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Treating hypertension in patients with medical comorbidities

BMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i101 (Published 16 February 2016) Cite this as: BMJ 2016;352:i101
  1. Lucinda Kennard, specialist registrar in clinical pharmacology1,
  2. Kevin M O’Shaughnessy, consultant, reader in clinical pharmacology1
  1. 1Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Addenbrooke’s Hospital, Cambridge CB2 2QQ, UK
  1. Correspondence to: K M O’Shaughnessy kmo22{at}medschl.cam.ac.uk

What you need to know

  • Two out of three people with hypertension have a comorbidity

  • There is NICE guidance on blood pressure targets and drug therapy for patients with hypertension and comorbidities such as chronic kidney disease, diabetes, atrial fibrillation, and heart failure

  • There remains uncertainty regarding which agents to choose for patients with multiple comorbidities

Hypertension affects more than one in four adults in the UK1 and prevalence is rising as the population ages. One British study found that around two in every three patients with hypertension has a comorbidity.2 Hypertension is a public health priority but may not be the individual patient’s priority. This mismatch may help to explain why in one study a quarter of all hypertensive patients did not fill out their first prescription,3 and in another, patients did not take their prescribed medication 50% of the time.4

Advice offered here to rationalise prescribing in patients with hypertension and comorbidities is taken from several guidelines from the National Institute for Health and Care Excellence (NICE): CG127, CG182 (chronic kidney disease), CG108 (chronic heart failure), CG87 (type 2 diabetes), NG17 (type 1 diabetes), CG180 (atrial fibrillation).5 6 7 8 9 10 When collating evidence, patients with multiple comorbidities or extremes of age are poorly represented in these datasets. These same patients are likely to have a substantial tablet burden already, so the emphasis here has been to suggest drugs that are most likely to benefit the patient’s blood pressure and comorbidity. By avoiding drugs with less clear benefits it is hoped drug side effects can be reduced and compliance increased.

With all hypertensive patients who would like to lower their blood pressure, discuss lifestyle modification including regular exercise, a low salt diet (<6 g/day), low alcohol and caffeine consumption, smoking cessation, and a healthy body weight.

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