Totality of Care Addressed in New ACC/AHA Hypertension Guidelines

Ileana L. Piña, MD, MPH


February 05, 2018

Hello. I'm Ileana Piña from Montefiore Medical Center and the Albert Einstein College of Medicine in the Bronx, New York. This is my blog.

I have been waiting to talk to you about the new blood pressure (BP) guidelines.[1,2] These were awaited with great anticipation because the Eighth Joint National Committee (JNC8) was never really JNC8 but a committee that decided to come out with their findings. There have been a lot of discussions in our heart failure (HF) and cardiology worlds about those guidelines.

First, I will give you my overall view of these new guidelines, which were released at the American Heart Association meeting in November.

What I like about these guidelines is that they're not just, "BP is X, and here is the next drug." They talk about the totality of care and how to measure BP. How often do we really spend time measuring the BP? We may have a patient in a room, and our medical assistant, nurse, or technician has already taken the BP. It is recorded in the electronic medical record, and we take off. Did anybody teach these individuals how to take BPs accurately?

One of the beautiful points of this new document is that it details how to take a BP. What are you listening to? How do you know what the systolic blood pressure (SBP) is and what the diastolic blood pressure (DBP) is?

On the first table, we have the Korotkoff sounds. I wonder how many of you remember from medical school that those are the sounds you hear as you deflate the BP cuff. The very first Korotkoff sound is, in fact, the SBP. There may be a silence before you hear the pulse rate at a regular rate. There are other Korotkoff sounds, but the fifth one is the DBP. What you are listening to is the change in the tone of the heart rate at the time of the DBP.

Pulse pressure is the difference between the SBP and the DBP. In our HF patients, for example, one of the signs of a low cardiac output is, in fact, a very narrow pulse pressure. It's a good idea to pay attention to that. The mean arterial pressure (MAP) is the DBP plus one third of the pulse pressure. My residents are very hung up on the MAP. I more consistently look at the SBP. The mid-BP, which we really do not use clinically, is the sum of the SBP and the DBP divided by 2.

The guidelines also want us to look at BP readings in the context of modifiable and relatively fixed risk factors. What are the modifiable risk factors? Cigarette smoking, secondhand smoking, diabetes, dyslipidemia, overweight or frank obesity, physical inactivity, and an unhealthy diet can be modified by patients.

Fixed risk factors include chronic kidney disease, family history, age, low socioeconomic status, obstructive sleep apnea (OSA), and psychological stress. We hear time and time again that men have more cardiovascular risk factors than women, but women catch up in older age.

The first recommendation that is a class of recommendation 1 with a level of evidence B-NR comes from, I think more than anything else, a consensus statement that the BP should be categorized as normal, elevated, or stage 1 or stage 2 to prevent and treat high BP. Our terminology is changing a little bit.

Let's look at some of the categories. An SBP <120 mm Hg and a DBP <80 mm Hg is considered normal. By the time you pass SBP 120-129 mm Hg, it's called elevated, even though the DBP may still be <80 mm Hg. Hypertension (HTN) stage 1 is SBP 130-139 mm Hg.

Where are some of these numbers coming from? A lot of them are coming from the SPRINT trial,[3] which showed us that if we bring the SBP down to 120 mm Hg, a reduction in events is actually quantifiable. Stage 2 HTN is now ≥140 mm Hg or ≥90 mm Hg. Again, we have seen a very consistent message.

On the next table, I'm just showing you some of the changes that are going to happen with this definition. Everybody is saying, "Wait a minute. We're going to have more hypertension than ever before because we've lowered the number." BPs do increase with age. It does not mean that they are normal. There are racial differences. We know that African Americans have the most HTN and that they may have it in the early years, even in the teenage years. Women have much more HTN if they are African American than if they are white. Again, this table is bringing our attention to the fact that, yes, we have a high prevalence of HTN. There is no way to hide it; there is no way to deny it. It's a fact; it's here.

On this slide is one of these tables that I've taken from the paper, again going over the definitions of normal, elevated, stage 1, and stage 2 HTN. When you see a patient and make that diagnosis, it's a good time to write it in the chart so the next person coming to see that patient can say, "This patient was already diagnosed as having stage 1 HTN. Let me see what's happening with their BPs."

We are always in a hurry. We have 8-10 minutes to see a patient. Even in the HF world, we are supposed to have 20 minutes to see a patient. This slide says, "Make sure the patient is prepared." How do you do that?

I do it by having the patient sit there for a little while. We have a conversation. That allows the patient to relax and sit back. They may have rushed to get to the appointment. There is always a little bit of apprehension when going to a clinic or seeing a doctor or nurse practitioner. Document and average the BP readings. If you get two or three readings, average them and put that in the chart. Let the patient know their BP.

A clinic in Cleveland gave patients a pocket card so that they could write down their BP every time they came in, and they could see how their BP had been previously.

What else do you want to do? You want to be able to identify patients whose BPs are abnormal because they are scared—so-called "white coat hypertension." Those are the patients whose BP at home is totally different. I have patients who say to me, "Wait a minute. At home, my home monitor says that my blood pressure is fine. Every time I come here, it's a bit high." Identifying white coat HTN is very important.

This table shows guideline recommendations. A patient may have HTN with you in the office, and when they go home and take their own reading, there is no HTN. There is also the trend in these guidelines to recommend ambulatory BP monitoring in the home. I'm not sure right now whether insurance companies or even Medicare pays for that.

What is masked HTN? That is when the BP at one point may be perfectly normal, and then as the patient takes their BPs in the home and different situations, the BP is elevated. There are a lot of small nuances here about how to take the BP, how to label it, how to record it, and it gives warnings about white coat HTN.

They have a very nice algorithm to detect white coat HTN, and you can probably even take this. This is online, and it is free. Paste it somewhere in your office so that your staff can look at it and differentiate between white coat HTN and masked HTN.

What are the causes of secondary HTN? I mentioned one to you that is common, but we do not identify it early enough, and that is OSA. As our population gets more and more obese, we are seeing a lot of OSA, which gets better when patients lose weight.

Other causes include drugs or alcohol, and then there are the more rare things like primary aldosteronism. If you suspect that, you should probably check potassium and sodium and get this patient to an endocrinologist. There are the uncommon causes such as Cushing syndrome, hypothyroidism or hyperthyroidism, congenital hyperplasia of the adrenal glands, and acromegaly. These are rare. If you see any of these, just like with primary aldosteronism, you should probably send these patients to an endocrinologist who could do them well.

The guidelines tell us not to underestimate, with the other risk factors, what that patient's total risk is for cardiovascular disease. This is similar to the cholesterol guidelines because they send you to find what a particular patient's 10-year risk is. If it's 10% or higher, you may want to get more aggressive with those patients. They are giving this a class of recommendation level 1. For patients who already have this [HTN] diagnosis, you should still estimate what their 10-year risk is, particularly if they have a DBP >90 mm Hg.

Once again, nice algorithms really walk you through the thinking. None of the algorithms immediately say to start with medications. On the left, the first green box says "nonpharmacologic therapy." The guidelines tell us that at each and every visit, you should be advising patients about weight loss, healthy diet, and exercise. Aerobic exercise can lower BP as successfully as weight loss. I do not want patients to think that they are going to totally come off their drugs, but there can be significant changes with lifestyle changes. We should be advocating lifestyle change.

What are we being told about drugs? We are being told that if the patient has ischemic heart disease, you should treat them with the medications that we know work in ischemic heart disease. If the patients already have some element of HF, then you should really think of the drugs that we use for HF. Use guideline-directed medical therapy: beta blockers, angiotensin-converting enzyme inhibitors, and angiotensin II receptor blockers.

If you need to add other drugs, we have thiazide diuretics, spironolactone (a mineralocorticoid antagonist), or a calcium blocker. I am not a big fan of calcium blockers, particularly in older women who can have a lot of side effects like ankle swelling.

Rather than running to the medications, these guidelines ask us to think very critically about who the patient is. Where does he or she fall in terms of other risk factors? Has the BP been taken correctly? Are we dealing with true HTN, or are we dealing with white coat HTN?

I'm going to leave you with those thoughts today. We will come back and talk a bit more specifically about the medications. This is good to get you started.

This is Ileana Piña. Thank you for joining me today. Have a good day.


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