Cardiovascular diseases (CVD) account for almost 50%their highest levels while coronary blood flow and of the 2 million deaths annually in the United States. plasma fibrinolytic activity are at their lowest levels of Coronary heart disease (CHD) (ie, myocardial infarction, the day. Moreover, BP rapidly rises from its nocturnal sudden death) account for the largest proportion (32%) nadir during the early morning hours. Prevention of of this mortality. Over the last 3 decades both CVD and pressure-related CVD events in hypertensive patients age-adjusted coronary death rates have fallen dramatiover the long term can be best accomplished by concally. However, crude CVD (and CHD) incidence is actutrolling BP throughout the 24 h time period with drugs ally increasing, almost exclusively as a function of risthat do not adversely impact (or favorably affect) other ing CVD incidence amongst older Americans. metabolic, neurohormonal, and hemostatic parameters. Population groups at highest for premature CVD compli-BP control (minimally to Ͻ140/90 mm Hg) may be partications include African-Americans, diabetics, men, cularly important in the early morning hours since elevsmokers, and those with high levels of single risk fac-
ated BP and/or rapidly rising BP is a plausible biological tors (ie, stage III hypertension). Individuals with multiple trigger for the aforementioned CVD events. One effec-CVD risk factors as well as those with manifestations of tive strategy for achieving this goal is to utilize antihyblood pressure (BP)-related target-organ damage (TOD)pertensive drugs with long therapeutic half-lives. Such (ie, left ventricular hypertrophy, hypercreatinemia) are at agents will provide smooth whole-day BP control and an inordinately high risk for clinical events. CVD events also will minimize the loss of BP control during time do not randomly occur throughout the 24-h time period. period(s) between missed medication doses in the setThe peak incidence of myocardial infarction (MI), thromting of therapeutic non-compliance. Practitioners botic stroke, sudden cardiac death, and transient myoshould give due consideration to nocturnal adminiscardial ischemia is between 6 am and 12 noon. tration of antihypertensive drugs prescribed once-daily During the morning hours coinciding with the peak as a means of achieving more effective morning BP conincidence of CVD events, coronary vasomotor tone, trol. plasma catecholamines, and platelet aggregability are at
Patients with hypertension and concomitant cardiovascular (CVD) conditions are at high risk for developing deleterious CVD-related clinical sequelae. The selection of therapeutic strategies for hypertension management in patients with cardiovascular diseases is an important first step in normalizing blood pressure (BP) levels (<140/90 mmHg). The ultimate goal of BP normalization for this high-risk group of hypertensive patients is target-organ protection. This review will discuss the management of hypertension in patients with selected CVD conditions (congestive heart failure, coronary artery disease, renal insufficiency/end-stage renal disease) and will incorporate both nondrug and drug therapies. Nondrug therapy, including weight reduction, physical activity, restriction of dietary sodium and alcohol intake are effective strategies for lowering BP. If these measures are not adequate, then the addition of drug therapy is needed in order to provide gradual BP normalization. Drug regimens may include a single antihypertensive agent with up-titration of the dose, or a combination of antihypertensive agents at a lower dose of each agent. The availability of different classes of antihypertensive agents enables therapeutics strategies to be implemented in the management of hypertension that provide maximum target-organ protection for each entity of CVD. Thus, aggressive hypertension management is crucial for delaying/preventing target organ damage and subsequent CVD clinical events.
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