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Treatment of HypertensionA Review

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Importance  Hypertension, defined as persistent systolic blood pressure (SBP) at least 130 mm Hg or diastolic BP (DBP) at least 80 mm Hg, affects approximately 116 million adults in the US and more than 1 billion adults worldwide. Hypertension is associated with increased risk of cardiovascular disease (CVD) events (coronary heart disease, heart failure, and stroke) and death.

Observations  First-line therapy for hypertension is lifestyle modification, including weight loss, healthy dietary pattern that includes low sodium and high potassium intake, physical activity, and moderation or elimination of alcohol consumption. The BP-lowering effects of individual lifestyle components are partially additive and enhance the efficacy of pharmacologic therapy. The decision to initiate antihypertensive medication should be based on the level of BP and the presence of high atherosclerotic CVD risk. First-line drug therapy for hypertension consists of a thiazide or thiazidelike diuretic such as hydrochlorothiazide or chlorthalidone, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker such as enalapril or candesartan, and a calcium channel blocker such as amlodipine and should be titrated according to office and home SBP/DBP levels to achieve in most people an SBP/DBP target (<130/80 mm Hg for adults <65 years and SBP <130 mm Hg in adults ≥65 years). Randomized clinical trials have established the efficacy of BP lowering to reduce the risk of CVD morbidity and mortality. An SBP reduction of 10 mm Hg decreases risk of CVD events by approximately 20% to 30%. Despite the benefits of BP control, only 44% of US adults with hypertension have their SBP/DBP controlled to less than 140/90 mm Hg.

Conclusions and Relevance  Hypertension affects approximately 116 million adults in the US and more than 1 billion adults worldwide and is a leading cause of CVD morbidity and mortality. First-line therapy for hypertension is lifestyle modification, consisting of weight loss, dietary sodium reduction and potassium supplementation, healthy dietary pattern, physical activity, and limited alcohol consumption. When drug therapy is required, first-line therapies are thiazide or thiazidelike diuretics, angiotensin-converting enzyme inhibitor or angiotensin receptor blockers, and calcium channel blockers.

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Article Information

Corresponding Author: Robert M. Carey, MD, University of Virginia Health System, PO Box 801414, Charlottesville, VA 22908-1414 (rmc4c@virginia.edu).

Accepted for Publication: October 4, 2022.

Author Contributions: Dr Carey had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Carey.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Supervision: Carey.

Conflict of Interest Disclosures: Dr Carey reported receiving grants from the National Institutes of Health (NIH) during the conduct of this work; serving as vice chair of the 2017 ACC/AHA High Blood Pressure Guideline Writing Committee; serving as chair of the AHA Scientific Statement on Resistant Hypertension; and serving as cochair of the Endocrine Society Clinical Practice Guideline on Primary Aldosteronism Panel. Dr Whelton reported serving as chair of the SPRINT Steering Committee and the 2017 ACC/AHA High Blood Pressure Guideline Writing Committee and reported receiving grants from the National Institutes of Health. Dr Moran reported receiving grants from the National Institutes of Health. No other disclosures were reported.

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Keisler-Starkey  K , Bunch L. Health Insurance Coverage in the United States: 2020. US Government Publishing Office; 2021.
Healthy People 2020: access to health services. US Department of Health and Human Services. Updated December 28, 2021. Accessed January 1, 2022. https://www.cdc.gov/nchs/healthy_people/hp2020.htm https://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/Access-to-Health-Services/data - primary-care
Egan  BM , Li  J , Sutherland  SE , Rakotz  MK , Wozniak  GD .  Hypertension control in the United States 2009 to 2018: factors underlying falling control rates during 2015 to 2018 across age- and race-ethnicity groups.   Hypertension. 2021;78(3):578-587. doi:10.1161/HYPERTENSIONAHA.120.16418PubMedGoogle ScholarCrossref
The surgeon general’s Call to Action to Control Hypertension. Centers for Disease Control and Prevention. Published 2020. Updated October 22, 2020. Accessed January 1, 2022. https://www.cdc.gov/bloodpressure/CTA.htm
Havranek  EP , Mujahid  MS , Barr  DA ,  et al; American Heart Association Council on Quality of Care and Outcomes Research, Council on Epidemiology and Prevention, Council on Cardiovascular and Stroke Nursing, Council on Lifestyle and Cardiometabolic Health, and Stroke Council.  Social determinants of risk and outcomes for cardiovascular disease: a scientific statement from the American Heart Association.   Circulation. 2015;132(9):873-898. doi:10.1161/CIR.0000000000000228PubMedGoogle ScholarCrossref
Commodore-Mensah  Y , Turkson-Ocran  RA , Foti  K , Cooper  LA , Himmelfarb  CD .  Associations between social determinants and hypertension, stage 2 hypertension, and controlled blood pressure among men and women in the United States.   Am J Hypertens. 2021;34(7):707-717. doi:10.1093/ajh/hpab011PubMedGoogle ScholarCrossref
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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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