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Treating Newly Diagnosed Asymptomatic Hypertension



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Am Fam Physician. 2002 Oct 15;66(8):1547-1548.

In patients with diastolic blood pressures between 115 and 129 mm Hg, only three patients require treatment to prevent one death, stroke, or myocardial infarction. In other forms of hypertension, the numbers needed to treat to prevent cardiovascular or cerebrovascular events depend largely on age and additional risk factors (see the accompanying table). The measurable benefits of treating asymptomatic hypertension are highlighted by A'Court in a case-based guide to managing the patient with newly detected hypertension.

In patients with newly diagnosed hypertension, the medical history should address symptoms of end-organ disease—especially coronary artery disease—and include questions concerning contraindications to antihypertensive medications. A detailed history can reveal potential additional medical benefits that may result from selection of specific antihypertensive agents. Patients also should be asked about symptoms of renal parenchymal disease and other causes of secondary hypertension, although only 5 percent of hypertension cases result from secondary causes. Family history is especially important for hypertension and related conditions, as well as in assessing cardiac risk. The history also should address exercise habits, diet (especially salt intake), alcohol use, and use of medications such as steroids and nonsteroidal antiinflammatory drugs.

Consideration should be given to discontinuing or changing any routine medications that affect blood pressure, and all patients who use tobacco should be assisted to quit. Advice and written information on hypertension and the benefits of reducing blood pressure should be provided. The Mediterranean diet and a reduction in dietary salt and alcohol should be recommended. An exercise program should be started, and patients should be given information about organizations, support groups, and Web sites that assist patients with hypertension. Physical examination should concentrate on cardiovascular function and include funduscopy. Initial laboratory investigations include electrocardiography, urinalysis, blood chemistry and lipoprotein studies, and screening for diabetes.

Benefits of Treating Hypertension Vary by Severity of Hypertension, Age, and Formally Estimated Risk Level

Treatment and problem Events prevented NNT for five years to prevent one event

Antihypertensives for severe diastolic hypertension (115 to 129 mm Hg)

Death, stroke, myocardial infarction

3

Antihypertensives for mild or moderate diastolic hypertension (90 to 109 mm Hg)

Death, stroke, myocardial infarction

141

Antihypertensives for uncomplicated hypertension, no risk assessment (age 70 to 84)

Stroke

34

Antihypertensives for uncomplicated hypertension, no risk assessment (age 60)

Stroke

43

Antihypertensives for uncomplicated hypertension, no risk assessment (age 36 to 64)

Stroke

850

Antihypertensives if 10-year CHD risk is 30 percent (cardiovascular risk 40 percent)

Cardiovascular event

20

Antihypertensives if 10-year CHD risk is 15 percent (cardiovascular risk 20 percent)

Cardiovascular event

40


NNT = number needed to treat; CHD = coronary heart disease.

Adapted with permission from A'Court C. 10-minute consultation: newly diagnosed hypertension. BMJ 2002;324:1375.

Benefits of Treating Hypertension Vary by Severity of Hypertension, Age, and Formally Estimated Risk Level

View Table

Benefits of Treating Hypertension Vary by Severity of Hypertension, Age, and Formally Estimated Risk Level

Treatment and problem Events prevented NNT for five years to prevent one event

Antihypertensives for severe diastolic hypertension (115 to 129 mm Hg)

Death, stroke, myocardial infarction

3

Antihypertensives for mild or moderate diastolic hypertension (90 to 109 mm Hg)

Death, stroke, myocardial infarction

141

Antihypertensives for uncomplicated hypertension, no risk assessment (age 70 to 84)

Stroke

34

Antihypertensives for uncomplicated hypertension, no risk assessment (age 60)

Stroke

43

Antihypertensives for uncomplicated hypertension, no risk assessment (age 36 to 64)

Stroke

850

Antihypertensives if 10-year CHD risk is 30 percent (cardiovascular risk 40 percent)

Cardiovascular event

20

Antihypertensives if 10-year CHD risk is 15 percent (cardiovascular risk 20 percent)

Cardiovascular event

40


NNT = number needed to treat; CHD = coronary heart disease.

Adapted with permission from A'Court C. 10-minute consultation: newly diagnosed hypertension. BMJ 2002;324:1375.

The author recommends formal assessment of cardiovascular disease risk as a guide to specific treatment of hypertension. Comprehensive therapy can include statins and other interventions to prevent cardiovascular events, as well as to control blood pressure.

A'Court C. 10-minute consultation: newly diagnosed hypertension. BMJ. June 8, 2002;324:1375.



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