What is the difference between elevated systolic blood pressure vs elevated diastolic blood pressure and antihypertensive medications?

Elderly patients with hypertension are often dominated by increased systolic blood pressure and large pulse pressure difference due to arteriosclerosis, volume load and increased stiffness of the aortic arteries.

Unlike elderly hypertensive patients, young and middle-aged patients with hypertension have increased peripheral resistance, but there are no obvious abnormalities in the elasticity of the aortic arteries. Clinically, young and middle-aged hypertension is mainly based on elevated diastolic blood pressure, normal systolic blood pressure (simple diastolic hypertension), or only mildly elevated.

What is the difference between antihypertensive medications? Some of the drugs are discussed as follows:

Elevated systolic blood pressure

Antihypertensive drugs include: CCB, ACE Inhibitor, ARB, diuretic, β receptor blocker, etc. Among them, CCB, ACE Inhibitor, ARB, diuretics and monolithic fixed compound preparations can be used as initial or long-term maintenance drugs for hypertension and antihypertensive therapy in the elderly.

01. Diuretics

Mainly thiazide diuretics, belonging to the medium-acting diuretics, according to the molecular structure can be divided into thiazide type (such as hydrochlorothiazide) and thiazide-like diuretics (such as indapamide).

Potassium-sparing diuretics belong to weak diuretics and are divided into two categories: one is aldosterone receptor antagonists, representing drugs including spironolactone and eplerenone; the other class of effects is not dependent on aldosterone, representing drugs including triamterene and amiloride.

Diuretics are particularly suitable for patients with elderly hypertension, refractory hypertension, heart failure with hypertension, and salt-sensitive hypertension.

02. CCB

Mainly by blocking calcium ion channels on vascular smooth muscle cells, it plays a role in dilating blood vessels and lowering blood pressure, including dihydropyridine CCBs and non-dihydropyridine CCBs.

Clinical trials have demonstrated that antihypertensive regimens based on dihydropyridine CCB significantly reduce the risk of stroke in patients with hypertension.

Dihydropyridine CCB can be used in combination with 4 other classes of drugs and is particularly indicated in patients with elderly hypertension, simple systolic hypertension, with stable angina, coronary or carotid atherosclerosis, and peripheral vascular disease.

03. THOSE

The mechanism of action of various ACEI preparations is roughly the same, and ACEI has good target organ protection and cardiovascular endpoint event prevention, especially in elderly hypertensive patients with chronic heart failure and a history of myocardial infarction.

ACE inhibitors have no adverse effect on glycolipid metabolism, can effectively reduce urinary albumin excretion, delay the progression of renal lesions, and are suitable for elderly hypertensive patients with diabetic nephropathy, metabolic syndrome, CKD, proteinuria, or microalbuminuria.

04. ARB

In patients with hypertension and high risk of cardiovascular events, ARB may reduce the risk of a combination of endpoint events such as cardiovascular death, myocardial infarction, stroke, or hospitalization for heart failure.

ARB reduces proteinuria and microalbuminuria in patients with diabetes or nephropathy, especially in patients with left ventricular hypertrophy, heart failure, diabetic nephropathy, metabolic syndrome, microalbuminuria or proteinuria, and in patients who cannot tolerate ACE Inhibitor.

05. β receptor blockers

β receptor blockers are indicated in elderly patients with hypertension with tachyarrhythmias, angina, and chronic heart failure.

In comparative studies with other antihypertensive drugs, β receptor blockers have not shown an advantage in reducing the incidence of stroke events. Therefore, β blockers are not recommended for elderly patients with simple systolic hypertension and stroke unless there are strong indications for the use of β blockers, such as co-ordinated coronary heart disease or heart failure.

Elevated diastolic blood pressure

For young and middle-aged hypertension patients without comorbidities, 5 major classes of antihypertensive drugs (including diuretics, β blockers, CCBs, ACE Inhibitors, and ARBs) can be used as initial treatment options.

Given that young and middle-aged hypertensive patients have SNS or RAS activation, β receptor blockers and RAS blockers (ACE Inhibitors or ARBs) have a definite effect on lowering blood pressure (especially lowering diastolic blood pressure) in such patients and can be preferentially used.

01. β receptor blockers

β receptor blockers directly inhibit SNS activity, effective in treating hypertension in young and middle-aged people and reducing cardiovascular events. Due to the potential adverse effects on sugar and lipid metabolism, caution should be exercised in combination β receptor blockers with diuretics in hypertensive patients with diabetes mellitus or metabolic syndrome.

However, β receptor blockers can be used in younger patients with hypertension, especially those with significant SNS activation (e.g., resting heart rate > 80 beats/min) or clinical conditions such as coronary atherosclerotic heart disease (coronary heart disease) and chronic heart failure.

02. RAS Blocker

RAS blockers (e.g., ACE inhibitors and ARBs) have well-defined antihypertensive and target organ-protecting effects and can be used as the initiating antihypertensive agents for hypertension in young and middle-aged people.

ACE Inhibitor or ARB is preferred for patients with obesity, glucose-lipid metabolic disorders, and chronic kidney disease (stage 3a and above to reduce the risk of albuminuria and end-stage renal disease).

RaS system activation is more pronounced in the presence of risk factors such as obesity, dyslipidemia, and smoking, and RAS blockers are particularly useful in these patients.

It is important to note that RAS blockers such as ACE and ARB are at potential teratogenic risk and should not be used in young and middle-aged women of planning pregnancy or childbearing age with hypertension. In this case, β receptor blockers, especially labetalol, can be preferred as an alternative to antihypertensives.

Understand the difference in antihypertensive medications in elderly/young hypertensive patients, and what are the differences in antihypertensive goals between the two? How to develop a hypotensive regimen for patients with comorbidities?

Click on the video to watch the "Detailed Explanation of Hypertension Medication and Diagnosis and Treatment Practice" from the Clove Open Class | 2022 New Edition" in the experience of Mr. Mai Jianting:

Case time: 34 years male, no special discomfort, BMI 27.2 kg/m, BP 146/84 mmHg (left), BP 140/80 mmHg (right), HR 72 bpm, other tests are normal. The father developed hypertension at the age of 50.

Please ask: 1. Is hypertension diagnosed? 2. Screening for secondary hypertension? 3. Are medications prescribed? 4. How many drugs are prescribed? 5. What drugs are prescribed?