hypertension-II

**HYPERTENSION**
Hypertension accounts for more than 30 million physician office visits per year and is among the most frequent diagnoses made. Despite this fact, it is still one of the most poorly controlled conditions in the United States.1,2 In May 2003, the National High Blood Pressure Education Program Coordinating Committee of the National Heart, Lung, and Blood Institute released new guidelines for the detection, prevention, and management of hypertension.1 These guidelines are for adult patients 18 and older and are based on the average of two or more properly measured, seated blood pressure readings during two or more office visits. According to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), normal blood pressure is defined as a systolic blood pressure of less than 120 mmHg and a diastolic blood pressure of less than 80 mmHg; prehypertension is defined as a systolic blood pressure of 120 to 139 mmHg or a diastolic blood pressure of 80 to 89 mmHg; and hypertension is defined as a systolic blood pressure of 140 mmHg or greater or a diastolic blood pressure of 90 mmHg or greater. Blood pressure classifications, as defined by the JNC 7, are listed in **[|TABLE 1]**. With the addition of a prehypertensive classification, the more recent guidelines have widened their target population in the hopes of drawing more attention to earlier intervention.1,3,4 The JNC 7 guidelines recommend a treatment goal of less than 140/90 mmHg for people with a diagnosis of hypertension. Lower blood pressure goals of less than 130/80 mmHg are set for patients with hypertension and comorbid diabetes or chronic kidney disease. Patients who have these comorbid diseases have an inflated risk for cardiovascular disease and must be treated more aggressively.1 The management of hyper-tension involves the combination of nonpharmacologic treatments, such as modifications in diet, exercise, and alcohol consumption, as well as the use of individualized pharmacotherapy. Lifestyle modifications are an important component in the prevention and treatment of hypertension. The JNC 7 recommends lifestyle modifications for all patients who are either prehypertensive or hypertensive. Recommended modifications (see **[|TABLE 2]**) include: (1) reducing sodium intake; (2) following the Dietary Approaches to Stop Hypertension (DASH) eating plan; (3) moderating alcohol consumption; (4) increasing physical activity; and (5) losing weight.1 A list of other modifiable risk factors can be found in **[|TABLE 3]**. A dietary sodium intake of no more than 2.4 g has been shown to decrease systolic blood pressure by 2 to 8 mmHg. Following the DASH diet has been shown to decrease blood pressure more effectively than only reducing sodium. The DASH diet instructs patients to stick to a diet that is low in sodium as well as rich in fruits and vegetables, high in potassium, calcium, and low-fat dairy products, and low in total saturated fats. Adoption of this diet is associated with decreases in systolic blood pressure of approximately 8 to 14 mmHg.5 Reducing alcohol consumption has also been shown to decrease blood pressure. In one meta-analysis, a dose-response was demonstrated between alcohol consumption and blood pressure reduction. An overall reduction of 3.31 mmHg in systolic blood pressure was observed in patients in the alcohol reduction group. Therefore, alcohol consumption should be limited to no more than two drinks per day for men and no more than one drink per day for women.1,6 Patients with hypertension should participate in at least 30 minutes of regular, aerobic physical activity on most days of the week. Aerobic exercise has been associated with an average 4% reduction in systolic blood pressure.7 Weight loss is also an important component in lowering blood pressure. Hypertension is 50 times more prevalent in overweight patients.8 A weight loss of 20 lb can reduce systolic blood pressure by approximately 5 to 20 mmHg, and even a weight loss of 10 lb has been shown to reduce and prevent hypertension.9,10
 * **Table 1** ||
 * ****Classification of Blood Pressure for Adults**** ||
 * Classification**
 * **Systolic Blood** **Pressure (mmHg)** ||  || **Diastolic Blood**  **Pressure** **(mmHg)** ||
 * Normal || <120 || and || <80 ||
 * Prehypertension || 120 – 139 || or || 80 – 89 ||
 * Stage I hypertension || 140 – 159 || or || 90 – 99 ||
 * Stage II hypertension || 160 || or || 100 ||
 * Treatment Goals**
 * Treatment Goals**
 * Treatment**
 * Nonpharmacologic Therapy**
 * **Table 2** ||
 * ****Blood Pressure Benefits Achieved Through Lifestyle Modification**** ||
 * Modification**
 * **Targeted **Changes**** || **Change** **in Blood Pressure (mmHg)** ||
 * Sodium reduction || <2.4 g/day || -5.8/2.5 ||
 * Weight loss || -4.5 kg || -7.2/5.9 ||
 * Alcohol reduction || -2.7 drinks/day || -4.6/2.3 ||
 * Exercise || Three or more times per week || -10.3/7.5 ||
 * Dietary patterns || DASH diet || -11.4/5.5 ||
 * Dietary patterns || DASH diet || -11.4/5.5 ||

Pharmacotherapy for hypertension involves the use of agents from several classes of medications: diuretics, aldosterone receptor blockers, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), calcium channel blockers (CCBs), alpha-1 blockers, alpha-2 agonists, central alpha-2 agonists and other centrally-acting drugs, and direct vasodilators. The JNC 7 recommends thiazide diuretics as initial therapy for patients with uncomplicated hypertension and as a second-line agent in those patients with compelling indications. Compelling indications are comorbidities that require specific antihypertensive treatment based on positive outcomes from clinical trials. The various compelling indications and their recommended treatments are listed in **[|TABLE 4]**. Most patients require more than one pharmacologic agent to reach their target blood pressure. For patients with a blood pressure reading of more than 20/10 mmHg above goal, initial treatment with two agents is recommended.1 The choice of agents depends on issues such as cost, safety, adverse event profile, presence of compelling indications, and presence of risk factors for cardiovascular disease. //**Diuretics:**// Data from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) has provided the most supportive evidence that thiazide-type diuretics should be considered first-line agents in the treatment of hypertension.11 The exact mechanism of action by which thiazide diuretics lower blood pressure is unknown. Initially, the hypotensive effect is due to diuresis, which causes reductions in plasma and stroke volume, thereby decreasing cardiac output and, eventually, blood pressure. The chronic antihypertensive effects of thiazide diuretics are due to a decrease in peripheral vascular resistance. Diuretics are commonly used in combination with other antihypertensive agents— typically ACE inhibitors and beta-blockers—to provide an additive or synergistic antihypertensive effect. Even if a diuretic is not used as a first-line agent, it may be beneficial as a second- or third-line agent when treating hypertension.12,13 Current guidelines recommend hydrochlorothiazide at doses of 12.5 to 25 mg/day. Doses greater than 25 mg may not offer any additional blood pressure–lowering effect; therefore, another agent should be strongly considered to achieve a patient’s blood pressure goal. In general, diuretics are well tolerated. Patients should be told to take their dose in the morning to avoid nocturnal diuresis. Metabolic abnormalities, such as hypokalemia, hyperuricemia, hypercalcemia, hypomagnesemia, and hyperglycemia, may occur with use of thiazide diuretics. The low recommended doses of hydrochlorothiazide rarely cause these imbalances; however, careful monitoring is suggested. Patients should lower the salt content in their diets while on thiazide therapy, because increases in salt intake can blunt the effects of thiazide diuretics and worsen the hypokalemia associated with their use. Because hydrochlorothiazide increases blood glucose levels, diabetic patients should be instructed to routinely monitor blood glucose levels for any abnormalities. An increase in insulin doses or diabetic medications may be necessary to control glucose. Uric acid levels may increase by approximately 1 mg/dL. This increase is not associated with adverse renal effects and may precipitate a gout attack, especially in patients with a previous history. If an attack occurs, the agent of choice for treatment is allopurinol, which can be used without compromising the patient’s blood pressure control.
 * **Table 3** ||
 * ****Modifiable Risk Factors for Blood Pressure Management**** ||
 * Excess salt intake
 * Heavy alcohol use
 * Licorice
 * Sleep apnea
 * Recreational drugs
 * Certain medications
 * Excess weight
 * Lack of regular activity
 * Poor diet ||
 * Pharmacotherapy**
 * Pharmacotherapy**
 * **Table 4** ||
 * ****Compelling Indications and Recommended Therapy**** ||
 * Heart failure || Diuretic, beta-blocker, ACE inhibitor, ARB, Aldo Ant ||
 * Post–myocardial infarction || Beta-blocker, ACE inhibitor, Aldo Ant ||
 * High coronary disease risk || Diuretic, beta-blocker, ACE inhibitor, CCB ||
 * Diabetes || Diuretic, beta-blocker, ACE inhibitor, ARB, CCB ||
 * Chronic kidney disease || ACE inhibitor, ARB ||
 * Recurrent stroke prevention || Diuretic, ACE inhibitor ||
 * ACE: angiotensin-converting enzyme; ARB: angiotensin II receptor blocker; CCB: calcium channel blocker; Aldo Ant: aldosterone antagonist. ||

//**ACE Inhibitors:**// According to current guidelines, ACE inhibitors are typically considered second-line agents for the treatment of hypertension. In hypertensive patients with a previous history of myocardial infarction, heart failure, diabetes, chronic kidney disease, or stroke, or in those with a high coronary disease risk, this class of agents may be considered first-line treatment.1 ACE inhibitors have been shown to be beneficial in decreasing the incidence of heart failure and stroke. The effects of ACE inhibitors are similar to those of diuretics and beta-blocker monotherapy. CCBs and beta-blockers work synergistically with ACE inhibitors, when combined. However, ACE inhibitors are more effective in younger and white populations and less effective in black patients, unless higher doses have been used or are given in combination with a diuretic.14-17 ACE inhibitors block the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor and stimulator of aldosterone and vasopressin. In addition, ACE inhibitors cause an increase in bradykinin levels, which stimulate the synthesis of other vasodilatory substances, such as nitric oxide.
 * [[image:http://www.uspharmacist.com/ce/105443/image1.jpg width="427" height="588" align="center"]] ||
 * Management of hypertension involves the combination of nonpharmacologic treatments, such as modifications in diet, exercise, and alcohol consumption, as well as the use of individualized pharmacotherapy. ||

Currently, there are 10 ACE inhibitors available, which differ based on their pharmacokinetic profiles— benazepril, captopril, enalapril, fosinopril, lisinopril, moexipril, perindopril, quinapril, ramipril, and trandolapril. Benazepril, enalapril, fosinopril, perindopril, quinapril, and ramipril are prodrugs. Captopril is administered three times daily and should be taken on an empty stomach. All other agents are given once daily. The primary site of excretion is the kidneys; therefore, a dosage reduction is required for patients with renal insufficiency. However, because benazepril, trandolapril, and fosinopril are eliminated both hepatically and renally, dosage reductions are not necessary for these agents.

ACE inhibitors are generally well tolerated by patients. The most common adverse effects experienced by patients include hypotension, hyperkalemia, cough, and angioedema. Hypotension is most apparent when the patient is sodium depleted or has high renin and is most common with captopril use. Hyperkalemia is usually seen in patients with chronic kidney disease or diabetes and in those patients who are concurrently taking ARBs, nonsteroidal anti-inflammatory agents, potassium supplements, or potassium-sparing diuretics. This is most problematic within four weeks of initiating therapy or increasing the dosage. Hyperkalemia is usually asymptomatic; however, patients may complain about heart palpitations or “skipped heartbeats.” More than 20% of patients on ACE inhibitor therapy will develop a dry, nonproductive cough. The mechanism behind the cough has been attributed to the buildup of bradykinin. This cough is very bothersome to patients and can develop at any time during therapy. If an ACE inhibitor is indicated in a patient who experiences this ACE inhibitor–induced cough, an ARB should be considered. Angioedema, although rare, is a serious adverse effect of ACE inhibitor therapy. It is seen in up to 2% of patients, especially African-Americans and smokers. It is characterized by lip and laryngeal swelling, which may be accompanied by difficulty breathing. If angioedema is experienced by a patient, drug discontinuation is appropriate. Patients with a history of angioedema should not use ACE inhibitors.18 //**ARBs:**// ARBs are usually used as an alternative to ACE inhibitor therapy in the management of hypertension. ARBs directly block angiotensin II at the receptor site from all pathways, unlike ACE inhibitors, which only block angiotensin II production through the renninangiotensin-aldosterone system. ARBs, unlike ACE inhibitors, do not prevent the degradation of bradykinin, thereby preventing dry cough associated with ACE inhibitor therapy. ARBs are a good alternative to ACE inhibitor therapy, since they have beneficial blood pressure–lowering capability and possess protective qualities for the kidneys when used in diabetic patients. Most patients will not be initiated on ARB therapy prior to at least a trial of ACE inhibitor therapy; however, it is not unheard of.

The combined use of ACE inhibitor and ARB therapy has not been well established and is a controversial topic. Studies have both supported and opposed the use of this combination.19,20 Typically, the combination would be considered a duplication of therapy, and it is necessary to ensure that all other options for lowering hypertension are exhausted before considering this combination.

Compared with other hyper-tensive agents, ARBs appear to have the lowest incidence of adverse effects. Compared with ACE inhibitors, ARBs have similar potential to cause orthostatic hypotension and hyperkalemia and are less likely to cause angioedema. In addition, there have been reports of cross-reactivity with ACE inhibitors. Therefore, ARBs should be used with caution in this patient population. //**Beta-Blockers:**// Beta-blockers are typically considered as adjunct therapy in the treatment of hypertension; however, in patients with a previous history of myocar-dial infarction, ischemic heart disease, arrhythmias, heart failure, or diabetes, they may be considered as first-line therapy. Beta-blockers are an effective therapy for hyper-tension, especially in young, white patients. They have also demonstrated benefits in patients who also suffer from angina pectoris, atrial fibrillation or tachycardia, hyperthyroidism, essential tremor, and migraine headaches.1,11,21-23 There are several mechanisms of action that have been postulated as to the antihypertensive effect of beta-blockers. No one mechanism can be attributed alone. Beta-blockers possess negative chronotropic and inotropic cardiac effects that reduce cardiac output. In addition, they reduce plasma renin activity. They have been proven to be beneficial antihypertensive agents, reducing mortality in patients.13 When choosing which beta-blocker to use in hyper-tensive therapy, a more cardioselective beta-blocker would be most appropriate. Cardioselective beta-blockers (atenolol, betaxolol, bisoprolol, and metoprolol) include those agents that have more affinity for the beta-1 receptors located in the heart. They produce fewer adverse effects than nonselective beta-blockers and may be a safer alternative for patients with asthma, chronic obstructive pulmonary disease, peripheral vascular disease, and diabetes. Unfortunately, the specificity of cardioselective agents is lost when higher doses are used. Nonselective beta-blockers have greater affinity for other beta-receptors such as the beta-2 receptors that are located in the lungs, smooth muscles, liver, and pancreas, causing bronchodilation and vasodilation. Agents that possess intrinsic sympathomimetic activity may be beneficial in patients who experience bradycardia with other beta-blockers. These agents include acebutolol, carteolol, penbutolol, and pindolol.

Adverse effects of beta-blockers are dependent on their ability to antagonize beta-receptors. Bradycardia results from blockade of beta-receptors in the myocardium. This is often a dose-limiting effect of beta-blockers; doses of beta-blockers cannot be increased if a patient’s heart rate is too low, due to risk of increased adverse effects such as dizziness and heart block. Caution must be used when giving beta-blockers to patients with heart failure. Although beta-blockers are not contraindicated in heart failure, extreme caution, care, and monitoring must be utilized. If beta-blockers are initialized at too high a dose in patients with heart failure, an acute attack could be induced; therefore, doses should be started extremely low and then titrated upward at two-week intervals. //**CCBs:**// Although CCBs are effective antihypertensive agents, they are not commonly prescribed as first-line agents in therapy. CCBs are more effective in treating African-American patients, the elderly, and patients with higher pretreatment blood pressure readings. Dihydropyridines, in particular, seem to be efficacious in the treatment of isolated systolic hypertension. CCBs also seem to have additive benefits when used to treat patients with concurrent migraine headaches, angina, and arrhythmias.1,21 CCBs prevent the transport of calcium in vascular smooth muscles, thereby causing a decrease in the force of contractility, vascular smooth muscle tone, and peripheral resistance. They are divided into two subclasses: dihydropyridines and nondihydropyridines. Both of these subclasses lower blood pressure; however, mechanistically, they act very differently. Nondihydropyridines (verapamil and diltiazem) decrease heart rate and slow the electrical conduction of the heart. This subclass is more commonly used to treat certain types of arrhythmias. In contrast, dihydropyridines do not block electrical conduction of the heart but produce a very potent vasodilating effect, causing reflex tachycardia. Adverse effects of CCBs can be categorized as vasodilatory, negative inotropic, conduction disturbances, gastrointestinal, and metabolic. The vasodilatory effects, which are more commonly seen with the dihydropyridines, include flushing, headaches, palpitations, hypotension, and peripheral edema. Verapamil is associated with the greatest negative inotropic effect as well as conduction disturbances and constipation. //**Alpha-Blockers:**// Alpha-blockers are commonly used as third- or fourth-line adjunct therapy in resistant forms of hypertension. They should only be used in combination with other antihypertensive therapies and never alone for the treatment of high blood pressure. An added benefit of the use of alpha-blockers is in men with benign prostatic hypertrophy (BPH). In the presence of BPH, an alpha-blocker may be higher up on the list of options to treat this patient’s blood pressure since there is a comorbid disease state that will benefit from its therapy.24 Alpha-blockers are commonly associated with ortho-static hypotension. It is essential to counsel patients who are prescribed this class of antihypertensive medication to be extra cautious when moving from a sitting to a standing position, as well as from a supine to a sitting position. This must be done extra slowly and carefully to allow the patient’s body to compensate blood flow. For this reason, most patients will not be able to tolerate the alpha-blockers as part of their antihypertensive therapy.

The use of alpha-blockers in hypertension is well established. This class of medication, however, is highly associated with rebound hypertension if the drug is stopped abruptly, which is due to a compensatory mechanism that causes an increase in norepinephrine release. Once again, patients must be notified of the critical importance of taking these medications exactly as prescribed. It is the pharmacist’s responsibility to assure that these patients are properly informed on the instructions for use. It should be emphasized to patients that if this medication cannot be tolerated, they must inform their physician, who may then slowly taper the patient off the medication. Of course, not all adverse events associated with every antihypertensive class have been discussed. Pharmacists should always refer to the prescribing information to ensure that they have a comprehensive list of all possible adverse events. Furthermore, it should be noted that various older antihypertensive therapies have not been discussed due to lack of use in current practice. Many recent studies have shown benefits of using ambulatory blood pressure monitoring, compared with traditional clinical blood pressure monitoring.26 Complications, such as white coat hypertension (i.e., blood pressure that is elevated in the physician’s office at 140/90 mmHg or higher on at least three readings, but normal outside of the physician’s office at less than 140/90 mmHg on at least two readings), can arise in the clinical setting when trying to assess a patient’s blood pressure, which can lead to a false diagnosis of hypertension. Ambulatory blood pressure monitoring has come a long way. Devices known as Holter monitors can now automatically record a patient’s blood pressure for 24 hours or longer without the patient having to hinder his or her normal daily activities. These devices are worn on a belt and connect via a plastic tube to a sphygmomanometer cuff, which is wrapped around the upper arm. Blood pressure readings are taken every 15 to 30 minutes throughout the course of the day and can be recorded into a computer for record keeping. This technique is beneficial not only for the patient but also for the health care provider in determining a patient’s diagnosis and assessing drug regimen.25 Many studies have been conducted comparing conventional clinical blood pressure monitoring with the newer ambulatory techniques. In general, findings have shown that the ambulatory technique is able to more accurately predict cardiovascular events than the conventional clinical technique.26 Patients will often seek the pharmacist’s help in purchasing a home blood pressure monitoring kit. Pharmacists should be educated not only about which kits are best for patients but also about how to teach patients about proper utilization of these kits. There are different types of blood pressure monitors, all with different levels of user friendliness and accuracy. Mercury sphygmo-manometers are usually used to check blood pressure; typically, these are the most common type of monitors used by health care professionals. The system has a mercury-filled column, an inflatable cuff, and a stethoscope. However, these monitors are infrequently recommended for patient use, since they require training on taking blood pressure readings. The most optimal recommendation for a home blood pressure monitoring kit would be automatic devices. Automatic devices usually come with a cuff attached to a unit that reads the patient’s blood pressure results. Some pumps must be manually inflated by the patient, requiring very little skill, while others are completely automatic, requiring the push of a start button to take the blood pressure reading. When recommending a blood pressure monitoring kit, the pharmacist should consider its affordability as well as its accuracy. The further the cuff is placed away from the heart, the less accurate the blood pressure reading will be. Therefore, the most optimal blood pressure monitor is one with a cuff that reads from the upper arm. Cuffs that read from the wrist run the chance of losing accuracy in readings.25,26
 * Ambulatory Blood Pressure Monitoring**
 * Choosing a Home Blood Pressure Monitoring Kit**

A few important guidelines must be conveyed to patients who choose to utilize home blood pressure monitoring (see **[|TABLE 5]**). If the machine is used incorrectly, then blood pressure readings will be inaccurate. The most common errors made when utilizing home blood pressure monitoring kits include using the wrong cuff size and positioning the arm incorrectly. Using a blood pressure cuff that is the wrong size can greatly impact blood pressure readings. A cuff that is too small or tight around the upper arm will give a blood pressure reading that is elevated. Pharmacists should make sure that the patient’s needs are met when determining cuff size. A larger or smaller cuff can always be ordered to ensure proper use of the monitor. Arm position during the blood pressure reading is also extremely important. The arm should be correctly positioned at heart level when obtaining a blood pressure reading to ensure accuracy. In order to achieve the most accurate readings, it is also crucial that the patient knows to take his or her blood pressure at the same time each day. Readings can differ throughout the day; blood pressure may be high in the morning and lower at nighttime. Furthermore, using caffeine, alcohol, or tobacco products 30 minutes prior to taking one’s blood pressure will result in higher readings, so the patient should be advised to stay away from these products. The patient should also be advised to sit down and remain seated for at least two minutes before taking the measurement. Often times, patients do not fully understand why they are taking multiple medications to treat the same disease and will choose to take only one or two medications. In order for antihypertensive therapy to be effective, patients must be motivated to be compliant with all their medications. Therefore, pharmacists should use positive reinforcement to promote patient adherence. By establishing a relationship with the patient, the pharmacist will be able to better understand the patient’s health perceptions and counsel him or her on each medication as well as on its role in therapy. By telling patients that each drug lowers blood pressure in a unique and individual manner to help achieve their blood pressure goals, pharmacists can encourage better compliance and positive therapy management. It is imperative to inform the patient about the importance of the treatment plan. Patients should be aware of their blood pressure goal and be encouraged to utilize a home blood pressure monitoring system. In addition, patients should be reminded to take their blood pressure medications prior to an office visit. Many patients purposely skip their medications prior to a physician appointment, because they are misinformed or they misunderstand the purpose of doing so. As a result, their blood pressure becomes falsely elevated and may be interpreted as uncontrolled, leading to increased dosage strengths or the inappropriate utilization of additional medications.
 * **Table 5** ||
 * ****Important Tips for Patients Taking Home Blood Pressure Readings**** ||
 * Patients Should**
 * Empty bladder
 * Remain quiet
 * Be seated and rest for two minutes prior to reading
 * Take blood pressure on both arms
 * Take two readings and average them together
 * Be sure that cuff is placed properly on arm
 * Take blood pressure at the same time every day
 * Patients Should Not**
 * Drink caffeine within 60 minutes of reading
 * Smoke within 30 minutes of reading
 * Wear tight clothing on the arm or forearm
 * Take substances that contain stimulants
 * Be under stress, anxious, or in pain ||
 * Counseling Patients**
 * Counseling Patients**

When counseling patients on antihypertensive therapy, pharmacists should stress the importance of routine follow-ups and monitoring. Follow-ups are necessary to determine if treatment should be adjusted. Some patients may also need additional treatments or dosage adjustments. Patients should be warned about dangerous side effects that can occur if they alter medication doses or discontinue drugs on their own.

Pharmacists have the opportunity to become disease state educators; they should educate patients on lifestyle modifications and counsel on hypertension medications. Taking the time and effort to review a patient’s medication enables the pharmacist to teach and reinforce the benefits of drug therapy. It is important for pharmacists to keep up to date with new medications, treatments, and guidelines in order to provide optimal patient care. Pharmacists also have a key role in helping patients control blood pressure through nonpharmacologic interventions. Patients should be advised to follow lifestyle modifications; following a diet plan that is low in sodium and exercising can provide efficient weight loss. In addition to diet and exercise, smoking cessation is an important lifestyle modification that patients should be counseled about. Pharmacists should not only point out the importance of these lifestyle modifications but also assist patients in developing a realistic plan and routine. Although pharmacists cannot force patients to quit smoking, they should strongly encourage patients to do so. Patients should feel that, when they are ready, they have the pharmacist’s support and help. Overall, it is important to make sure that patients are aware of all of the pharmacologic and nonpharmaco-logic methods that can help control their disease state. Patients should also understand the consequences that can occur if hypertension isn’t properly managed. Exercise, along with lifestyle modifications, drug therapy, and patient education, is vital to maintaining adequate blood pressure goals. By stressing these points, pharmacists can not only control blood pressure but also decrease the incidence of cardiovascular events. Elvis is a 58-year-old man who comes to your pharmacy to get information about high blood pressure. He sees a cardiologist for high cholesterol and is urged to see a generalist to manage this and other issues. The cardiologist recently placed him on atenolol for hypertension. He has not started it because his blood pressure readings are always normal at home, ranging from 112-134/54-84 mmHg—his daughter, a certified nursing assistant, takes his blood pressure. His blood pressure readings are only high when taken in his doctor’s office. “I feel nervous when I go see the cardiologist, and then my blood pressure is high,” he says. He reports that his blood pressure has been 200/100 mmHg in the cardiologist’s office, but he feels he does not need medication. //1. Does this man meet the diagnostic criterion for hypertension?// No, this is a typical case of white coat syndrome. The pharmacist should be sure to tell the patient to keep a log of his blood pressure readings that his daughter takes at home. He should record not only the blood pressure reading but also the time at which the reading was taken. //2. Would you tell him to start taking atenolol?// No. This patient should first try lifestyle modifications. Losing weight and starting an exercise routine should keep his blood pressure under control. If this patient develops hypertension, then the drug of choice to start him on would be a thiazide diuretic.
 * ****Case Study 1**** ||

Sandra is a 65-year-old woman with diabetes. Her blood pressure has been difficult to control despite multiple medications. ACE inhibitors have been avoided because of borderline hyperkalemia. Except for mild exertional dyspnea, she is asymptomatic, although she reports episodes of pedal edema after prolonged dependency. She has not taken her “water pills” today, because she wishes to avoid urinary frequency during her medical visit. Her medications include hydrochlorothiazide 50 mg twice per day, propranolol 60 mg three times per day, and clonidine 0.2 mg twice per day; fluticasone 110-mcg metered dose inhaler as needed; insulin glargine 10 U at bedtime; and sliding scale regular insulin before breakfast and dinner. //1. Why is she not at her blood pressure treatment goal?// Sandra is not at her treatment goal due to noncompliance. The pharmacist should counsel the patient on the increased cardiovascular disease risk associated with uncontrolled blood pressure. //2. How would you manage her?// Her therapy is also not optimized. The hydrochlorothiazide is at a dose that is above a clinical therapeutic dosage; 50 mg twice per day is only adding unwanted additional side effects that she is complaining of. This dose can be cut back to 25 mg daily. A low-dose ACE inhibitor is strongly recommended for this patient, especially since she also has diabetes—ACE inhibitors have been shown to be kidney protective in patients with diabetes. Her potassium level should be monitored carefully to avoid any further increase in her potassium level. She should be instructed to avoid foods that are high in potassium, such as bananas, kiwis, and orange juice. Propranolol is a nonselective beta-blocker that is not optimal for treating her blood pressure and is inconvenient to take three times per day. Switching to a more selective beta-blocker such as Toprol XL will increase the patient’s compliance, thereby better controlling her blood pressure. For now, clonidine therapy should be discontinued, and the patient should be reassessed. Clonidine is last-line treatment for blood pressure, and the patient has many other options (including increases in dosages) that she may utilize prior to using these agents. Clonidine should not be stopped abruptly, however. A taper of the dosage should be used cautiously to avoid rebound hypertension. 1. Chobanian AV, Bakris GL, Black HR, et al. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. //Hypertension//. 2003;42:1205-1252. 2. Hing E, Cherry DK, and Woodwell DA. National ambulatory medical care survey: 2004 summary. //Advance Data//. 2006;374:1-36. 3. Wang Y, Wang QJ. The prevalence of prehypertension and hypertension among US adults according to the new joint national committee guidelines: new challenges of the old problem. //Arch Intern Med//. 2004;164:2126-2134. 4. Wexler R, Aukerman G. Nonpharmacologic strategies for managing hypertension. //Am Fam Physician//. 2006;73:1953-1956. 5. Sacks FM, Svetkey LP, Vollmer WM, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. //N Engl J Med//. 2001;344:3-10. 6. Xin X, He J, Frontini MG, et al. Effects of alcohol reduction on blood pressure: a meta-analysis of randomized controlled trials. //Hypertension//. 2001;38:1112-1117. 7. Whelton SP, Chin A, Xin X, et al. Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials. //Ann Intern Med//. 2002;136:493-503. 8. Schotte DE, Stunkard AJ. The effects of weight reduction on blood pressure in 301 obese patients. //Arch Intern Med//. 1990;150:1701-1704. 9. Effects of weight loss and sodium reduction intervention on blood pressure and hypertension incidence in overweight people with high-normal blood pressure. The Trials of Hypertension Prevention, phase II. The Trials of Hypertension Prevention Collaborative Research Group. //Arch Intern Med//. 1997;157:657-667. 10. He J, Whelton PK, Appel LJ, et al. Long-term effects of weight loss and dietary sodium reduction on incidence of hypertension. //Hypertension//. 2000;35:544-549. 11. ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs. diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trail (ALLHAT). //JAMA//. 2002;288(23):2981-2997. 12. SHEP Cooperative Research Group. Prevention of stroke by antihyper-tension: final results of the Systolic Hypertension in the Elderly Program (SHEP). //JAMA//. 1991;265:3255-3264. 13. Dahlof B, Lindholm LH, Hansson L, et al. Morbidity and mortality in the Swedish Trial in Old Patients with Hypertension (STOP-Hypertension). //Lancet//. 1991;338:1281-1285. 14. Saseen JJ, MacLaughlin EJ, Westfall JM. Treatment of uncomplicated hypertension: are ACE inhibitors and calcium channel blockers as effective as diuretics and beta-blockers? //J Am Board Fam Pract//. 2003;16:156-164. 15. Wing LM, Reid CM, Ryan P, et al. A comparison of outcomes with angiotension-converting enzyme inhibitors and diuretics for hypertension in the elderly. //N Engl J Med//. 2003;348:583-592. 16. Arauz-Pacheco C, Parrott MA, Raskin P. The treatment of hypertension in adult patients with diabetes. //Diabetes Care//. 2002;25:134-147. 17. Hansson L, Lindholm LH, Ekbom T, et al. Randomised trial of old and new antihypertensive drugs in elderly patients: cardiovascular mortality and morbidity the Swedish Trial in Old Patients with Hypertension-2 study. //Lancet//. 1999;354:1751-1756. 18. Pylypchuk GB. Ace inhibitor– versus angiotensin II receptor blocker–induced cough and angioedema. //Ann Pharmacother//. 1998;32:1060-1066. 19. Pitt B, Segal R, Martinez FA, et al. Randomised trial of losartan versus captopril in patients over 65 with heart falure (Evaluation of Losartan in the Elderly Study, ELITE). //Lancet//. 1997;349:747-752. 20. Brenner BM, Cooper ME, de Zeeuw D, et al. Effect of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. //N Engl J Med//. 2001;345:861-869. 21. Staessen JA, Wang JG, Thijs L. Cardiovascular prevention and blood pressure reduction: a quantitative overview updated until March 2003. //J Hypertens//. 2003;21:1055-1076. 22. Self TH, Soberman JE, Bubla JM, et al. Cardioselective beta-blockers in patients with asthma and concomitant heart failure or history of myocardial infarction: when do benefits outweigh risks? //J Asthma//. 2003;40:839-845. 23. Salpeter SR, Orminston TM, Salpeter EE. Cardioselective ?-blockers in patients with reactive airway disease: a meta-analysis. //Ann Intern Med//. 2002;137:715-725. 24. Diuretic versus alpha blocker as first step antihypertensive therapy: final results from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack (ALLHAT). //Hypertension//. 2203;42:239-246. 25. Bickley, L. //Bates’ Guide to Physical Examination and History Taking//. 8th ed. Philadelphia, PA: Lippincott. 2003. 26. Pickering TG, Shimbo D, Haas D. Ambulatory blood pressure monitoring. //N Engl J Med//. 2006;354:2368-2374.
 * ****Case Study 2**** ||
 * REFERENCES**
 * REFERENCES**