Essential, or Secondary, Hypertension?Your hypertension treatment, first of all, will be based on whether your high blood pressure is being caused by a specific underlying medical condition (that is, secondary hypertension), or whether you are in the vast majority of patients with essential hypertension (in which there is no specific underlying cause). If you have secondary hypertension, the main approach to treatment likely will be to treat the underlying cause.
So, for the rest of this discussion we will assume you have the far more common essential hypertension.
Typical Treatment Steps For Essential HypertensionThe initial treatment for hypertension often depends on the "stage" of your hypertension, which is determined by your systolic and diastolic blood pressure.
- Stage 1 hypertension: systolic 140 - 159 mmHg, OR diastolic 90 - 99 mmHg
- Stage 2 hypertension: systolic greater than 159 mmHg, OR diastolic greater than 99 mmHg
If your hypertension is relatively mild (Stage 1 hypertension), your doctor may begin by advising lifestyle changes. Lifestyle changes that may help to reduce your blood pressure include:
- Adopting a diet for hypertension
- Adopting salt restriction
- Adopting a regular exercise program
- Quitting smoking
Drug TherapyFive major classes of medications are used to treat hypertension:
- Thiazide diruetics
- ACE inhibitors
- Calcium blockers
- Beta blockers
- Angiotensin receptor blockers, ARBs
Typically, if you have Stage I hypertension, the odds are good that your blood pressure can be brought to target levels with a single drug. If you have Stage 2 hypertension, single drug therapy rarely is effective enough, and your doctor may want to begin right away with a combination of drugs.
If single drug therapy (or monotherapy) is chosen, it appears best to begin with either a thiazide diuretic (usually chlorthalidone or hydrochlorothiazide), a long-acting calcium blocker, or an ACE inhibitor. (ARBs can be used instead of an ACE inhibitor if the ACE inhibitor is poorly tolerated). Young patients often respond well to ACE inhibitors; black patients and elderly patients tend to do better with thiazide diuretics or calcium channel blockers. Beta blockers are usually a poor choice for monotherapy.
If the first try at monotherapy is insufficiently effective or poorly tolerated, switching to another single drug, and then to a third if necessary, is generally recommended as the next step.
If three or more attempts at monotherapy have not worked well enough, the next step is to try combination therapy with two or more drugs. While numerous combinations are possible, recent evidence suggests that using a calcium blocker together with an ACE inhibitor or ARB may be the most effective and best tolerated combination. Most doctors will now try this combination first, even if the monotherapy was with a thiazide diuretic.
With these step-wise maneuvers, the large majority of patients with hypertension will reach their target blood pressure levels with minimal side effects. Keep in mind that finding successful therapy for hypertension often requires several weeks or months, and several drug trials. But it is important for you to stick with the program. Getting your blood pressure to target levels, and keeping it there, will give you a very large payout for your efforts -- a greatly reduced risk of heart attack and stroke.
Law, MR, Morris, JK, Wald, NJ. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. BMJ 2009; 338:b1665.
Staessen, JA, Wang, JG, Thijs, L. Cardiovascular prevention and blood pressure reduction: A quantitative overview updated until 1 March 2003. J Hypertens 2003; 21:1055.