Patients and their families should understand the treatment principles and cooperate with clinical treatment.

At present, there is no consensus on how fast to reduce elevated blood pressure. Existing guidelines recommend that except for acute stroke, pulmonary edema or aortic dissection, the mean arterial pressure should drop by ≤25% in the first hour. Within the next 2-6 hours, under the condition of close blood pressure monitoring, the blood pressure should be gradually reduced to 160/110 mmHg, and gradually reduced to normal within 24-48 hours. At the same time, it should be noted that excessive treatment can lead to tissue hypoperfusion, resulting in additional ischemic damage.

Treatment of hypertensive crisis generally considers continuous intravenous infusion or pumping of stable doses of drugs. Commonly used drugs are sodium nitroprusside, nitroglycerin, nicardipine or labetalol.

General Treatment

For most patients with hypertension, blood pressure should be gradually lowered to the target level within 4 weeks or 12 weeks, depending on the condition. Patients whose blood pressure still exceeds 140/90 mmHg and/or the target level after improving their lifestyle should be given drug treatment.

Treatment Drugs

Due to the large individual differences, there is no absolute best, fastest, and most effective medication. In addition to commonly used OTC drugs, the most appropriate drugs should be selected under the guidance of a doctor in combination with personal conditions.

The newly promulgated "Clinical Practice Guidelines for Hypertension" points out that the time to start hypertension drug treatment is:

- Systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg, it is recommended to start antihypertensive drug treatment immediately;

- Systolic blood pressure 130-139 mmHg and/or diastolic blood pressure 80-89 mmHg with clinical complications, it is recommended to start antihypertensive drug treatment;

- Systolic blood pressure 130-139 mmHg and/or diastolic blood pressure 80-89 mmHg with target organ damage (GPS) or >3 cardiovascular risk factors, antihypertensive drug treatment can be started.

The basic principles of drug treatment for hypertension include the following aspects:

- Use a smaller effective dose for initial treatment, and gradually increase to a sufficient dose as needed. The five commonly used antihypertensive drugs can be used as initial treatment drugs;

- Long-acting antihypertensive drugs should be used first, and strive to effectively control 24-hour blood pressure;

- Patients who do not meet the target of monotherapy should receive combined drug treatment, and can choose free combination or single-tablet compound preparations;

- Choose antihypertensive drugs suitable for the condition according to the individual condition of the patient;

- Antihypertensive drugs need to be taken for life, and the cost-effectiveness ratio should be considered.

Commonly used antihypertensive drugs include CCB, ACEI, ARB, diuretics and beta-blockers. The guidelines recommend that these five types of drugs can be used as initial treatment drugs. Doctors will select targeted drugs according to the type and comorbidities of special populations for individualized treatment. Long-acting antihypertensive drugs should be used first to effectively control 24-hour blood pressure and prevent cardiovascular and cerebrovascular complications.

CCB

Can be used alone or in combination with other 4 types of drugs, especially for elderly patients with hypertension, isolated systolic hypertension, stable angina, coronary or carotid atherosclerosis and peripheral vascular disease.

Common adverse reactions include increased heart rate, facial flushing, ankle edema, gingival hyperplasia, etc. There are no absolute contraindications for dihydropyridine CCB, but patients with tachycardia and heart failure should use them with caution.

ACEI

The antihypertensive effect is clear, and there is no adverse effect on sugar and lipid metabolism. Salt restriction or the addition of diuretics can increase the antihypertensive effect of ACEI. It is especially suitable for patients with chronic cardiac failure, cardiac insufficiency after myocardial infarction, prevention of atrial fibrillation, diabetic nephropathy, non-diabetic nephropathy, metabolic syndrome, proteinuria or microalbuminuria.

The most common adverse reaction is dry cough, which is more common in the early stage of medication. Patients with mild symptoms can take the medication, and those who cannot tolerate it can use ARB instead. Other adverse reactions include hypotension, rash, and occasionally angioedema and taste disturbance. Long-term use may lead to increased blood potassium, and blood potassium and creatinine levels should be monitored regularly. Contraindications are bilateral renal artery stenosis, hyperkalemia, and pregnant women.

ARB

Can reduce the incidence of cardiovascular complications in patients with a history of cardiovascular disease (coronary heart disease, stroke, peripheral arterial disease) and the risk of cardiovascular events in hypertensive patients, and reduce proteinuria and microalbuminuria in patients with diabetes or kidney disease. ARB is particularly suitable for patients with left ventricular hypertrophy, heart failure, diabetic nephropathy, coronary heart disease, metabolic syndrome, microalbuminuria or proteinuria, and patients who cannot tolerate ACEI, and can prevent atrial fibrillation.

Adverse reactions are rare, with occasional diarrhea. Long-term use can increase blood potassium, and attention should be paid to monitoring changes in blood potassium and creatinine levels. Patients with bilateral renal artery stenosis and hyperkalemia, and pregnant women are prohibited from taking it.

Diuretic

Especially suitable for elderly patients with hypertension, isolated systolic hypertension or patients with heart failure, and is also one of the basic drugs for refractory hypertension.

Adverse reactions are closely related to the dose, so a small dose should usually be used. Thiazide diuretic can cause hypokalemia. Long-term users should monitor blood potassium regularly and supplement potassium appropriately.

Gout patients are prohibited from taking it; patients with hyperuricemia and obvious renal insufficiency should take it with caution.

β-blocker

Especially suitable for patients with hypertension accompanied by tachyarrhythmias, coronary heart disease, chronic heart failure, increased sympathetic nerve activity and hyperdynamic state. Common adverse reactions include fatigue, cold limbs, restlessness, gastrointestinal discomfort, etc., and may also affect glucose and lipid metabolism. Patients with moderate to severe atrioventricular block and asthma are prohibited from using it; patients with chronic obstructive pulmonary disease, athletes, peripheral vascular disease or impaired glucose tolerance should use it with caution.

β-blocker is generally not the first choice when glucose and lipid metabolism is abnormal, and highly selective β-blocker can also be used with caution when necessary. Long-term users may experience a rebound phenomenon if they suddenly stop taking the drug, that is, the original symptoms worsen or new manifestations appear. The most common one is a rebound increase in blood pressure, accompanied by headache, anxiety, etc. This is called withdrawal syndrome.

Other Treatments

Lipid-lowering treatment

If hypertension is accompanied by dyslipidemia, active antihypertensive treatment, and moderate lipid-lowering treatment should be received based on lifestyle changes. If there is no cardiovascular and cerebrovascular disease, lifestyle intervention should be strictly implemented for 6 months. If the blood lipid level is still not up to standard, drug lipid-lowering treatment should be considered. If there is already cardiovascular and cerebrovascular disease and hypertension is found, statin treatment should be started immediately, and cholesterol-lowering drugs should be combined if necessary.

Antiplatelet treatment

If hypertension is accompanied by ischemic cardiovascular and cerebrovascular disease, doctors generally recommend antiplatelet treatment. Hypertensive patients should pay attention to the long-term use of aspirin: it should be started after blood pressure is stabilized (<150/90 mmHg); aspirin may increase the risk of cerebral hemorrhage in patients with hypertension who are not well controlled.

Blood sugar control

The blood sugar target for hypertension combined with diabetes is HbA1c <7%; fasting blood sugar 4.4-7.0 mmol/L; blood sugar 2 hours after a meal or peak blood sugar <10.0 mmol/L.

If the patient is an elderly diabetic, or is prone to hypoglycemia, has a long course of illness, or has multiple comorbidities or complications, the blood sugar control target can be appropriately relaxed.

Treatment of concurrent atrial fibrillation

For hypertensive patients who are prone to atrial fibrillation (such as those with left atrial enlargement, left ventricular hypertrophy, and reduced cardiac function), doctors will recommend the use of renin-angiotensin system inhibitors (especially ARB) to reduce the occurrence of atrial fibrillation. When atrial fibrillation is combined with thromboembolic risk factors, doctors often perform anticoagulant therapy under current guidelines.

Management of multiple risk factors

Lifestyle intervention is the basis for the prevention of cardiovascular disease in patients with hypertension and multiple risk factors. When the examination indicates that homocysteine is elevated, fresh vegetables and fruits should be appropriately supplemented, and folic acid should be supplemented if necessary.