COMMENTARY

The Latest in Hypertension Guidelines: What Is a Primary Care Clinician to Do?

Charles P. Vega, MD; Michael J. Blaha, MD, MPH

Disclosures

December 15, 2017

Charles P. Vega, MD: Greetings. I'm Charles Vega, a clinical professor of family medicine at the University of California at Irvine. Welcome to a short discussion about the 2017 guidelines from the American Heart Association and American College of Cardiology on hypertension and hypertension management.

Today, I'm delighted to be joined by someone with real expertise in this area—Mike Blaha. He's an associate professor of medicine and a member of the division of cardiology at Johns Hopkins University, as well as director of clinical research at the Ciccarone Center for the Prevention of Heart Disease. Mike, welcome.

Michael J. Blaha, MD, MPH: My pleasure to be here. I'm anxious to talk about these exciting guidelines.

New Guidelines, More Patients With Hypertension

Dr Vega: I see the value of the guidelines. We know that there is an increase in the risk for cardiovascular events as systolic blood pressure (BP) rises above 115 mm Hg and the diastolic BP rises above 75 mm Hg. What's blowing my mind and that of others is the sheer number of people who have hypertension. About 30% of US adults have hypertension; but, of great importance, just over half of these patients have their hypertension under control.

The main headline for the guidelines is that stage 1 hypertension can be defined by BP as low as 130 mm Hg over 80 mm Hg. You're talking about adding 30 million more people into that pool of individuals with hypertension. Do you think we're ready to handle this as a medical system in terms of getting these patients the right types of screening and treatment?

Dr Blaha: The answer to that is complicated. Prehypertension is now considered stage 1 hypertension, and what we called hypertension before is now stage 2 hypertension. There is a new 130-140 mm Hg systolic BP-defined group of patients for whom we're more aggressively thinking about antihypertensive therapy. It's a big change. It brings a lot of people into the fold—a lot of people who didn't have hypertension yesterday have hypertension today.

I can say without a doubt that this matches the epidemiology of BP and cardiovascular risk as well as the clinical trial evidence. If nothing else, this change raises awareness about BP. People who might have said before that their "BP is trending high" will now have to be much more aware of their BP.

Many more people are now eligible for "treatment," but I would point out that the guidelines emphasize that for stage 1 hypertension, the first-line therapy is still lifestyle modification.

Dr Vega: The guidelines emphasize that point. The DASH diet in and of itself can lower systolic BP by more than 10 mm Hg, depending on which study you're looking at. That can be a very powerful tool to get patients out of the hypertensive range. In clinical practice, I'm not sure that we always reach that kind of efficacy.

The Element of Risk

Dr Blaha: Unfortunately, lifestyle change doesn't always work. That's why it's more an issue of raising awareness early in the process. The guidelines say that for stage 1 hypertension, you need to think harder about that patient. This doesn't mean that you have to start a pharmacologic therapy right away, but you have to think about risk and have that discussion. A unique feature of these guidelines is their risk-guided nature. For example, for the stage 1 hypertension group, the guidelines say that if the patient's atherosclerotic cardiovascular disease (ASCVD) risk score is <10% over 10 years, then you should predominantly consider lifestyle therapy, and you should consider pharmacologic therapy less aggressively. If the ASCVD risk is >10%, then you should consider more aggressive upfront BP therapy.

It's bringing risk back into the BP guidelines like we did for the cholesterol guidelines. We're going to be treating higher-risk stage 1 and stage 2 patients more aggressively. For the low-risk patient with stage 1 hypertension, it's great to emphasize everything from weight loss to physical activity, the DASH diet, potassium supplementation, and treatment of sleep apnea—all of the factors that work to some degree in lowering BP.

Dr Vega: That's a great point. We're not going to be managing 26-year-old patients whose only risk factor is being overweight as aggressively with pharmacotherapy. There's a back end to that. The guidelines aren't necessarily going to change my management for those patients already on hypertensive therapy who are very sick and have a very high 10-year cardiovascular risk but are also frail and prone to severe side effects of therapy. For example, patients on dialysis whose systolic BP drops to 80 mm Hg, and they get dizzy coming out of the dialysis center. That's a real risk.

Guidelines are just that. They are a demarcation of where we should aim, but results may vary patient to patient. We don't necessarily need to push the BP down in older, frailer patients, particularly if there are such side effect as presyncope or the risk of falling.

Dr Blaha: We will struggle a little bit with these guidelines. As we lower the BP goal more and more, almost all older adults will have at least stage 1 hypertension, and many will not be "controlled." Risk is highly dependent on age. It's pushing us towards more aggressive treatment of older individuals, which sometimes I agree with and sometimes I don't. There's going to be some tension with the older adult involving how we balance these guidelines and the SPRINT[1,2] results that show that more aggressive therapy in high-risk patients is good, but with the understanding that the older folks also have more side effects of therapy.

Benefits of Home BP Monitoring

Dr Vega: Speaking of tension, these guidelines promote the concept of measuring the BP outside of the medical office and that at-home and 24-hour ambulatory BP readings can give us some incredibly valuable information. But there are challenges in the routine application of ambulatory BP monitoring. How do you see the practical implementation of measuring BP outside of the medical office, particularly in light of all of these new individuals who may come into the fold with new stage 1 hypertension?

Dr Blaha: I actually love this part of the guidelines because in-office BP measurement (especially when it's not taken by you, or when you repeat it and it's different from when the patient checked in) is very hard to use. I'm not a big fan of the office BPs, or at least full reliance on them. I love the idea of out-of-office BP measurement, and that can take two forms. Patients can take their BP at home and create a BP log, which I love. Also, I like the occasional use of 24-hour ambulatory BP monitoring, particularly to look for masked hypertension or white-coat hypertension.

Masked hypertension can be missed in the office, but when you look at that the patient's home BP logs, you see measurements that are way out of range, especially in the middle of the day. With white-coat hypertension, you might have a patient in your office who insists that at home, his or her BP is always normal; and, indeed, sometimes you get a 24-hour ambulatory BP, and it is normal.

The guidelines' recommended use of out-of-office BP measurement is going to reclassify some patients. We're changing the categories of BP, but we're also going to reclassify some people based on the data from home BP monitoring. I always ask my patients to bring in their BP logs. I feel uncomfortable sometimes making decisions based on one BP reading in the office. This has potential to increase patient engagement, which is a big part of this too.

Ambulatory BP Monitoring: Who Needs It?

Dr Vega: You're absolutely right. Just knowing their numbers enables them to have some sense of control over their hypertension, whether they've already been diagnosed or are still in the diagnostic process. It might help down the line when you recommend lifestyle change or medications. What percentage of patients need ambulatory BP monitoring as opposed to home BP checks daily or three times weekly?

Dr Blaha: That's a good question. When you see discrepancies, you might have to move to ambulatory BP monitoring. Some patients insist that their home BP measurements are at one level, but in the office, they are different. Or you might have a patient whose office BP is on the high side, and it always differs from their home readings. Ambulatory BP is useful in those discrepant situations where you need more information or when the patient doesn't have a home BP device. The answer is: Ambulatory BP isn't needed often, but for select patients, it's very helpful.

Dr Vega: Absolutely. We know from research that ambulatory BP monitoring has benefits. The intensity of it is counterbalanced by the fact that we can make better treatment decisions and prevent cardiovascular events for those individuals.

This was a brief talk, but it was really great. We determined that we have some very evidence-based guidelines. They tend to be a little more patient-centered because of the risk assessment, and they emphasize lifestyle change very appropriately. Out-of-office BP readings are very important as well, but it will be a challenge for us as a medical system to take all of these patients in and try to move the needle toward appropriate BP management. Mike, I know you are working on it every day, so thank you very much for everything you do.

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