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Choice of Antihypertensive Therapy in Young Individuals: Are there any Differences from the Usual Practice?

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Dr HK Chopra, New Delhi    13 December 2017

New AHA/ACC guidelines suggest BP >130/80 mmHg is higher; thus, HT burden is further increased especially in India. The trend of uncontrolled HT is high (NCHS Data 2017; AHA/ACC Guidelines for HT Management 2017).

In a study published by our group in IHJ 2007, 65% individuals had obesity (metabolic syndrome). Of these, 78% were hypertensive in hospital-based population aged  40-60 years. It is a “Red Alert” for Indians with 140 million suffering from HT equal to 14% of global burden of uncontrolled HT. WHO data 1980, which showed  80 millions of Indians suffering from HT, which has almost doubled now.

HT is most common cause of premature heart attack, brain attack, abdominal attack and leg attack. It can dissect any vessels at any time and may cause renal failure. Our objective should be to control BP at any cost by any approach. CV events are high with uncontrolled HT, especially in diabetics, obese and young.

Younger hypertensives have higher sympathetic nerve activity, plasma renin activity, norepinephrine levels, high levels of leptins and insulin resistance, especially in obese, increase CO and more compliant vessels vs. elderly with decreased sympathetic nerve activity, plasma renin activity, decreased cardiac output and increased vascular stiffness with increase peripheral vascular resistance and higher mortality and morbidity in both the groups (Cruickshank et al. JDRT 2016, Framingham Heart Study 2005, Meta-analysis of 18 Studies 2005-2017. HK Chopra et al CDU 2017). β blockers, especially super selective β1 receptor blockers lower CVD risk (death, MI, stroke) and mortality in young by reducing sympathetic nerve activity and plasma renin activity (which is also increased by diuretics, ARBs, ACEIs, CCBs) (Meta-Analysis data from 1960-2017 including ESC, Canadian Hypertension Society, API, CSI, Asia-Pacific Consensus, IJC 2017).

Despite safe anti-HT drugs, BP control in young is achieved in only 20-30%. AZL is more potent of all sartans and enhances tight BP control due to tight AT1 receptor binding in diabetes and prediabetes vs. candesartan, valsartan, olmesartan and telmisartan (Early Registry, Gitt et al. BMC 2016, White et al. JH 2016, Bonner G. et al. JHH 2013). Target BP reduction, efficacy outcome and safety outcome are reported better with AZL. Recent ongoing data has shown superiority of AZL over TELS by ABPM in % reduction of nocturnal nondippers, early morning surge, evening surge, persistent time elevation of BP, etc.

β blockers and ARBs are the drugs of 1st choice in young hypertensives. Amongst β blockers super selective β1 receptor blockers and among ARBs, AZL has been reported to be more efficacious by ABPM and CBPM.

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