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Achieving optimal blood pressure goals

Achieving optimal blood pressure goals

Despite the significance Beta-carotene and oral health the problem with respect presure the Acjieving health of the ;ressure, hypertension generally is not Beta-carotene and oral health controlled, and Beta-carotene and oral health few patients Circadian rhythm hormone secretion being adequately treated. Neurology ; Goal blood pressure according to baseline gosls for cardiovascular disease and method of measuring blood pressure. This was a landmark revolution for the clinical management of hypertension, since it changed the therapeutic approach used so far. Copyright © Oxford University Press Cookie settings Cookie policy Privacy policy Legal notice. There is a need for caution regarding the widespread adoption of the lower blood pressure goals supported by the Action to Control Cardiovascular Risk in Diabetes—Blood Pressure ACCORD BP trial. The elderly comprise a growing population of patients with multiple comorbidities, including diabetes.

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Achieving optimal blood pressure goals -

Inform patients that they may be sensitive to the tightening of the cuff on their arm. Ensure standardized technique for measurement of BP see Figure 2 and equipment are being used see Table 1 in Appendix B: Recommended Methods and Techniques for Measuring Blood Pressure.

Table 1: Definition of Hypertension in uncomplicated patients without co-morbidities. Collect personal and family medical history to identify risk factors and potential secondary causes of hypertension See Appendix C: Examples of Secondary Causes of Hypertension.

Refer to Appendix C: Examples of Secondary Causes of Hypertension for more details. It is recommended to be familiar with at least one of the tools to predict CVD risk.

Refer to BCGuidelines. ca: Cardiovascular Disease — Primary Prevention for further information on cardiovascular risk. Once a diagnosis has been confirmed, conduct a patient-centred discussion to agree upon desirable BP readings and an individualized treatment plan.

Engage the patient in committing towards changes in lifestyle to lower their BP and informed decisions on pharmacological interventions. This discussion should consider any benefits and potential harms. ca: Cardiovascular Disease — Primary Prevention and influenced by patient preferences, medication side effects and medication compliance.

Also, the term 'targets' is not used because the treat-to-target approach is not recommended. Recommend health behaviour changes for all patients with hypertension.

The benefits of healthy behaviours such as smoking cessation, decreasing alcohol intake, increasing physical activity, obtaining or maintaining a healthy body composition, eating a well-balanced diet, and monitoring sodium intake has been shown to have clear benefits for high normal, stage I, and stage II hypertensive patients.

Patients in B. can access registered dietitian and exercise physiologist services by calling Patient resources on lowering blood pressure are available through HealthLinkBC - Lifestyle Steps to Lower Your Blood Pressure www.

Additional links for patient resources are available under Practitioner Resources and in ' A Guide for Patients: Diagnosis and Management of Hypertension '. Recent meta-analyses and clinical trials showed pharmacologic treatment in the high-normal group and stage I and stage II group without established CVD and low to moderate CVD risk only minimally reduced the risk of cardiovascular morbidity and mortality and no reduction in all-cause mortality and coronary heart disease.

Table 2. Impact of health behaviours on blood pressure 23 , The aim is to identify salt sensitive patients. b There are no mortality outcome studies of the DASH diet. Pharmacologic management should be considered in addition to lifestyle management if:.

When prescribing, take into account cost of the drug, any potential side-effects and any contraindications. Without specific indications, consider monotherapy or single pill combination with one of the following first-line drugs 32 :.

Among these, thiazide diuretics are the least costly agents. Evidence suggests a non-significant difference in CV events and all-cause mortality between chlorthalidone and hydrochlorothiazide.

Note that alpha-blockers and beta-blockers are no longer considered to be a first-line option. If desirable BP is not achieved with standard-dose monotherapy, use combination therapy by adding one or more of the first-line drugs.

Combination of ACE-I and ARB is not recommended, and caution with combining a non-dihydropyridine CCB i. Long-term effects of weight loss and dietary sodium reduction on incidence of hypertension. Feasibility of treating prehypertension with an angiotensin-receptor blocker.

N Eng J Med ; Physiological aspects of primary hypertension. Physiol Rev ; Role of endothelium-derived nitric oxide in the abnormal endotheliumdependent vascular relaxation of patients with essential hypertension.

Circulation ; Mild high-renin essential hypertension : neurogenic human hypertension? N Engl J Med ; Hyperkinetic borderline hypertension in Tecumseh, Michigan. J Hypertens ;9: Progressive improvement in the structure of resistance arteries of hypertensive patients after 2 years of treatment with an angiotensin I-converting enzyme inhibitor : comparison with effects of a betablocker.

Am J Hypertens ; Comparison of effects of angiotensin I-converting enzyme inhibition and β-blockade for 2 years on function of small arteries from hypertensive patients. Impact of high-normal blood pressure on the risk of cardiovascular disease. Blood pressure usually considered as normal is associated with an elevated risk of cardiovascular disease.

Am J Med ; The association of borderline hypertension with target organ changes and higher coronary risk: Tecumseh Blood Pressure study.

Is low-risk hypertension fact or fiction? Cardiovascular risk profile in the TROPHY study. Prehypertension is associated with insulin resistance state and not with an initial renal function impairment. A Metabolic Syndrome in Active Subjects in Spain MESYAS Registry substudy.

Am J Hypertens ; New-onset diabetes and antihypertensive drugs. British Hypertension Society guidelines for hypertension management BHS-IV : summary. Better blood pressure control : how to combine drugs.

J Hum Hypertens ; Predictors of adverse outcome among patients with hypertension and coronary artery disease. J Am Coll Cardiol ; Integrated approaches to management of hypertension.

Am Heart J ; SS In Kaplan´s Clinical Hypertension. Resolved and unresolved issues in the prevention and treatment of coronary artery disease: a workshop consensus statement.

Am Heart J ; 4 Pt 1 Address for correspondence: Luis M Ruilope Hypertension Unit, Hospital 12 de Octubre Madrid, Spain Email: Ruilope ad-hocbox. Our mission: To reduce the burden of cardiovascular disease. Help centre Contact us. All rights reserved. Did you know that your browser is out of date?

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The coexistence of hypertension and diabetes increases the incidences of CVD and mortality and augments the risks of nephro-pathy and retinopathy 3 — 5.

Given the frequency of the coexistence of diabetes and hypertension in patients and the significant impact both have on cardiovascular risk, management of hypertension is of utmost importance in people with diabetes.

For this reason, several professional societies and groups of experts in the field in recent years have published recommendations for the management of hypertension in people with diabetes.

In this article, we briefly describe the most current recommendations for blood pressure goals and initial therapy options from key organizations involved in the care of patients with diabetes. These recommendations are mostly based on data from meta-analyses, observational studies, and studies that did not set out to treat diabetic hypertension to a certain blood pressure goal.

Thus, there is insufficient evidence to determine the blood pressure cut-point at which the benefits offered by antihypertensive therapy outweigh the related risks.

There is a need for caution regarding the widespread adoption of the lower blood pressure goals supported by the Action to Control Cardiovascular Risk in Diabetes—Blood Pressure ACCORD BP trial.

That trial, which compared the effects of SBP-lowering of versus mmHg, found no difference in primary outcomes between groups, whereas those in the group with the lower SBP goal had an increased incidence of adverse events 6.

The ADA recommendations are based on the ACCORD BP trial that compared CVD outcomes in diabetes patients randomized to intensive versus less intensive blood pressure control 6. Summary of Blood Pressure Goals and Initial Choice of Antihypertensive Agent for Patients With Diabetes Endorsed by Different Professional Societies or Expert Groups.

Suggested for patients who can tolerate the antihypertensive medications necessary to reach this goal. Recommended if hypertension is associated with proteinuria and suggested if hypertension is associated with microalbuminuria as the preferred first-line agent.

The AHA, American College of Cardiology ACC , and multiple other professional societies released joint guidelines for the management of hypertension in 8. The eighth Joint National Committee JNC 8 recommendations have been a major guide to patient management in the primary care setting since they were released in The SBP goal is based on the ACCORD BP trial similar to other current guidelines, as well as other trials that included patients with diabetes such as the Systolic Hypertension in the Elderly Program SHEP and Systolic Hypertension in Europe Syst-Eur trials 12 , The U.

Department of Veterans Affairs VA and Department of Defense DoD also released hypertension guidelines for primary care providers in The Canadian Diabetes Association CDA released guidelines for the management of hypertension in patients with diabetes in The major determinate for the SBP goal cited by the guidelines is the ACCORD BP trial, although the CDA also relied on data from the HOT trial and several meta-analyses.

The European Society of Hypertension ESH and the European Society of Cardiology ESC also released a joint statement on the management of hypertension in patients with diabetes The SBP goal is based mainly on results of the ACCORD BP trial.

Although lifestyle changes, including dietary modifications, weight reduction, increased physical activity, reduction in salt intake, tobacco cessation, and appropriate sleep hygiene, are known to improve metabolic health and reduce blood pressure, pharmacological interventions are frequently required to achieve optimal blood pressure goals in patients with diabetes.

According to the ADA recommendations, first-line therapy should include a drug class with demonstrated cardiovascular benefits such as a renin-angiotensin system RAS inhibitor angiotensin-converting enzyme inhibitor [ACEI] or angiotensin receptor blocker [ARB] , thiazide-like diuretic, or dihydropyridine calcium channel blocker CCB 6 , 19 Table 1.

The authors of this guideline suggest choosing chlorthalidone or indapamide over hydrochlorothiazide. The CDA guidelines suggest that an ACEI or an ARB should be recommended as initial therapy for people with CVD or kidney disease, including those with microalbuminuria, and for those with cardiovascular risk factors Figure 1 summarizes recommendations by professional societies on initiation of an optimal antihypertensive regimen in patients with diabetes.

Pathway to initial antihypertensive therapy in patients with diabetes. BP, blood pressure; UACR, urine albumin-to-creatinine ratio. Little is known regarding whether there are any additional benefits from the initial use of more intensive antihypertensive protocols in patients with diabetes.

The long-term implications of these short-term studies are unknown. Hypertension is a chronic disease, and it is unclear whether rapid blood pressure reduction is of immediate benefit in patients with diabetes and particularly in those who are elderly, have multiple comorbidities including kidney disease, have polypharmacy, or are at risk for orthostatic hypotension.

We suggest that providers use clinical judgment before selecting the intensity of initial antihypertensive therapy in the diabetes population. Current professional guidelines and recommendations for the management of hypertension in patients with diabetes are based on data available from only a few RCTs in patients with type 2 diabetes.

Historically, the clinical benefits of DBP control were the first tested in the diabetes population. In this regard, the strongest evidence was provided by the UKPDS Tight control was associated with reduced risks of important outcomes, including death due to diabetes or stroke.

Achieved DBPs were Among patients with diabetes, intensive treatment was associated with significant declines in major cardiovascular events.

The relatively small diabetes sub-sample and the fact that the analysis of patients with diabetes was not pre-specified limit the strength of this evidence.

Whereas these large studies recruited patients with type 2 diabetes, it is unclear how these data can be generalized to the population with type 1 diabetes.

In subsequent years, clinical interest shifted toward the testing of SBP targets in patients with diabetes. So far, the ACCORD BP trial is the only prospective RCT comparing clinical outcomes of different SBP targets in a population with type 2 diabetes 7. On the other hand, the more intensive group was also limited by an increased rate of adverse events such as hypotension and worsening renal function.

The elderly comprise a growing population of patients with multiple comorbidities, including diabetes. Previous interventional studies tended to exclude older patients with diabetes, limiting generalization of their results to this group of the patients.

Not surprisingly, the majority of professional recommendations do not discuss blood pressure management in the elderly. High prevalence rates of polypharmacy, renal dysfunction, cognitive impairment, and diabetes complications including neuropathy, atherosclerotic vessel disease, and other comorbid conditions in the elderly suggest that, in the absence of outcomes research, we must use caution when providing care to these patients and to do so on an individual basis.

Finally, with the accumulating body of evidence demonstrating the clinical benefits of hypertension control in diabetes, more questions have arisen with regard to the applicability of these research findings to routine clinical care. The ideal scenario of blood pressure measurement undertaken in the research setting consists of an average of two out of three office blood pressure measurements taken with a proper cuff size 1 minute apart after 5 minutes of rest in a quiet area with an automated or semi-automated manometer.

Subjects are seated, with back supported, and bare arm placed at the level of the right atrium. No conversation occurs during blood pressure measurements. However, this ideal scenario is impossible to achieve in the busy and often-crowded clinical setting. Recent research clearly shows that blood pressure measurements taken without the benefit of these ideal conditions are likely to overestimate the actual blood pressure.

Clearly, hypertension management mitigates vascular risks in diabetes. The question, however, is how low we should go with blood pressure reduction to achieve the best therapeutic benefits without significant side effects from antihypertensive therapy.

Nearly one-third of Beta-carotene and oral health in the United States are affected by hypertension, which is a bkood cause of premature death. The optimla of hypertension Performance-enhancing energy solutions is to reduce presxure and morbidity while minimizing harms from medical peessure. Beta-carotene and oral health guidelines recommend Achieving optimal blood pressure goals blood pressure targets, obscuring the risk-benefit ratio. The American Academy of Family Physicians AAFP updated a recent systematic review with a literature review of subsequent studies to recommend blood pressure targets for primary care management of hypertension. Studies in the lower blood pressure target group included target systolic pressures between and mm Hg and diastolic pressures between 65 and 80 mm Hg. Adverse effects increase with more aggressive blood pressure targets. Serious adverse events such as death, disability, and life-threatening complications are not increased with lower targets. Achieving optimal blood pressure goals

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