often, at an earlier age and more severely in African-Americans than in Caucasians. The risk of developing hypertension also is increased in individuals whose parents or other close blood relatives have hypertension.
The most common cause of secondary hypertension is chronic kidney disease. Other causes of secondary hypertension include medications, sleep apnea, Cushing’s disease, thyroid disease and primary aldos-teronism. Medications can play a significant role in blood pressure elevation. Medications that have been shown to increase blood pressure include nonsteroidal anti-inflamma-tory agents, corticosteroids, decongestants, tacrolimus, cyclosporine and erythropoietin. When a patient is newly diagnosed with hypertension, the pharmacist should review current medications for any potential causes. The pharmacist should also inquire about herbal preparations, including licorice and bitter orange, as these may cause increased blood pressure. The pharmacist also can inquire about illicit drug use because amphetamines and cocaine can increase blood pressure.
Hypertension can contribute to the development of cardiovascular disease and target organ damage, including kidney disease. Due to the risk of developing these conditions, controlling hypertension is critical. Hypertension is not the only risk factor for developing cardiovascular disease. Other risk factors include cigarette smoking, obesity, physical inactivity, dyslipi-demia, diabetes mellitus, age, microalbuminuria and family history of premature cardiovascular disease (men under age 55 or women under age 65). Target organ damage can involve the heart (in the form of left ventricular hypertrophy, angina, myocardial infarction and heart failure), brain (in the form of a stroke or transient ischemic attack), chronic kidney disease, peripheral arterial disease or retinopathy.
stage 1 hypertension and stage 2 hypertension (Table 2).
Prehypertension, a new category in this version of the guidelines, is intended to designate individuals at high risk of developing hypertension. This classification allows healthcare providers to encourage lifestyle modifications to prevent or delay hypertension. Patients with prehypertension are not candidates for treatment with medications unless they have diabetes or chronic kidney disease and have failed to achieve reductions in blood pressure despite lifestyle modifications.
The guidelines recommend that all patients with stage 1 or stage 2 hypertension be treated to reduce their blood pressure. The goal of treatment for these patients is a blood pressure <140/90 mmHg. For patients with compelling indications, goal blood pressures are lower. These compelling indications are high-risk conditions that can be the direct results of hypertension or are frequently associated with hypertension. Conditions that can be the direct result of hypertension include heart failure, ischemic heart disease, chronic kidney disease or recurrent stroke. Conditions that are frequently associated with hypertension include diabetes and high coronary disease risk. Although ideal blood pressure goals are not firmly established for most of these compelling indications, the blood pressure goal for patients with diabetes or chronic kidney disease is <130/80 mmHg.
Patient Case
Mr. Ellis, a local business man who is in his early 60s, is standing at the pharmacy counter with a prescription in his hand. As he hands the prescription to the pharmacist to be filled, Mr. Ellis comments that the doctor has prescribed another medication to help control his blood pressure. He appears very frustrated by this. The pharmacist notices in the medication profile that Mr. Ellis has been on numerous different antihypertensive agents over the past two years.
Discussion
Patients taking medications for hypertension often visit the pharmacy for refills on medications, more often than they visit their primary care provider. Pharmacists should seize this opportunity to assist patients in achieving their blood pressure goals through education and reinforcement. Of course, in order to provide effective counseling, the pharmacist needs to first listen to the patient’s concern and gain an understanding of the challenges the patient is facing.
TABLE 2
Stages of hypertension
Systolic blood
pressure (mmHg)
<120
120-139
140-159
>160
Classification Normal Prehypertension Stage 1 Stage 2
Diastolic blood pressure (mmHg)
<80 80-89
90-99 >100
Patient Case
Mrs. Smith, a 60-year-old patient who has come to XYZ Pharmacy for many years, asks to speak with the pharmacist. She is well-known by the pharmacist and pharmacy staff because she fills her prescriptions for insulin, syringes and other medications on a monthly basis. When the pharmacist and Mrs. Smith enter the counseling area, Mrs. Smith informs the pharmacist that she has just come from her physician’s office. This was the first time that she had an appointment with this physician, as her previous physician recently retired.
Mrs. Smith asks the pharmacist to explain to her what it means to have hypertension. Her new physician said that she needed to be started on a medication to control her blood pressure. The new doctor told her that her blood pressure is 150/95 mmHg. Her previous physician never said anything about blood pressure, so she does not understand why she should start taking more medication now—she doesn’t feel any different than she did before.
TREATMENT GUIDELINES
FOR HYPERTENSION
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC- 7) provides guidelines on the classifications of high blood pressure. 1 The guidelines classify blood pressure as normal, prehypertension,
PHARMACIST’S ROLE
IN IMPROVING OUTCOMES
For many patients, the pharmacist is the healthcare provider who they visit most often. The pharmacist should utilize this unique opportunity to improve the patient’s care. Many patients do not understand or do not retain the information that they are given pertaining to their health conditions. The pharmacist frequently should reiterate important counseling points to the patient to improve outcomes. For patients with high blood pressure, it is essential for the pharmacist to evaluate adherence to medication therapy, stress the importance of and educate about lifestyle modifications and ensure that routine blood pressure monitoring occurs.
Pharmacists should look for opportunities to spend even a few minutes
The pharmacist explains to Mrs. Smith that her blood pressure falls in the range of stage 1 hypertension. For patients without compelling indications, such as heart failure, post-myocardial infarction, diabetes or chronic kidney disease, treatment with an antihypertensive agent is warranted at this stage. Without compelling indications, lifestyle modifications are the first step toward blood pressure control in patients in the prehypertensive stage (systolic blood pressure 120 to 139 mmHg or diastolic blood pressure 80 to 89 mmHg). For patients, such as Mrs. Smith, who have a compelling indication, treatment with an antihypertensive is indicated even in the prehypertensive stage.
Discussion
Patients often are confused or upset by the need for treatment of hypertension. Patients with elevated blood pressure typically do not feel ill, leading them to believe that nothing is wrong. Unfortunately, this is not true. Hypertension, known as a silent killer, can cause significant morbidity and mortality despite the limited symptoms. Such patients as Mrs. Smith, who have compelling indications, are at an increased risk of cardiovascular complications due to hypertension.
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