Hypertension

New Hypertension Guidelines: Which Treatments Are Best For Each Patient?

Approximately 46% of the US population now meets the criteria for hypertension, according to newly released hypertension guidelines from the American Heart Association (AHA) and the American College of Cardiology (ACC).1

Under the previous guidelines, only 32% of the US population was considered to have hypertension. As a result of the new guidelines, hypertension will now have to be diagnosed and treated in more patients than ever before, according to Wilbert S. Aronow, MD, FAHA, FACC, professor of medicine and director of cardiology research at Westchester Medical Center and New York Medical College in Valhalla, New York.
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Recently, Consultant360 spoke with Dr Aronow about appropriate treatment options for individuals with hypertension, which often vary based on factors like demographics, comorbidities, and health history. Dr Aronow presented “Initiation of Antihypertensive Therapy” at the AHA Scientific Sessions 2017 and is a member of the 21-person committee of experts who composed the new guidelines.2

Treating Hypertension in Black and Non-Black Adults

Appropriate treatment regimens for hypertension can vary by race, especially in black patients.

“Black patients have a higher prevalence of hypertension and adverse clinical outcomes than whites with hypertension,” Dr. Aronow said. “Genetics and socioeconomic factors contribute to this. Blacks are also more salt-sensitive than whites.”

According to the AHA/ACC guidelines, black adults with hypertension should be treated with:

  • A thiazide diuretic (preferably chlorthalidone) or a calcium channel blocker as the first antihypertensive drug.
  • A combination of a thiazide diuretic plus a calcium channel blocker plus an angiotensin converting enzyme inhibitor or angiotensin receptor blocker, if 3 drugs are needed.

Treatment recommendations are different for white and other non-black patients with hypertension, and vary based on age. According to the new guidelines, white adults who are younger than 60 years should be treated with:

  • An angiotensin-converting enzyme inhibitor or angiotensin receptor blocker as the first antihypertensive drug.
  • A thiazide diuretic (preferably chlorthalidone) or a calcium channel blocker as the second antihypertensive drug.
  • A combination of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker plus a thiazide diuretic plus a calcium channel blocker, if a third drug is needed.

White and other non-black adults with hypertension who are older than 60 years should receive:

  • A thiazide diuretic (preferably chlorthalidone) or a calcium channel blocker as the first antihypertensive drug.
  • A combination of a thiazide diuretic plus a calcium channel blocker plus an angiotensin receptor blocker, if 3 drugs are needed.

Addressing Hypertension in Adults With Comorbidities

When forming and prescribing hypertension treatment regimens, physicians must also be conscious of any comorbidities that patients may have.

“Comorbidities contribute to increased cardiovascular events in patients with hypertension,” said Dr Aronow. “As a result, patients with comorbidities especially need adequate control of their hypertension by lifestyle measures plus antihypertensive drug therapy.”

Treatment recommendations vary based on specific comorbidities that are present, including diabetes, chronic kidney disease (CKD), and various cardiovascular (CV) conditions.

For patients with comorbidities in addition to hypertension, the AHA/ACC guidelines recommend:

  • Thiazide diuretics (preferably chlorthalidone) angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and calcium channel blockers as initial therapy in patients who also have diabetes.
    • An angiotensin-converting enzyme inhibitor or angiotensin receptor blocker as initial treatment in patients with diabetes and persistent albuminuria.
  • An angiotensin-converting enzyme inhibitor in patients with CKD stage 3 or higher or in those with CKD stage 1 or 2 with albuminuria of at least 300 mg per day.
    • Patients with CKD who are intolerant to an antiotensin-converting enzyme inhibitor should be treated with an angiotensin receptor blocker.
  • A beta-blocker (ß-blocker) plus an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker in patients who also have ischemic heart disease.
    • If a third drug is needed, patients with ischemic heart disease should be treated with a combination of a ß-blocker plus an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker plus a thiazide diuretic or a calcium channel blocker.
    • Atenolol should not be used as the ß-blocker in these patients.
    • Those who are treated with a ß-blocker plus an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker should also be treated with dihydropyridine calcium channel blocker if angina pectoris is present despite the use of a ß-blocker.
  • ß-blockers—including carvedilol, metoprolol succinate, or bisoprolol—in patients who also have HF with reduced left ventricular ejection fraction.
    • After treatment of volume overload with diuretics, these patients may be treated with a ß-blocker and an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker.
    • A mineralocorticoid receptor antagonist may also be considered for these patients.
  • A thiazide diuretic or an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in patients who have also had a stroke or transient ischemic attack.
    • If a third drug is needed, these patients may also be treated with a thiazide diuretic plus an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker plus a calcium channel blocker.
    • If a fourth drug is indicated to control blood pressure in adult patients who have been treated with adequate doses of 3 antihypertensive drugs including a thiazide diuretic, a mineralocorticoid receptor agonist may be considered.
  • ß-blockers in adult patients who also have thoracic aortic aneurysm and in adult patients with type A and type 2 acute and chronic thoracic aortic dissection.

Note: Simultaneous use of an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, and/or direct renin inhibitor is potentially harmful.

Managing Hypertension in Pregnant Women

Methyldopa, nifedipine, and/or labetalol should be used to treat pregnant women with hypertension, Dr Aronow noted. Conversely, pregnant women should not be treated with an angiotensin-converting enzyme inhibitor, an angiotensin receptor blocker, or a direct renin inhibitor.

—Christina Vogt

References:

1. Vogt C. New AHA/ACC guidelines lower high BP threshold [published online November 14, 2017]. Consultant360. https://www.consultant360.com/exclusives/new-ahaacc-guidelines-lower-high-bp-threshold.

2. Aronow WS. Initiation of antihypertensive therapy. Presented at: American Heart Association (AHA) Scientific Sessions 2017; November 11-15, 2017; Anaheim, CA. http://www.abstractsonline.com/pp8/ - !/4412/presentation/55060.