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These guidelines have been written to provide a straightforward approach to managing hypertension in the community. We have intended that this brief curriculum and set of recommendations be useful not only for primary care physicians and medical students, but for all professionals who work as hands-on practitioners.We are aware that there is great variability in access to medical care among communities. Even in so-called wealthy countries there are sizable communities in which economic, logistic, and geographic issues put constraints on medical care. And, at the same time, we are been reminded that even in countries with highly limited resources, medical leaders have assigned the highest priority to supporting their colleagues in confronting the growing toll of devastating strokes, cardiovascular events, and kidney failure caused by hypertension.Our goal has been to give sufficient information to enable health care practitioners, wherever they are located, to provide professional care for people with hypertension. All the same, we recognize that it will often not be possible to carry out all of our suggestions for clinical evaluation, tests, and therapies. Indeed, there are situations where the most simple and empirical care for hypertension-simply distributing whatever antihypertensive drugs might be available to people with high blood pressure-is better than doing nothing at all. We hope that we have allowed sufficient flexibility in this statement to enable responsible clinicians to devise workable plans for providing the best possible care for patients with hypertension in their communities.We have divided this brief document into the following sections:

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Glaucoma and ocular hypertension are highly prevalent conditions in individuals over the age of 40 and are commonly seen together in patients with cardiovascular disease. Many of the antiglaucoma medications, when systemically absorbed, affect the sympathetic and parasympathetic nervous systems of patients and can cause cardiovascular toxicity. Such adverse effects are frequently associated with the long-term use of potentially toxic agents in elderly people, who are most prone to chronic eye disease. Moreover, patients may not associate their symptoms with the topical eye medications, and consequently may not report adverse drug effects. Drug-drug interactions can also occur when patients are taking medications for both cardiovascular disease and glaucoma. This review focuses on beta-adrenergic blockers as topical antiglaucoma medications and other topical antiglaucoma drugs. The systemic toxicity of these agents is reviewed, along with the possible drug interactions. Brief mention is also made of other antiglaucoma medications used alone and in combination with topical beta-blockers.

Hyperkalemia is a common occurrence in patients with congestive heart failure, particularly when renal failure coexists. The level of renal function in congestive heart failure is often difficult to ascertain because good measurement tools for estimation of renal function are not available. Serum creatinine values have often been offered as a good gauge of renal function, although in most cases true renal function is appreciably lower than the estimate derived from a specific serum creatinine value. Thus, patients with congestive heart failure very commonly, particularly in the advanced stages of the disease, have moderate renal insufficiency, either due to specific heart failure-related renal perfusion changes or as the result of renal involvement from the same processes having caused the heart failure, as is the case with diabetes. It is in this setting of mild-to-moderate levels of renal failure that therapies, such as angiotensin-converting inhibitors, angiotensin-receptor blockers, and aldosterone-receptor antagonists, are administered either individually or collectively. Each of these drug classes reduces the homeostatic ability to eliminate ingested potassium loads by the renal route and increase the tendency to evolve into a hyperkalemic state. This is noteworthy because aldosterone-receptor antagonists are increasingly considered as important therapies in the long-term management of heart failure. Spironolactone has been employed in this capacity and a new aldosterone-receptor antagonist, eplerenone, will become available in the near future, which further increases the importance of evaluating and treating the hyperkalemia risk in a timely manner.

Eplerenone pharmacokinetics were studied in subjects with varying degrees of renal function after single (100 mg) and multiple doses (100 mg daily for 5 days). This open‐label, parallel‐group study enrolled 32 renally impaired subjects and 32 normal matches. Subjects were stratified based on CLcr: normal CLcr80 mL/min; mild CLcr=50–80 mL/min, moderate CLcr=30‐49 mL/min, or severe impairment CLcr<30 mL/min; and hemodialysis. The pharmacokinetics of eplerenone and metabolites were determined from plasma and urinary results. Following single or multiple dosing, eplerenone AUC, Cmax, CL/F, and CL/F/WT were not statistically different (P>0.093) between renally impaired and normal subjects. Compared to normal subjects, eplerenone renal clearance was significantly decreased in subjects with moderate and severe impairment. Since <2% of eplerenone is excreted unchanged, decreases in renal clearance did not result in significant alterations in CL/F. Subjects with severe impairment displayed the greatest decrease (18%) in mean CL/F/WT as compared to normal matches. In subjects with end‐stage renal failure, approximately 10% of the dose was removed after 4 hours of hemodialysis. Eplerenone was well tolerated in all subjects. Dose adjustment based on pharmacokinetic alterations does not appear necessary in patients with renal impairment; rather, dose adjustment for eplerenone in renal failure, as with spironolactone, should be based on its potential effect on serum potassium values. Clinical Pharmacology & Therapeutics (2004) 75, P37–P37; doi: