Hypertension and Hypertensive Heart Disease

Contents

Foreword xi

Michael H. Crawford

Preface: Hypertension and Hypertensive Heart Disease xiii

George A.Mensah

Pathogenesis and Clinical Physiology of Hypertension 545

Mukesh Singh, GeorgeA.Mensah, andGeorge Bakris

Significant advances have been made in understanding the pathogenesis and clin-ical physiology of primary hypertension. This article presents an overview of thephysiology of normal blood pressure control and the pathophysiologic mechanismsthat predispose individuals and populations to primary hypertension. The role ofgenetics, environment, and the gene-environment interaction is discussed. Thespectrum of changes in physiologic states that result in chronic increases of arterialblood pressure are reviewed. The nature and characteristics of feedback loops andthe primary modulating systems, the central and peripheral nervous systems, andcirculating and tissue hormones are reviewed. The role of the endothelium of theartery and its production of endothelin, nitric oxide, angiotensin II, as well as othervasoactive substances in response to various stimuli, is also discussed. A unifyingpathway for the development of hypertension and the practical implications forthe prevention and control of hypertension are discussed.

Prehypertension: An Opportunity for a New Public Health Paradigm 561

BrentM. Egan, Daniel T. Lackland, andDaniel W. Jones

From 2005 to 2006, approximately 3 of 8 adults in the United States had blood pres-sure (BP) in the prehypertensive range of 120 to 139/80 to 89mmHg and roughly 1 in8 adults had BP in the range of 130 to 139/85 to 89 mm Hg, which is referred to ashigh normal BP or stage 2 prehypertension. Adults with stage 2 prehypertension arealso roughly twice as likely as adults with normotension to suffer cardiovascular dis-ease. The Seventh Report of the Joint National Committee on Hypertension recom-mended only lifestyle changes for most prehypertensive patients. BP in the range of120 to 129/80 to 84 mm Hg is also associated with increased risk but roughly half ofthat of stage 2 prehypertension.

Principles and Techniques of Blood Pressure Measurement 571

GbengaOgedegbe and Thomas Pickering

Although the mercury sphygmomanometer is widely regarded as the gold standardfor office blood pressure measurement, the ban on use of mercury devices con-tinues to diminish their role in office and hospital settings. To date, mercury deviceshave largely been phased out in United States hospitals. This situation has led to theproliferation of nonmercury devices and has changed (probably forever) the prefer-able modality of blood pressure measurement in clinic and hospital settings. In thisarticle, the basic techniques of blood pressure measurement and the technicalissues associated with measurements in clinical practice are discussed. The devicescurrently available for hospital and clinic measurements and their important sources

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of error are presented. Practical advice is given on how the different devices andmeasurement techniques should be used. Blood pressure measurements in differ-ent circumstances and in special populations such as infants, children, pregnantwomen, elderly persons, and obese subjects are discussed.

Initial Clinical Encounter with the Patient with Established Hypertension 587

UchechukwuK.A. Sampson andGeorge A.Mensah

The initial encounter with the patient with hypertension presents the opportunity toreprogram the trajectory of overall cardiovascular risk in the patient with suspectedor established hypertension. The practicing clinician should strive to recognize otherimportant considerations beyond drug prescription and treatment guidelines, suchas the patient’s level of health literacy, social and economic implications of lifelongdrug therapy and health care costs, and readiness for and effectiveness of patientself-management. This should be followed by delivery of patient education that isappropriate for literacy level. Self-monitoring should be a tool to engage patientsin active participation. Comprehensive risk stratification should be encouraged inall patients. Careful clinician adherence to established practice guidelines in overallrisk assessment and treatment and control of blood pressure to target levels remaincrucial.

Management of High Blood Pressure in Children and Adolescents 597

Rae-EllenW. Kavey, Stephen R. Daniels, andJosephT. Flynn

Hypertension in childhood is now recognized to be a common and serious problemwith a prevalence of 2% to 5%. Large epidemiologic studies have established nor-mative tables for blood pressure beginning in early childhood based on age, gender,and height. Making a diagnosis of hypertension in a child or adolescent identifies anindividual at increased risk for early-onset cardiovascular disease who requires spe-cific treatment. Routine blood pressure measurement is recommended at everyhealth care encounter beginning at 3 years of age, but often this is not being accom-plished. This measurement is especially important in relation to the obesity epi-demic, because approximately one-third of obese children have high bloodpressure. Hypertension can be effectively managed with effective lifestyle changeand medication when necessary.

Treatment and Control of High Blood Pressure in Adults 609

George A.Mensah andGeorge Bakris

Hypertension and prehypertension are major public health challenges. Preventionand control of prehypertension through lifestyle changes and the treatment of hyper-tension to goal blood pressure (BP) are important objectives. In most patients, 2 ormore medications with complementary mechanisms of action should be used incombination. Referral for evaluation of resistant hypertension should be madewhen goal BP is not attained while patients are adherent on 3 or more appropriatelydosed antihypertensive medications, including a diuretic. There are compelling indi-cations for the use of specific drugs in patients with underlying ischemic heartdisease, chronic heart failure, diabetes, chronic kidney disease, stroke, peripheralarterial disease, left ventricular hypertrophy, obesity, and metabolic syndrome.Adverse drug effects should be identified early and managed promptly to addresspatient safety and adherence. Other factors that affect adherence include thepatient’s health literacy level and ability to self-manage. The social, environmental,cultural, and financial sources of support in care must be addressed to achievethe full benefits of treatment and control of hypertension and prehypertension.

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Hypertension in Special Populations: Chronic Kidney Disease, Organ Transplant Recipients,Pregnancy, Autonomic Dysfunction, Racial and Ethnic Populations 623

JohnM. Flack, Keith C. Ferdinand, Samar A. Nasser, andNoreen F. Rossi

The benefits of appropriate blood pressure (BP) control include reductions in pro-teinuria and possibly a slowing of the progressive loss of kidney function. Overall,medication therapy to lower BP during pregnancy should be used mainly for mater-nal safety because of the lack of data to support an improvement in fetal outcome.The major goal of hypertension treatment in those with baroreceptor dysfunction isto avoid the precipitous, severe BP elevations that characteristically occur duringemotional stimulation. The treatment of hypertension in African Americans optimallyconsists of comprehensive lifestyle modifications along with pharmacologic treat-ments, most often with combination, not single-drug, therapy.

Resistant Hypertension, Secondary Hypertension, and Hypertensive Crises: DiagnosticEvaluation and Treatment 639

Maria Czarina Acelajado andDavid A. Calhoun

Hypertension is a very common modifiable risk factor for cardiovascular morbidityand mortality. Patients with hypertension represent a diverse group. In addition tothose with primary hypertension, there are patients whose hypertension is attribut-able to secondary causes, those with resistant hypertension, and patients who pres-ent with a hypertensive crisis. Secondary causes of hypertension account for lessthan 10% of cases of elevated blood pressure (BP), and screening for these causesis warranted if clinically indicated. Patients with resistant hypertension, whose BP re-mains uncontrolled in spite of use of 3 or more antihypertensive agents, are atincreased cardiovascular risk compared with the general hypertensive population.After potentially correctible causes of uncontrolled BP (pseudoresistance, second-ary causes, and intake of interfering substances) are eliminated, patients with trueresistant hypertension are managed by encouraging therapeutic lifestyle changesand optimizing the antihypertensive regimen, whereby the clinician ensures thatthe medications are prescribed at optimal doses using drugs with complementarymechanisms of action, while adding an appropriate diuretic if there are no contrain-dications. Mineralocorticoid receptor antagonists are formidable add-on agents tothe antihypertensive regimen, usually as a fourth drug, and are effective in reducingBP even in patients without biochemical evidence of aldosterone excess. In thesetting of a hypertensive crisis, the BP has to be reduced within hours in the caseof a hypertensive emergency (elevated BP with evidence of target organ damage)using parenteral agents, and within a few days if there is hypertensive urgency, usingoral antihypertensive agents.

Patient Self-Management Support: Novel Strategies in Hypertension and Heart Disease 655

Hayden B. Bosworth, Benjamin J. Powers, and Eugene Z. Oddone

Cardiovascular diseases (CVDs) have become the leading cause of death anddisability in most countries in the world. This article addresses how patient self-man-agement is a crucial component of effective high-quality health care for hypertensionand CVD. The patient must be a collaborator in this process, andmethods of improv-ing patients’ ability and confidence for self-management are needed. Successfulself-management programs have often supplemented the traditional patient-physi-cian encounter by using nonphysician providers, remote patient encounters(telephone or Internet), group settings, and peer support for promoting self-manage-ment. Several factors need to be considered in self-management. Given the healthcare system’s inability to achieve several quality indicators using traditional office-based physician visits, further consideration is needed to determine the degree to

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which these interventions and programs can be integrated into primary care, theireffectiveness in different groups, and their sustainability for improving chronic dis-ease care.

The Role of Diets, Food, and Nutrients in the Prevention and Control of Hypertensionand Prehypertension 665

Michelle L. Slimko andGeorge A.Mensah

Hypertension is the leading risk factor for death worldwide, even surpassing tobaccouse, high blood glucose, high blood cholesterol, and obesity. Globally, the estimatedprevalence of hypertension is nearly 1 billion persons with an annual mortality ofalmost 7.5 million deaths. In the United States, hypertension affects an estimated65 million Americans, and is the leading risk-factor cause of death in women andonly second to tobacco use as a contributory cause of death in men. Multiple sour-ces of data from prospective observational, cohort, and randomized controlledclinical trials show that hypertension and its complications are highly preventablewhen the raised blood pressure is prevented, or treated and controlled. To promotepositive behavior change and create a broader impact on public health, it hasbecome necessary to leverage multilevel stakeholders such as all health care pro-viders, researchers, policy makers, schools, the food industry, and the generalpublic to drive policy changes and future innovation from research and developmentendeavors, and to emphasize the importance of diet-related lifestyle modificationsto effectively prevent and control hypertension and prehypertension.

Prevention, Diagnosis, and Treatment of Hypertensive Heart Disease 675

Vasiliki V. Georgiopoulou, Andreas P. Kalogeropoulos, Paolo Raggi, and Javed Butler

Hypertensive heart disease (HHD), a result of long-standing hypertension, is charac-terized by changes in the myocardial structure and function in the absence of otherprimary cardiovascular abnormalities. Although increased blood pressure is theinitiating stimulus, neurohormonal factors, particularly the renin-angiotensin system,play a key role in remodeling of cardiac chamber geometry and walls. Optimal anti-hypertensive therapy in the setting of therapeutic lifestyle changes is crucial in theprevention and control of HHD. Regression of left ventricular hypertrophy (LVH) isachievable and associated with improved prognosis. However, prevention of myo-cardial remodeling before LVH establishes would further increase the benefits tocardiac function and prognosis. Antihypertensive agents exhibit variable effective-ness in inducing LVH regression. Currently, renin-angiotensin system blockingagents seem to be the most effective approach for LVH regression and reverseremodeling in these patients.

Index 693