The following targets are currently recommended for reducing blood pressure:
• in general, less than 140 mm Hg systolic and less than 90 mm Hg diastolic
• for patients with diabetes or chronic kidney disease, less than 130/80 mm Hg
Use Combinations of Medications and Lifestyle Modifications to Achieve Blood Pressure Targets
Most patients require 2 or more drugs to achieve recommended blood pressure targets. Individualization of antihypertensive therapy should always be considered (Table 1). In general, the average reduction in blood pressure with a single blood-pressure-lowering medication is 10/5 mm Hg. Combining medications is therefore to be expected in therapy for hypertension. Using lifestyle modifications can reduce the number and doses of medications required for blood pressure control and should be recommended for all hypertensive patients. The systolic blood pressure target is usually more difficult to achieve; however, the patient’s cardiovascular prognosis is at least as closely associated (if not more closely associated) with systolic blood pressure as with diastolic blood pressure.
Table 1. Considerations in the Individualization of Antihypertensive Therapy
NEW RECOMMENDATIONS FOR 2006
Treatment of Patients with Hypertension
• 6-Blocker therapy remains strongly recommended for hypertensive patients of all ages who have specific indications, such as prior myocardial infarction, angina, or congestive heart failure. New evidence supports the use of ^-blockers as first-line therapy in uncomplicated hypertension only for patients younger than 60 years of age.
• Angiotensin II receptor blockers (ARBs) are recommended after myocardial infarction for patients in whom angiotensin-converting enzyme (ACE) inhibitors are not well tolerated.
• Patients with hypertension who are taking ACE inhibitors and ARBs must undergo monitoring for hypotension, hyperkalemia, and worsening renal failure.
• For patients with diabetes, normal urinary albumin excretion, and hypertension, any of an ACE inhibitor, ARB, dihydropyridine calcium channel blocker, or thiazide diuretic is recommended, with special consideration to the ACE inhibitors and ARBs (given their potential renal benefits).
Diagnosis of Hypertension
It is becoming increasingly evident that blood pressure measured in the office may overestimate or underestimate risk. Accordingly, emphasis is now being placed on home or self-administered blood pressure readings. In the 2006 recommendations, CHEP identified that treated hypertensive patients with masked hypertension (blood pressure controlled in the officebut not at home) should monitor home/self blood pressure regularly because the cardiovascular prognosis for patients with confirmed masked hypertension is similar to that of patients with uncontrolled hypertension.
DELETED 2005 RECOMMENDATION
For patients with proteinuria greater than 1 g/day, the recommendation for a target blood pressure of 125/75 mm Hg has been deleted in 2006. This revision is based on new evidence demonstrating that in patients with proteinuria greater than 1 g/day, a target blood pressure of less than 125/75 mm Hg was not superior to a target of less than 130/80 mm Hg.
As in previous years, it needs to be reiterated that the CHEP hypertension management recommendations are based solely on efficacy data. Considerations relating to individual patient or physician preferences and the cost-effectiveness of different drug classes have notbeen a component of this process and need to be considered by the physician and patient when individualizing therapy.