Guidelines for hypertension
In 2017, the American College of Cardiology, American Heart Association and 9 other professional organizations published new guidelines on high blood pressure. It incorporated the evidence from randomized control trials including the systolic blood pressure intervention trial (Sprint) as well as expert opinions.
The category of pre-hypertension was eliminated and it should have been.
Stage I Hypertension is defined as a lower blood pressure threshold of 130/80 mmHg or higher. The earlier threshold was 140/90, but that is now considered stage II hypertension.
According to this definition, 46% of the US population has stage I or stage II hypertension.
Hypertension, in my opinion, is not an isolated diagnosis. It usually keeps company with cardiometabolic syndrome and other factors certainly influence the management of hypertension. If hypertension was treated in isolation with pharmacological management, then a lot more patients will be on blood pressure medications, and other associated factors would not be treated, and the overall benefit to the patient will be limited.
It is my expert opinion, I believe hypertension is associated and probably etiologically related to insulin resistance. Management of insulin resistance will therefore, in turn, reduce hypertension. High blood pressure is also associated with obesity, sedentary lifestyle, obstructive sleep apnea, chronic inflammatory states such as connective tissue diseases, nutritional deficiencies such as Magnesium and Vitamin-D and we ought to look at all these factors as well.
Ambulatory monitoring provides additional information such as the presence or absence of nocturnal dipping (normal defined as a nighttime drop in blood pressure of 10-20%) we must do more than one reading before we label the patient as hypertensive. Echocardiograms will demonstrate left ventricular hypertrophy even if it is mild. Left ventricular hypertrophy predicts congestive heart failure and cardiovascular death in the future. Do not label patients as having white coat syndrome unless you have clearly documented low-end normal readings at home and done ambulatory blood pressure recordings. You must do multiple blood pressure readings on numerous occasions and have a conversation with the patients to let them know your concerns and your desire to make an accurate diagnosis.
The American College of Cardiology encourages the use of their risk estimator which includes age, sex, race, total cholesterol, HDL level, systolic blood pressure, use of blood pressure medications, diabetes, smoking status and it is available at http:/tools.acc.org/ASCVD-Risk-Estimator. I am not particularly fond of it. If the patient already has cardiovascular disease, then it is straightforward that we need aggressive blood pressure management. The guidelines recommend a blood pressure of less than 130/80 for patients including elderly patients, and patients with chronic renal failure as well as diabetes. In my opinion, low-risk patients with a blood pressure of 135/85 in the office can be followed with aggressive lifestyle changes especially dietary changes and exercise weight loss intermittent fasting and treatment of Obstructive Sleep Apnea, and we can avoid pharmacological management in these patients unless there is left ventricular hypertrophy. In very elderly patients over the age of 80 who are frail and at risk of falls or have renal insufficiency, low diastolic blood pressures due to stiff arteries, the mean blood pressure may be too low, and we must individualize these patients because they will have a high systolic blood pressure very low diastolic pressure and the mean pressure will be normal. Although they are at high risk of cardiovascular complications by virtue of a large pulse pressure, chasing the systolic hypertension can be more harmful with pharmacological interventions.
Although most of the recommendations for salt restrictions are dating back to the 1970s, and the recommended optimal dose of sodium is less than 1.5 g a day, recent data suggest that the intake should be liberalized, so I do not make a specific recommendation to reduce salt unless the patient has nephrotic syndrome or overt congestive heart failure with hypervolemia and edema.
In the pharmacological management of hypertension, the use of a RAAS inhibitor is recommended and preferable over a calcium channel blocker or diuretics. Try to avoid Clonidine because of rebound hypertension as well as orthostatic hypotension. Do not combine ACE inhibitors and angiotensin receptor blockers. You may use beta-blockers if there is evidence of arrhythmias, coronary artery disease, and most patients will require two or maybe even three medications to control blood pressure. This conversation must happen early on because monotherapy for hypertension is the exception and not the rule.
Dr. Pradip Jamnadas, MD FACC FACP FSCAI
Clinical assistant Professor of Medicine at University of Central Florida and Florida State University
