Hypertension and Clinical Practice

Kidney News Editorial Board member Edgar Lerma, MD, FASN, interviewed George Bakris, MD, FASN, about clinicians’ experience with the 2017 American College of Cardiology/American Heart Association (ACC/AHA) Hypertension Guidelines (1).

Dr. Lerma What are the highlights of the new ACC/AHA 2017 Hypertension Guidelines? How are they different from the previous guidelines?

Dr. Bakris Highlights and novel features of the new hypertension guidelines are as follows, compared with previous reports:

  1. They are the first to focus on overall 10-year cardiovascular (CV) risk and attempt to provide a goal blood pressure (BP) to minimize CV risk.
  2. They strongly endorse home BP measurement for all patients with hypertension to provide them with more feedback and improve adherence. Note that home BP has been validated against daytime ambulatory BP monitoring.
  3. They emphasize proper measurement of BP in the office.
  4. They expand the previous Joint National Committee 7 guidance on lifestyle modification as the cornerstone of BP therapy.
  5. They put more emphasis on sleep disorders than did previous guidelines.
  6. They change the threshold to diagnose hypertension and make it the goal as well: <130 mm Hg.
     

Dr. Lerma Under the new hypertension classification, there is an increase in the incidence and prevalence of hypertension. There is some perception that this benefits the pharmaceutical industry tremendously. What is your take on this?

Dr. Bakris This assertion couldn’t be further from the truth. First, no new BP-lowering medication has been developed in over 15 years. Second, no one on the committee had any ties to industry. Last, the guidelines clearly emphasize lifestyle management as initial treatment and specifically state no drug therapy in the 130 mm Hg to 139 mm Hg goal unless the risk of CV disease is very high and lifestyle approaches have failed to reduce BP.

Dr. Lerma What have we now learned about white coat hypertension that we didn’t know before? How is this going to affect clinical practice?

Dr. Bakris We know that white coat hypertension is not benign, and with the recent publication of Banegas and colleagues from Spain we know that white-coat and masked hypertension have higher all-cause mortality rates in comparison with sustained primary hypertension (2). Anxiety or inability to handle stress effectively is a major component of white coat hypertension, but it is not the only factor. Hence, identifying anxiety or stress and providing the patient with a psychologist or approaches to handle such situations could minimize these BP increases, which can be as high as 50 mm Hg systolic.

Dr. Lerma One of the issues that has received a lot of attention (and criticism) with the Systolic Blood Pressure Intervention Trial (SPRINT) is the method of taking blood pressure. What is your opinion on this, and how do you think it will affect clinical practice?

Dr. Bakris The reason SPRINT’s method of taking blood pressure received criticism was that it is time consuming and requires trained, qualified personnel. This is fine for a trial, but not for routine practice. Unfortunately, there is a difference of as much as 13 to 15 mm Hg in systolic pressure between the SPRINT approach and routine practice. Hence, you may be overtreating a subset of people. This would lead to more side effects being ascribed to drugs rather than BP being too low. It is worth the effort to make the change.

Dr. Lerma What about 24-hour urine sodium?

Dr. Bakris This is a great test to check on whether patients are following a low-sodium diet. Check sodium and total creatinine. I have used this sometimes in people who swear they are following a low-sodium diet and always find that they are taking in two to five times more sodium than they should be. In many cases, correction by the patient results not only in better BP control but also in a reduction of medication doses or in termination of some drugs.

Dr. Lerma What is your prediction about the future of hypertension management? Do you think we’ll keep these present guidelines before another revision?

Dr. Bakris I think these recent guidelines are an excellent public health document and have a lot of useful information. As for the goal and the staging and the risk, those will change over time.

The European Society of Hypertension guidelines were just announced, and they have <140/90 mm Hg as the goal. The American Diabetes Association has <140/90 mm Hg for everyone, and those at higher risk (>10% over 10 years) should be at <130/80 mm Hg. Moreover, numerous well-done studies have just been published or are in press from populations in Europe and Asia, all uniformly showing no significant advantage to going below 130/80 mm Hg in the general population or even among those with diabetes and low CV risk. Moreover, separate and recent studies demonstrate that one needs at least 18% 10-year CV risk to benefit from <130/80 mm Hg, with greater likelihood of harm than benefit at lower risk (3). Also, the Heart Outcomes Prevention Evaluation 3 trial showed no benefit among those with low CV risk unless BP was above 140 mm Hg (4).

September 2018 (Vol. 10, Number 9)

References

1. Carey RM, et al The 2017 American College of Cardiology/American Heart Association Hypertension Guideline: A resource for practicing clinicians. Ann Intern Med 2018; 168:359–360.

2. Banegas JR, et al Relationship between clinic and ambulatory blood-pressure measurements and mortality. N Engl J Med 2018; 378:1509–1520.

3. Phillips RA, et al Impact of cardiovascular risk on the relative benefit and harm of intensive treatment of hypertension. J Am Coll Cardiol 2018; vol. 71 (PDF article).

4. Yusuf S, et al Blood-pressure and cholesterol lowering in persons without cardiovascular disease. N Engl J Med 2016; 374:2032–2043.