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ABSTRACT: About one half of patients who have essential hypertension have obstructive sleep apnea, and about one half of patients who have obstructive sleep apnea have essential hypertension. A growing body of evidence suggests that obstructive sleep apnea is a major contributing factor in the development of essential hypertension. Despite many patients with obstructive sleep apnea having clear symptoms of the disorder, an estimated 80 to 90 percent of cases are undiagnosed. When physicians routinely seek the diagnosis of obstructive sleep apnea by asking patients (especially those with hypertension) three basic sleep-related questions about snoring, excessive daytime sleepiness and reports of witnessed apneic events, the number of cases diagnosed and treated increases by about eightfold. Eliminating snoring and occurrences of apneic-hypopneic episodes will dramatically improve patients' quality of sleep and eliminate excessive daytime sleepiness, which has a detrimental effect on general functioning. Increased alertness will reduce the likelihood that patients will be involved in motor vehicle crashes. In most studies in which blood pressure was measured following treatment for obstructive sleep apnea, daytime and nighttime blood pressure levels were found to decrease significantly. This decrease in blood pressure may also reduce the likelihood of cardiovascular complications. The key to the diagnosis of obstructive sleep apnea is physician knowledge about the disorder. The dramatic improvement in quality of life that occurs when patients are successfully treated for obstructive sleep apnea makes detecting and treating this disorder imperative.
ABSTRACT: Hypertension is a common comorbidity in patients with diabetes, and adequate control of blood pressure significantly reduces the risk of macrovascular and microvascular complications. Patients with diabetes should achieve a target blood pressure of less than 130/80 mm Hg. The use of angiotensin-converting enzyme inhibitors may slow progression to kidney failure and cardiovascular mortality; these agents are the preferred therapy for managing coexisting diabetes and hypertension. Angiotensin receptor blockers can prevent progression of diabetic kidney disease and are a first-line alternative for patients intolerant of angiotensin-converting enzyme inhibitors. Thiazide diuretics provide additional antihypertensive effects when combined with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. With lower doses of these drugs, the risk of clinically significant metabolic alterations is minimal. Beta blockers and calcium channel blockers also have beneficial effects in managing hypertension in patients with diabetes. Beta blockers reduce cardiovascular events and are useful in a multidrug regimen. Dihydropyridine calcium channel blockers should be reserved for patients intolerant of preferred agents or those who need additional therapy to achieve target blood pressure. Many patients with diabetes require combination therapy with multiple antihypertensive agents.
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Risk-Assessment Tools for Detecting Undiagnosed Diabetes - Point-of-Care Guides
Screening for High Blood Pressure - Putting Prevention into Practice
ABSTRACT: High blood pressure is often difficult to control. Resistant hypertension is blood pressure above goal despite adherence to a combination of at least three antihypertensive medications of different classes, optimally dosed and usually including a diuretic. The approach to blood pressure that is apparently difficult to control begins with an assessment of the patient's adherence to the management plan, including lifestyle modifications and medications. White-coat hypertension may need to be ruled out. Suboptimal therapy is the most common reason for failure to reach the blood pressure goal. Once-daily fixed-dose combination pills may improve control through the synergism of antihypertensive agents from different classes and improved adherence. Truly drug-resistant hypertension is commonly caused by chronic kidney disease, obstructive sleep apnea, or hyperaldosteronism, all of which can lead to fluid retention. Higher doses of diuretics (or a change to a loop diuretic) are usually needed. Other strategies include adding an alpha blocker, alpha-beta blocker, clonidine, or an aldosterone antagonist (e.g., spironolactone). Particularly in patients with diabetes or renal disease, combining a long-acting nondihydropyridine with a dihydropyridine calcium channel . blocker can also be considered. Obesity, heavy alcohol intake, high levels of dietary sodium, and interfering substances (especially nonsteroidal anti-inflammatory drugs) contribute to hypertension that is resistant or difficult to control.
A Tool for Evaluating Hypertension - Improving Patient Care
ABSTRACT: Poorly controlled hypertension is a common finding in the outpatient setting. When patients present with severely elevated blood pressure (i.e., systolic blood pressure of 180 mm Hg or greater, or diastolic blood pressure of 110 mm Hg or greater), physicians need to differentiate hypertensive emergency from severely elevated blood pressure without signs or symptoms of end-organ damage (severe asymptomatic hypertension). Most patients who are asymptomatic but have poorly controlled hypertension do not have acute end-organ damage and, therefore, do not require immediate workup or treatment (within 24 hours). However, physicians should confirm blood pressure readings and appropriately classify the hypertensive state. A cardiovascular risk profile is important in guiding the treatment of severe asymptomatic hypertension; higher risk patients may benefit from more urgent and aggressive evaluation and treatment. Oral agents may be initiated before discharge, but intravenous medications and fast-acting oral agents should be reserved for true hypertensive emergencies. High blood pressure should be treated gradually. Appropriate, repeated follow-up over weeks to months is needed to reach desired blood pressure goals.
Increasing the Success of Antihypertensive Therapy - Editorials