Hypertension in the elderly is mainly systolic. Trials especially addressing treatment of isolated systolic hypertension have shown the benefits of thiazides and calcium channels blockers (CCBs).
Certain trials like LIFE showed the advantages of angiotensin receptors blockers (ARBs) in the treatment of hypertension in elderly, especially in patients with left ventricular hypertrophy (LVH).
The recommended target blood pressure in diabetic hypertensive patients is
In all individuals with metabolic syndrome, intense lifestyle measures should be adopted. When there is hypertension, drug treatment should start with a drug unlikely to facilitate onset of diabetes. Therefore a blocker of the renin-angiotensin system should be used followed, if needed, by the addition of a calcium antagonist or a low dose of thiazide diuretic.
Resistant hypertension is seen quite frequently in clinical practice and the possible causes include: poor adherence to the therapeutic plan, failure to modify lifestyle including weight gain, continued intake of drugs that raise blood pressure, obstructive sleep apnea, unsuspected secondary cause, irreversible or scarcely reversible organ damage and volume overload due to inadequate diuretic therapy, progressive renal insufficiency, high sodium intake, and hyperaldosteronism.
Resistant hypertension can be managed by careful elicitation of the history, a meticulous examination and good investigational take up. Ambulatory blood pressure monitoring is recommended. Test whether compliance is good or not. Administration of more than 3 drugs. Use of aldosterone antagonists in low doses. Use of endothelin antagonists (investigational). Interventional therapy includes chronic field stimulation of carotid sinus nerves and renal artery denervation.
Several large-scale population-based studies in different parts of the world indicate that only 25-30% of hypertensive patients actually achieve target blood pressure with life style and medicinal measures.
Inadequate blood pressure control is due to a number of factors related to misdiagnosis, doctor-and-patient related causes. The most important causes are improper blood pressure recording techniques, physician inertia, and patient non-compliance to therapy.
Several large-scale international studies show that more than 75% of patients require more than one drug to achieve target blood pressure.
Various combinations can be preferred. They include thiazide diuretics with angiotensin converting enzyme (ACE) inhibitors, angiotentin receptor blockers (ARBs) or dihydropyridines; dihydropyridines with ACE-inhibitors, ARBs or beta-blockers.
The major advantages of the use of fixed dose combinations are: (1) they improve patient compliance to antihypertensive therapy; (2) they improve the degree of blood pressure control; (3) they reduce the number of adverse events.
