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814 PA R T V / Health Promotion and Disease Prevention
such as diuretics in large doses, peripheral adrenergic blockers, stage renal disease from treating HTN, the American Diabetes As-
and -blockers. 7 sociation and JNC 7 have set goal BP for persons with diabetes at
130/80 mm Hg. 7,178 Lifestyle interventions are also recom-
HTN in Racial and Ethnic Minorities. Although the
mended and include weight control and exercise, which are keys to
prevalence of HTN differs among ethnic groups, there is little ev- 210–212
BP control in persons with diabetes. JNC 7 recommended
idence that the relationship of BP to TOD differs substantially by the use of five drug classes, including diuretics, -blockers, ACE
race or ethnicity. 203 Some risk factors, such as obesity, physical in-
inhibitors, ARBs, and calcium channel blockers for the treatment
activity, and dietary excesses/deficiencies, confer quantitatively 7
of HTN in the presence of diabetes. Importantly, ACE inhibitors
different risks for HTN in various ethnic groups, due to variabil- and ARBs have beneficial effects in diabetes beyond HTN control,
ity in prevalence across ethnic groups. 203 In addition to behavioral 7
including reducing renal dysfunction, CVD, and stroke.
and socioeconomic factors, such as limited health care access, lack
of health insurance, and transportation issues, failure of clinicians HTN with Renal Disease. Control of HTN has been
to treat HTN early and to continue treating it persistently to shown to be extremely effective in preventing the progression of
reach and maintain an appropriate target BP has also been renal failure in persons with renal disease regardless of etiol-
demonstrated to contribute to racial and ethnic disparities in ogy. 211,213,214 JNC 7 has set the goal BP for persons with renal
7
HTN care and control. 154,204,205 Recent NHANES data show disease at 130/80 mm Hg. Three or more optimally dosed an-
HTN treatment rates as follows: non-Hispanic Whites, 54%; tihypertensive medications are often needed to achieve the goal
non-Hispanic Blacks, 55%; and Mexican Americans, 48%. 3 BP of 103/80 mm Hg. Dietary recommendations for potassium
HTN control rates were significantly lower among treated ethnic restriction must be considered for patients with more advanced re-
minorities: non-Hispanic Whites, 68%; non-Hispanic Blacks, nal disease. JNC 7 recommends use of ACE inhibitors and ARBs
3
52%; and Mexican Americans, 57%. Limited data are available in treating persons with renal disease based on clinical trials
on the efficacy in different drugs in non-Black minorities but demonstrating their effectiveness. 180–183,215,216
greater rates of ACE inhibitor side effects occur in some minori-
Hypertensive Crisis. Hypertensive emergencies are charac-
ties: angioedema and cough in Blacks, cough and flushing in terized by severe elevations in BP ( 180/120 mm Hg) complicated
Asians. 203 7
by evidence of impending or progressive target organ dysfunction.
Acute hypertensive crises are rare situations in which patients re-
HTN in Pregnancy. HTN occurs in pregnancy either be-
cause of preexisting chronic HTN or because of the development quire immediate intervention to reduce BP. These crises may oc-
of pregnancy-induced HTN including gestational HTN, cur either in persons whose HTN previously was not diagnosed
preeclampsia, and eclampsia. HTN ( 140/90 mm Hg) existing or in persons with known but poorly controlled HTN. Hyper-
prior to pregnancy, develops before the 20th week of pregnancy, tensive crises have been classified into two types: hypertensive
or that persists more than 6 weeks after delivery is considered emergencies and urgencies. Hypertensive emergency occurs when
chronic HTN. 206 Gestational HTN is defined as an elevated BP end-organ damage is acute or imminent and immediate reduc-
that usually occurs in the third trimester and is not accompanied tion in BP, usually via intravenous medication in an intensive
by other signs and symptoms. 207 In preeclampsia and eclampsia, care unit, is required. Hypertensive urgency occurs when the BP
the elevated BP is considered as one of several signs and symptoms is critically high, with signs such as edema of the optic disk, but
of an underlying disorder of organ perfusion. Edema and protein- there is less evidence of TOD, so that BP reduction can occur 7
uria usually occur with pregnancy-induced HTN. over a longer period using oral antihypertensive medications.
JNC 7 and the recent Working Group Report on High Blood There is a continuum from emergencies to urgencies and excel-
Pressure in Pregnancy recommend the use of -blockers, lent assessment and judgment are required. Acute elevations of
methyldopa, or vasodilators for pregnant women. 7,206 ACE in- BP may occur after certain medications such as clonidine are dis-
hibitors are contraindicated because of their documented ad- continued or the individual either forgets to take or runs out of
217
verse effects on fetal growth and development. Because of the medication.
adverse effects of ACE inhibitors, ARBs have not been studied JNC 7 recommends that persons with hypertensive urgency be
7
in pregnant women and their use is also contraindicated. 206 treated immediately with oral combination therapy. In the man-
Methyldopa is considered the drug of choice because of the long agement of hypertensive emergencies, the goal is to reduce the
experience with using it and the relative lack of adverse effects pressure so that TOD from the HTN is prevented or minimized
on mother and infant. 206 while preventing the cerebral or myocardial ischemia that could
result from too rapid a reduction in pressure. 218 The parenteral
HTN in Patients With Diabetes. Coexistent HTN con- drugs that may be used in hypertensive emergencies are listed in
tributes significantly to the development of CVD and associated Table 35-8. One drug that is not recommended because of the
premature morbidity among diabetics. Furthermore, among high rate of adverse events that accompany its use is sublingual
treated hypertensives, those with diabetes are significantly less nifedipine. 219,220 Nitroprusside is also recognized as a medication
likely to have controlled HTN compared to those without dia- with great potential toxicity that should used with great hesi-
3
betes. Numerous clinical trials including the United Kingdom tancy. 220 After the BP has been brought under control, the patient
Prospective Diabetes Study Group Study 39 (UKPDS39), the who has experienced an HTN emergency or urgency will require
Losartan Intervention for Endpoint reduction in HTN Study extended expert outpatient HTN management.
(LIFE), the Heart Outcomes Prevention Evaluation (HOPE)
Study, ALLHAT, and the Appropriate Blood Pressure Control in Achieving BP Control
Diabetes (ABCD) Study have documented the benefits of treating
HTN among individuals with diabetes. 157,175,179,206–209 Because Despite the impressive array of effective lifestyle and pharmaco-
of this documented reduction in mortality and progression to end- logic treatments for HTN, the rates of HTN awareness, treatment,