A new study shows that people with hypertension can respond significantly better to some treatments than others, suggesting that hypertension medicine decisions might become far more personalised in the future.
It’s traditionally been challenging to get hypertension under control, in part because a single antihypertensive drug often doesn’t achieve sufficient BP reduction and many patients don’t want to add a second medication.
However, this new study suggests that hypertension control might be far less of a challenge if each patient was prescribed the optimal medication for them the first time around. Patients treated with blood pressure-lowering drugs can experience much greater improvements from a change of medication than from doubling the dose of their current medication. The new study was published in the Journal of the American Medical Association (JAMA). In the study, 280 patients tested four different blood pressure-lowering drugs over the course of a year.
“In real world practice, the choice of medication is largely influenced by the physician’s experience, although patient specific characteristics, especially existing co-comorbidities, are often included in the therapeutic decisions,” explains Dr Abdul Rauoof Malik, Specialist Cardiologist, Aster Hospital Qusais. “This one-size-fits-many approach derives its legitimacy from the fact that epidemiological studies have repeatedly shown that lowering blood pressure in a broad population of people would reduce cardiovascular events compared to placebo.”
Hypertensive patients are nonetheless different from one another and people may respond differently to the same treatment. Therefore, while a one-size-fits-many treatment strategy for hypertension may be efficacious for most people, a more personalised approach could be useful in some patients. “For example, it is widely recognised that patients with certain specific forms of hypertension called “secondary hypertension” would require specific diagnostic and therapeutic approaches,” says Dr Malik. “Even in the larger majority of the hypertensives who are supposed to have the so-called essential or primary hypertension, we often need to incorporate various considerations in clinical decision making, such as body weight, personal lifestyle choices including food and alcohol intake, stress level, comorbidities and other interacting medications.”
What is hypertension
Hypertension is defined as a systolic blood pressure of 140 mm Hg or greater, or diastolic blood pressure of 90 mm Hg or greater. Hypertension is a complex disease modified by environmental and genetic determinants. It contributes to the development of myocardial infarction, stroke or cerebrovascular accident, systolic and diastolic heart failure, peripheral vascular disease, and increased total mortality among men and women of all ages and ethnic groups, with or without signs or symptoms of coronary artery disease.
Detecting hypertension begins with proper blood pressure measurements, which should be obtained during each healthcare appointment. Data for evaluation is acquired through medical history, physical examination, laboratory tests, and other diagnostic procedures. The evaluation of patients with documented hypertension is to identify known causes of high blood pressure, assess the presence or absence of target organ damage, and identify other cardiovascular risk factors.
High vs low blood pressure
There is always the question on whether it is worse to have high or low blood pressure. Dr Arun Asok Cheriyan, Specialist Cardiologist, Aster Clinic, Discovery Gardens, says that when our blood pressure is low, we feel faint, light-headed or dizzy. Very low blood pressure is very dangerous as it can compromise the normal functioning of our organs. “This is why we are given IV fluids when we are sick so that the blood pressure is maintained,” says Dr Cheriyan.
When blood pressure is high, we can end up with a stroke or a heart attack. We can also damage our eyes or kidneys when blood pressure is persistently high. This is why we take blood pressure medications, so that organ damage is avoided.
So why is high blood pressure worse than low blood pressure? “Simply put”, says Dr Cheriyan, “low blood pressure always give us warning signs such as light-headedness or dizziness or feeling faint so that we can do something about it. High blood pressure on the other hand is a silent killer where in majority of us will have no warning signs and the damage is ongoing or would have a reached a significant level before we can do something about it.
“So, it is essential to keep monitoring our blood pressure regularly especially if we have the risk factors such as advancing age, smoking, sedentary lifestyle, being overweight, higher stress levels either at work or at home and other metabolic disorders such as hypertension, diabetes or thyroid disorders.”
Managing hypertension starts with proper detection of other risk factors and modification. Weight reduction reduces systolic and diastolic blood pressure and the need for medical therapy may be averted for one half of these patients through weight loss using physical activities and calorie restriction. Salt restriction is recommended for most patients with hypertension. Cessation of smoking and excessive alcohol use markedly reduces blood pressure and further reduces cardiovascular risk.
“Pharmacologic therapy for most patients with hypertension stage 1 should begin with the lowest dose to prevent adverse effects,” says Dr Ahmed Gaber, Specialist Cardiology, Burjeel Medical City.
“If blood pressure remains uncontrolled after one to two months, the next dose level may be prescribed. For patients at higher risk, drug therapy to achieve maximum beneficial reductions in blood pressure should proceed without delay.”
There is no debate regarding the need for aggressive blood pressure reduction in patients with diastolic blood pressure greater than 115 mm Hg and systolic blood pressure greater than 160 mm Hg. Although some patients may respond to a single therapy, two or more drugs often are required. The intervals between changes in the regimen should not be prolonged, and the maximum dose of some drugs may be increased.
“For a selection of medications, special considerations include concomitant disease, demographic characteristics, quality of life, cost, and use of other drugs that may cause drug interactions,” says Dr Gaber. “A wide variety of antihypertensive medications are available, including beta-blockers, calcium channel blockers, diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and alpha-blockers. Personalised treatment may reduce the need for higher doses and multiple medications, with the potential to improve treatment adherence, patient outcomes, and cost efficacy.”
While personalised medicine has the potential to create a paradigm shift in hypertension management, says Dr Malik, whether personalisation is the key to greater health benefit compared to simpler one-size-fits-many interventions is open to debate. In the near future, it will be increasingly important and potentially difficult to resolve the tension between the benefits of simplicity and the benefits of personalisation when treating hypertension.
“Current guideline-based hypertension interventions that do not involve personalised medicine have long a track record of success,” says Dr Malik. “Yet, the increasing availability of technologies that could help personalise care raise the question to what extent will personalising the treatment of hypertension impact the health of patients. Overall, for now, it may be safe to anticipate that the two approaches — personalisation, or a one-size-fits-many approach — will co-exist, to be called upon when most useful.”