Hypertension with Compelling Indications

VI. TREATMENT OF HYPERTENSION IN ASSOCIATION WITH ISCHEMIC HEART DISEASE

A-  Recommendations for Hypertensive Patients with Coronary Artery Disease

1. An ACE inhibitor is recommended for patients with hypertension and documented coronary artery disease (Grade A).
2. For patients with stable angina, beta-blockers are preferred as initial therapy (Grade B).  CCBs may also be used (Grade B).
3. Short-acting nifedipine should not be used (Grade D).
4. For patients with coronary artery disease, but without coexisting systolic heart failure, the combination of an ACE inhibitor and ARB is not recommended (Grade B).
5. In high-risk patients, when combination therapy is being used, choices should be individualized. The combination of an ACE inhibitor and a dihydropyridine CCB is preferable to an ACE inhibitor and a diuretic in selected patients (Grade A).

B-  Recommendations for Patients with Hypertension Who Have Had a Recent ST-elevation Myocardial Infarction or Non-ST Segment Elevation Myocardial Infarction 

1. Initial therapy should include both a beta-blocker and an ACE inhibitor (Grade A).  An ARB can be used if the patient is intolerant of an ACE inhibitor (Grade A in patients with left ventricular systolic dysfunction).
2. CCBs may be used in postmyocardial infarction patients when beta-blockers are contraindicated or not effective.  Nondihydropyridine CCBs should not be used when there is heart failure, as evidenced by pulmonary congestion on examination or radiography (Grade D).

VII. TREATMENT OF HYPERTENSION IN ASSOCIATION WITH HEART FAILURE

1. In patients with systolic dysfunction (EF A) are recommended for initial therapy. Aldosterone antagonists (mineral corticoid receptor antagonists) may be added for patients with a recent cardiovascular hospitalization, acute myocardial infarction, elevated BNP or NT-proBNP level, or NYHA Class II to IV symptoms (Grade A). Careful monitoring for hyperkalemia is recommended when adding an aldosterone antagonist to ACE inhibitor or ARB. Other diuretics are recommended as additional therapy if needed (Grade B for thiazide diuretics for BP control, Grade D for loop diuretics for volume control). Beyond considerations of blood pressure control, doses of ACE inhibitors or ARBs should be titrated to those found to be effective in trials unless adverse effects become manifest (Grade B).
2. An ARB is recommended if ACE inhibitors are not tolerated (Grade A).
3. A combination of hydralazine and isosorbide dinitrate is recommended if ACE inhibitors and ARBs are contraindicated or not tolerated (Grade B).
4. For hypertensive patients whose blood pressure is not controlled, an ARB may be added to an ACE inhibitor and other antihypertensive drug treatment (Grade A). Careful monitoring should be used if combining an ACE inhibitor and an ARB due to potential adverse effects such as hypotension, hyperkalemia and worsening renal function (Grade C).  Additional therapies may also include dihydropyridine CCBs (Grade C).

VIII. TREATMENT OF HYPERTENSION IN ASSOCIATION WITH STROKE

Blood Pressure Management in Acute Stroke (Onset to 72 Hours)

1.  For patients with ischemic stroke not eligible for thrombolytic therapy, treatment of hypertension in the setting of acute ischemic stroke or TIA should not be routinely undertaken [Grade D]. Extreme blood pressure elevation (e.g. systolic > 220 mmHg or diastolic > 120 mmHg) may be treated to reduce the blood pressure by approximately 15 percent [Grade D], and not more that 25%, over the first 24h with gradual reduction thereafter [Grade D]. Avoid excessive lowering of blood pressure as this may exacerbate existing ischemia or may induce ischemia, particularly in the setting of intracranial arterial occlusion or extra cranial carotid or vertebral artery occlusion [Grade D]. Pharmacological agents and routes of administration should be chosen to avoid precipitous falls in blood pressure (Grade D).
2. For patients with ischemic stroke eligible for thrombolytic therapy, very high blood pressure (>185/110mmHg) should be treated concurrently in patients receiving thrombolytic therapy for acute ischemic stroke to reduce the risk of secondary intracranial hemorrhage. [Grade B] 

Blood Pressure Management After Acute Stroke

3. Strong consideration should be given to the initiation of antihypertensive therapy after the acute phase of a stroke or transient ischemic attack (Grade A).
4. Following the acute phase of a stroke, blood pressure lowering treatment is recommended to a target of consistently lower than 140/90 mmHg (Grade C).
5. Treatment with an ACE inhibitor/diuretic combination is preferred (Grade B).
6. For patients with stroke, the combination of an ACE inhibitor and ARB is not recommended (Grade B).

IX. TREATMENT OF HYPERTENSION IN ASSOCIATION WITH LEFT VENTRICULAR HYPERTROPHY

1. Hypertensive patients with left ventricular hypertrophy should be treated with antihypertensive therapy to lower the rate of subsequent cardiovascular events (Grade C).
2. The choice of initial therapy can be influenced by the presence of left ventricular hypertrophy (Grade D). Initial therapy can be drug treatment using ACE inhibitors, ARBs, long-acting CCBs or thiazide diuretics. Direct arterial vasodilators such as hydralazine or minoxidil should not be used.

X. TREATMENT OF HYPERTENSION IN ASSOCIATION WITH NONDIABETIC CHRONIC KIDNEY DISEASE

1. For patients with non-diabetic chronic kidney disease, target blood pressure is < 140/90 mmHg (Grade B).
2. For patients with hypertension and proteinuric chronic kidney disease (urinary protein > 500 mg/24hr or albumin to creatinine ratio [ACR] > 30 mg/mmol), initial therapy should be an ACE inhibitor (Grade A) or an ARB if there is intolerance to ACE inhibitors (Grade B).
3. Thiazide diuretics are recommended as additive antihypertensive therapy (Grade D). For patients with chronic kidney disease and volume overload, loop diuretics are an alternative (Grade D).
4. In most cases, combination therapy with other antihypertensive agents may be needed to reach target blood pressures (Grade D).
5. The combination of an ACE inhibitor and ARB is not recommended for patients with non-proteinuric chronic kidney disease (Grade B).

XI. TREATMENT OF HYPERTENSION IN ASSOCIATION WITH RENOVASCULAR DISEASE

1. Renovascular hypertension should be treated in the same manner as hypertension without compelling indications, except for caution in the use of ACE inhibitors or ARBs due to the risk of acute renal failure in bilateral disease or unilateral disease with a solitary kidney (Grade D).
2. Close follow-up and early intervention (angioplasty and stenting or surgery) should be considered for patients with uncontrolled hypertension despite therapy with three or more drugs, deteriorating kidney function, bilateral atherosclerotic renal artery lesions (or tight atherosclerotic stenosis in a single kidney) or recurrent episodes of flash pulmonary edema (Grade D).

XII. TREATMENT OF HYPERTENSION IN ASSOCIATION WITH DIABETES MELLITUS

1. Persons with diabetes mellitus should be treated to attain systolic blood pressures of less than 130 mmHg (Grade C) and diastolic blood pressures of less than 80 mmHg (Grade A). (These target blood pressure levels are the same as the blood pressure treatment thresholds.) Combination therapy using two first-line agents may also be considered as initial treatment of hypertension (Grade B) if systolic blood pressure is 20 mmHg above target or if diastolic blood pressure is 10 mmHg above target. However, caution should be exercised in patients in whom a substantial fall in blood pressure is more likely or poorly tolerated (e.g. elderly patients and patients with autonomic neuropathy).
2. For persons with cardiovascular or kidney disease, including microalbuminuria or with cardiovascular risk factors in addition to diabetes and hypertension, an ACE inhibitor or an ARB is recommended as initial therapy (Grade A).
3. For persons with diabetes and hypertension not included in the above recommendation, appropriate choices include (in alphabetical order): ACE inhibitors (Grade A), angiotensin receptor blockers (Grade B), dihydropyridine CCBs (Grade A) and thiazide/thiazide-like diuretics (Grade A).
4. If target blood pressures are not achieved with standard-dose monotherapy, additional antihypertensive therapy should be used. For persons in whom combination therapy with an ACE inhibitor is being considered, a dihydropyridine CCB is preferable to hydrochlorothiazide (Grade A).

XIII. ADHERENCE STRATEGIES FOR PATIENTS

1. Adherence to an antihypertensive prescription can be improved by a multipronged approach as outlined in (Table 5).

XIV. TREATMENT OF SECONDARY HYPERTENSION DUE TO ENDOCRINE CAUSES

1. Treatment of hyperaldosteronism and pheochromocytoma are outlined in (Table 6) and (Table 7).