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 The leading web portal for pharmacy resources, news, education and careers December 12, 2017
Pharmacy Choice - Hypertension Disease State Management - December 12, 2017

Hypertension Disease State Management

New Guidelines for the Treatment of Hypertension

Gina D. Moore, PharmD, MBA


Hypertension is a common disease in the U.S. population. Approximately 46% of adults have hypertension; the prevalence increases to almost 65% in adults over the age of 60.1,2 In May of 2017, the American College of Physicians and the American Academy of Family Physicians issued hypertension treatment guidelines for adults 60 years of age and older, specifically evaluating higher versus lower blood pressure targets. Just recently, the American College of Cardiology (ACC) and American Heart Association (AHA) issued new clinical practice guidelines for all adults, as well as adults with various comorbidities.

These new guidelines now define hypertension as a systolic blood pressure (SBP) greater than 130 or a diastolic blood pressure (DBP) greater than 80 mm Hg, replacing the previous hypertension classification of > 140/90 from in the JNC 7 guidelines.3 These new targets have been defined in response to numerous studies that have demonstrated lowering of blood pressure levels reduce the risk of death from stroke, heart disease, and other vascular disease. High blood pressure is second only to smoking as a modifiable risk factor as a preventable cause of death, and the single most important modifiable risk factor in preventing death from cardiovascular disease (CVD).

Because of these new targets, a great many more adults will be diagnosed with hypertension. The primary treatment approach for all individuals with hypertension include non-pharmacologic interventions; specifically, weight loss in individuals that are overweight or obese, increased physical activity, consumption of heart-healthy meals, limiting sodium intake, increasing potassium intake, and restriction of alcoholic beverages. If a patient is not successful at decreasing their blood pressure levels after three to six months of non-pharmacologic means, or if a patient has an estimated 10-year cardiovascular disease risk greater than 10%, initiation of antihypertensive therapy is indicated. Antihypertensive therapy is also appropriate for patients with stage 2 hypertension, defined as blood pressure values equal to or greater than 140/90 mm Hg.

First-line agents for the treatment of hypertension include thiazide or thiazide-type diuretics (chlorthalidone is preferred based on its longer duration of action and proven reduction of CVD), calcium-channel blockers, angiotensin converting enzyme (ACE) inhibitors, or angiotensin receptor blockers (ARBs). Patients should be reassessed after one month of treatment. If a patient has not achieved desired blood pressure targets, they should be assessed for medication adherence and consideration given to intensification of antihypertensive therapy. Patients who have achieved blood pressure goals should be reassessed within three to six months to ensure they are still at goal.

Treatment of hypertension in older adults (≥65 years of age) to a SBP goal of less than 130 mm Hg is recommended for individuals that are ambulatory and living in the community. For older adults with numerous comorbidities and limited life expectancy, providers are encouraged to utilize a team-based approach, consider patient preferences, and assess risk versus benefit of intensive blood pressure lowering. Most of the evidence from lowering blood pressure in older adults is from studies in which patients presented with moderate to severe hypertension (SBP > 160 mm Hg) and achieved SBP targets with treatment. In adults over age 75, a subgroup analysis showed a non-statistical increase in the incidence of hypotension and syncope treated to SBP targets of less than 120 mm Hg. Older adults do benefit from antihypertensive treatment, but patients should be educated on potential side effects and monitored regularly.

Pharmacists can play a significant role in these new guidelines. Pharmacists in community settings may educate patients on the new blood pressure targets, lifestyle changes, and the importance of medication adherence in minimizing cardiovascular risk. Home blood pressure monitors are an important tool for patients to assess blood pressure values at various times during the day, and to monitor improvements resulting from various pharmacologic and non-pharmacologic interventions. Team-based care is also included in the new guidelines with roles identified for providers, specialists, nurses, dietitians, social workers, community health workers and pharmacists. Pharmacists may participate in patient education and comprehensive medication management, such as identification of medication-related problems, initiating, modifying, or discontinuing medications to address various medication-related problems and to optimize therapeutic outcomes.
References
  1. Yoon SS, Fryer CD, Carroll MD. Hypertension prevalence and control among adults: United States, 2011-2014. NCHS Data Brief no. 220. Hyattsville, MD: National Center for Health Statistics, 2015.
  2. Whelton PK et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2017; e-pub ahead of print.
  3. Chobanian et al. The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report. JAMA 2003;289(19):2560-2572.


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