Blood Pressure Thresholds and Targets for Pharm Therapy

Population	Threshold	Target
Macrovascular disease	140/90	<140/90
Diabetes	130/80	<130/80
High risk (SPRINT)	SBP 130 and other risk factors (see below)	SBP < 120
PKD	HALT-PKD population	SBP < 95-110
Non-SPRINT CKD		SBP < 140
History of spontaneous ICH		<130/80

Pharmacotherapy

First-Line Therapy

• Single-Pill Combinations (SPCs):
  • ACEi + CCB preferred.
  • ARB + CCB
  • ACE/ARB + diuretic
• Diuretics: long-acting TDs (chlorthalidone, indapamide) preferred over HCTZ
• ACE/ARB
• Long-acting CCB
• Beta-blockers (if young or with CVD)

Second-Line Therapy

• add on drugs from the first-line choices:
  • thiazide + DHP-CCB
  • DHP-CCB + ACEi
• avoid:
  • ACE + ARBC
  • Dilt/verapamil + Beta blocker

Specific Population Therapies

Population	Recommendations
Diabetes	ACE/ARB (especially with albuminuria or CKD), DHP-CCB, thiazide. If combination therapy with ACEi is needed, a DHP-CCB is preferred over a thiazide.

Lifestyle Interventions

Intervention	Recommendation
Exercise	30-60 minutes, moderate intensity, 4-7 days weekly
Weight	BMI 18.5-25, waist circumference <102 cm (M) <88 cm (F) for HTN prevention
Alcohol	Abstain from alcohol
Diet	DASH diet
Salt intake	<5 grams daily, <2 grams sodium
Potassium supplementation	Consider if not at risk of hyperK
Stress reduction	CBT, relaxation, etc.
Smoking cessation	Pharmacotherapy + counselling
Ca++/Mg++ supplementation	None

Major Hypertension Trials

SHEP (1991)

DASH (1997)

ALLHAT (2002)

RCT to determine whether the occurrence of fatal CHD or nonfatal myocardial infarction (MI) is lower for high-risk patients with hypertension treated with amlodipine, lisinopril, doxazosin, or chlorthalidone.

Upon analysis of the data, the primary outcome, fatal coronary artery disease or nonfatal MI at 6 years, was similar among all groups. There was also no significant difference in all-cause mortality, a secondary outcome, among the groups. - When comparing amlodipine with chlorthalidone, the amlodipine group had a 38% higher risk of heart failure (HF) (P<.001) and a 35% higher risk of hospitalized/fatal HF (P<.001). - When comparing lisinopril with chlorthalidone, the lisinopril group had a 15% higher risk for stroke (P=.02), a 10% higher risk of combined cardiovascular disease (CVD) (p<0.001), a 19% higher risk of HF (P<.001), and an 11% higher risk of hospitalized/treated angina (P=.01).

As a result, the authors of the study concluded that thiazide-type diuretics are superior in preventing CVD and recommended that they be preferred for first-step antihypertensive therapy. Because of results from the study, the JNC 7 hypertension guidelines recommended that diuretics should be initiated in stage I hypertension.

ACCOMPLISH (2008)

In patients with hypertension at high risk for cardiovascular complications, the combination of benazepril-amlodipine is superior to benazepril-hydrochlorothiazide in reducing cardiovascular events.

ACCORD (2010)

In diabetic, is SBP < 120 better than < 140? No significant difference in mortality, total CV events, or renal protection.

SPRINT (2015)

Among patients at high risk for cardiovascular events but without diabetes, intensive blood pressure control to a target SBP <120 mmHg improves cardiovascular outcomes but increases the rates of some adverse events.

Secondary Hypertension

Causes

1. Renovascular Hypertension
2. Endocrine (pheochromocytoma, thyroid disease)
3. Primary hyperaldosteronism
4. Obstructive Sleep Apnea

References

1. 5 Blood Pressure Studies Pharmacists Should Know About
2. Frontiers | Timeline of History of Hypertension Treatment
3. Hypertension 2020 Guidelines
4. IM Review 2021 - Nephrology Slides