Hypertension: Practice changers resulting from the new guidelines
This story appears courtesy of Clinician Reviews.
By Lisa Hack
REPORTING FROM THE ANNUAL CARDIOLOGY, ALLERGY, AND RESPIRATORY DISEASE SUMMIT
SAN DIEGO—The first practice changer is with the diagnosis of hypertension, began Leslie L. Davis, PhD, RN, ANP-BC, FAANP, FPCNA, FAHA. “The 2017 American Heart Association/American College of Cardiology guidelines1 show us that Stage 1 hypertension is now 130 to 139 mm Hg systolic, and that has always been traditionally 140 mm Hg and above, so this dramatically changes how we diagnose and treat hypertension.”
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“That means that another 14% or so of Americans will now fall under the category of Stage 1 hypertension. It doesn’t mean that all of these people will be on medication; however, when we reclassify, that’s a big chunk of the population. We go from about 32% prevalence to about 46% of adults in the United States having hypertension,” Davis said during a presentation at the annual Cardiology, Allergy, and Respiratory Disease Summit.
According to the guidelines, normal blood pressure (BP) is now <120 mm Hg systolic and <80 mm Hg diastolic. Elevated BP is 120 to 129 mm Hg systolic and <80 mm Hg diastolic. And Stage 2 hypertension is 140 mm Hg systolic and 90 mm Hg diastolic.
“This means we need to be a little more vigilant about screening and about getting patients in the system a little sooner . . . and potentially about making some critical lifestyle changes because we know that blood pressure over time in men and women will gradually go up,” Davis said at the conference, held by Global Academy for Medical Education. “Systolic and diastolic blood pressure increases every year of life on average, and by the fifth decade of life, diastolic will start going down, but systolic will continue to increase. If we can catch folks sooner, we can prevent the poor outcomes associated with having hypertension,” she stated.
The new guidelines, Davis continued, mean that “more than ever, accuracy in blood pressure measurement really matters.” She said, "It’s essential to take accurate blood pressures,” and to pay attention to things like having patients in a sitting position, at rest, with both feet planted on a flat surface, with back supported, and with arm at heart level for at least 5 minutes when taking BP measurements; to remove constrictive clothing and not just push it up; to make sure the patient hasn’t used caffeine or tobacco for at least 30 minutes prior to the measurement; to use the correct size sphygmomanometer cuff; to have the patient not talk during the measurement; and to consider out-of-office BP measurements in the overall assessment.
"We might have been late in the game in my opinion in the United States of really pushing this issue of using blood pressures from other settings—not just using in-office blood pressure readings,” Davis said making the point that the European and Canadian guidelines incorporated BP readings from other settings in the recommendations for diagnosing hypertension about 5 years ago.
“We need more than just the blood pressure readings we’re getting in the office,” she said, to identify things like white coat hypertension and masked hypertension, which is the opposite of white coat hypertension, meaning a patient’s BP is within normal limits in the office or clinic, but elevated when he/she is away from a medical setting.
When to start meds
Another practice changer, according to Davis, is when to start medications based on the new guidelines. “We are now looking at 10-year atherosclerotic risk, and that hasn’t been part of the management guidelines in the past for hypertension.” Similarly, “Treatment goals now have lower targets,” she said.
She explained that for patients who require secondary prevention of recurrent CVD (or if they have clinical CVD), then 10-year risk is irrelevant, and practitioners should start medication when systolic blood pressure (SBP) is 130 mm Hg or diastolic blood pressure (DBP) is 80 mm Hg. If the patient requires primary prevention (ie, no history of CVD or additional markers of increased risk of CVD) and their atherosclerotic 10-year risk is 10%, then medication is also warranted when SPB is 130 mm Hg or DBP is 80 mm Hg. Davis explained, “Some people might say [10% is] not much of a risk, but that’s considered as high a risk as someone who’s had a heart attack or stroke.”
If a patient requires primary prevention (ie, no history of CVD) and they have a 10-year atherosclerotic risk <10%, then health care providers should start medication when the patient’s SBP is 140 mm Hg or DBP is 90 mm Hg. Yet, Davis added, as with any patient with any elevation of BP, these patients should adopt lifestyle changes to reduce their BP.
In the end, Davis reminded that these are simply evidence-based guidelines, and that practitioners still need to have discussions with patients about when to start pharmacotherapy.
Follow-up and nonpharmacologic care
“If patients have low atherosclerotic risk and an SBP that is 120 to 129 mm Hg, you can repeat the BP measurement after up to 6 months of lifestyle changes,” said Davis. “These guidelines don’t add anything magical about lifestyle changes,” Davis explained. “It’s stuff we’ve known” and been doing for a long time, such as the DASH diet and weight loss, which “are as good as low-dose medication at reducing BP in many cases.”
She cautioned, however, that with patients who are Stage 1 and Stage 2, “Don’t wait too long to bring them back; bring them back within a month.” She said that most patients with Stage 1 hypertension are managed with a combination of lifestyle changes and a medication, while those with Stage 2 hypertension are often started on 2 medications at once, along with lifestyle changes.
Lastly, Davis explained that older adults are defined as those 65 years of age, and that this population can range widely from those who are ambulatory and well to those who have many comorbid conditions. As a result, practitioners really need to talk to these patients and perhaps their families to determine through shared decision-making what treatment is necessary.
1. Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71(6):1269-1324.
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