The treatment of hypertension during pregnancy: when should blood pressure medications be started?

Hypertensive pregnancy disorders (HPD) are important causes of maternal and fetal morbidity and mortality worldwide. In addition, a history of HPD has been associated with an increased risk for maternal cardiovascular disease later in life, possibly because of irreversible vascular and metabolic changes that persist beyond the affected pregnancies. Therefore, treatment of HPD may not only improve immediate pregnancy outcomes, but also maternal long-term cardiovascular health. Unlike the recommendations for hypertension treatment in the general population, treatment recommendations for HPD have not changed substantially for more than 2 decades. This is particularly true for mild to moderate hypertension in pregnancy, defined as a blood pressure of 140-159/90-109 mm Hg. This review focuses on the goals of therapy, treatment strategies, and new developments in the field of HPD that should be taken into account when considering blood pressure targets and pharmacologic options for treatment of hypertension in pregnant women.

Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers: is there a difference in response and any advantage to using them together in the treatment of hypertension?

In April 2008, a panel was convened to discuss the effects of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers in the treatment of hypertension and the possible added benefit of using these agents together. The panel was moderated by Marvin Moser, MD, Clinical Professor of Medicine at Yale University School of Medicine, and included Clive Rosendorff, MD, PhD, Professor of Medicine at Mount Sinai School of Medicine and William B. White, MD, Division Chief, Hypertension and Clinical Pharmacology and Professor, Calhoun Cardiology Center at the University of Connecticut Health Center, Farmington.

The treatment of hypertension in the elderly.

Following a hypertension symposium in San Francisco in September 2007, an expert panel was convened to discuss the treatment of hypertension in the elderly. Based on recent data, new recommendations may be indicated. The session was moderated by Marvin Moser, MD, Clinical Professor of Medicine at Yale University, New Haven, CT. Participants were William Cushman, MD, Professor of Preventive Medicine and Medicine at the University of Tennessee in Memphis, and Michael Ziegler, MD, Professor of Medicine, University of California at San Diego. The discussion was supported by Novartis Pharmaceuticals and Merck & Company, and each author received an honorarium from Novartis Pharmaceuticals and Merck & Company for time and effort spent participating in the discussion and reviewing the transcript for intellectual content before publication. The authors maintained full control of the discussion and the resulting content of this article.

Dietary management in the prevention and treatment of hypertension: does it work?

During a meeting of the American Society of Hypertension in New Orleans, LA, in May 2008, an expert panel was convened to discuss nonpharmacologic therapy in hypertension. This is an update of a panel discussion that was held in March 2007. The panel was co-moderated by Marvin Moser, MD, Clinical Professor of Medicine at Yale University School of Medicine, New Haven, CT, and Mark Houston, MD, Associate Clinical Professor at the Vanderbilt University School of Medicine, Nashville, TN. Panelists included Laura Svetkey, MD, Professor of Medicine at Duke University, Durham, NC, and Brent Egan, Professor of Medicine at the Medical University of South Carolina, Charleston, SC.

Diuretics as monotherapy or as part of combination therapy for hypertension: an update.

At a meeting of The American Society of Hypertension in May 2008, a panel was convened to discuss the use of diuretics. Are they still preferred initial therapy, are they still the preferred agent to add in combination therapy, and is there a difference between or among the diuretics that have been used in the clinical trials? The session was moderated by Marvin Moser, MD, of the Yale University School of Medicine, New Haven, CT. Participants included Domenic Sica, MD, Virginia Commonwealth University, Richmond, VA; William Cushman, MD, University of Tennessee, Memphis, TN; and Ken Jamerson, MD, University of Michigan, Ann Arbor, MI.

How to treat hypertension in patients with coronary heart disease disease.

Following a hypertension symposium in Los Angeles in October 2007, a panel was convened to discuss how to treat hypertension in patients with coronary artery disease or with evidence of multiple major risk factors for coronary heart disease. Marvin Moser, MD, Clinical Professor of Medicine at the Yale University School of Medicine, New Haven, CT, moderated the discussion. Jackson T. Wright Jr, MD, PhD, Professor of Medicine, Program Director of William T. Dahms Clinical Research, and Director of the Clinical Hypertension Program at Case Western Reserve University, Cleveland, OH; Ronald G. Victor, MD, Professor and Division Chief, Hypertension, University of Texas Southwestern Medical Center, Dallas, TX; and Joel Handler, MD, Hypertension Lead, Care Management Institute, Kaiser Permanente, Anaheim, CA, participated in the discussion.

Hypertension management: results of a new national survey for the hypertension education foundation: Harris interactive.

A new national online survey by Harris Interactive of 1245 hypertensive individuals indicates that >90% were aware that elevated blood pressure (BP) is a major risk factor for cardiovascular disease. The majority discovered that they had elevated BP levels as a result of a routine examination. More than two thirds of persons identified 120/80 mm Hg as an optimal BP level; only 6.0% stated that the Internet was their primary source of information about high BP. More than 60% of respondents had a body mass index >30 kg/m(2), and >50% had other cardiovascular risk factors. More than 50% were involved in some lifestyle change to control BP, and >90% were taking medication. More than 60% reported that BP was controlled (<140/90 mm Hg) at the last visit, although approximately 50% were told that their BP was high at some time. The survey results suggest that >90% of hypertensive patients are aware of the risks of elevated BP and that a high percentage of hypertensive patients are being treated with medication. Control rates as reported by respondents were >60% based on last BP recorded; however, between 31% and 40% of patients (based on differences in ethnic groups) were continued on the same therapy despite elevated BP levels. The survey suggests a high degree of risk awareness and treatment, and what appears to be an increase in control rates among hypertensive patients.

The nonpharmacologic treatment of hypertension: how effective is it? An update.

Following a hypertension symposium in Los Angeles, CA, in October 2006, a panel was convened to update information about lifestyle changes or the nonpharmacologic treatment of hypertension. Dr Marvin Moser, Clinical Professor of Medicine at the Yale University School of Medicine, moderated the panel. Dr Stanley S. Franklin, Clinical Professor of Medicine and Associate Medical Director of the Heart Disease Prevention Program at the University of California, Irvine, and Dr Joel Handler, Director of the Orange County Kaiser-Permanente Hypertension Clinic and clinical hypertension leader of the Care Management Institute of Kaiser Permanente, participated in the discussion.

Microalbuminuria, chronic renal disease, and the effects of the metabolic syndrome on cardiovascular events.

In March 2007, a panel discussion was held following a hypertension symposium in New York, New York. The panel was moderated by Marvin Moser, MD, Clinical Professor of Medicine at the Yale University School of Medicine, New Haven, Connecticut. Serving on the panel were James R. Sowers, MD, Professor of Medicine and Physiology at the University of Missouri, Columbia, Missouri, and Henry R. Black, MD, Clinical Professor of Medicine at the New York University School of Medicine, New York, New York. This expert panel discussion was supported by Novartis and each author received an honorarium from Novartis for time and effort spent participating in the discussion and reviewing the transcript for important intellectual content prior to publication. The authors maintained full control of the discussion and the resulting content of this article; Novartis had no input in the choice of topic, speakers, or content.

The ALLHAT study revisited: do newer data from this trial and others indicate changes in treatment guidelines?

Following a hypertension symposium in Washington, DC, in November 2006, a panel was convened to discuss new data from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) and to revisit the significance of this trial in the management of hypertension. Based on these data and information from other trials, the expert panel also addressed the questions, "Is it time for a new Joint National Committee report?" and "Should the 2003 hypertension treatment recommendations be updated or are they still valid?" The panel was moderated by Marvin Moser, MD, Clinical Professor of Medicine, Yale University School of Medicine, New Haven, CT. On the panel were Suzanne Oparil, MD, Professor of Medicine at the University of Alabama in Birmingham, and President of the American Society of Hypertension (ASH); William Cushman, MD, Professor of Preventive Medicine and Medicine at the University of Tennessee in Memphis and attending physician at the Washington, DC, VA Medical Center; and Vasilios Papademetriou, MD, Professor of Medicine at Georgetown University in Washington, DC, and attending physician at the Washington, DC, VA Medical Center. This expert panel discussion was supported by Pfizer Inc and each author received an honorarium from Pfizer Inc for time and effort spent participating in the discussion and reviewing the transcript for important intellectual content prior to publication. The authors maintained full control of the discussion and the resulting content of this article; Pfizer had no input in the choice of topic, speakers, or content.

Control of blood pressure: does it matter which agent you use?

A panel was convened to discuss the question, "Is blood pressure lowering the sole determinant of outcome, or do specific drugs make a difference?" The panel was moderated by Marvin Moser, MD, Clinical Professor of Medicine at the Yale University School of Medicine, New Haven, CT. Panelists included Norman Kaplan, MD, Clinical Professor of Medicine at the University of Texas Southwestern Medical Center at Dallas, TX, and William Cushman, MD, Professor of Medicine at the University of Tennessee in Memphis, TN. The discussion was supported by Boehringer Ingelheim, and each author received an honorarium from Boehringer Ingelheim for time and effort spent participating in the discussion or reviewing the transcript for intellectual content before publication. The authors maintained full control of the discussion and the resulting content of this article.

Historical perspectives on the management of hypertension.

As late as the 1950s, elevated blood pressure was considered by many expert physicians to be necessary for the adequate perfusion of vital organs. Although the morbidity and mortality risks of hypertension were known at that time to insurance companies, which often refused life insurance policies to people with high blood pressure, there was a lag in the recognition of the dangers of hypertension in the medical community. Following the pioneering efforts of researchers who began to treat patients with malignant hypertension, the results of clinical trials and population studies, and the availability of effective antihypertensive agents, hypertension management improved rapidly. This review traces the history of hypertension management from the 1940s, when President Franklin Delano Roosevelt died of a cerebrovascular accident-a result of uncontrolled hypertension-to today, when a large number of patients, even those with less severe hypertension, are being treated successfully, with a resulting dramatic decrease in hypertension-related vascular disease.

Is new-onset diabetes of clinical significance in treated hypertensive patients?--Con.

There is little doubt that diabetes is more common in hypertensive than normotensive individuals. There are also some data suggesting that the use of certain antihypertensive agents, i.e., diuretics and more specifically some beta blockers will increase the occurrence of new onset diabetes (NOD) when compared to other medications, especially angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. The clinical significance of this 1%-3.5% difference, however, has not been established. Different studies report different outcomes. In large outcome trials the occurrence of NOD did not effect mortality or morbidity outcomes. Although one study reported that NOD had the same prognosis as pretreatment diabetes, another did not. At present, data are insufficient to suggest that NOD is of important clinical significance or that present treatment recommendations, especially regarding the use of diuretics, should be changed.

Resistant or difficult-to-treat hypertension.

Following a hypertension symposium in Los Angeles, CA, in October 2005, an expert panel discussion was held to discuss resistant hypertension. Are there patients whose blood pressures cannot be controlled? Do inappropriate uses of medications or drug combinations or, on the other hand, poor adherence on the part of patients, play a major role in resistance? Dr. Marvin Moser, Clinical Professor of Medicine at the Yale University School of Medicine, New Haven, CT, moderated the discussion. Participants on this panel included Dr. William Cushman of the University of Tennessee College of Medicine, Memphis, TN, and Dr. Joel Handler of the Kaiser Permanente Group in Anaheim, CA.

Out-of-office blood pressures -- are they helpful in guiding the treatment of hypertension patients? Roundtable discussion.

Following a hypertension symposium in Philadelphia in September 2005, a roundtable was convened to discuss the significance of out-of-office blood pressure. Dr. Marvin Moser of the Yale School of Medicine, New Haven, CT, moderated the panel discussion. Participants included Dr. Raymond Townsend of the University of Pennsylvania School of Medicine, Philadelphia, PA, and Dr. Norman Kaplan of the University of Texas Health Science Center in Dallas, Dallas, TX.

Hypertensive emergencies.

Following a hypertension symposium in Rochester, NY, in October 2005, a roundtable was convened to discuss hypertensive emergencies. Dr. Marvin Moser, Clinical Professor of Medicine at the Yale University School of Medicine, New Haven, CT, moderated the session, which included Dr. Joseph L. Izzo, Jr., Professor of Medicine at the State University of New York at Buffalo, Buffalo, NY, and Dr. John Bisognano, Associate Professor of Medicine at the University of Rochester School of Medicine, Rochester, NY.

The metabolic syndrome--what is it and how should it be managed?

Following a hypertension symposium in Portland, ME, in October 2005, a roundtable was convened to discuss the metabolic syndrome and its significance. Dr. Marvin Moser of the Yale University School of Medicine, New Haven, CT, moderated the discussion. Participating in the discussion were Dr. Bonita Falkner of the Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA; Dr. Michael A. Weber of SUNY Downstate College of Medicine, New York, NY; and Dr. Leonard Mark Keilson of the University of Vermont College of Medicine.

Hypertension, renal disease, and cardiovascular outcomes.

During the meeting of the American Society of Hypertension in San Francisco, CA on May 17, 2005, a roundtable was convened to discuss the relationship between hypertension, renal disease, and cardiovascular outcomes. Dr. Marvin Moser, Clinical Professor at Yale University School of Medicine, New Haven, CT, chaired the session. Dr. Jan Basile, Professor of Medicine at the Ralph Johnson VA Medical Center and the Medical University of South Carolina in Charleston, SC and Dr. William Cushman, Professor of Preventive Medicine and Medicine at the University of Tennessee in Memphis, TN participated in the discussion.

A conversation with Drs. Kaplan and Moser about conflicting data, confusing results, and some recent treatment recommendations for the management of hypertension.

Following a hypertension symposium in Baltimore, MD, on June 1, 2005, Dr. Wendy Post from the Johns Hopkins University School of Medicine, Baltimore, MD, had the opportunity to interview two of the outstanding hypertension experts in the United States on several controversial issues in hypertension management. Dr. Norman Kaplan is Clinical Professor of Medicine at the Southwestern Health Science Center in Dallas, TX, and Dr. Marvin Moser is Clinical Professor of Medicine at the Yale University School of Medicine, New Haven, CT. Both have been leaders in the field of hypertension treatment and education for more than 40 years. Dr. Kaplan's book Clinical Hypertension has been a standard textbook since 1973 and is now in its ninth edition. Dr. Marvin Moser was the Senior Medical Consultant to the National High Blood Pressure Education Program from 1974 to 2002 and was Chairman of the first Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure and a member of the six subsequent committees. His book Clinical Management of Hypertension is in its seventh edition. Drs. Moser and Kaplan were corecipients of the 2004 International Society of Hypertension Award for Outstanding Contributions to Hypertension Treatment and Education and have lectured extensively throughout the United States and overseas.