In this post, I link to and excerpt from The Curbsiders‘ #321 Hypertension FAQ: Common Outpatient Cases with Dr. Jordy Cohen, FEBRUARY 14, 2022 By MATTHEW WATTO, MD.
All that follows is from the above resource.
Master common hypertension scenarios in the clinic! Our guest Dr. Jordy Cohen (@jordy_bc) will lead us through the FAQs of outpatient hypertension management, including making a diagnosis of hypertension, managing blood pressure in patients with chronic kidney disease, working up refractory hypertension, and more.
- Given the difficulties with obtaining high-quality standardized blood pressure readings in the office, out-of-office home blood pressure measurement is recommended to confirm a diagnosis of hypertension. Patients should be instructed to acquire a validated blood pressure machine and educated on the steps of taking their blood pressure. A minimum of three days of home blood pressure readings (two back-to-back readings every AM and two every PM) is sufficient.
- For an initial blood pressure regimen, low-dose combination therapy is preferable to single agent therapy. A low-dose calcium channel blocker + ARB is a good starting regimen. Choose ARBs over ACE inhibitors due to their superior side effect profile. ARBs should be first-line in blood pressure management..
- 24 hour ambulatory blood pressure measurements are useful to diagnose white coat hypertension.
- For patients with chronic kidney disease, fear of a creatinine bump should not discourage providers from using ACEis/ARBs; on the contrary, these medications are protective in patients with kidney disease. Up to a 30% rise in creatinine with initiation of an ACEi/ARB is acceptable. Close monitoring of potassium is important, with a potassium threshold of 5.5.
- Diuretics are underutilized in patients with chronic kidney disease. Chlorthalidone is a promising agent in this population based on the CLICK trial.
- In a patient with refractory hypertension, primary hyperaldosteronism should be on the differential. Testing serum renin and aldosterone does not require stopping your patient’s anti-hypertensive medications (with the exception of mineralocorticoid antagonists (MRA) and amiloride).
- Mineralocorticoid antagonists (spironolactone, eplerenone) are useful in treating patients with primary hyperaldosteronism.
- Salt-sensitive hypertension is likely if renin is suppressed even when aldosterone is not elevated. Thus, target renin suppression (ex: MRA or amiloride). Amiloride is a particularly good treatment option for this population.
Hypertension FAQ – Notes
Managing a new diagnosis of hypertension
How to confirm a new diagnosis of hypertension
To accurately make a diagnosis of hypertension, office readings need to be high quality, standardized measurements – which per Dr. Cohen are rarely done in practice. Patients need to have rested for several minutes beforehand, be sitting comfortably with their back supported, their feet on the floor, and their arm bare with the mid-arm at heart level, and be fitted with the correct cuff size (Unger et al, ISH guidelines, 2020). Yet Dr. Cohen notes that routine blood pressure readings in the clinic are frequently done with incorrect cuff sizes, over clothing, and with the patient sitting on the exam table (which leaves their back unsupported, their feet off the floor, and their arm dangling). A recent study comparing formal trial blood pressure measurements for patients in the SPRINT study with these same patients’ routine outpatient clinic blood pressure measurements found significant discordance between the two; while on average the routine clinic measurements were found to be slightly higher than the trial measurements, there was a high degree of variability, without a single common “correction factor” to convert between them (Drawz, 2020).
Given that standardized ideal office blood pressure measurements (which our research trials are based on) are so rarely actually achieved in practice, the USPSTF now recommends out-of-office home blood pressure checks to confirm a diagnosis of hypertension with Grade A evidence (USPSTF guidelines). Dr. Cohen notes that home blood pressures may actually be closer to approximating perfect “research quality” measurements since patients are often in a more ideal resting state when at home. Of course, obtaining reliable home measurements hinges on educating patients about the proper steps in taking their blood pressure. Dr. Cohen suggests the infographics on targetBP.org as good patient-friendly educational tools. Patients should be instructed to obtain a validated device, ideally, one listed on www.validateBP.org.
With regards to the number of blood pressure measurements needed to reliably estimate home blood pressure, Bello, 2018 indicated that a minimum of 3 days of morning and evening measurements was sufficient. Over those three days, Dr. Cohen recommends that patients obtain two consecutive readings in the morning (before their AM medications and before their morning coffee), and two consecutive readings in the evening about 12 hours later (before their PM medications.)
When to start anti-hypertensive medication for young, low-risk patients
For young, healthy patients without risk factors with blood pressures >130/80 but <140/90, ACC/AHA guidelines recommend counseling patients on lifestyle changes (including weight loss and low sodium / high potassium diets), without an indication for pharmacologic management; if their blood pressure is ≥140/90, pharmacologic intervention is recommended (Whelton et al, ACC/AHA guidelines, 2017.) However, Dr. Cohen notes that there isn’t much good data for young, low-risk patients with blood pressures between 130/80 and 140/90. In fact, many of these patients can’t even be entered into the ASCVD risk calculator for cardiovascular risk as they are too young! Dr. Cohen’s expert opinion is that she would prefer more stringent blood pressure control (<130/80). In her practice, she has an open, honest conversation with her young, low-risk patients with blood pressures in the 130-139/80-89 range, explaining that there isn’t good data for patients like them but that medication could potentially help with little risk.
Initial blood pressure regimen: Single agent vs. combination therapy
For patients that have borderline high blood pressures (eg 140/90), Dr. Cohen says that starting with monotherapy (for instance, low-dose amlodipine) may be appropriate. However, Dr. Cohen stresses that for patients with higher blood pressures (>150 systolic), she advocates for low-dose combination therapies as an up-front regimen. There is a growing body of literature in support of low-dose combination therapy as opposed to monotherapy for initial blood pressure management (Salaam et al, 2019).