In this post I link to The Curbsiders‘ [Link is to the complete episode list] #254 Hypertension Update with Dr. Wanpen Vongpatanasin
FEBRUARY 1, 2021 By DEB GORTH:
L isten as our esteemed guest Dr. WanpenVongpatanasin, @DrWanpen (UT Southwestern) discusses the nitty-gritty of blood pressure monitoring and hypertension treatment. We review the thresholds for HTN diagnosis and how to accurately measure blood pressure levels at home and in the office. Dr Vongpatanasin shares the latest guideline recommendations for first line pharmaceutical therapies as well as her pearls about how to treat special populations.
- Hypertension is the presence of sustained elevated blood pressure, defined by the 2017 ACC/AHA Guidelines as systolic blood pressure (BP) ≥ 130mm Hg and/or a diastolic BP ≥ 80 mm Hg.
- Even high normal or pre-hypertension patients have a higher risk of morbidity/mortality, and people who achieve blood pressure control in the lower range have better cardiovascular outcomes.
- Both masked and white coat hypertension are associated with an increased risk of cardiac events and target organ damage as compared to normotensive individuals, though not as high as patients with sustained hypertension.
- Not all automated blood pressure machines are created equal. Check for their accuracy at validateBP.org.
- Wrist blood pressure cuffs do not provide reliable comparisons to upper arm (brachial) cuffs.
- For first line treatment of hypertension, consider starting a combination pill of two medications at low dose (ACE-i/ARB+CCB).
- Consider work up of primary hyperaldosteronism if the patient has resistant hypertension even if the patient doesn’t have hypokalemia.
Three Great Infographics From The Show Notes
First Infographic: Definitions and Background
Second Infographic: Accurate Measurement of Blood Pressure
Third Infographic: Treatment of Hypertension
Here are excerpts from the show notes:
CHOOSING A TARGET
The first step of treating hypertension is choosing a blood pressure target. For most patients, including high cardiovascular risk patients, that target should < 130/80 (2017 ACC/AHA Guidelines). Although the SPRINT trial suggested that a target SPB < 120 mmHg is better than < 140 mmHg in reducing cardiovascular events in hypertensive patients (SPRINT), careful BP measurement minimized the potential white coat or alerting reaction. A recent analysis showed that SBP was 7 mmHg higher in the SPRINT participants randomized to the intensive arm, when BP was measured in the real world office setting outside of the research context (Drawz et al 2020). In other words, BP measured in the research setting of 120 mmHg is correlated with BP of 127 mmHg when measured in the real world, which makes the target systolic BP goal of <130 mmHg proposed by the 2107 ACC/AHA guideline a very reasonable goal that is supported by SPRINT. However, coexisting orthostatic hypotension should be considered (the SPRINT trial excluded patients with a standing systolic BP ≤ 110). In geriatric patients, the best target blood pressure may be more relaxed when balancing lifetime risk and polypharmacy concerns (Aronow 2020, Agarwala 2020).
After lifestyle modification, the first line pharmacological therapies for hypertension are Angiotensin Converting Enzyme Inhibitors/Angiotensin Receptor Blockers (ACEi/ARBs), Thiazide Diuretics, and Calcium Channel Blockers (CCBs) (2017 ACC/AHA Guidelines). The ISH Hypertension Practice Guidelines suggest starting with low dose combination therapy (ACEi/ARB + CCB). Dr. Vongpatanasin notes that starting with ACEi/ARB + diuretics are also very reasonable in some patients. There is evidence of stronger benefit from using half dose of two medications rather than full dose on one medication, with lower side effects. Full dose (ie 50mg of hydrochlorothiazide) tends to have more side effects with less significant benefit (Bennett 2017, Jaffe 2013).
At around 36:00 in the talk, Dr Vongpatanasin gives more details on the above. She says that Kaiser uses one pill with a single strength of lisinopril of 20 mg combined with a single strength of hydrochlorothiazide of 25 mg.
She says that Kaiser Permanente uses 1/2 tab of the above for mild hypertension (less than 10 mm hg above the goal) [only mildly above the goal of 130/80], 1 tab for more severe hypertension (≅ 10 mm hg above goal) and two tabs a day for more severe hypertension.
Dr. Vongpatanasin says that a combination pill including an ace inhibitor and chlorthalidone (which was what was used in the SPRINT but it was supplied to the trial at no cost by the pharmaceutical company) is very very expensive.
I looked up the cost of lisinopril/hydrochlorothiazide 20/25 and it is very affordable.
Although the first priority is ensuring that the patient can consistently take their medication, patients with nocturnal hypertension or reverse dipping may benefit from nighttime dosing.
For patients with autonomic failure and supine hypertension, Dr Vongpatanasin suggests using a shorter acting medication at night time.
Dr Vongpatanasin suggests an alpha blocker would be a 4th line option in a patient with bradycardia. In a patient with tachycardia, using a beta blocker or a combo beta-alpha blocker like carvedilol could be a good choice.
In patients with isolated systolic hypertension and a low diastolic BP (wide pulse pressure), Dr. Vongpatanasin tries to avoid beta blockers, because slowing HR will increase stroke volume exacerbating the high pulse pressure. In the SPRINT trial those with DBP < 65 mmHg also benefited from lowering systolic pressure suggesting that there is not a large detriment to low diastolic – (Beddhu et al 2018).
Consider hyperaldosteronism in patients who have treatment resistant hypertension (patients uncontrolled on three standard HTN medications) even if they do not have hypokalemia (Rossi et al 2006). To screen for hyperaldosteronism test plasma aldosterone and renin concentration, if renin is suppressed even on multiple HTN medications this is consistent with hyperaldosteronism (Wolley and Stowasser 2017). If blood pressure control cannot be managed with the above first line medications, mineralocorticoid receptor antagonists like spironolactone should be used. Beware of the anti-androgenic effect of spironolactone in men; this is less of an issue in women. Eplerenone has lower anti-androgenic side effects, and so Dr Vongpatanasin suggests using this in younger men, though it requires higher mg to mg dose and BID dosing.
Dr Vongpatanasin states that primary aldosteronism is present in up to 10% of patients with mild hypertension.
For an excellent brief discussion of Primary Aldosteronism from emedicine.medicine.com see:
- Primary Aldosteronism – Practice Essentials Updated: Mar 24, 2020
Author: Gabriel I Uwaifo, MD
- Primary Aldosteronism Workup – Screening (First-Tier) Tests Updated: Mar 24, 2020 Author: Gabriel I Uwaifo, MD