“The most important condition most of you will ever treat.” These are the words that Karol E. Watson, MD, PhD, used to introduce the topic of hypertension during her presentation at Pri-Med Southwest in Houston. “It is the difference between a major cardiovascular event, or even mortality, in many of your patients,” Dr. Watson continued.
An attending cardiologist and professor of Medicine/Cardiology at the David Geffen School of Medicine at UCLA, Dr. Watson spoke for 30 minutes on wide-ranging topics related to hypertension, but chose to focus at the outset on the 2017 ACC/AHA Hypertension Guidelines and how the revised recommendations incorporated there should be applied in clinical practice.
“The big headline on the new Guidelines is that we have recategorized blood pressure,” Dr. Watson said. “Where previously high blood pressure was 140/90 or greater, the new guidelines state that Stage 1 hypertension begins at systolic BP of 130-139 mmHG or diastolic BP of 80-89 mmHG.”
Dr. Watson noted that these standards are meant to apply to all patients, regardless of their co-morbidities, including kidney failure and diabetes. And, the new standards have significant meaning for clinicians.
“If everyone’s goal is 130, that means a lot of new patients are being diagnosed with hypertension,” Dr. Watson said. “It’s about half of the U.S. population.” The previously existing standards identified about a third of the U.S. population as being hypertensive.
“Elevated” Is Important, Too
Dr. Watson asked her audience to also pay attention to blood pressure readings that are pre-hypertensive, those now described as “elevated” in the new Guidelines— having systolic pressure between 120 and 129 and diastolic over 80.
“Think about it,” she said. “How many of your patients come in with numbers like that? Pretty much everyone.”
“If I see a healthy woman, 25 years of age, with a blood pressure of 122/82, that’s good, right?” It’s okay for the time being, but does not bode well for the future,” Dr. Watson said.
“In the Framingham cohort study, they took people who eventually developed hypertension and looked at their trajectory from a few years before,” she said. “They saw that, regardless of age, as soon as you hit a systolic BP of about 120, there is a rapid rise into hypertension. So if you get to a systolic BP of 120, it’s not like you’re doing great. You have to pay attention to these patients, because if you do nothing, you probably will have hypertension in a few years.”
Why 130 mmHG?
Wondering how the Guidelines committee arrived at 130 SBP as the starting point for hypertension? The committee relied largely on the results of the SPRINT trial, the first randomized, controlled trial demonstrating that an SBP goal of <120 mmHg can deliver cardiovascular benefits in patients beyond those achieved when BP is reduced to merely <140 mmHg.
But, is such an aggressive goal realistic, or even safe, for everyone?
“What if you’re really old? Over 75?,” Dr. Watson said. “In fact, in SPRINT, when they looked at the study sub population over age 75, they saw an even greater relative risk reduction in the primary outcome, and an even greater total mortality reduction.” As for the most frail individuals, they saw the greatest benefit.
Treating Elevated BP and Stage 1 Hypertension
If a patient’s SBP is between 120 and 129, you start applying non-pharmacologic strategies for reducing BP, and check in again in 3 to 6 months, Dr. Watson said. Such nonpharmacologic treatments have been part of the guidelines “for decades,” Dr. Watson noted, going on to list them:
“Weight loss, whether the patient is overweight or not. A low-sodium diet. Exercise—and isometric exercise turns out to be the most beneficial. Alcohol reduction—definitely not more than 1 to 2 drinks per day. And potassium repletion.”
A Word to the Wise
Concluding her presentation, Dr. Watson advised her audience with these final words:
“Even if you get to age 65 with stone cold normal blood pressure, remember that virtually everyone develops hypertension. So, whether you have it now or not, you probably will get it, and that’s something we should all know and prepare for.”