Treating hypertension in the primary care population

Hypertension is the most important modifiable risk factor that can be treated medically, and better overall cardiovascular and renal outcomes are directly dependent on better control of systolic hypertension by primary care physicians. Systolic blood pressure (BP) increases with age in all gender and ethnic groups in industrialized societies. An individual with normotensive BP who is 55 to 65 years of age still has a 94% likelihood of developing hypertension (BP >140/90 mm Hg) if he/she lives an additional 20 years. Isolated systolic hypertension is the predominant type of hypertension, occurring in all age groups, especially in those patients older than 65 years. Cardiovascular risk is related logarithmically to systolic BP: each increment of 20 mm Hg in systolic BP (or 10 mm Hg in diastolic BP) above the range of 115/75 to 185/115 mm Hg is associated with a 2-fold increase in mortality from ischemic heart disease or stroke. Drugs to treat hypertension partially correct inappropriate balances among the 3 major interacting pathophysiologic systems that control BP: the sympathetic nervous system, the renin-angiotensin- aldosterone system, and the kidneys. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure provides a streamlined management approach to hypertension for the primary care physician. The report's general principles of care emphasize lifestyle modifications and combination antihypertensive drug therapy, including the initial use of combinations for stage 2 hypertension. Special therapeutic considerations are recommended for high-risk individuals with "compelling indications" (eg, diabetes mellitus, chronic kidney disease, heart failure, coronary heart disease/high coronary risk, or recurrent stroke).