Melissa Walton-Shirley, MD; Paul K. Whelton, MB, MD, MSc


November 16, 2017

Melissa Walton-Shirley, MD: Hello. I'm Melissa Walton-Shirley for | Medscape Cardiology. I'm speaking to you from the American Heart Association (AHA) Scientific Sessions in Anaheim. I am delighted to be joined by Dr Paul Whelton, chair of the 2017 American College of Cardiology (ACC)/AHA Hypertension Practice Guidelines.[1,2] Welcome, Dr Whelton.

The day where the physician does everything is long past. We're just too busy.

Paul K. Whelton, MB, MD, MSc: Thank you so much, Melissa; lovely to be with you and the viewers.

Prehypertensive Yesterday, Hypertensive Today

Dr Walton-Shirley: Today all over America, patients are waking up with stage 1 hypertension. Can you explain to us the new classification of stage 1 hypertension?

Dr Whelton: Yes. 'It's a systolic of 130-139 mm Hg or a diastolic of 80-89 mm Hg. It needs to be an accurate measurement, and it needs to be the average of two to three measurements on two to three occasions. If somebody's blood pressure is in that range, they're already at double the risk for heart attack or a stroke compared with someone with normal blood pressure. Normal blood pressure remains the same: < 120 mm Hg systolic; < 80 mm Hg diastolic. In the > 130/80 mm Hg range, we now know they're at risk, and we now know from both nondrug and drug trials that treating them is valuable.

Dr Walton-Shirley: Who will get medication today that did not get medication yesterday?

Dr Whelton: These guidelines introduce a new concept, at least for blood pressure management. And that is to not only get a good estimate of the blood pressure level, but to also understand whether that individual is at high risk for cardiovascular disease, either because they've already had a major event such as a stroke or a heart attack, or they seem to be at high risk based on the atherosclerotic cardiovascular disease (ASCVD) risk calculator. We define high risk as > 10% risk of having an event over the next 10 years.

If they have stage 1 hypertension but are otherwise low risk, we recommend nonpharmacologic approaches, mostly lifestyle change. If they have that level of blood pressure and they're also at high risk, they're going to benefit from any hypertensive drug therapy in addition to lifestyle changes.

Dr Walton-Shirley: I was really appreciative of the fact that there was a lot of common sense included in these guidelines and the recommendation for lifestyle modification. When I see a patient in the office setting, the first question I ask is, do you ever touch a salt shaker? That's how I introduce the concept that maybe we're not doing things correctly. Do you have specific talking points that you use to speak to patients about lifestyle modification?

Dr Whelton: We do. The AHA website is a very good resource for clinicians and for patients as well. It provides a lot of information.

The things we're talking about are fairly obvious. If you're overweight, you want to aim to get as close as you can to ideal weight. You want to eat a healthy diet. A really good one is the DASH diet. It's a healthy diet that is specifically good for lowering blood pressure. We recommend moderation of sodium intake, enhancing potassium through diet, being physically active, and if somebody is drinking alcohol, be moderate in the alcohol intake. If they're not drinking, don't start.

Dr Walton-Shirley: Are there new targets for the elderly?

Dr Whelton: There are. They're based on a lot of recent, very strong information from clinical trials. Now we're saying that if an older person has a systolic of 130 mm Hg or above, they should be treated with lifestyle and hypertensive drug therapy. The target ought to be < 130 mm Hg.

That said, It depends on the individual circumstances. If they're healthy, then <130 mm Hg is probably going to be a great goal. If somebody is not healthy and perhaps they're in a nursing home or the hospital, or they have a lot of comorbidities, I think that's where a conversation between the patient and the clinician will determine whether, and to what extent, blood pressure should be lowered.

Measuring Blood Pressure Correctly

Dr Walton-Shirley: One concern I have is about the likely uptake of the recommendations for how to measure blood pressure. In a busy office setting, with patients waiting in the room, you have to ask them, did you empty your bladder? Do you have the appropriate chair to have the arm at atrium level, etc? Do you think the level of appropriate in-office blood pressure measurement is going to be where it needs to be a year from now?

Dr Whelton: I would love to think so. It's really important. We would close down a laboratory if they didn't meet quality-control standards. We wouldn't fly in a plane if a captain didn't follow the recommendations for what she or he has to do before flying. Yet, we've tolerated poor measurements of blood pressure. We know how to get an accurate blood pressure measurement. Before we label somebody as having high blood pressure or have them embark on a course of therapy, especially if it includes drugs, it's important to get an accurate measure.

I think this is one area where the patient can be a very valuable part of the team and an asset to the clinician. We know increasingly that out-of-office blood pressure measurements are very helpful, not only to confirm the diagnosis of office hypertension but also to spot white-coat hypertension (where blood pressure is high in the office but normal outside), which seems to have a risk the same as normotensives; or the more insidious problem of masked hypertension (normal in the office, high outside). Those adults seem to have a risk pattern very similar to that of sustained hypertension.

I hope physicians will have a trained staff member who will know how to get good pressures; I hope that they'll get readings on several occasions to get the estimate of what the body sees on average, and that they'll take advantage of training patients how to get their blood pressure out of the office.

Dr Walton-Shirley: We probably need to go back and do some systems analyses for the way that we take patients back and how long we have them sit, etc. I think we can do better. I just hope that we will do better.

The Role of Pharmacists

Dr Walton-Shirley: I was struck by the fact that you have a PharmD on your guideline panel, and you mentioned the importance of pharmacists and the chain of care. Not all pharmacists in all states get reimbursed for their time or can titrate medications. Do you think that should change? How important are pharmacists?

Dr Whelton: We have lots of clinical trials that document that pharmacists leading the team, being the clinician, do a great job.[3,4] Pharmacists, nurses, even community healthcare workers can do a great job. We're busy as clinicians, so we should take as much advantage as we can of the team.

Some states allow pharmacists to be the clinician and to prescribe and follow. Some states don't. We just have to know what state we're in. I think the day where the physician does everything is long past. We're just too busy. There are other members of the team who can be terrific in either assisting a clinician or taking the lead in the treatment process.

Dr Walton-Shirley: There was an area that I would have liked to have seen a little more information about. There is mention of the pregnant hypertensive patient in the guidelines, but what about the patient who develops hypertension, perhaps toxemia during pregnancy? They're at such great risk. I didn't see a specific recommendation for surveillance of those types of patients.

Dr Whelton: Right. We tried to cover as much as we could to be comprehensive. We realize that in some areas, there are others who have even greater expertise. We've covered blood pressure in pregnancy to the extent that we can. It is heterogeneous. We've made a referral to other guidelines that go into that in much more detail than we could in our guideline.

Moving the Dial

Dr Walton-Shirley: I appreciate that. How long do you think it will take to move the dial on hypertension-related disease outcomes? I know that's a broad question. You must have some idea what you're hoping for.

Dr Whelton: We've done a progressively better job in the United States. We're not perfect, but we are better than most countries. The United States and Canada lead the world in control rates. If you look at our population as a whole, at the 140/90 mm Hg level, just about half of our adults are controlled (ie, < 140/90 mm Hg). If we go to systems of care, like the Veterans Administration and some of the big private systems, like Kaiser Permanente, their control rates are about 90%.[5,6,7] We also do well when we do the same in clinical trials, where we've got good systems of care. We know we can do better.

These new guidelines are going to be difficult to implement, but I think they'll capture risk from blood pressure better. They will better identify the people who will benefit from drugs. Having a lower target blood pressure for treatment is going to help drive us in the right direction for improved cardiovascular health.

Dr Walton-Shirley: Is there anything you would have liked to have included in these guidelines that you didn't? I can't imagine that you would have an afterthought. This was a 3-year process.

Dr Whelton: This is a living document. We will modify it. I think one area that has come up already at this meeting is in regard to the use of risk calculators to predict events. They work well for somebody in my age range, but they're not so useful in younger people, in the 20-40 years age range. For younger people, we need to look at lifetime risk. We'll probably have to adapt the guideline for that.

It's a comprehensive guideline. It is long. It's in 15 different sections, all self-contained. For the busy clinician, I think it allows her or him to go right to the point of what they need to know. I hope it will be helpful.

Dr Walton-Shirley: I found it very easy to navigate last night. I thought it was really excellent.

Dr Whelton: Thank you.

Dr Walton-Shirley: What do you see as the legacy of these guidelines?

Dr Whelton: I hope the legacy will be that it'll help clinicians. I also hope that it will empower patients to be part of their own care. In the long term, I hope it'll improve cardiovascular health. That's the mission of the 11 organizations that supported the development of this guideline.

Dr Walton-Shirley: I appreciate your effort so much.

I hope you found this discussion informative. This is Melissa Walton-Shirley, saying goodbye from Anaheim.

Thank you, Dr Whelton, and your panel for your great efforts. You've helped patients all over the world with your effort.

Dr Whelton: Thank you very much, Melissa.


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