Blood Pressure More Than 130/80 mmHg is Now Hypertension!!!

The recent AHA/ACC 2017 guidelines have lowered the blood pressure limits for the diagnosis of hypertension, thus resulting in more individuals qualifying for the diagnosis.

Highlights:

The American Heart Association / American College of Cardiology (AHA /ACC) along with several partner organizations have released guidelines on the prevention, detection, evaluation and management of high blood pressure
Individuals with a systolic blood pressure of 130 mm of Hg or more or a diastolic blood pressure of 80 mm of Hg or more will now qualify for the diagnosis of hypertension. An average of readings rather than a single reading will be necessary for the diagnosis
The guidelines also encourage patients to participate in the management of their hypertension

The recently published 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure published by the American Heart Association / American College of Cardiology (AHH /ACC) along with partner organizations are an update to “The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure” (JNC 7) released in 2003. Some of the salient features of the guidelines are as followed:

1. A blood pressure of 130/80 mm of Hg is now hypertension

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High blood pressure or hypertension is a chronic condition, which usually lasts a lifetime once it is developed.

‘The recent AHA/ACC 2017 guidelines have lowered the blood pressure limits for the diagnosis of hypertension, thus resulting in more individuals qualifying for the diagnosis.’

The earlier limits of 140/90 mm of Hg which were required for a person to qualify as a hypertensive have now been reduced. According to the new guidelines, even if you have a blood pressure of 130/80 mm of Hg, you suffer from hypertension. Your blood pressure is normal if it is less than 120/80mm of Hg. Levels of 130 to 139 systolic or 80-89 mm of Hg diastolic blood pressure are considered as grade 1 hypertension, while more or equal than 140 mm of Hg systolic or 90 mm of Hg is considered as grade 2 hypertension. The blood pressure of 120-129 / <80 mm of Hg, readings between normal and grade 1 hypertension is labelled as elevated blood pressure. The term ‘prehypertension’ that was used earlier has not been included in the new classification since it implied that the patient is normal, and did not reflect the underlying risks.

This change in the classification of hypertension could have major implications in the treatment of blood pressure. Many people who were earlier considered normal will now be hypertensive.

The goal of hypertension treatment should be a blood pressure of 130/80 mm of Hg

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The guidelines recommend a target blood pressure of 130/80 mm of Hg following treatment. This lower blood pressure as compared to the earlier goal of 140/90 mm of Hg has been suggested to reduce the risk of cardiovascular disease in these patients.

2. Not all stage 1 hypertensive patients require treatment with medications

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High blood pressure or hypertension is defined as a blood pressure of above 140 mm Hg (systolic) and or 90mm Hg (diastolic).

The change in classification does not mean that all people with stage 1 hypertension will require treatment. Treatment with medications will be offered only to those with clinical cardiovascular disease or an estimated risk of 10% or more of atherosclerotic cardiovascular disease (ASCVD). The 10-year ASCVD risk is estimated taking into consideration several factors which include age, race, sex, cholesterol levels, treatment with aspirin or a statin, systolic BP, treatment for hypertension, history of diabetes, and smoking. The remaining individuals will be recommended lifestyle modifications, which include weight loss, a DASH (Dietary Approaches to Stop Hypertension) - pattern diet, a sodium intake of less than 1500 mg/day and potassium intake of more 3500 mg/day in the diet, a minimum of 30 minutes of exercise three times per week, and alcohol intake limited to two drinks or less per day for men and one drink or less for women.

Accurate measurement of hypertension is important for the diagnosis

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The guidelines recommend detailed steps for the accurate measurement and recording of blood pressure. The blood pressure should be measured with a machine in the clinic that has been validated and calibrated on a regular basis to obtain accurate readings. The initial blood pressure should be measured in both arms, and subsequent readings are taken from the arm with a higher reading. The blood pressure should be an average of the two or more readings on two or more occasions.

3. Patient participation is necessary for the management of hypertension

Monitoring of blood pressure at home, after proper instructions to the patient, is encouraged to confirm the diagnosis and titrate the dosage. Home monitoring will also help to detect white coat hypertension, a condition where the blood pressure increases in the clinic due to anxiety, or masked hypertension, where the blood pressure in the clinic may be normal but may be high outside the clinic and require treatment. Home monitoring of blood pressure along with adopting lifestyle changes will ensure a more active participation of patients in maintaining a normal blood pressure.

4. Several tests are recommended in patients with hypertension

Tests that should be done in a patient with primary hypertension include a complete blood count, fasting blood glucose, lipid profile, serum creatinine with estimated glomerular filtration rate, serum sodium, potassium and calcium levels, thyroid stimulating hormone levels, urine tests and electrocardiogram, with tests like echocardiogram, serum uric acid and urinary albumin to creatinine ratio are optional. Screening tests for secondary hypertension are also listed in the guidelines.

5. Treatment of hypertension may be with one or more drugs

The first choice of drugs to begin treatment includes thiazide diuretics, calcium channel blockers (CCBs), and angiotensin converting enzyme inhibitors (ACE inhibitors) or angiotensin receptor blockers (ARBs). A combination of two such drugs is required in stage 2 hypertension and an average blood pressure of more than 20/10 mm Hg above the blood pressure target. ACE inhibitor, ARB, and/or renin inhibitor should not be used together due to their potential for harmful effects. The use of once-a-day medications and combination pills instead of separate pills could encourage patient compliance with the treatment. The treatment choices are also determined by the presence of underlying conditions like heart failure, ischemic heart disease and chronic kidney disease. Methyldopa, nifedipine, and/or labetalol are the drugs of choice in pregnancy. Regular follow ups are necessary to ensure good blood pressure control.

6. The intake of substances or medications that can affect blood pressure control should be limited or avoided

The intake of several substances and medications can affect the control of blood pressure. The intake of alcohol, recreational drugs and caffeine should be limited. Drugs whose dosage should be reduced or should be avoided if possible include amphetamines, antidepressants, atypical antipsychotics, decongestants, herbal supplements like Ma Huang, immunosuppressant drugs like cyclosporine, oral contraceptives, NSAIDs, systemic corticosteroids and anticancer medications like bevacizumab, Sunitinib and sorafenib.

References:

Whelton PK, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Hypertension 2017 https://doi.org/10.1161/HYP.0000000000000065

Source-Medindia