Question

principles of treatment assignment​

Answer 1

Answer:

1

The objectives of treatment are to control hypertension and prevent the occurrence of cardiovascular diseases due to sustained high blood pressure, thereby reducing mortality. In patients who have already developed cardiovascular disease, treatment is aimed at preventing their progression or recurrence, reducing mortality and improving the quality of life (QOL).

2

Treatment is necessary for all patients with hypertension (blood pressure ⩾140/90 mm Hg) and for those with a blood pressure of ⩾130/80 mm Hg if they have diabetes, chronic kidney disease (CKD) or myocardial infarction. The recommended target for blood pressure control is <130/85 mm Hg in young and middle-aged people. It should be <130/80 mm Hg in those with diabetes mellitus, CKD or myocardial infarction and <140/90 mm Hg in elderly people and patients with cerebrovascular diseases.

3

Antihypertensive treatment consists of lifestyle modifications (step 1) and antihypertensive drug therapy (step 2). Lifestyle modifications include restriction of salt intake and, if the patient is obese, weight control and exercise, restriction of alcohol intake, promotion of fruit and vegetable consumption, restriction of intake of saturated fatty acids and total lipids, and cessation of smoking (see Chapter 4). To prevent hypertension, one has to modify his or her lifestyle. The time of initiating antihypertensive drug therapy should be determined according to the level of blood pressure and the presence or absence of risk factors for cardiovascular disease and organ damage.

4

In principle, antihypertensive drug therapy should be started with a low dose of a long-acting drug once a day. If the dose must be increased, twice-daily administration may be considered. Appropriate combinations of drugs (combination therapy) are recommended to prevent adverse effects and enhance antihypertensive effects. Combination therapy should be considered from the outset for grade II or more severe hypertension.

5

Home blood pressure measurement is useful not only for the diagnosis of white coat hypertension and masked hypertension, but also for evaluating the effectiveness of antihypertensive treatment. It is also important to maintain good patient concordance (adherence) (see Chapter 2). Patients with white coat hypertension should be followed up periodically (every 3–6 months) even without treatment.

6

The QOL of patients with hypertension is affected by physical and psychological problems due to hypertension itself, the effects of antihypertensive drug therapy (including adverse effects) and the doctor–patient relationship.

7

In addition to sufficient communication, information, and consideration of the QOL and adverse effects, reducing the amount and frequency of medication is effective in improving adherence and controlling blood pressure.

8

The attending physician must eventually determine treatment by comprehensively evaluating the results of epidemiological and clinical studies, the clinical background of the patient, the pharmacological actions and cost of antihypertensive drugs, and also the long-term cost-effectiveness of antihypertensive treatment

Answer 2

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• The objectives of antihypertensive treatment are to prevent the occurrence of cardiovascular disease due to damage to the heart and blood vessels caused by sustained high blood pressure, and consequent functional impairment and death. In patients who have already developed cardiovascular disease, treatment is aimed at preventing progression or recurrence, reducing mortality and, thus, helping patients with hypertension to lead their lives as do healthy people.

• The higher the risk of cardiovascular disease, the greater the effect of hypertension treatment.178 The results of randomized case–control comparative studies provide the best scientific basis for evaluating the effects of antihypertensive treatment (lifestyle modifications and drug therapy). However, the effects of antihypertensive drug therapy are often underestimated in randomized case–control comparative studies, and the duration of such studies is only a few years, whereas hypertension is treated over a lifetime. Therefore, the significance of the results of randomized case–control comparative studies is limited.60