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Most patients with new hypertension under revised BP guidelines won’t need pharmacotherapy


 

EXPERT ANALYSIS FROM CARPS 2019

– An additional 14% of Americans have been reclassified as having hypertension – an increase from 32% to 46% of adults – under the latest guidelines on management of high blood pressure released by the American College of Cardiology and American Heart Association in 2017. However, this does not mean these patients are mandated for pharmacologic therapy, since most of them have been reclassified as having stage 1 hypertension, said Leslie L. Davis, PhD, RN, ANP-BC, FPCNA, FAANP, FAHA, associate professor of nursing at the University of North Carolina, Greensboro.

Dr. Leslie Davis

According to the new guidelines, normal BP is classified as less than 120 mm Hg systolic and less than 80 mm Hg diastolic. Elevated BP is 120-129 mm Hg systolic and under 80 mm Hg diastolic, while patients are classified as having stage 1 hypertension if their systolic BP is 130-139 mm Hg or diastolic BP is 80-90 mm Hg. Patients now have stage 2 hypertension if their systolic BP is higher than 140 mm Hg or diastolic BP is above 90 mm Hg.

This raises the importance of getting an accurate BP measurement from patients. At least two readings over two or more visits should be used before categorizing a patient. To take an ideal reading, patients should be sitting at rest with their back supported, feet positioned on a flat surface (no crossing legs), and their arm at heart level for at least 5 minutes. Patients should also refrain from tobacco or caffeine use 30 minutes before the reading. “These numbers need to be correct, because we’ve got new [BP] categories, and also for managing blood pressure, you’re making decisions based on these numbers,” said Dr. Davis at the Cardiovascular & Respiratory Summit by Global Academy for Medical Education.

When taking a patient’s BP, neither the patient nor the provider should talk, and constricting clothes on the upper extremity should be removed instead of pushed up. Using a incorrectly sized cuff can artificially raise or lower a patient’s BP level, so clinicians should use one that is 80% of the length and 40% of the width of the patient’s arm circumference. If the BP reading is elevated, confirm the reading in the other arm and use the arm with the higher reading for future measurements. BP measurements taken in different settings, such as ambulatory BP monitoring or home BP monitoring, can help give context to the in-office reading and whether the patient has white-coat hypertension or masked hypertension.

After a patient has their accurate BP reading, they can calculate their atherosclerotic cardiovascular disease (ASCVD) risk using the ACC’s ASCVD Risk Estimator, said Dr. Davis. If a patient has confirmed cardiovascular disease or has a 10% or greater 10-year ASCVD risk, the target to lower BP is 130 based on high-quality evidence, but expert opinion recommends targeting 130/80 for patients with confirmed hypertension as well.

In terms of nonpharmacologic therapies for these patients, the largest benefit is in getting patients to lose weight. “If somebody is overweight or obese, 10 pounds is 10 points,” said Dr. Davis. “Even if you don’t get them to the appropriate body mass index over 3 months’ time, that’s as much as a low or medium dose of antihypertensive therapy. For you to be able to get double-digit reduction, that’s what a med does.”

Other nonpharmacologic interventions for these patients include a heart-healthy diet such as the DASH diet, lowering sodium and increasing potassium, structuring exercise and physical activity, lowering use of or avoiding alcohol, and smoking cessation. The goal of nonpharmacologic therapy is not only to lower BP, but make the medication work better, said Dr. Davis.

Pharmacologic therapy should be initiated when patients exceed or are above the cutoff values for the new BP categories and if a patient has already had a cardiovascular event. “Basically, if you’re above that line in the sand of your goal, that’s when to start medications,” she said.

For stage 1 hypertension, first-line therapy is lifestyle change plus thiazides, calcium-channel blockers, or ACE inhibitors, with stage 1 hypertension therapy consisting of a combination of two first-line therapy therapies to reduce systolic BP by about 20 mm Hg and diastolic BP by 10 mm Hg. Beta-blockers are not first-line antihypertension therapy, but can be considered in patients with coronary artery disease and heart failure with reduced left ventricular ejection fraction.

With regard to follow-up, patients with low ASCVD risk and stage 1 hypertension can be monitored in 3-6 months after lifestyle changes, while patients with high ASCVD risk and stage 1 hypertension should be followed up in 1 month. Patients with stage 2 hypertension should follow up with their primary care provider 1 month after beginning their therapy, and those with very high BP should promptly be started on drug treatment with lifestyle changes, with upward dose adjustments as needed.

In adults aged 65 years or older, the ACC/AHA guidelines also focused on how to prevent cognitive decline and dementia, said Dr. Davis. The goal for ambulatory, community-dwelling adults is still to have a systolic BP of less than 130 mm Hg, but clinical judgment should prevail because of comorbid conditions and limited life expectancy in these patients. Patient preference should also be considered, and clinicians should use a team-based approach with shared decision making to determine goals for each patient.

Dr. Davis reported no relevant financial disclosures. Global Academy for Medical Education and this news organization are owned by the same parent company.

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