Uptitration

Uptitration of the original drug to double the dosage is reasonable only if distinctly enhanced antihypertensive efficacy has been documented and the cost is not prohibitive. Most antihypertensive drugs have a rather shallow dose-response curve and increasing the dose has little additional effect on BP. For instance, doubling the starting dose oflosartan from 50 mg to 100 mg, has not been shown to increase antihypertensive efficacy. In a situation like this, it is more rational to combine a low...

The nothing worksallergic to everything patient

These patients are also called heart sink patients because the physician's heart sinks whenever they show up in the waiting room. What, perhaps, is most important with patients like this is to try to sort the wheat from the chaff. Thus, a very thorough, detailed history regarding previous medications, duration of use and reasons for discontinuation can often provide an astonishing insight. If a patient who is allergic to everything lists among these allergies a dry cough with certain drugs, or...

Clinicians Manual Treatment of Hypertension

Director, Hypertension Program St Luke's-Roosevelt Hospital Center 1000 Tenth Avenue New York, NY Published by Springer Healthcare Ltd, 236 Gray's Inn Road, London, WC1X 8HB, UK www.springerhealthcare.com 2011 Springer Healthcare, a part of Springer Science+Business Media All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise without the prior written...

To twofer or not to twofer

The two-for-one therapeutic concept or, namely, to treat two conditions with one drug, is attractive for a variety of reasons among these are a reduction in adverse effects, the number of pills, and cost. Physicians and patients, therefore, like the twofer and use it whenever possible. Unfortunately, the concept of the twofer has never been vigorously tested. Ironclad trials have shown that beta-blockers confer secondary cardioprotection in patients who have suffered an acute MI 26 . However,...

Hypertension as a gateway to cardiovascular risk modification

Measurement of BP is a simple, straightforward procedure that allows us to identify the risk of cardiovascular disease. However, treatment of raised BP is clearly inefficient to reduce the overall associated cardiovascular disease risk. Antihypertensive therapy should, therefore, serve as a gateway to overall cardiovascular risk management and give rise to normal risk estimation. This can be done by using the Framingham risk score 1 or the systems put forward by the European Society of...

Erectile and orgasmic dysfunction

Long-standing, untreated hypertension is well known to have a negative impact on sexual function and can lead to complete impotence. Unfortunately, antihypertensive drugs still have a bad reputation with regard to erectile function. Some of the older antihypertensive drugs, such as resurpine and guanethidine, have a well-known negative effect on erectile and orgasmic function. Diuretics, beta-blockers, and antiadrenergic drugs, as well as alpha-blockers, diminish erectile function. Failure to...

Pill burden and compliance

Experienced clinicians have long recognized that the patient's compliance with a given treatment regimen depends, to some extent, on its complexity. As a simple rule, the more pills a patient has to take the sicker he or she feels and the lesser the compliance. This is particularly true when the treatment regimen requires dosing several times a day. Fixed combinations, therefore, have a distinct advantage. Putting two or three drugs into the same pill may reduce side effects thus, the patient...

Betablocker and diuretic combinations

Several beta-blocker and diuretic combinations were marketed a number of decades ago when beta-blockers became available in the USA (Figure 12). In most of these fixed combinations, the beta-blocker is combined with 25 mg, or even 50 mg, of HCTZ (or the corresponding dose of a thiazide derivative), a dose that, by today's standard, would have to be considered high. It has been learned that HCTZ doses of 12.5 mg, and even 6.25 mg, lower BP and cause fewer endocrine metabolic adverse effects than...

Stepdown therapy

Should the patient be successful in modifying their lifestyle weeks or months after BP is controlled with antihypertensive therapy, it is reasonable to consider using the step-down approach to decrease the dose, or number, of antihypertensive drugs taken, or even to stop therapy completely. Lowering BP over the long term by using antihypertensive drugs such as ACE inhibitors, ARBs and calcium antagonists, will reduce vascular hypertrophy and target organ disease and will restore endothelial...

Antihypertensive efficacy

Concomitant medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), or a high salt intake can mitigate the antihypertensive efficacy of certain drug classes, such as ACE inhibitors or ARBs. Beta-blockers have little, if any, effect in isolated systolic hypertension in elderly patients. A high salt intake can counteract the effects of diuretics and blockers of the RAS. In contrast, few, if any, drugs or dietary interventions affect the efficacy of calcium antagonists. Calcium...

Early morning hypertension

Ever since the pioneering studies of Sir George Pickering, we have known that BP follows a distinct diurnal pattern, decreasing throughout the evening to a nadir at midnight, followed by an early morning rise shortly before awakening. This pattern is qualitatively similar in both normotensive and hypertensive patients. Hypertensive complications, such as stroke, acute MI, and sudden death follow a very similar pattern the time period between 6 00 a.m. and 10 00 a.m. seems to confer the highest...

Isolated systolic hypertension

There are three main reasons why isolated systolic hypertension has become increasingly important over the past few years We are seeing more and more elderly patients, and isolated systolic hypertension is the most common form of high BP in the geriatric population. Systolic BP has finally been recognized as the most powerful predictor of cardiovascular morbidity and mortality and, therefore, treatment of systolic BP has become more important than that of diastolic BP. The treatment goals of...

Dual RAS blockade Blood pressure

Most BP studies showed a small additional drop in systolic and diastolic pressure when an ARB was added to an ACE inhibitor, and vice versa, regardless of the dose level of the first drug. A thorough systematic review and metaanalysis assessed 14 BP studies in hypertensive patients in which patients were evaluated by 24-hour ambulatory BP monitoring 91 . The authors found that the combination of an ACE inhibitor and an ARB reduced BP by an average of 4 3 mmHg when compared with monotherapy. The...

Combination therapy

Cardiovascular risk factors, such as hypertension, diabetes, and hyperlipidemia, as well as cardiovascular disease states, such as coronary heart disease, heart failure, and certain arrhythmias, are amenable to a variety of therapeutic interventions that have been proven to be beneficial. However, the combination ofthese interventions has rarely been studied in a rigorous scientific way. No data are available that analyze the relevant contribution of each drug to the overall outcome in a given...

Outcome trials

The ASCOT study further attests to the benefit ofthe combination of an ACE inhibitor with a dihydropyridine calcium antagonist 54 . ASCOT was designed to compare the effect of the standard antihypertensive regimen (a beta-blocker and a diuretic) with that of a more contemporary regimen (calcium antagonist and an ACE inhibitor) on coronary artery disease. A total of almost 20,000 patients were randomized to either atenolol plus bendroflumethiazide (if needed) or amlodipine plus perindopril (if...