Blood pressure goals

Criteria for initiation of drug treatment now take into consideration total cardiovascular risk rather than blood pressure alone, such that treatment is now recommended for persons whose blood pressure is in the normal range but still bear a heavy burden of cardiovascular risk factors. Thus, the role of simultaneous reduction of multiple cardiovascular risk factors in improving prognosis in hypertensive patients is stressed. In addition, more aggressive blood pressure goals are recommended for hypertensive patients with comorbid conditions such as diabetes mellitus or renal insufficiency. 

Evaluate the patient if pharmacologic treatment has reached the target blood pressure goal. If the patient is at the goal, skip to step 8. 

CKD compared to patients with normal kidney function. All antihypertensive agents have similar effects on reducing blood pressure. However, three or more agents are generally required to achieve the blood pressure goal of less thanl30/80 mm Hg in CKD patients. 

Bakris GL. A practical approach to achieving recommended blood pressure goals in diabetic patients. Arch Intern Med 2001 161 2661-2667. 

Unfortunately, the percentage of hypertensive older men and women being treated is lower than doctors would like to see. And of those receiving treatment, the number of older people achieving their blood pressure goals is far from desirable. 

Initial therapy choices for hypertension in diabetes mellitus usually include angiotensin-converting enzyme inhibitors or an angiotensin receptor blocker due to their well documented renoprotective effects. Currently, angiotensin receptor blockers have less robust data to support cardiovascular reduction compared to other therapeutic choices, yet the data that exists appears to be positive in patients with type 2 DM. Also, diuretics have shown superior results to an ACE inhibitor in the ALLHAT trial. The ADA currently recommends the use of any class (ACE inhibitors, angiotensin receptor blockers, /3-blockers, diuretics, or calcium channel blockers) of antihypertensive medication that has shown benefit in prevention of poor cardiovascular outcomes. Choice of monotherapy may not be important, as an average of two to three antihypertensive medications are needed to reach blood pressure goals. 

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