Hypertension is the world's number 1 public health problem,

according to the World Health Organization

Care credeti ca va fi probabilitatea de a atinge
controlul tensional sub tratament?
70%-80%
60%-69%
50%-59%
<50%
<50%

Correct Answer

Less than 2/3 of hypertensive patients receive treatment.

Of patients who do receive treatment, less than half achieve
control.
Thus, although effective treatment is available, roughly 65% of
persons in the United States are untreated or undertreated.
Treatment of hypertension remains a challenge for clinicians.
One of every 3 Americans, and half of those 60 or older, has
hypertension.
Hypertension effectively doubles or triples the risk of detrimental
cardiovascular outcomes.
HTA confers a greater than 50% lifetime risk of stroke.

Furthermore, hypertension is a common antecedent of chronic

kidney disease and end-stage renal disease, second only to
diabetes.
The risk of heart disease is compounded in patients who have
hypertension and additional risk factors, such as elevated
cholesterol levels, cigarette smoking, diabetes, and left
ventricular hypertrophy.
1

Effective therapy for hypertension has been associated

with:
a 35%-40% reduction in the incidence of strokes,
a 20%-25% reduction in the incidence of heart attacks,
a 50% reduction in the incidence of heart failure.
Lowering blood pressure by 5 mm Hg has been shown to
reduce:
death due to stroke by 14%,
death due to coronary heart disease by 9%, and
death from all causes by 7%.
Bazindu-ne pe potentialul reducerii riscului CV, care ar fi
conditia care ar prioritiza primirea tratamentului
medicamentos?
Hypertension
Diabetes
Both should receive equal priority
Therapeutic lifestyle changes should be prioritized
over medication at this point

Hypertension

Correct Answer

In diabetic patients, tight blood pressure control reduces CV

risk to a greater extent than does tight glucose control.

Among diabetic patients, blood pressure reduction has a

greater impact on cardiovascular risk reduction compared with
tight glucose control.
DM is one of several conditions that compound the risk of
cardiovascular disease in persons with hypertension. Also
shown are the focal points of end-organ damage from
cardiovascular disease.
Hence, the ultimate goal of treatment is to reduce the burden
of cardiovascular complications and end-organ damage related
to the condition.

B., 28 ani, obez, fumator, TA 145/85 mmHg.,

3

Ex. fizic negativ, subiectul este asimptomatic.

Prehypertension

Correct Answer

Prehypertension is not a disease entity but is instead a

designation that identifies individuals at high risk of developing
hypertension.
The Joint National Commission on High Blood Pressure (JNC
7) has defined normal blood pressure as less than 120/80 mm
Hg and has established a new category in blood pressure
staging, prehypertension (systolic blood pressure 120-139 mm
Hg or diastolic blood pressure 80-89 mm Hg). The inclusion of
prehypertension recognizes that hypertension is a spectrum
of disease and an important marker for cardiovascular
disease risk.

What should be the next step for this patient with

prehypertension?
He should be instructed to monitor his blood pressure and
seek treatment if his blood pressure exceeds 140/90 mm Hg.
He should be referred for antihypertensive medication.
He should be informed that his blood pressure level triples
his risk of myocardial infarction and stroke.
He should be referred for aggressive risk factor modification.
What should be the next step for this patient with
prehypertension?
He should be referred for
aggressive risk factor
modification.

Correct
Answer

83
%

Aggressive proactive lifestyle modification is warranted

because cardiovascular risk doubles with each 20/10 mm Hg
increment above normal blood pressure.
The new category of prehypertension is intended to identify
individuals in whom early intervention with lifestyle change
could reduce blood pressure, decreasing the rate of
progression to hypertension. Although prehypertension does
not increase stroke risk, the risk of myocardial infarction is
tripled.
Drug therapy is not recommended for treatment of
prehypertension. However, therapeutic lifestyle modification
strategies such as salt reduction, weight loss, exercise, and
smoking cessation must be aggressively pursued at this stage
to forestall cardiovascular risk.
General guidelines for implementing lifestyle modifications,
and the beneficial effect on systolic blood pressure, are
summarized:

4. A 40-year-old female has returned for a follow-up visit. Three

months ago, she was diagnosed with hypertension and given
an antihypertensive. Diabetes and kidney disease were ruled
out. She is consistently taking her medication and following
recommended lifestyle changes. Her blood pressure is 138/88
mm Hg.
What should be the next step for this patient?
She should be instructed to discontinue her antihypertensive
and continue the lifestyle changes.
She should continue on the present therapy with regular
follow-up.
She should be treated with an additional antihypertensive
until her blood pressure is <120/80 mm Hg (JNC 7 definition of
normal blood pressure).
She should be treated with an additional antihypertensive
until her blood pressure is <130/80 mm Hg for optimal risk
factor reduction.

What should be the next step for this patient?

Your Colleagues
Responded:
She should be
instructed to
discontinue her
antihypertensive and
continue the lifestyle
changes.
She should continue Correc
on the present
t
therapy with regular Answe
follow-up.
r

3%

65%

She should be
treated with an
additional
antihypertensive until
her blood pressure is
<120/80 mm Hg
(JNC 7 definition of
normal blood
pressure).

13%

She should be
treated with an
additional
antihypertensive until
her blood pressure is
<130/80 mm Hg for
optimal risk factor
reduction.

19%

For most hypertensive patients without other compelling

conditions (As discussed in section 13), 140/90 mm Hg remains
an appropriate blood pressure goal.[1,17]
7

The standard blood pressure benchmark, 140/90 mm Hg,

remains the goal of medical therapy for most patients.[1] The
Cochrane Collaboration[18] recommends treating blood pressure
to targets 140-160 mm Hg / 90-100 mm Hg, noting that lower
targets are being evaluated for patients with diabetes and
chronic kidney disease.
Regardless, due to the substantial contribution of blood
pressure to cardiovascular morbidity and mortality, hypertension
must be treated aggressively to these general targets if the
hypertension epidemic and its consequences are to be
reduced.
5. A 66-year-old female is noted with blood pressure 162/70
mm Hg. She takes an angiotensin-converting enzyme
inhibitor (ACEI) and thiazide diuretic combination.
Her blood pressure should be:
Your Colleagues
Responded:
Observed since her
diastolic blood
pressure is
controlled.

2%

Observed since
cardiovascular risk
is conferred
predominately by
the diastolic blood
pressure.

2%

Treated with a third Correc

antihypertensive.
t
Answe
r

90%

Observed since her

diastolic blood
pressure is
controlled and
since
cardiovascular risk
is conferred
predominately by
the diastolic blood
pressure.

6%

Most patients with uncontrolled hypertension exhibit isolated

systolic blood pressure elevation.[19,20] Specific attention to
systolic blood pressure is warranted, because systolic
hypertension is usually the most difficult to control and
disproportionately contributes to risk of adverse cardiovascular
outcomes.[19,21] Furthermore, most persons with hypertension
older than 50 years will reach the diastolic goal once the
systolic goal is achieved.[22]
After age 50, systolic hypertension is most common and is
also the more potent cardiovascular risk factor.[22] The risk of
systolic hypertension is continuous, consistent, and
independent of other risk factors such as hyperlipidemia,
smoking, and diabetes. Compounding the risk is that the
majority of hypertensive patients are not meeting their systolic
blood pressure goal where cardiovascular risk peaks.[13]
6. A 50-year-old male with diabetes and hypertension is
being treated with an ACEI. He is adherent to lifestyle
changes, yet his blood pressure remains elevated at 158/85
mm Hg.
To achieve and maintain target blood pressure goals, blood
pressure treatment will likely require:
Your Colleagues
9

Responded:
More vigorous
adherence to lifestyle
changes such as diet
and exercise but no
additional
antihypertensive
medication.

3%

An additional
antihypertensive
medication.
Two additional
antihypertensive
medications.
More aggressive
glucose control.

30%

Correct
Answe
r

67%

1%

Initiating therapy with more than 1 drug increases the

likelihood of achieving the blood pressure goal, and the
use of multidrug combinations often produces greater
reduction at lower doses of the component agents,
resulting in fewer side effects.[23,24]
Most diabetics with hypertension require 3 or more drugs.
Diuretics, ACEIs, beta blockers, angiotensin-II receptor
blockers (ARBs), and calcium channel blockers have a
demonstrated antihypertensive benefit in both type 1 and
type 2 diabetes.[25-29]
The use of an ACEI or ARB, in conjunction with a low-dose
diuretic, a calcium channel blocker, or a third-generation
beta blockeror some combination of these agentsis
currently seen as the preferred initial therapeutic regimen
for patients with diabetes.[30]
10

In patients with diabetes, blood pressure is often difficult to

control and typically requires multiple agents because of
the pervasive atherosclerotic effect of the disease
throughout the vascular tree.[31] Even hypertensive patients
without diabetes often require multiple medications to achieve
blood pressure goals.[23] Only two-thirds of patients in the
largest published blood pressure trial in the United States[26]
achieved blood pressure targets even though they were treated
with 2 drugs, and recent landmark trials[32] found that a mean of
3 agents was needed to achieve blood pressure targets.
Importance of RAAS as a Therapeutic Target
Successful management of hypertension requires that
clinicians be familiar with the intricacies of cardiovascular
and renal physiology and the basic modes of action of
common antihypertensives. The renin-angiotensinaldosterone system (RAAS) is recognized as the hub of
cardiovascular pathophysiology,[33] and chronic pathologic
RAAS activation and resultant hypertension mediate a variety of
cellular, tissue, and intracellular signaling mechanisms
contributing to end-organ damage. Although RAAS
schematics offer complexity rivaling the Krebs cycle or the
clotting cascade, blood pressure management essentially
requires understanding and manipulating a pressure-flowvolume loop dynamic composed of a pump, a volume
control, and a resistance regulator.
7. A 56-year-old African-American female presents for
routine examination. She has no complaints.
ROS: CV, neuro unremarkable
PMSH: Unremarkable
BP 156/96, P. 72
PE: Normal except trace pedal edema; no other signs of
CHF
U/A: Protein (-)
ECG: NSR
What treatment is recommended according to JNC 7?
11

Your Colleagues
Responded:
An ACEI

10%

An ARB

3%

A beta blocker

4%

A thiazide
diuretic
No medication

Correct
Answer

82%
1%

For most hypertensive patients without a compelling

indication for another class of drug, a diuretic as mono- or
polydrug therapy should be considered as the initial
therapy. This is based on comparative trial data,
availability, and cost.[17] Evidence validates the efficacy of
thiazide diuretics in reducing the cardiovascular morbidity
and mortality outcomes of hypertension.
Thiazide diuretics have consistently reduced blood
pressures and detrimental cardiovascular outcomes such as
myocardial infarction and stroke in clinical trials when compared
with other antihypertensives. Hence, thiazide diuretics serve
as the foundation of JNC medication treatment guidelines.
Hence the recommendation favoring thiazides remains strong.
However, the potential augmentation (or lack of prevention) of
diabetes provides a strong rebuttal to overconfident use of
thiazides.
8. A 52-year-old white male with hyperlipidemia presents
for recheck.
Meds: aspirin, simvastatin, hydrochlorothiazide
ROS: Unremarkable
PMSH: Nonsmoker
12

BP 144/88, P 72, R 16
PE: HRRR, chest clear, pedal edema +
U/A: 1+ protein
Renal panel: BUN 24, Creat 1.6
ECG: Normal

What are the treatment recommendations?

Your Colleagues
Responded:
Stop the
hydrochlorothiazide

2%

Add a beta blocker

4%

Add an ACEI
Stop the
hydrochlorothiazide
and add a beta
blocker

Correct
Answer

89%
6%

ACEIs are superior to beta blockers in stroke reduction.[40]

The inferiority of beta blockers to thiazides, RAAS inhibitors,
calcium channel blockers, and ACEIs in cardiovascular risk
reduction has diminished their use in many hypertensive
patients.[41]
The use of beta blockers has diminished especially for
early and uncomplicated hypertension.[34] Beta blockers
impact every aspect of the vascular pressure-flow-volume loop,
including the RAAS by means of sympathetic tone as well as
the peripheral vasculature.[34] However, their primary impact is
on the pump.[41] Less selective beta blockers may produce
mild peripheral vasoconstriction, which counters the
antihypertensive effect.

13

9. A 62-year-old white male presents status post myocardial

infarction. He lost his discharge prescriptions and restarted his
prehospitalization medications, which included aspirin,
simvastatin, lisinopril, and hydrochlorothiazide.
ROS: (+) DOE (+) PND (1+) pedal edema
PMSH: Nonsmoker
BP 144/88, P 72 R 16
PE: NAD, HRRR, chest clear, trace pedal edema
U/A: 1+ protein
Renal panel: BUN 24, Creat 1.8
ECG: LV dysfunction
What is the treatment recommendation for this patient?
Your Colleagues
Responded:
Stop the ACEI

2%

Add an ARB

6%

Add a beta
blocker
Stop the ACEI and
add a beta blocker

Correct
Answer

87%
6%

Beta-blockers remain a standard of care in hypertensive

patients with angina pectoris, those who have had a
myocardial infarction, and those who have left ventricular
dysfunction with or without heart failure symptoms, unless
contraindicated.[46]
Recommendations regarding beta blockers in primary treatment
of hypertension do not apply to patients who are status post
myocardial infarction or who have congestive heart failure.
It should also be noted that older, less selective beta blockers
provided much of the data on which recent meta-analyses were
14

based. Whether more selective beta blockers will produce

favorable cardiovascular outcomes relative to primary treatment
of hypertension remains to be consistently demonstrated.
10. A 44-year-old white female with hypertension complains of
worsening dyspnea.
Meds: Metoprolol, HCTZ
ROS: Morning cough-clear sputum
PMSH: Smoker No allergies.
BP 142/92 Pulse 60 R 20
PE: HRRR Chest-expiratory wheezing No edema
U/A: 1+ Protein
Renal panel: BUN 12 Creat 0.9 K+ 3.2
Cardiac evaluation: No ischemia
EF: WNL
What is the treatment recommendation?
Your Colleagues
Responded:
Stop the beta
blocker

4%

Stop the thiazide

diuretic

2%

Add an ACEI

9%

Add an ARB

6%

Stop the beta

blocker and add
an ACEI

Correct
Answer

79%

Antihypertensives impacting the RAAS such as ACEIs are

now favored over beta blockers.

15

Drugs that inhibit RAAS activity rival thiazides as a

reasonable first-line therapy in hypertension.[33] The RAAS
has emerged as the fundamental unit of hypertension
pathophysiology as a result of data demonstrating both
blood pressure reduction, favorable cardiovascular
outcomes, and end-organ protection resulting from RAAS
blockade.
The end-organ protective effects of drugs that inhibit
activity in the RAAS system, such as ACEIs and ARBs, are
greater than that predicted by their blood pressure
lowering capacity alone.
Mechanism of Antihypertensive Drug Action Within the
RAAS
There are 2 approved antihypertensive classes that exert
their predominant effect within the RAAS. ACEIs are the
oldest of the RAAS agents and have withstood test of time
and numerous clinical trials. ARBs impact the RAAS at the
level of peripheral tissues.
Each of these agents is intended to reduce the impact of
angiotensin II (AT II). AT II is one of the body's primary
defense mechanisms against hypotension, raising the
blood pressure by exerting potent venous and arterial
vasoconstriction and stimulating aldosterone secretion,
resulting in sodium and water retention.
AT II stimulation of antidiuretic hormone results in further water
retention, and super-stimulation of the sympathetic response
increases myocardial norepinephrine with resultant cardiac
chronotropy and inotropy.[30] Direct stimulation of renin further
reinforces the cycle, and activation of the thirst center in the
pituitary increases blood volume.
When the RAAS remains activated in a noncritical context,
blood pressure increases inappropriately, yielding
endothelial stress with resultant plaque formation and
rupture. Furthermore, AT II stimulation of myocardial
16

growth factor results in cardiac remodeling and left

ventricular hypertrophy predisposing to ventricular
arrhythmias.
11.A 44-year-old Hispanic male presents for recheck. Past
medical history includes myocardial infarction, type 2
diabetes, congestive heart failure, and cerebrovascular
disease with a history of stroke.
Meds: Metoprolol, furosemide, aspirin, simvastatin
ROS: (+) DOE
PMSH: Smoker
BP 142/92 Pulse 60 R 20
PE: HRRR Chest-clear No edema.
U/A: 1+ Protein
Renal panel: BUN 18 Creat 1.9 GFR <60 K+ 3.5
Cardiac evaluation: EF: 35% with diastolic dysfunction
What is the treatment recommendation?
Your Colleagues
Responded:
Add an ACEI

Correct
Answer

80%

Add an ARB

8%

Add a DRI

5%

Add a CCB

3%

Add an
aldosterone
blocker

4%

By virtue of a mechanism of action involving RAAS modulation,

ACEIs are the only antihypertensives effective in all stages of
heart failure, and heart failure is a compelling indication for the
use of an ACEI.
17

Certain comorbid conditions with hypertension represent a

compelling indication for the use of a particular
antihypertensive agent, based on clinical trial data.
Compelling indications for the use of specific subtypes of
antihypertensives include both the high-risk conditions directly
caused by HTA (heart failure, ischemic heart disease, chronic
kidney disease, recurrent stroke) and conditions commonly
associated with hypertension (diabetes, coronary disease risk).
Therapeutic choices in patients with compelling indications
should be directed at both the compelling indication and
the hypertension.
Table 4 provides a list of compelling indications and
recommended antihypertensives.

12.A 48-year-old white male with hypertension and newonset type 2 diabetes presents for recheck.
Meds: Hydrochlorothiazide
ROS: Polyuria
PMSH: No allergies
18

BP 164/106, P 72
PE: Obese, HRRR, chest clear, no edema
U/A: 2+ protein
Renal panel: Na 140, K+ 3.8, BUN 14, Creat 1.7

What is the treatment recommendation?

Your Colleagues
Responded:
Stop the thiazide
diuretic

4%

Add an ACEI
Add an ARB

41%
Correct
Answer

47%

Add a DRI

3%

Add a calcium
channel blocker

5%

In hypertensive type 2 diabetics, ARBs are better tolerated and

are comparable in preventing cardiovascular morbidity and
mortality. Adding an ARB and an ACEI does not bestow
additional benefit over adding an ARB, and the combination is
associated with greater morbidity.

Utility of ARBs in Diabetics With Hypertension

ARBs are ACEI-like drugs that act peripherally on RAAS.
Previously, research on RAAS-inhibiting drugs was
19

predominantly in type 1 diabetics. Subsequently, ARB trials

revealed benefit in hypertensives with type 2 diabetes,
particularly relative to progression of renal disease. We
should also remember that ACEI data in type 2 diabetes are
strong. Substantial cardiovascular outcomes data with the
ARBs have also accumulated in recent years.
Although the ARBs have not proved superior to ACEIs in
cardiovascular mortality and morbidity reduction, they have
demonstrated equivalence and are better tolerated. Due to the
mechanism of action of ARBs, the so-called ACEI cough is not
a significant issue. Recent data also indicates that ACEI-ARB
combination therapy is associated with more adverse events
(particularly hypokalemia) without an increase in benefit. ARBs
are an excellent alternative not only for type 2 diabetics, but
also for hypertensive patients who are intolerant of ACEIs.
13.A 45-year-old female with hypertension presents for
recheck. Past medical history includes type 2 diabetes,
chronic kidney disease and congestive heart failure.
Meds: Hydrochlorothiazide, beta blocker
ROS: Unremarkable
BP 138/88, P 50
PE: Obese, HRRR, chest clear, no edema
U/A: 2+ protein
Renal panel: Na 140, K+ 4.0, BUN 14, Creat 1.9
What is the treatment recommendation?
Your Colleagues
Responded:
Stop the thiazide
diuretic
Add an ACEI or
ARB

2%
Correct
Answer

93%

20

Add a DRI

2%

Add a calcium
channel blocker

2%

Several studies have shown that antihypertensive

regimens containing an ACEI or ARB are more effective in
slowing progression of chronic kidney disease (CKD) than
other antihypertensive regimens.[53-57] The joint
recommendations of the American Society of Nephrology and
the National Kidney Foundation[32] recommend a blood pressure
goal of less than 130/80 mm Hg for all CKD patients. The
guidelines indicate that most patients should receive an ACEI
or an ARB in combination with a diuretic, with many patients
requiring a loop diuretic rather than a thiazide.
14.
A 78-year-old African-American male with hypertension
would likely be more responsive to which agent(s) for
treatment of hypertension?
An ACEI
An ARB
A DRI
A thiazide diuretic
A 78-year-old African-American male with hypertension
would likely be more responsive to which agent(s) for
treatment of hypertension?
Your Colleagues
Responded:
An ACEI

5%

An ARB

3%

21

A DRI
A thiazide
diuretic

4%
Correct
Answer

88%

African Americans are more likely to have low-renin

hypertension, which preferentially responds to diuretics.[35]
Monotherapy with beta blockers, ACEIs, or ARBs lowers
blood pressure to a somewhat lesser degree in African
Americans than in whites.
Antihypertensive Selection in the Elderly
Elderly hypertensives tend to be more responsive to
calcium channel blockers, which are not as dependent on
the RAAS to lower blood pressure.[12]
Elderly hypertensives, as well as patients with low-renin
excretion, are more salt-sensitive and also respond well to
thiazides.[67] Reduction of mortality, stroke, and myocardial
infarction has been demonstrated with thiazides in
hypertensives between the ages of 60 and 80. Treatment of
hypertension beyond age 80 with thiazides retains the stroke
reduction benefit but not the mortality benefit.[68]
As noted previously, cardiovascular risk is conferred
primarily by the systolic blood pressure most prominent in
elderly hypertensives.[13] Fortunately, several landmark
trials have demonstrated reduction in cardiovascular
events in elderly hypertensives not only with thiazides and
calcium channel blockers but also with ACEIs.[69]
Many elderly individuals have widely variable blood pressure
with exaggerated highs and lows. Although slow titration should
be considered in such individuals, the misperception that many
elderly have brittle hypertension has contributed to widespread
inadequacy of drug titration and to poor blood pressure control.
15. A 52-year-old white male with hypertension presents for
recheck. Past medical history includes asthma.
22

Meds: Calcium channel blocker

ROS: WNL
BP 162/102, P 80
PE: HRRR, chest clear, (2+) pedal edema
U/A: Microalbuminuria
Renal panel: Na 140, K+ 4.1, BUN 24, Creat 1.0
ECG: WNL

What is the treatment recommendation?

Your Colleagues
Responded:
Add a thiazide
diuretic

10%

Add furosemide

3%

Add a thiazide
and furosemide

3%

Add an ACEI

Correct
Answer

84%

Combination therapy with a calcium channel blocker and

an ACEI is superior to therapy with an ACEI and a thiazide
for cardiovascular risk reduction.
Combination therapy with a calcium channel blocker and
an ACEI takes advantage of the potency of the calcium
channel blocker in blood pressure reduction while also
blocking the RAAS, yielding both arteriolar and venous
dilation. Recent data indicate the superiority of this
combination over an ACEI and a hydrochlorothiazide in
reducing cardiovascular disease endpoints such as stroke
and myocardial infarction.

23

Calcium channel blockers dilate coronary arteries, which

may explain the superiority of combination therapy with
these agents versus thiazides in reducing cardiovascular
events.
16. A 72-year-old white male presents status post recent
myocardial infarction. His medications include aspirin,
doxazosin, simvastatin, lisinopril, and hydrochlorothiazide.
PMSH: Nonsmoker
ROS: (+) DOE (+) PND
BP 144/88, P 72 R 16
PE: NAD, HRRR, chest clear, (1+) pedal edema
U/A: 1+ protein
Renal panel: BUN 28, Creat 1.8
ECG: Left ventricular hypertrophy
What is the treatment recommendation?
Your Colleagues
Responded:
Stop the alpha
blocker

1%

Stop the ACEI

1%

Add an ARB

3%

Add a beta blocker

11%

Stop the alpha

Correct
blocker and add a Answer
beta blocker

84%

Alpha blockers carry an increased risk of congestive heart

failure,whereas beta blockers are indicated in hypertensive
patients status post myocardial infarction.
Peripheral alpha blockers prevent norepinephrine-induced
vasoconstriction by binding smooth muscle alpha-1
24

receptors surrounding blood vessels. These agents also

relax the prostate gland and were thought to be promising
for hypertensive men with concomitant urinary retention
symptoms.
Mode of Action and Safety of Clonidine
Clonidine is an older centrally acting alpha agonist, which
binds alpha-2 receptors in the brain and inhibits release of
norepinephrine, resulting in decreased sympathetic tone,
decreased cardiac output, and decreased peripheral vascular
resistance.[75] Clonidine use is prominent in accelerated
hypertension[1] and in patients with renal disease because
it has no renal side effects. However, when used long-term,
clonidine should be given with a diuretic because of
accompanying salt and water retention.[75]
17, A 48-year-old female presents for annual evaluation.
She has no complaints.
PMSH: Unremarkable
Meds: None
ROS: WNL
BP 148/96
PE: WNL
Lab: WNL
ECG: WNL
The patient practices relaxation therapy and resists taking
prescription medication. She wants your opinion about treating
her hypertension with red tea, calcium, magnesium, potassium,
coenzyme Q10, and aspirin.
You should prescribe an antihypertensive and inform her
that the following are also effective hypertension
treatment(s):
Your Colleagues
Responded:

25

Relaxation therapy

9%

Red tea and

coenzyme Q10

2%

Calcium,
magnesium,
potassium

4%

Aspirin

4%

None of the above

Correct
Answer

81%

Relaxation therapy, aspirin, red tea, calcium, magnesium,

potassium, and coenzyme Q10 are proven ineffective in
treating hypertension.[76]
Questions often arise regarding treatment of hypertension
with natural agents or stress relief techniques. In addition,
some patients incorrectly perceive that aspirin alone is sufficient
to reduce cardiovascular risk when the blood pressure is high.
Patients should be informed that therapies such as red tea,
calcium, magnesium, potassium, coenzyme Q10, and
relaxation therapy have proven ineffective in treating
hypertension.
White-Coat Hypertension
The JNC 7 guidelines validate ambulatory blood pressure
monitoring,[1] which might assist in diagnosing white-coat
hypertension. Furthermore, blood pressure that does not
drop by 10%-20% during the night signals possible
increased risk for cardiovascular events.[1] Treatment
recommendations for white-coat hypertension remain
ambiguous. However, data are emerging that suggest whitecoat hypertension increases the likelihood of future
hypertension as well as increasing risk of significant
26

cardiovascular disease. At minimum, white-coat hypertension

mandates aggressive risk factor modification by means of
lifestyle changes similar to those recommended for treatment of
prehypertension.[34]
Management of Accelerated Hypertension and
Hypertensive Crisis
Only ACEIs and nitrates have a proven mortality benefit
with accelerated hypertension in the setting of acute
myocardial infarction.[47] Neither immediate nor short-term
beta blockers or calcium channel blockers have
demonstrated a mortality benefit in acute myocardial
infarction.[47] Furthermore, according to the Cochrane
Collaboration,[77] there are not enough data to draw firm
conclusions regarding treatment of blood pressure in acute
stroke. Similar ambiguity is noted with the treatment of a
hypertensive emergency, for which there is no evidence
from randomized controlled trials that antihypertensives
reduce mortality or morbidity in the acute setting. The
benefits and harms of such treatment remain unknown, as
does the best first-line treatment.
Conclusion
Data supporting long-term treatment of hypertension to
appropriate systolic and diastolic therapeutic goals remain
strong. Clinicians must aggressively apply current prevention
and treatment recommendations if the worldwide hypertension
epidemic is to be controlled and incidence of cardiovascular
disease reduced.

27