• Recognize that hypertension remains a large public health issue in part because of under diagnosis and poor control.
• Understand lifestyle and pharmacologic treatment approaches for control of hypertension.
• Appreciate controversies regarding initial drug choices for treating hypertension.

David A. Calhoun, MD
Associate Professor of Medicine
University of Alabama at Birmingham

The University of Alabama School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The University of Alabama School of Medicine designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

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Hypertension is estimated to affect an estimated 60 million adult Americans, making it the most common chronic disease in the United States. In spite of large initiatives by the American Heart Association and the National Heart Lung and Blood Institute, hypertension remains under-diagnosed, undertreated, and overall, poorly controlled. Based on the most recent National
Health and Nutrition Examination Survey (NHANES), 28.7% of adults have hypertension (receiving antihypertensive medications or >140/90 mm Hg).[1] Of these, 68.9% were aware of having hypertension, 58.4% were receiving treatment, and 31% were controlled. Accordingly, of the 60 million Americans with hypertension, less than one-third are being treated and controlled.

The etiology of hypertension is, in most cases, multifactorial. Strong associated factors include obesity, older age, black race, chronic kidney disease, sleep apnea, and high dietary salt intake. Non-pharmacologic treatment (i.e., lifestyle changes) can be effective in providing significant blood pressure reduction or delay development of sustained hypertension and should be recommended to all patients. Lifestyle strategies include weight loss/control, regular exercise, ingestion of a low salt diet, and ingestion of a high fiber/low fat diet (e.g., the DASH diet).

There has been and continues to be much discussion about drug choice when initiating pharmacologic antihypertensive treatment. Some of these considerations in the case studies, but 2 points should be emphasized. First, there is a consensus among “experts” that the major benefit of any of the classes of antihypertensive agents is blood pressure reduction. That is, no matter how it is accomplished, a hypertensive patient will be better off with a lower blood pressure. There may (or may not) be incremental advantages between the different classes of agents, hence the continuing discussion of preferential drug choice. On an individual basis, however, what is most important is simply beginning a treatment that the patient will likely persist in taking.

Secondly, while it is intellectually stimulating to consider and debate potential advantages between the various classes of agents, the reality is that the large majority of patients will need at least 2 medications to control their blood pressure. In the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), which was a randomized and blinded comparison of different classes of antihypertensive agents as initial therapy, only 20% of participants were controlled on monotherapy.[2] So for most patients with hypertension, which agent is better as initial therapy is an academic consideration as most will need combination therapy to control their blood pressure.

JT is a 38-year-old male who has been checking his blood pressure with automated machines in drug stores. He says those reading have been generally in the 140-160/95-100 mm Hg. He reports feeling well with no specific complaints. He admits to gaining about 30 pounds in the last several years and is not exercising. He describes his diet as regular.

On exam, his weight is 255 pounds (BMI 32 kg/m²). His sitting blood pressure is 158/96 mm Hg and upon repeat is 154/94 mm Hg. His fundi are without lesions. Cardiovascular exam is unremarkable except for a probable S₄ gallop. Extremities are without edema. On biochemical evaluation, his creatinine is 0.9 mg/dL, BUN is 12 mg/dL, potassium is 4.4 mEq/L, and his glucose (non-fasting) is 118 mg/dL.