Hypertension
Management of hypertension
BP treatment thresholds and targets1
The 2017 US ACC-AHA BP Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults recommends the use of antihypertensive medication in patients with pre-existing CVD and those without a CVD event but an estimated 10-year ASCVD risk of ≥10% at BP levels of ≥130/80 mmHg. In individuals without CVD and with 10-year ASCVD risk of <10%, antihypertensive medication should be initiated at BP of ≥140/90 mmHg (Figure 1)1.
Figure 1. Algorithm for the management of hypertension1.
Nonpharmacological management1
Lifestyle advice is recommended for all patients with hypertension. The most effective interventions are the same as those used for the prevention of hypertension. Targeted dietary approaches can reduce the systolic BP in individuals with hypertension1. Lifestyle advice including:
- Reduced salt intake
- Increased potassium intake
- Moderate alcohol consumption
- Physical activity
- Weight loss
Pharmacological management2
Each set of guidelines notes that sodium restriction in patients with hypertension is needed as there is a linear relationship between reduction in sodium intake and subsequent reduction in blood pressure in patients with hypertension. Both the ESC-ESH and ACC-AHA guidelines recommend angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers, and thiazide or thiazide-like diuretics as first-line agents (Figure 2). Additionally, although lifestyle modifications can delay hypertension or allow patients to meet their BP targets, initiation of first-line pharmacological therapy should not be delayed in patients with hypertension who qualify.2
Figure 2. Mechanisms of action for first-line antihypertensive medications
Why ARBs matter?3,4
ACE inhibitors target one of the enzymes that generate angiotensin II from angiotensin I (Figure 2). However, angiotensin II is not produced exclusively by this mechanism; other enzymes, such as chymase, are also able to generate angiotensin II. ARBs overcome the detrimental effects of angiotensin II by preventing it binding to the type 1 receptors3. ACE inhibitors and ARBs are equally guideline-recommended first-line treatments for hypertension. One study compared the real-world effectiveness and safety of ACE inhibitors versus ARBs in the first-line treatment of hypertension. They found ARBs do not differ statistically significantly in effectiveness at the class level compared with ACE inhibitors as first-line treatment for hypertension but present a better safety profile4.
Clinical benefits of ARBs5
Studies show that ARBs have clinical benefits across the spectrum of disease severity. In particular, recent large studies have demonstrated that these benefits extend to patients with conditions predisposing to cardiovascular events, such as diabetes, left ventricular hypertrophy and microalbuminuria, and where risk factors coexist.
Data from these studies suggest that the cardiovascular protective effects of ARBs are independent from the BP lowering action. In addition, ARBs are extremely well tolerated, and strong evidence suggests that compliance with therapy — a key factor in achieving adequate BP control — with ARBs is higher than with other antihypertensive agents. Furthermore, flexible dosing and good tolerability profile mean that, where necessary, ARBs can be combined with other classes of antihypertensive agents to achieve adequate BP control and reduce the risk of hypertension-associated morbidity5.
Footnotes:
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ACC, American College of Cardiology; ACE; angiotensin-converting enzyme; AHA, American Heart Association; ARBs, angiotensin receptor blockers; ASCVD, atherosclerotic cardiovascular disease; BP, blood pressure; CVD, cardiovascular disease; ESC, European Society of Cardiology; ESH, European Society of Hypertension; US, United States.
References:
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Oparil S, et al. Nat Rev Dis Primers. 2018;4:18014.
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Brouwers S, et al. Lancet. 2021;398(10296):249-261.
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Galzerano D, et al. Vasc Health Risk Manag. 2010;6:113-133.
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Chen R, et al. Hypertension. 2021;78(3):591-603.
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Volpe M, et al. Journal of Human Hypertension (2005) 19, 331–339.