10 Pharmacologic Interventions BP-lowering medications are recommended for: • Patients with existing CVD and stage 1 hypertension (BP ≥130/80 mm Hg1-8.1.2) • Patients with stage 1 hypertension and 10-year risk of atherosclerotic cardiovascular disease (ASCVD) greater than 10% • Patients with stage 2 hypertension (BP ≥140/90 mm Hg) There are multiple tools for CVD risk assessment. The AHA recommends use of the ACC/AHA Pooled Cohort Equations to estimate 10-year ASCVD risk.1-8.1.2 The Pooled Cohort Equations tool has been validated for U.S. adults 40–79 years old in the absence of concurrent statin therapy. Because people who are older than 79 generally have a 10-year ASCVD risk greater than 10%, the BP threshold for beginning antihypertensive drug treatment is 130/80 mm Hg.1-8.1.2 Initial Pharmacotherapy Recommendations Pharmacotherapy plus lifestyle modification remains the primary treatment for high BP. Multiple classes of oral and topical antihypertensive agents are available. 1-8.1.5, Table 18. See 1-Table 18 for agent-specific comments. Pharmacologic agents with complementary activity (synergy) can lower BP even more. Thiazide diuretics, for example, may stimulate the renin-angiotensin-aldosterone system (RAS), so adding an ACE inhibitor or ARB to a thiazide diuretic can produce additional BP lowering. Patients can begin with a single primary agent, but increasing evidence supports a two-drug approach. Initial combination Fixed-dose combination therapy, which is multiple medications combined into a single oral dose, is the preferred first-line strategy and recommendation for patients with stage 2 hypertension. Single-pill combinations give greater BP-lowering effects than multiple pills.1-12.1.1 Single-pill combinations also improve adherence to reduce CV events and all-cause mortality compared to multiple pills.3-Abstract, Conclusions Once-daily dosing improves adherence, and adherence falls as dosing frequency increases.1- 8.6.1 therapy has been shown to be more effective for BP control and CVD risk reduction than single-drug therapy. Combination therapy also demonstrates benefits earlier and promotes longer-term adherence.2-Combination Treatment as the First Step Drug combinations that have similar mechanisms of action or clinical effects should be avoided. Do not prescribe more than one drug from the same class, e.g. two different ACE inhibitors, beta blockers or nondihydropyradine CCBs.1-8.1.4 Multiple drugs from classes that target the same BP pathway, such as ACE inhibitors and ARBs, are less effective in combination and may be harmful. Avoid simultaneous use of RAS blockers, including ACE inhibitors with ARBs, ACE inhibitor or ARB with renin inhibitors, which increase cardiovascular and renal risk.1-8.1.4.1 The effects of incretin mimetics on blood pressure have not been well studied, but the class has documented benefits in CVD, weight loss and other metabolic conditions.33-Efficacy End Points People with stage 2 hypertension (BP ≥140/90 mm Hg) should begin BP-lowering medications regardless of preexisting CVD and regardless of their calculated ASCVD risk.1-8.1.2
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