Controversies in hypertension therapy. How to choose best treatment? 8
Decisions on high blood pressure treatment are complex and highly personalized. Hypertension treatment guidelines are 98 pages long. Leading hypertension expert explains key debated issues on how to treat hypertension best. Hypertension treatment requires complex decisions about the therapy. Dr. Anton Titov, MD. We have already discussed it. But nevertheless there are some controversies. There are some particular nuances of hypertension treatment. Dr. Anton Titov, MD. Could you discuss controversies in hypertension treatment? Dr. Ehud Grossman, MD. The controversy is mainly what should be the target of blood pressure in hypertension treatment. Blood pressure control target is important especially for the elderly. What medication should be the first medication of choice in treatment of hypertension? Dr. Ehud Grossman, MD. How deep you have to evaluate the patient for secondary causes of hypertension? Sometimes you need to do a genetic consultation in hypertension. There are controversies, but today they are less controversial. We still have a controversy about optimal blood pressure target. Whether it should be 130/80 or 140/90? When to define a patient as hypertensive? Dr. Anton Titov, MD. Whether to use the beta-blocker or not use the beta blocker? Whether to start with ACE inhibitor or not? Not too many hypertension therapy controversies, but we have some. Let’s discuss pharmacological therapy of hypertension. Treatment of hypertension is complex. It often requires a combination of medications. There is a broad concept of “old medications” for hypertension. Then there are “new medications” for high blood pressure.They are also used in combination. There are some reviews in the literature. You co-authored one of the reviews that discusses relative merits of hypertension medications. There are pros and cons of new hypertension medication combinations vs. old hypertension medication combinations. Dr. Ehud Grossman, MD. Yes, in the last few years, unfortunately, last 5-6 years, we don’t have new medications to treat hypertension. The “new medications” now are also “old medications” for hypertension treatment. In the past we used more beta-blockers and diuretics. These were the basic cornerstones of hypertension treatment. Then we had the ACE inhibitors and Angiotensin receptor blockers [ARBs]. We had calcium channel blockers [CCBs]. Now we know that the combination of ACE inhibitor or Angiotensin receptor blocker with the calcium channel blocker is the best combination to get targeted blood pressure. It is also the best combination to prevent end organ damage and heart attacks and strokes. Then the third medication is the diuretic. We add diuretic to the combination of hypertension treatment. Beta blocker was one of the lead medications in the past to treat high blood pressure. Dr. Anton Titov, MD. Beta-blockers are now less popular. We know today that it protects less cardio vascular system. Dr. Ehud Grossman, MD. We don’t know exactly why. But these are the facts. Beta-blockers are less efficient, especially in the elderly. That’s why we keep the beta blocker for certain cases of hypertension. We use beta blockers when there is an indication to give a beta blocker. we give beta blocker after myocardial infarction and tachyarrhythmia. Of course, in the elderly beta-blockers would carry more potential side effects. Yes, more side effects and less benefit. So in the elderly, definitely, we would go to diuretic, ACE inhibitor and calcium channel blockers. Among diuretics there are also some relatively new medications like indapamide. It’s amazing. Because most of the positive clinical trials with diuretics were done with chlorthalidone. Dr. Ehud Grossman, MD. But in practice now you mostly use Hydrochlorothiazide. Some clinical trials with hydrochlorothiazide failed. This means hydrochlorothiazide was less beneficial than the calcium antagonist. There is another medication in Israel, indapamide. There is data about the benefit of indapamide, especially in the elderly. So I prefer today to use a fixed dose combination of ACE inhibitor or angiotensin receptor blocker and calcium antagonist to treat hypertension. Sometimes the patient does not reach the blood pressure goal with this combination. Then I add diuretic, since the diuretic is not part of the fixed dose combination. We use today indapamide. Dr. Ehud Grossman, MD. Because indapamide in several clinical trials showed very positive effect on hypertension. It is despite the fact that indapamide is very similar to hydrochlorothiazide. It is much better. Dr. Anton Titov, MD. There are also some fixed-dose combinations of ACE inhibitors with indapamide. Yes, but not in Israel. Dr. Ehud Grossman, MD. Sometimes you have a combination of ACE inhibitor and indapamide, and you on top of it use a calcium antagonist, or you have an option of ACE inhibitor and calcium antagonist and then on top of it add diuretic indapamide.
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