Pharmacologic and Nonpharmacolgic Hypertensions

More than 30% of adults in the United States have hypertension, although more of the cases are uncontrolled (35.8 million) than are controlled (31.1 million), according to data from the National Health and Nutrition Examination Survey from 2003 to 2010.¹ Of the people whose hypertension is not controlled, more than half are either unaware they have the condition or are aware but are not receiving treatment.

When people do receive treatment for hypertension, most see immediate benefits. One study found that therapies for the disease led to a 25% reduction in myocardial infarction, a 40% reduction in stroke, and a 50% reduction in congestive heart failure.²

“There’s a big payoff,” said Louis Kuritzky, MD, clinical assistant professor at the University of Florida. “It’s an important payoff.”

Evolution of Treatment

Kuritzky, who spoke at the 2013 Cardiometabolic Risk Summit, discussed the evolution of treatments for hypertension—beginning with peripheral sympatholytics, ganglion blockers, and veratrum alkaloids in the 1940s to renin inhibitors that were approved in recent years. Decades ago, it was assumed that a person’s normal blood pressure could be calculated by adding his or her age and 100. For example, normal blood pressure for someone 50 years of age would be 150.

As healthcare professionals have conducted additional research, Kuritzky said they have found that systolic blood pressure is a better predictor of who will succumb to hypertension than diastolic blood pressure. The normal blood pressure range is <120 mm Hg for systolic blood pressure and <80 mm Hg for diastolic blood pressure.² People with systolic blood pressure from 120 mm Hg to 139 mm Hg or diastolic blood pressure from 80 mm Hg to 89 mm Hg are considered to have prehypertension. 

• Stage 1 hypertension is defined as systolic blood pressure from 140 mm Hg to 159 mm Hg or diastolic blood pressure from 90 mm Hg to 99 mm Hg. 

• Stage 2 hypertension is defined as systolic blood pressure of 160 mm Hg or higher or diastolic blood pressure of 100 mm Hg or higher.

Through the years, research and treatment options have changed considerably. In 1967, the first randomized, double-blind, placebo-controlled study conducted for hypertension included people with diastolic blood pressure from 115 mm Hg to 129 mm Hg.³ If people have those diastolic blood pressure readings now, Kuritzky said, they would immediately be sent to the emergency room.

A randomized, double-blind Systolic Hypertension in the Elderly Program found that after 6 years of treatment with chlorthalidone (a diuretic), patients >60 years of age had a 36% reduction in stroke rate compared with a group that received placebo.⁴

Another trial found that adults with high blood pressure who went on a diet that emphasized fruits, vegetables, and low-fat dairy and also included whole grains, poultry, fish, and nuts had a reduction in blood pressure.⁵ The participants’ diet also contained a small amount of red meat, sweets, and sugared beverages and a reduced amount of total fat, saturated fat, and cholesterol. 

Further, the randomized, double-blind, active-controlled ALLHAT [Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial] study⁶ found that 12.5 mg to 25 mg per day of chlorthalidone, 2.5 mg to 10 mg per day of amlodipine, and 10 mg to 40 mg per day of lisinopril were equally effective at reducing fatal coronary heart disease and nonfatal myocardial infarction. Patients who received chlorthalidone had the best results when it came to the secondary endpoints of fatal and nonfatal stroke, combined coronary heart disease, and combined cardiovascular disease. The trial included 33,357 patients who were at least 55 years of age and had hypertension and 1 or more coronary heart disease risk factors. 

Most people with hypertension require 2 or more medications. The ACCOMPLISH [Avoiding Cardiovascular Events Through Combination Therapy in Patients Living with Systolic Hypertension] trial included 11,506 patients with hypertension who received benazepril and amlodipine or benazepril and hydrochlorothiazide.⁷ After a mean follow-up of 36 months, the combination of benazepril and amlodipine was superior to benazepril and hydrochlorothiazide in reducing cardiovascular events.

Gender-Specific Risks

Jeffrey P. Levine, MD, MPH, professor and director of women’s health programs at UMDNJ-Robert Wood Johnson Medical School, said that cardiovascular disease is the leading cause of death for women and more than the next 3 causes (stroke, lung cancer, and breast cancer) combined. One-third of women die from a cardiovascular event compared with 1 out of every 30 women who die from breast cancer.⁸

However, he said that 75% of trials that examined cardiovascular risk have excluded women. Women also receive less cholesterol screenings, fewer lipid-lowering therapies, less antiplatelet therapy for secondary prevention, less use of heparin, beta-blockers, and aspirin during myocardial infarction, fewer referrals to cardiac rehabilitation, and fewer implantable cardioverter-defibrillators compared with men with the same recognized indications. 

In 2011, the American Heart Association (AHA) released guidelines for the prevention of cardiovascular disease in women.⁹ The AHA defined high-risk as women who have a 10-year risk of at least 10% for all cardiovascular disease and noted that at-risk women should include those with systemic autoimmune collagen-vascular disease and a history of pregnancy-induced complications. 

Levine mentioned that 2 ways to determine cardiovascular risk are the Framingham Risk Score and the Reynolds Risk Score. 

• Framingham Risk Score. This test examines age, systolic blood pressure, diabetes, smoking, total cholesterol, and high-density lipoprotein (HDL) cholesterol. 

• Reynolds Risk Score. This evaluates age, systolic blood pressure, hemoglobin A1c (HbA1c), smoking, total cholesterol, HDL cholesterol, high-sensitivity C-reactive protein, and parental history of myocardial infarction before they were 60 years of age. 

For women younger than 65 years of age, there is a 3.3-fold elevation in the risk of cardiovascular disease if they have low-density lipoprotein cholesterol >160 mg/dL.¹⁰ In addition, women with low HDL cholesterol and elevated triglycerides are at an increased risk. If a woman increases her HDL cholesterol by 1 mg/dL, there is a 3% decrease in coronary heart disease risk.¹¹ 

Women with no history of coronary heart disease are at a higher risk of dying from the condition if they are depressed.¹² Although screening for and treating depression has not been shown to improve clinical outcomes, Levine recommended screening for depression in women with cardiovascular disease because depression can lead to reduced medication adherence.

Barriers to Effective Treatment

Martha M. Funnell, MS, RN, CDE, associate research scientist at the University of Michigan Medical School, said that even if healthcare professionals diagnose cardiovascular disease and prescribe the correct medication, they face challenges. She said that 1 in 3 people in the United States have low health literacy,¹³ which she defined as the capacity to obtain, process, and understand basic information needed to make appropriate health decisions. She added that low health literacy is associated with an increased use of healthcare services, shorter life expectancy, and worse physical and mental health.

Healthcare professionals can help by using simple language to explain their conditions, take the time to define medical terms, highlighting important recommendations, and listen to the patients.  While you cannot motivate another person, healthcare physicians should ask patients to share what is most important to them because people are most likely to adhere to treatments that they care about.

Funnell said that 5% to 15% of adults experience depression, which is associated with type 2 diabetes.^14,15 Patients with diabetes are twice as likely to be depressed and are more likely to have poor self-management, increased healthcare utilization and cost, higher risk of diabetes complications, and greater mortality. 

There are numerous ways to assess if a person is depressed, including the Beck Depression Inventory Scale, the Zung Self-Rating Depression Scale, the Center for Epidemiological Studies Depression, and the PRIME-ED Patient Health Questionnaire. If people are diagnosed with depression, they can benefit from a combination of medications and cognitive behavioral therapy. 

“We have to teach people how to live with this chronic disease,” Funnell said.

Funnell also discussed distress, which she noted is more common than depression. In fact, more than 70% of patients with type 2 diabetes and high distress are not clinically depressed.¹⁶ She defined people in distress as being fearful, frustrated, overwhelmed, anxious, guilty, angry, powerless, and/or discouraged. People with type 2 diabetes and distress are associated with poorer outcomes in HbA1c, diet, and physical activity. To reduce diabetes-related distress, Funnell recommended focusing attention on patients and implementing self-management education and distress-specific interventions. ■

References:

1.Centers for Disease Control and Prevention. Vital signs: awareness and treatment of uncontrolled hypertension among adults—United States, 2003-2010. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6135a3.htm?s_cid=mm6135a3_w. Accessed February 2014.

2.Chobanian A, Bakris G, Black H, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42(6):1206-1252.

3.VA Cooperative Study Group. Effects of treatment on morbidity in hypertension. Results in patients with diastolic blood pressure averaging 115 through 129 mm Hg. JAMA. 1967;202(11):1028-1034.

4.Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA. 1991;265(24):3255-3264.

5.Sacks FM, Svetkey LP, Vollmer WM, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. N Engl J Med. 2001;344(1):3-10.

6.ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heat Attack Trial (ALLHAT). JAMA. 2002;288(23):2891-2997.

7.Jamerson K, Weber MA, Bakris G, et al. Benazepril plus amlodine or hydrochlorothiazide for hypertension in high-risk patients. N Engl J Med. 2008;359(23):2417-2428.

8.Vasan RS, Larson M, Leip E, et al. Impact of high-normal blood pressure on the risk of cardiovascular disease. N Engl J Med. 2001;345:1291-1297.

9.Mosca L, Bejamin E, Berra K, et al. Effectieness-based guidelines for the prevention of cardiovascular disease in women—2011 update. Circulation. 2011;123(11):1243-1262.

10.Carr MC, Kim KH, Zambon A, et al. Changes in LDL density across the menopausal transition.
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11.Maron DJ. The epidemiology of low levels of high-density lipoprotein cholesterol in patients with and without coronary artery disease. Am J Cardiol. 2000;86(12A):11L-14L.

12.Wassertheil-Smoller S, Shumaker S, Ockene J, et al. Depression and cardiovascular sequelae in postmenopausal women. Arch Intern Med. 2004;164(3):289-298.

13.Osborn CY, et al. Clinical Diabetes. 2010;20:171-175.

14.Sharp LK, Lipsky MS. Screening for depression across the lifespan: a review of measures for use in primary care settings. Am Fam Physician. 2002;66:1001-1009.

15.Chen PC, Chan YT, Chen HF, et al. Population-based cohort analyses of the bidirectional relationship between type 2 diabetes and depression.
Diabetes Care. 2012;36:376-382.

16.Skovlund SE, Peyrot M. The Diabets Attitudes, Wishes and Needs (DAWN) program: a new approach to improving outcomes of diabetes care. Diabetes Spectrum. 2005;18(3):136-142.