PRINCIPLES OF TREATMENT

Goals of Therapy CASE 14-1, QUESTION 7: What are the goals of treating D.C.?
The overarching goal of treating hypertension is to lower hypertension-associated
complications. Control ofBP is the most feasible clinical end point to guide therapy
and should be viewed as a surrogate for attaining this goal D.C.'s goal BP is less
than 140/90 mm Hg according to both the JNC-7 and AIM guide-lines
Pharmacotherapy principles to achieve these goals indude selecting a treatment
regimen with antihypenensrve agent(s) that reduces risk of CV events,
complemented by appropriate lifestyle modifications (Table 14 6),
Health
eliefs and Patient Education
CASE 14-1, O.UESTiON 3: What patient education should be provided to D.C.
regarding his hyper tension?
Patient education is needed to ensure that D C understands his disease and its
complications (Table 14-7) This should coin prehensively includc information on
disease, treatment, adher-ence, and complications Several approaches can be
effective, but all methods should include direct communication between the
clinician and the patient. Multidisciplinary approaches to disease-state management
in hypertension can effectively use a team of different clinicians (e.g,, physicians,
nurse practitioners, physi-cian assistants, pharmacists). Providing face-to-face
education is most common, but the key components in patient eduattio-r. can be
delivered via indirect interactions (e.g_, telephone),
For a video that shows multidisciplinary team-based approaches to managing
hypertension (Courtesy of the University of Iowa), go to http://thep-oint.lwvv.comi
ATI Oe.
Education should be tailored to the patient's specific needs, For example, some
patients are able to comprehend the impor-tance of achieving controlled BP by
reading written materials, whereas others understand this only after implementing
self-BP monitoring. The patient education process must be contin-uous throughout
the duration of therapy. Not all aspects need to be discussed during each clinical
interaction, Careful selec-tion of both written and verbal information should be considered so that patients are not overwhelmed or intimidated..
saapiosKi irInDsrA pug DETzeD
Patient-Provider Interactions .`or Hypertetision Patient Education Assess patient's
understanding and acceptance of the diagnosis of hypertension Discuss patient's
concerns and clarify rmsunclerstandmgs When measunng1W inform the patient of
the reading both verbally and m writing Assure patient understands his or her goal

HP value Ask patient to rate (1-10) his or her chance of staying on treatment
Inform patient about recommended treatment, including lifestyle modification.
Provide specific written information using standard brochures when available Elicit
concerns and questions and provide opportunities for patient to state specific
behaviors to carry out treatment recommendanons Emphasize: - the need to
continue treatment -- that control does not mean cure - that elevated IW is usually
not accompanied by symptoms Individualize Treatment Regimens Include the
patient in decision making Simplify the regimen to once-daily dosing, whenever
possible Incorporate treatment into patient's daily lifestyle Set realistic shortterm objectives for specific components of the medication and lifestyle modification
plan Encourage discussion of diet and physical activity, adverse drug effects, and
concerns Encourage self-monitoring with validated BP devices Minimize the cost
of therapy, when possible Discuss adherence at each clinical encounter
Encourage gradual sustained weight loss
blood pressure.
National Hean, Lung, and Blood Institute patient education materials are available
at linp://w-vvw.nnlbienih.govi health publiciheartlindex.htin#hhp It is important that
clinicians review all materials provided to patients to identify the source of !
nforination, o.-less ease of reading, and identify omitted informa-tion and sources of
confusion or anxiety (e g . drug side effects) Patients such as RC, often incorrectly
ex-plain BP elevation as stress related. Although certain patients Cc. g , those with
white-coat hypertension) may have EP that is more highly reactive, most patients
with essential hypertension will have an elevated BP regardless of then- stress level
D C. should be informed about the cause of his disease and the lack of correlation
between stress or symptoms and high BP Importantly, D.C. needs to realize that
elevated BP is almost always asymptomatic, but that it can cause seriouslong-term
complications. It is essential that he understand the chronic nature of hypertension
and the need for lontterm therapy, Otherwise, he may adhere to his treatment only
when he "feels his BP is high" or during stressful events. Sonic patients believe they
can control their BP by stress management rather than with antihypertensive drug
therapy and lifestyle modifications. Controlled trials have not consis-tently proven
that stress management is beneficial in treating hypertension.4 It is important to
determine the patient's health beliefs and attitudes and to provide education about
the etiology and management of hypertension to promote BP control, Another
common myth patients believe is that treating hyper-tension commonly leads to
fatigue, lethargy, and sexual dysfunc tion. This misconception can compromise
adherence and be a limiting factor in appropriate management. Clinical trials have
repeatedly reported that quality of life is better with active medi-; cation than with
placebo.41-" Data have indicated that as many as 27% of men with hypertension
have erectile dysfunction. Although many patients believe this to be a medicationrelated

side effect, and that incidence rates vary ;tm ong antihypertensive ai:Nuits and
(lasses, erectile d\ NIIIIUMOn IS likety used in penile arterial changes (probably attic;
>sclerosis), which is relatied to uncontrolled or untreated hypei t on 'lc
Benefits of Treatment
CASE 14-1, QUESTION 9: How can antihypertensivo drug therapy reduce D.C.'s risk
of hypertension-associated com-plications?
Without a doubt, antihypertensive therapy reduces the risk of CV disease and CV
events in patients with hypertension. Numer ous landmark placebo-controlled
studies have clearly demon strated these benefits. The first large-scale trial,
published in 1967, was the Veterans Administration (VA) study in men with DBP
between 115 and 129 mm 1-ig:46 This study was prema rurely stopped because
benefits of treatment were so dramatic, Antth)pertensive therapy significantly
reduced cerebral he Ml, left ventricular dysfunction, retinopathy, and kidney
disease. Other landmark placebo controlled studies have evalu. aced
antihypertensive therapy in patients with less severe hyper-tension and have shown
a reduced risk of CV events (stroke, ischernic bean disease, left ventricular
dysfunction) and even CV death."*"'" Placebo-controlled studies evaluating morbidity and mortality in hypertension are now not only unneces-sary, but are considered
unethical because ofthe well established benefits of treatment Even small
reductions in BP have been associated with significant CV benefits Based on
prospective observational studies, a persistent 5 mm I ig reduction in D BP is
associated with a 21% reduction in CHD and a 34% reduction in stroke " 52
CASE 14-1 QUESTION 10: Will D.C.'s early signs of hypertension-associated
compiications improve or reverse with appropriate BP control?
Most antihypertensive drugs reduce 1,V! i through vutyang mechanisms ft is logical
thin regression of 1VI. I is desirable but this remains unproved. Theoretically,
myocardial function mig,ht be compiormsed ifhypertrophied mine le regresses in stir
because of the increased rape of collagen to muscle.. Nonetheless, until proven
othei wise, regression of 1.,V11 eta D C is (lest' able Reductions in BP can reverse
many of the changes asset toted with D.C's retinopathy. Studies have demonstrated
that the tisk of retinopathy in diabetes increases significantly when BP is ele-vated
and that HP lowering can slow this progression.. Although D C. has an elevated
Listing glucose, he does not have di theirs Regaidless, lowcnng BP is desirable for
anticipated betitlimi I effects on his retinopathy.
HYPERTENSION MANAGEMENT
Lifestyle Modifications
CASE 14-1, QUESTION 11: Should D.C. start antihyporten-shoo drug therapy, or aro
lifostylo Imidifications alone surfil-tient?

it is reasonable to assume that lifestyle modifications can partially help D C achieve

his BP goal Older JI\IC. guidelines recommended lifestyle modifications for 6 to 12
months before starting drug therapy in patients with few or no risk factors,
no hypertension-associated complications, and no compelling indications." The
2007 European guidelines recommend lifestnic modifications alone to treat
hypertension for only "sev erai weeks" before starting drug therapy in patients with
stage hypertension who have "moderate" CV risk (i.e., one to two risk factors), and
for 'several months" in patients with stage 1 hyper-tension who are at "low" CV risk
0 e,, no additional risk factors). D. C. has multiple major CV risk factors and has
early evidence of hypertension- associated complications. Lifestyle modifications
are germane to the appropriate treatment of hypertension, but prospective clinical
trials have not proven that this treatment approach prevents CV disease in patients
with hypertension Mm ilar to what is proven antihypertenswe drug therapy. Hence,
initi-ation oldrug therapy should not be delayed unnecessarily, espe yh for patients
with CV risk factors, " 5 Because DC. has stage hypertension with multiple risk
factors, both lifestyle modifica tions -and drug therapy should be implemented
simultaneously
AtIOOALITIES THAT LOWER BP