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Dyslipidemia

Epidemiology of Hyperlipidemia Prevalence Elevated cholesterol is a well-established and modifiable risk factor for cardiovascular disease (CVD). In 2008 there were an estimated 17.3 million CVD deaths worldwide, 2.6 million (15%) of which were caused by hyperlipidemia. Data from the 2012 National Health and Nutrition Examination Survey (NHANES) indicated that nearly 31 million (13%) adults in the United States over the age of 20 years have…

Diabetes Mellitus

Diabetes mellitus (“diabetes”) and hypertension, which commonly coexist, are global public health issues contributing to an enormous burden of cardiovascular disease, chronic kidney disease, and premature mortality and disability. The presence of both conditions has an amplifying effect on risk for microvascular and macrovascular complications. The prevalence of diabetes is rising worldwide ( Fig. 37.1 ). Both diabetes and hypertension disproportionately affect people in middle and…

Cerebrovascular Disease

Raised blood pressure has been referred to as the crown jewel of stroke prevention, and blood pressure lowering has been the focus of substantial study in acute stroke and recurrent stroke prevention as a means to improve outcomes. In this chapter we discuss hypertension and stroke within the context of acute and chronic stroke management. To provide a framework for subsequent discussion of acute and chronic…

Obesity

Association of Obesity And Hypertension Obesity has been called the epidemic of our time with approximately 70% of the adults in the United States either overweight or obese according to the American Heart Association (AHA) and the American Physiological Society. Estimates based on risk suggest that as much as 65% to 70% of essential hypertension occurs in association with obesity, although longitudinal population based studies indicate…

Transplant Hypertension

Hypertension is a common feature after solid organ transplantation, related to preexisting disease, the vascular effects of immunosuppressive medications, and in the setting of renal transplantation, the presence of acute or chronic allograft morbidity. Transplant patients frequently carry a heavy burden of atherosclerotic disease involving multiple vascular beds and thus are at increased risk for cardiovascular events including myocardial infarction, congestive heart failure, and stroke. Hypertension…

Hypertension and Chronic Kidney Disease

Chronic kidney disease (CKD) is defined by laboratory findings of a decreased estimated glomerular filtration rate (eGFR) to less than 60 mL per minute per 1.73 m 2 or evidence of renal parenchymal injury (i.e., albuminuria > 300 mg/day) present for 3 months or more. Both the Kidney Disease Outcomes Quality Initiative (KDOQI) and Kidney Disease Improving Global Outcomes (KDIGO) classify CKD into five stages based…

Heart Failure

The burden of heart failure remains ever present with a long-standing, inexorable association with hypertension. Though advances in evidence-based medical therapy for reduced ejection fraction heart failure have led to impressive reductions in morbidity and mortality, the residual burden of disease remains significant. Heart failure is recognized as any condition characterized by a mismatched relationship between metabolic, exercise, and/or cognitive needs and cardiac performance. Several important…

Hypertension in Ischemic Heart Disease

Hypertension and ischemic heart disease (IHD) are strongly related and the two co-occur frequently, particularly in aging populations. Both conditions cause or contribute to substantial disability and mortality worldwide and both are responsible for substantial health care use and economic burden. IHD affects only around 6% of adults in the United States but is the leading proximal cause of death in the U.S. with an age-adjusted…

Approach to Difficult to Manage Primary Hypertension

Primary, formerly essential, hypertension accounts for about 90% of cases of hypertension. Reduction in systolic and diastolic blood pressure in patients with primary hypertension reduces the risk for cardiovascular (CV) events including myocardial infarction, stroke, and congestive heart failure as well as a reduction in development and progression of chronic kidney disease (CKD). It is important to properly identify individuals with hypertension and document the type…

Alternative Approaches for Lowering Blood Pressure

High blood pressure (BP) is the leading risk factor for global morbidity and mortality. Clinical trials in hypertension have largely focused on the efficacy of oral medications to lower BP and reduce cardiovascular events. However, a variety of other nonpharmacologic treatments have been developed and studied with varying degrees of scientific rigor. The focus of this chapter is to review the BP-lowering efficacy of therapeutic approaches…

Device Therapies

Hypertension remains an almost ubiquitous entity as a chronic disease around the world today. Its relevance lies in the fact that it is one of the most common risk factors responsible for cardiovascular morbidity and mortality. It is estimated that there are over 78 million adults in the United States who have hypertension, with African Americans having the highest prevalence of hypertension in the world. Despite…

Use of Combination Therapies

Heart disease is the leading cause of death in the United States and hypertension is an important risk factor for cardiovascular (CV) disease. Affecting up to 30% of the population, when hypertension is well controlled it reduces the risk of CV events and death. The importance of lowering blood pressure (BP) to reduce CV outcomes is known. BP reduction to levels well below 140/90 mm Hg…

Central Sympathetic Agents and Direct Vasodilators

Mechanism of Action Central sympatholytics (e.g., methyldopa, guanabenz, guanfacine, clonidine, moxonidine, and rilmenidine) have a variety of antihypertensive actions that result in increased sodium excretion and decreases in the cardiac output, heart rate, total peripheral resistance, and renin release. Central sympatholytics cross the blood-brain barrier and stimulate the imidazoline 1 (I 1 ) receptors and/or central postsynaptic alpha 2 (α 2 ) adrenoceptors in the brainstem’s…

Calcium Channel Blockers

Calcium channel blockers (CCB) have extensive therapeutic applications. Three CCB were listed in the forty most commonly used prescriptions and over-the-counter drugs in the Slone Survey of Recent Medication Use by the adult ambulatory population of the United States in 1998 to 1999. Over the period 2001 to 2010 approximately 20% of hypertensive adults in the United States reported taking a CCB, with amlodipine being the…

Renin Angiotensin Aldosterone System Blockers

The renin angiotensin aldosterone (RAA) system plays a central role in regulating cardiovascular and renal functions, and is a key component of the blood pressure homeostasis system in humans. Renal hypoperfusion triggers the production and release of renin from the juxtaglomerular cells, converting angiotensinogen to the decapeptide angiotensin I (angiotensin [1-10]). In the next step, the dipeptidyl-carboxyl peptidase angiotensin-converting enzyme (ACE) cleaves angiotensin I into angiotensin…

Peripheral Adrenergic Blockers

The Sympathetic Nervous System in Hypertension The notion that sympathetic fibers are found on the vascular wall and when stimulated cause vasoconstriction was proposed in 1840. The activity of these fibers is one of the components that control peripheral vascular resistance. Hyperactivity of the sympathetic nervous system is well described not only in hypertensive patients, but also in subjects at risk of progressing to hypertension, namely…

Diuretics in Hypertension

Diuretics are one of the most important classes of drugs used in hypertension. In simplistic terms, the basic premise for their use is that they reduce extracellular fluid volume and increase sodium excretion, which leads to reductions in blood pressure. Historically, the degree of efficacy in lowering blood pressure was considered directly proportional to the dose. Diuretics have been used in hypertension for 60 years and…

Diet and Blood Pressure

Elevated blood pressure (BP) remains an extraordinarily common and important risk factor for cardiovascular (CV) and renal diseases throughout the world. According to the 2011-2012 National Health and Nutrition Examination Survey (NHANES), around 70 million adult Americans (29%) have hypertension (a systolic BP ≥ 140 mm Hg, a diastolic BP ≥ 90 mm Hg, or are being treated with antihypertensive medication), and at least as many…

Assessment of Target Organ Damage

Hypertension-induced cardiovascular (CV) morbidity and mortality is caused by structural and functional alterations of the brain, heart, eyes, kidneys, and vasculature. Importantly, these hypertensive target organ damage (TOD) can be detected in an early subclinical stage, that is, as an asymptomatic and reversible stage of disease before fatal and nonfatal CV events occur. The classical score systems used to estimate the total CV risk do not…

Isolated Systolic Hypertension

For many years, clinicians have used diastolic blood pressure as the main risk indicator in hypertensive patients. However, several developments have caused a paradigmatic shift in our thinking about hypertension as a risk factor. First of all, the recognition from epidemiological studies that systolic pressure is a much stronger predictor of future cardiovascular events than diastolic pressure. Secondly, many studies have shown that pulse pressure is…