Tips to Help Patients Manage Hypertension

Appoximately 46% of American adults have hypertension (HTN),¹ and pharmacists see a constant stream of patients with this chronic disease. The treatment goal is for patients to achieve and maintain optimal blood pressure (BP) control to prevent complications such as heart disease, stroke, and kidney failure. Several treatment approaches have proven effective.²

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Identifying patients with HTN is the first step. HTN is a silent disease and failure to diagnose it early leads to complications later. The American Heart Association recommends screening all adults older than 40 years with normal BP (< 120/80 mm Hg) at least once annually, and younger adults should be screened at least once every 2 years.^3,4 With BP monitoring devices ubiquitous in pharmacies and other health care locations, screening is easier than ever. By simply asking patients if they’ve checked their BP lately, pharmacists can prompt them to self-screen. Pharmacists should also screen patients with HTN for other cardiovascular risk factors, such as diabetes, smoking, and elevated lipid levels.

Once HTN diagnosis is made, patients need to be stratified by risk level (Table 15). Older age, ethnicity, family history, and lifestyle factors (eg, smoking and physical activity) can increase risk, and as risk increases, treatment needs to be more aggressive.²

Lifestyle modifications are also essential (Table 2^2,6-10) and may be effective alone for individuals with prehypertension, defined as a systolic BP of 120 to 139 mm Hg or a diastolic BP of 80 to 89 mm Hg.

Medication is often necessary, however, and therapy with a single drug may be sufficient for patients with stage 1 HTN.^3,5 Thiazide diuretics are usually the first-line medication class for HTN and rarely cause adverse effects. By increasing the amount of urine produced and excreted by the kidneys, diuretics decrease blood volume and lower BP. Clinicians should monitor patients taking thiazide diuretics for hypokalemia, hyperuricemia, gout, and orthostatic hypotension.^3,5

Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) are effective medications for hypertension treatment. Clinicians often prescribe them for patients with underlying heart disease, diabetes, or kidney disease. ACE inhibitors block the conversion of angiotensin I to angiotensin II, decreasing BP and reduc-ing sodium and fluid retention. ARBs block angiotensin II, decreasing BP and improving blood flow. ACE inhibitors and ARBs are usually well tolerated but may cause cough, dizziness, and hyperkalemia.^3,5

Calcium channel blockers and β-blockers are also effective. Calcium channel blockers block the entry of calcium into cardiac and vascular cells, decreasing BP and improving blood flow. β-blockers halt adrenaline’s action on the heart, decreasing BP and heart rate. Both classes may cause dizziness, fatigue, and gastrointestinal disturbances.^2,3,5 Once the BP exceeds 20/10 mm Hg above the target BP level, combi-nation therapy may be advised with 2 drugs, such as ACE inhibitors, ARBs, or calcium channel blockers with thiazide diuretics.^2,3,5 Prescribers should individualize the drugs in combination therapy based on the patient’s needs, tolerability, and potential adverse effects, particularly with drugs associated with electrolyte disturbances.^2,3,5 Encouraging medication adherence is a proven, effective way to promote a healthy BP. Pharmacists should suggest medication synchronization, pill reminder devices, and automatic refills for patients who have trouble with adherence. The guidelines recommend using combination pills when possible to improve adherence and reduce the patient’s pill burden.² Educating patients about the risks of HTN and the benefits of taking prescribed medications also improves adherence.

Finally, regularly monitoring BP levels is crucial, especially as HTN progresses.^3,4 Patients with stage 1 hypertension should have their BP monitored every 3 to 6 months until they reach their target BP, and those with stage 2 hypertension should have their BP checked monthly until the target is achieved. Clinicians should monitor BP in patients on combination therapies, older adults, those with comorbidities, or those with resistant hypertension.^3,4

CONCLUSION

HTN management is different for every patient. Pharmacists should remember the 5 underpinnings for patients with HTN: implement lifestyle modifications, initiate single-drug therapy, adopt combination therapy, adhere to medication, and monitor BP levels regularly. Reducing HTN reduces hypertension-associated morbidity and mortality.

References

1. Estimated Hypertension Prevalence, Treatment, and Control Among US Adults. Million Hearts. Updated May 12, 2023. Accessed May 30, 2023. https://millionhearts.hhs.gov/data-reports/hypertension-prevalence.html
2. Whelton PK, Carey RM, Aronow WS, et al. A Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/Amer-ican Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018;171:e127-e248. doi:10.1161/HYP.0000000000000066
3. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summa-ry: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;140(11):e563-e595. Published correction appears in Circulation. 2019;140(11):e-647-e648.
4. Heart-Health Screenings. American Heart Association. Updated March 22, 2019. Accessed May 30, 2023. https://www.heart.org/en/health-topics/con-sumer-healthcare/what-is-cardiovascular-disease/heart-health-screenings
5. Williams B, Mancia G, Spiering W, et al; ESC Scientific Document Group. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J. 2018;39(33):3021-3104. Published correction appears in Eur Heart J. 2019;40(5):475.
6. Whelton PK, Kumanyika SK, Cook NR, et al. Efficacy of nonpharmacologic interventions in adults with high-normal blood pressure: results from phase 1 of the Trials of Hypertension Prevention. Trials of Hypertension Prevention Collaborative Research Group. Am J Clin Nutr. 1997;65(suppl 2):652S-660S. doi:10.1093/ajcn.65.2.652S.
7. Effects of weight loss and sodium reduction intervention on blood pres-sure and hypertension incidence in overweight people with high-normal blood pressure. The Trials of Hypertension Prevention Collaborative Research Group. Arch Int Med. 1997;157(6):657-667.
8. Whelton PK, Appel LJ, Espeland MA, et al. Sodium reduction and weight loss in the treatment of hypertension in older persons: a randomized controlled trial of nonpharmacologic interventions in the elderly (TONE). TONE Collaborative Research Group. JAMA. 1998;279(11):839-846. doi:10.1001/jama.279.11.839.
9. Huang L, Trieu K, Yoshimura S, et al. Effect of dose and duration of reduction in dietary sodium on blood pressure levels: systematic review and meta-analysis of randomised trials. BMJ. 2020;368:m315. doi:10.1136/bmj.m315
10. Filippini T, Malavolti M, Whelton PK, Naska A, Orsini N, Vinceti M. Blood pressure effects of sodium reduction: dose-response meta-analysis of experimental studies. Circulation. 2021;143(16):1542-1567. doi:10.1161/CIR-CULATIONAHA.120.050371