Treating Hypertension Clinically

The object of treating systemic arterial hypertension is to reduce the risk of complications and to improve patient survival.

The benefits of treatment have to be weighed against its inconvenience and the possibility that the agents used may themselves have potentially harmful effects.

In most instances, the discovery of hypertension commits the patient to a lifetime supervision and treatment. It is important to treat the whole patient and not just the blood pressure.

Because of these considerations it is not particularly helpful to set up arbitrary levels of blood pressure at which treatment should be commenced.

Decisions about treatment should also take into account the fact that the natural history of hypertension tends to be more in women than in men and that Black people and diabetics are more prone to hypertensive complications.

General Measures:

Diet: Reducing alcohol consumption and correcting obesity are both effective antihypertensive measures. Very low sodium diets lower blood pressure but are not practical. Moderate sodium restriction is sometimes helpful and patients should therefore, be advised to stop adding salt to food and to avoid foods with very high sodium content.

Smoking: The effects of cigarette smoking and hypertension on cardiovascular morbidity are additive and smoking should be strongly discouraged.

Exercise: Regular exercise improves physical fitness and may lower blood pressure and should be strongly encouraged.

Relaxation: It is customary to advise patients to avoid stress but this is usually a pious hope. Spouses should be dissuaded from perpetually reminding patients of their hypertension.

Formal relaxation classes, meditation and biofeedback have all been shown to reduce blood pressure in small groups of patients their efficacy is usually proportional to the enthusiasm of the teacher and the commitment of the participant, it is unusual, however, for such treatment to replace the need for antihypertensive drug therapy.

Antihypertensive drug therapy: Many patients can be satisfactorily treated with a single antihypertensive drug, the choice of which will be determined by safety, convenience and freedom from side effects.

Another large group will require a combination of two or three hypertensive agents to give good control with a low level of side effects. A small minority will have severe hypertension refractory to conventional treatment and requiring intensive investigation and special treatment.

The principal agents used in single drug treatment of hypertension are thiazide diuretics, beta adrenoceptor and antagonists and ACE inhibitors, calcium angagonists and some vasodilators are also effective.

Most physicians start treatment with a beta blocker or a thiazide diuretic, depending on the likely side effects and the presence of any relevant additional pathology.

On the other hand a beta blocker is likely to benefit a patient with angina whereas a diuretic may be more appropriate if there is evidence of heart failure or fluid retention. If one agent fails to control the blood pressure a combination should be prescribed.

Beta adrenoceptor antagonists: A large number of beta blockers are available and these differ in several important respects. Those with a short half life are mostly available in slow release, once daily, formulations.

Metoprolol and atenolol are cardio selective and therefore preferentially block the cardiac B1 receptors as opposed to the B2 receptors which mediate vasodilatation and bronchodilatation. Pindolol and oxprenolol have partial agonist activity and therefore tend to cause less bradycardia.

Propranlol is subject to extensive first pass metabolism which means that a large and variable proportion of the drug is destroyed in its first passage through the liver. The dose of propranlol must, therefore be carefully titrated according to the patients individual needs.

Emergency treatment of hypertension: It is virtually never necessary or desirable to cause an instantaneous fall in blood pressure. Even in the presence of cardiac failure or hypertensive encephalopathy a controlled reduction over a period of 30-60 minutes to a level of about 150 / 90 is adequate and there is often less urgency.

Too rapid a fall in pressure may cause permanent cerebral ischaemic damage including blindness and may sometimes precipitate coronary or renal insufficiency.

 

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