Pharmacological treatment of hypertension

Currently, most clinical guidelines recommend determining whether to treat hypertension based on blood pressure levels. However, this approach has certain limitations. Munmer and Whelton conducted a review and summary of six relevant randomized studies to analyze the advantages and limitations of two decision-making approaches. The meta-analysis of randomized trials showed that antihypertensive treatment for individuals with systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg significantly reduces the risk of cardiovascular disease. However, these trials often exclude low-risk individuals. Furthermore, there is evidence supporting the treatment of individuals with lower blood pressure levels, especially those with cardiovascular disease or high overall cardiovascular risk.

Two populations are recommended for antihypertensive treatment: (1) all adults with systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg, and (2) individuals with systolic blood pressure of 130-139 mm Hg or diastolic blood pressure of 80-89 mm Hg and a 10-year cardiovascular disease risk ≥10%. Bohm et al. reevaluated the data from the NTARGET and TRANSCEND clinical trials and analyzed the relationship between average blood pressure during treatment, baseline blood pressure before treatment, time-pressure curves, and cardiovascular events such as cardiovascular death, myocardial infarction, stroke, and hospitalization due to heart failure. The results showed that patients with an average systolic blood pressure <120 mm Hg during treatment had an increased probability of cardiovascular events other than myocardial infarction and stroke, while patients with an average diastolic blood pressure <70 mm Hg during treatment had an increased risk of myocardial infarction and hospitalization due to heart failure. Pursuing excessively low blood pressure through treatment can increase the risk of various cardiovascular events, so blindly pursuing blood pressure reduction is not advisable.

Non-adherence to antihypertensive treatment is a significant cause of poor blood pressure control. Hamdidouche et al. included 174 primary hypertensive patients treated at a university hospital hypertension clinic. Ultra-high-performance liquid chromatography-tandem mass spectrometry was used to measure the adherence to antihypertensive treatment in the urine of the subjects during clinical visits and blood pressure measurements. The subjects were asked to report their medication adherence using a validated questionnaire (the 4-item Morisky Medication Adherence Scale). The results showed that urine detection of antihypertensive drugs by ultra-high-performance liquid chromatography-tandem mass spectrometry is an accurate and practical tool for directly monitoring medication adherence. Hypertension is associated with endothelial dysfunction, and blood pressure is significantly correlated with endothelial function in individuals not taking antihypertensive drugs. Maruhashi et al. measured flow-mediated vasodilation in 2,297 subjects, including 1,822 untreated patients with hypertension and 475 patients receiving antihypertensive treatment. The results showed that regardless of the blood pressure achieved through antihypertensive drug therapy, endothelial function assessed by flow-mediated vasodilation is impaired. Another study included primary hypertensive patients from the UK Clinical Practice Research Datalink. The proportion of days covered by antihypertensive medication was used to estimate medication adherence during the follow-up period and the adherence to each specific class of drugs. The researchers used generalized linear models to evaluate factors related to the proportion of days covered by antihypertensive medication. The results showed that several disease factors were identified as determinants of antihypertensive drug class and treatment adherence, which can help identify patients at risk of non-adherence and target them for adherence improvement interventions.

McDonough et al. studied the molecular mechanisms underlying the effects of sodium, potassium, and blood pressure reduction in different population groups. During the analysis, the researchers found that increasing dietary potassium intake effectively lowers blood pressure. The CSPPT sub-study included 20,702 hypertensive patients with a history of cardiovascular disease, among whom 10,348 patients received combined treatment with 10 mg enalapril and 0.8 mg folic acid, and 10,354 patients received monotherapy with 10 mg enalapril, with a follow-up period of 4.5 years. The study first demonstrated that supplementation with folic acid can reduce the risk of death caused by substantial proteinuria in hypertensive patients.

A post-analysis of the China Primary Stroke Prevention Trial included 20,327 hypertensive adults without a history of stroke or myocardial infarction. These adults were randomly assigned in a double-blind manner to receive either 10 mg enalapril and 0.8 mg folic acid daily (10,160 cases) or only 10 mg enalapril (10,167 cases). The results showed that in Chinese hypertensive adults, fasting blood glucose ≥7.0 mmol/L or diabetes is associated with an increased risk of first-ever stroke; this increased risk can be reduced by 34% through folic acid treatment.

Glaucoma is a common disease that causes visual impairment due to abnormal elevation of intraocular pressure, resulting from dysfunction in the regulation of intraocular pressure. Horwitz et al. used the Danish National Prescription Registry to identify all patients taking prescribed medications for glaucoma and antihypertensive drugs. The study suggested that antihypertensive drugs themselves have a preventive effect on the occurrence and progression of glaucoma. In a systematic review and meta-analysis conducted by Ben-nett et al., involving 42 studies and 20,284 subjects, at least a quarter-dose compared to a placebo and standard-dose monotherapy were evaluated. The results of 36 comparisons showed that, compared to a placebo, both single and dual quarter-dose therapies had no significant difference in adverse events, but they had significantly fewer adverse events compared to standard-dose monotherapy. Quarter-dose therapy may improve the effectiveness and tolerability of antihypertensive therapy. A meta-analysis evaluated the effect of vasodilating β-blockers on renal function parameters in hypertensive patients. The results showed that vasodilating β-blockers did not affect glomerular filtration rate or creatinine levels but reduced proteinuria.