Hypertension Treatment Guidelines Update

DECEMBER 14, 2018
Roger On, MD, FACC, and Saro Arakelians, PharmD
Health care providers often encounter patients with high blood pressure (BP), especially systolic, who come and go without proper treatment and eventually end up in the hospital with a heart attack, kidney failure, or a stroke. Below is a summary of the most recent national guidelines for evaluating these patients, and the Figure shows the BP classification by The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8)1 and 2017 American College of Cardiology/American Heart Association (AHA) hypertension guidelines:
  • Compare both upper extremes during the first visit, and if they are unequal, use the higher value.
  • Compare the home cuff’s reading with the office cuff’s reading to verify the accuracy of the home cuff’s.
  • Evaluate after 1 to 2 weeks of the patient’s taking the BP at home in the morning and at night.2
  • If there are still problems diagnosing true hypertension, consider a 24-hour ambulatory BP monitor.
  • Perform manual vital signs with irregular rhythms.


The Canadian guidelines, which are more advanced and clear, are3:
  • First choice: automatic oscillometric automated office blood pressure (AOBP), high >135/85 mm Hg
  • Non-AOBP, high >140/90 mm Hg
  • Ambulatory BP, high awake >135/80 mm Hg, mean 24-hour >130/80 mm Hg
  • Home BP, high >135/85 mm Hg
Nonpharmacologic Treatment
Health care providers should make sure that patients first make lifestyle changes. The AHA recommends no more than 2300 mg of sodium per day and ideally no more than 1500 mg per day for most adults. Because the average American eats so much excess sodium, cutting back by even 1000 mg per day can significantly improve BP and heart health. In Canada, the recommended daily sodium maximum intake is 2000 mg.

In addition, those with normal renal function should have 3.5 g or more of potassium per day, according to AHA guidelines.

Patients should aim for a body mass index of about 25, and their diets should include more fish, fruits, low-fat dairy, legumes, poultry, vegetables, and whole grains. They should eat less red meat, saturated and trans fats, and sweets. Alcohol intake should be limited. Patients should also engage in an aerobic exercise program of 150 to 250 minutes per week.4

Pharmacologic Treatment
Angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers, and thiazide diuretics should be used as first-line options, single or in combination. A β-blocker can be used in patients who have any of the following: coronary artery disease, postmyocardial infarction, dysrhythmia, and heart failure. Those older than 60 years, however, should not use a β-blocker as the initial agent.5 Finally, atenolol should not be used for hypertension treatment, as it has been shown to be less effective in the prevention of events compared with all other agents.

A suggested treatment protocol for moderate hypertension of >20 mm Hg above goal is:
  • An ACE inhibitor or an ARB with a diuretic or a dihydropyridine (DHP) calcium channel blocker (such as amlodipine, felodipine, or nifedipine) combination6
  • Start with a low dose and titrate upward.
If hypertension is not controlled, the following may be added in stepwise order:
  1.  A DHP calcium channel blocker or a thiazide diuretic (chlorthalidone is more potent than hydrochlorothiazide [HCTZ]; add whichever has not yet been used); can use combination low-dose amiloride/HCTZ in appropriate patients.
  2. A vasodilating β-blocker (such as carvedilol or nebivolol) and/or an aldosterone blocker.
  3. α-Blockers, direct vasodilators; consider referral.
The Table shows treatment recommendations for specific patient populations.



Conclusion
The BP goal for all US patients, including those with diabetes, should be <130/80 mm Hg. Patients over 80 years should have <150 mm Hg systolic, according to the American Society of Hypertension.8 Those with difficulty controlling BP despite the above recommendations should be investigated for outside factors that may worsen BP, such as β agonists, dietary changes, excessive alcohol consumption, and use of NSAIDs. Use of ARB and ACE inhibitors together or with a renin blocker is usually not indicated because of the risk of increased potassium and renal insufficiency.9

Above all, practitioners need to individualize treatment based on multiple parameters, such as age, atherosclerotic cardiovascular disease risk, concomitant diseases, and patient preference.
 
Roger On, MD, FACC is a cardiologist at Lakeside Community Healthcare in Burbank, California.

Saro Arakelians, PharmD, is the general manager and pharmacist in charge at BioScrip Infusion in Burbank.


References
  1. JNC 8 Hypertension Guideline algorithm. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. JNC8 guidelines: nmhs.net/documents/27JNC8HTNGuidelinesBookBooklet.pdf. Accessed November 15, 2018.
  2. Monitoring your blood pressure at home. American Heart Association website. heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings/monitoring-your-blood-pressure-at-home. Published November 30, 2017. Accessed November 7, 2018.
  3. About guidelines. Canadian Cardiovascular Society website. ccs.ca/en/guidelines. Accessed November 7, 2018.
  4. Use the nutrition facts label to reduce your intake of sodium in your diet. FDA website. fda.gov/food/resourcesforyou/consumers/ucm315393.htm. Updated June 12, 2018. Accessed November 7, 2018.
  5. Schumann A, Hickner J. When not to use beta-blockers in seniors with hypertension. J Fam Pract. 2008;57(1):18-21.
  6. Kalra S, Kalra B, Agrawal N. Combination therapy in hypertension: an update. Diabetol Metab Syndr. 2010;2(1):44. doi: 10.1186/1758-5996-2-44.
  7. Papadopolou E, Angeloudi E, Karras S, Sarafidis P. The optimal blood pressure target in diabetes mellitus: a quest coming to an end? J Hum Hypertens. 2018;32(10):641-650. doi: 10.1038/s41371-018-0079-5.
  8. Hypertension Canada guidelines. Hypertension Canada website. hypertension.ca/. Accessed November 7, 2018.
  9. Misra S, Stevermer JJ. ACE inhibitors and ARBs: one or the other—not both—for high-risk patients. J Fam Pract. 2009;58(1):24-27.


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