Primary hypertension
1. Traditionally, BP is measured in the office setting by mercury or aneroid BP devices; however, electronic (oscillometric) devices are being used in influential studies and are gaining acceptance as an alternative.
2. Home BP monitoring is better than office BP monitoring and is equivalent to ambulatory daytime BP monitoring for predicting cardiovascular events as well as a useful adjunct to guide management and improve patient adherence.
3. Ambulatory BP monitoring serves an important purpose to:
a. exclude white coat hypertension
b. define masked hypertension (BP elevated outside the office under high-stress conditions)
c. help define the presence of dipping during sleep; and
d. help define salt-sensitive-related elevations in BP
4. Prior to evaluating for secondary causes of hypertension, a thorough evaluation for more common contributing causes—high-salt diet, sleep apnea—should be conducted.
5. BPs below 140/90 mm Hg consistently reduce cardiovascular risk. More recent evidence suggests further mortality reductions with pressures as low as 120/80 in select populations.
Patients with advanced proteinuric kidney disease benefit from pressures below 130/80 mm Hg for cardiovascular risk reduction and, to a lesser degree, for additional CKD slowing. Among those with nondiabetic CKD, the high-quality Modification of Diet in Renal Disease and the African American Study of Kidney Disease and Hypertension (AASK) studies showed no benefit of lowering BP below 130/80 mm Hg with respect to the progression of CKD. However, in post hoc analysis of the AASK trial, among those with heavy proteinuria, BPs <130/80 offered additional benefit on slowing CKD progression.
There are no randomized trials evaluating the effects of different BP goals on the progression of diabetic nephropathy. Post hoc analysis suggests pressures of 130 to 140/80 to 90 are adequate, but prospective trials have yet to test this recommendation.
- 6. Patients who have a history of hypokalemia while off diuretics and blockers of the renin angiotensin system should have a 24-hour urine for sodium and total creatinine if, after counseling regarding a low-sodium diet, they have recurring hypokalemia. Primary hyperaldosterism should be considered if the patient has <2300 mg/day sodium intake.
- 7. While agent selection is tailored to the needs of the individual patient, thiazide-like diuretics have the longest track record and are particularly useful in those with salt-sensitive hypertension, such as the elderly, African Americans, the obese, and those with CKD.
