In an APhA2019 educational session titled “Managing Complex Patients and Hard-to-Control Hypertension,” co-presenters Joseph Saseen, PharmD, BCPS, BCACP, professor and vice chair, University of Colorado, and Cory P. Coffey, PharmD, BCACP, clinical pharmacy specialist–ambulatory care, The Ohio State University Wexner Medical Center, analyzed recent changes in hypertension definitions (now <130/80 mm Hg for most patients) and treatment goals. The experts also covered the evaluation principles for complex cases, and the adverse events and difficulties that impart cardiovascular risk in patients with hypertension.
The presenters explored the types and causes of resistant hypertension, offering logical steps to address the road barriers to treatment success. They described recommendations from the newest American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the treatment of patients with hypertension. In addition, they examined recent evidence assessing the efficacy of different blood-pressure goals in hypertensive patients who present with and without comorbid conditions.
When the revised ACC/AHA guidelines were released, said Dr. Saseen, the “headlines were that ‘blood pressure goals were lower,’ and that was the truth. We do not have a prehypertension category any longer; that was replaced with something called elevated blood pressure. Overall,” Saseen added, “there was a shifting down of blood pressure goals.”
Specifically, he said, “Anything that is 130/80 mm Hg or higher is now stage 1 hypertension. The big question is, does this apply to all patients? The general answer is yes, even older patients,” he said. “A lot more patients will be diagnosed with hypertension.”
Turning to hard-to-treat hypertension, Dr. Saseen related that the AHA Scientific Statement currently employs several criteria to define resistant hypertension. This include patients not at their goal blood pressure goal despite concurrent use of three antihypertensive drug classes, commonly including a long-acting calcium channel blocker, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and a diuretic; patients at maximum or maximally tolerated daily doses; and patients at their blood pressure target on four or more antihypertensive medications.
In general, the presenters said that adding a mineralocorticoid receptor antagonist and optimizing diuretic therapy are recommended strategies for resistant hypertension. However, certain patient populations, the presenters noted, are especially at risk for hypertension and may require unique regimens, including patients with heart failure (HF). The presenters described appropriate medication regimens for the treatment of hypertension in these patients, stressing that managing hypertension in patients with HF should be done through guideline-directed medical-therapy optimization.
Keying in on another special hypertension challenge, the presenters addressed high blood pressure following kidney transplantion, a common comorbidity in this patient population due to the use of immunosuppressive medications. In addition, they said, up to 90% of calcineurin inhibitor–based regimens are associated with elevated blood pressure.
Yet another special patient population, renal transplant recipients, is susceptible to hypertension. After kidney transplantation, it is reasonable to treat patients with hypertension to a blood-pressure goal of less than 130/80 mm Hg. Following renal transplantion, calcium antagonists, the presenters said, are the current drugs of choice.
With regard to treating hypertension in the growing geriatric population, the experts cautioned about the initiation of two antihypertensives simultaneously to manage hypertension in frail, older adults.
Despite the availability of newer medications and knowledge gained through clinical trials, traditional approaches retain therapeutic value. “Let’s not forget lifestyle modifications, such as exercise and weight loss,” said Dr. Saseen. “These are probably underemphasized by most clinicians, but they are nonetheless class I recommendations.”
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