All About Hypertension Treatment

Treating High Blood Pressure

Woman wearing blood pressure gauge
Joseph Rene Briscoe/Photolibrary/Getty Images

If you have been diagnosed with hypertension, or high blood pressure, it is important for you and your doctor to establish a reasonable goal for treatment, and then take the necessary steps to achieve that goal.

Keep in mind that, most often, achieving your blood pressure goal will only be accomplished after a series of steps — one step at a time. After each step, you and your doctor will determine whether the goal — reaching your "target" blood pressure without significant side effects — has been achieved.

Setting Treatment Goals

The treatment goals for treating hypertension have changed over time, and in fact have been a little bit controversial. But in 2017, the major medical societies collectively published consensus guidelines on diagnosing and treating hypertension. For the most part, doctors are now on the same page.

The goal of treating hypertension is to reduce the systolic blood pressure to less than 130 mmHg, and the diastolic pressure to less than 80 mmHg. The goal remains the same for anyone with hypertension, regardless of age.

Nonetheless, treatment goals do sometimes have to be individualized. For instance, some elderly people with primarily systolic hypertension may become lightheaded with aggressive antihypertensive therapy. In fact, prior to 2017 the treatment goal for such people was to aim for a systolic pressure of below 140, or even 150, mmHg. More recent data from clinical trials indicates that a goal of less than 130 mmHg yields better outcomes in even elderly people, and the 2017 guidelines were changed to reflect that new information.

Still, for some older people the lower goal may still prove to be too aggressive, so some individuals may have different treatment targets.

Do You Have Essential or Secondary Hypertension?

Your hypertension treatment, first of all, will be based on whether your high blood pressure is being caused by a specific underlying medical condition (that is, secondary hypertension), or whether you are in the vast majority of patients with essential hypertension (in which there is no specific underlying cause).

If you have secondary hypertension, the main approach to treatment likely will be to treat the underlying cause.

So, for the rest of this discussion we will assume you have the far more common essential hypertension.

Typical Treatment Steps For Essential Hypertension

The initial treatment for hypertension often depends on the "stage" of your hypertension, which is determined by your systolic and diastolic blood pressure.

• Stage 1 hypertension: systolic 130 - 139 mmHg, OR diastolic 80 - 89 mmHg

• Stage 2 hypertension: systolic greater than 140 mmHg, OR diastolic greater than 89 mmHg

In addition, a systolic blood pressure of 120 mmHg or higher (but less than 130 mmHg) is considered to be prehypertension. Prehypertension indicates a somewhat increased cardiovascular risk, but is not considered a condition that warrants antihypertensive drug therapy. Instead, lifestyle changes are recommended to reduce risk.

Lifestyle Changes

If your hypertension is relatively mild (Stage 1 hypertension), your doctor may begin by advising lifestyle changes. Lifestyle changes that may help to reduce your blood pressure include:

• Adopting a diet for hypertension

• Adopting salt restriction

• Adopting a regular exercise program

• Quitting smoking

If you are successful at adopting these lifestyle changes but your blood pressure still has not reached your goal (or if you are a more typical human, and your efforts at diet and exercise still fall somewhat short of what the experts recommend) your doctor will recommend drug treatment for hypertension.

Drug Therapy

Five major classes of medications are used to treat hypertension:

• Thiazide diruetics

• ACE inhibitors

• Calcium blockers

• Beta blockers

• Angiotensin receptor blockers, ARBs

Several specific drugs have been marketed for hypertension within each of these classes, and several prescription medications contain a combination of these drugs.

Here is a reasonably complete list of the many specific prescription drugs now available for treating hypertension.

If you have Stage I hypertension, the odds are good that your blood pressure can be brought to target levels with a single drug. If you have Stage 2 hypertension, single drug therapy less likely to be effective enough, and your doctor may want to begin right away with a combination of drugs.

If single drug therapy (or monotherapy) is chosen, it appears best to begin with either a thiazide diuretic (usually chlorthalidone or hydrochlorothiazide), a long-acting calcium blocker, or an ACE inhibitor. (ARBs can be used instead of an ACE inhibitor if the ACE inhibitor is poorly tolerated). Young patients often respond well to ACE inhibitors; black patients and elderly patients tend to do better with thiazide diuretics or calcium channel blockers. Beta blockers are usually a poor choice for monotherapy.

If the first try at monotherapy is insufficiently effective or poorly tolerated, switching to another single drug, and then to a third if necessary, is generally recommended as the next step.

If three or more attempts at monotherapy have not worked well enough, the next step is to try combination therapy with two or more drugs. While numerous combinations are possible, recent evidence suggests that using a calcium blocker together with an ACE inhibitor or ARB may be the most effective and best tolerated combination. Most doctors will now try this combination first, even if the monotherapy was with a thiazide diuretic.

With these step-wise maneuvers, the large majority of patients with hypertension will reach their target blood pressure levels with minimal side effects. Keep in mind that finding successful therapy for hypertension often requires several weeks or months, and several drug trials. But it is important for you to stick with the program. Getting your blood pressure to target levels, and keeping it there, will give you a very large payout for your efforts -- a greatly reduced risk of heart attack and stroke.

Sources:

Law, MR, Morris, JK, Wald, NJ. Use Of Blood Pressure Lowering Drugs In The Prevention Of Cardiovascular Disease: Meta-Analysis Of 147 Randomised Trials In The Context Of Expectations From Prospective Epidemiological Studies. BMJ 2009; 338:b1665.

Staessen, JA, Wang, JG, Thijs, L. Cardiovascular Prevention And Blood Pressure Reduction: A Quantitative Overview Updated Until 1 March 2003. J Hypertens 2003; 21:1055.

Continue Reading