Ups and Downs of Outpatient

Hypertension Management

Jay Shah M.D.Carolina Cardiology

Greenville Health System

Disclosures

• None

Objectives

• Discuss optimal methods for BP measurement

• Recognize the stages of HTN as defined by

2017 ACC/AHA Guidelines

• Discuss new targets for BP in the management of HTN

• Discuss lifestyle approaches to improve BP during

treatment

Background

• HTN is the most common chronic disease of adulthood

• A leading cause of disability and mortality worldwide

• HTN is the #1 modifiable risk factor for CV disease in US

• The effects of HTN in promoting CV disease appears to be more prominent in women vs men and among blacks vs whites

New Guidelines

• 2014 AHA and ACC convened a 21 member

group to develop new guideline for the diagnosis

and management of HTN

Applying Class of

Recommendation and

Level of Evidence to

Clinical Strategies,

Interventions,

Treatments, or

Diagnostic Testing

in Patient Care* (Updated August 2015)

New 2017

AHA/ACC HTN Guidelines

Emphasis on 5 main areas:

• BP measurement

• New BP classification system

• New approach to decision making for treatment

incorporates CV risk

• Lower target BP during management of HTN

• Strategies to improve BP during treatment- emphasis

on lifestyle approaches

2017 Hypertension Guideline

Accurate Measurement of BP in the Office

COR LOERecommendation for Accurate Measurement of BP in

the Office

I C-EO

For diagnosis and management of high BP,

proper methods are recommended for accurate

measurement and documentation of BP.

Arm Circumference Usual Cuff Size

22–26 cm Small adult

27–34 cm Adult

35–44 cm Large adult

45–52 cm Adult thigh

Key Steps for Proper BP Measurements

Step 1: Properly prepare the patient.

Step 2: Use proper technique for BP measurements.

Step 3: Take the proper measurements needed for diagnosis and

treatment of elevated BP/hypertension.

Step 4: Properly document accurate BP readings.

Step 5: Average the readings.

Step 6: Provide BP readings to patient.

Out-of-Office and Self-Monitoring of BP

COR LOERecommendation for Out-of-Office and Self-

Monitoring of BP

I ASR

Out-of-office BP measurements are recommended to

confirm the diagnosis of hypertension and for titration

of BP-lowering medication, in conjunction with

telehealth counseling or clinical interventions.

SR indicates systematic review.

BP Measurement

• Out of office and self monitoring BP are recommended to confirm diagnosis and titration of BP lowering medication

• Ambulatory BP monitor and home BP monitors are strongly recommend

• Aid in screening for white coat hypertension and masked hypertension

BP Measurement

• Important to use an average based on > 2

readings obtained on > 2 occassions to estimate

BP for diagnosis

*Individuals with SBP and DBP in 2 categories should be

designated to the higher BP category.

BP indicates blood pressure (based on an average of ≥2

careful readings obtained on ≥2 occasions, as detailed in

DBP, diastolic blood pressure; and SBP systolic blood

pressure.

BP Category SBP DBP

Normal <120 mm Hg and <80 mm Hg

Elevated 120–129 mm

Hg

and <80 mm Hg

Hypertension

Stage 1 130–139 mm

Hg

or 80–89 mm Hg

Stage 2 ≥140 mm Hg or ≥90 mm Hg

Blood Pressure

Classification

Blood Pressure

Classification

BP Risk

• 2010 - HTN was leading cause of death and disability

• Greater contributor to events in women and African Americans

• Risk of CVD increase in log linear fashion

• A 20 mg Hg higher SBP and 10 mm Hg DBP are each associated with doubling in the risk of death, stroke, heart disease and vascular disease.

• SBP has consistently been associated with increase CVD risk

New Goals for

Treatment of HTN

• Target recommended BP is 130/80

• This also includes older adults based

upon results from the SPRINT study

BP Thresholds for and Goals of Pharmacological

Therapy in Patients With Hypertension According to Clinical Conditions

Clinical Condition(s)BP Threshold,

mm Hg

BP Goal,

mm Hg

General

Clinical CVD or 10-year ASCVD risk ≥10% ≥130/80 <130/80

No clinical CVD and 10-year ASCVD risk <10% ≥140/90 <130/80

Older persons (≥65 years of age; noninstitutionalized,

ambulatory, community-living adults)

≥130 (SBP) <130 (SBP)

Specific comorbidities

Diabetes mellitus ≥130/80 <130/80

Chronic kidney disease ≥130/80 <130/80

Chronic kidney disease after renal transplantation ≥130/80 <130/80

Heart failure ≥130/80 <130/80

Stable ischemic heart disease ≥130/80 <130/80

Secondary stroke prevention ≥140/90 <130/80

Secondary stroke prevention (lacunar) ≥130/80 <130/80

Peripheral arterial disease ≥130/80 <130/80

ASCVD indicates atherosclerotic cardiovascular disease; BP,

blood pressure; CVD, cardiovascular disease; and SBP,

systolic blood pressure.

2017 Hypertension Guideline

Elevated Blood Pressure

120-129 mm Hg and <80 mm High

• Healthy Lifestyle Changes

• Lose weight

• Reduce NA intake to < 1500 mg/day

• Increase K+ to 3500 mg/day

• Increase physical activity to a minimum of 30

min exercise 3X/week

• Limit alcohol to 2 drink or less for men and 1

drink or less for women per day

2017 Hypertension Guideline

Nonpharmacological Interventions

COR LOERecommendations for Nonpharmacological

Interventions

I A

Weight loss is recommended to reduce BP in adults

with elevated BP or hypertension who are overweight

or obese.

I A

A heart-healthy diet, such as the DASH (Dietary

Approaches to Stop Hypertension) diet, that facilitates

achieving a desirable weight is recommended for

adults with elevated BP or hypertension.

I ASodium reduction is recommended for adults with

elevated BP or hypertension.

IA

Potassium supplementation, preferably in dietary

modification, is recommended for adults with elevated

BP or hypertension, unless contraindicated by the

presence of CKD or use of drugs that reduce

potassium excretion.

Nonpharmacological Interventions (cont.)

COR LOERecommendations for Nonpharmacological

Interventions

I A

Increased physical activity with a structured exercise

program is recommended for adults with elevated BP or

hypertension.

I A

Adult men and women with elevated BP or hypertension

who currently consume alcohol should be advised to

drink no more than 2 and 1 standard drinks* per day,

respectively.

*In the United States, 1 “standard” drink contains roughly 14 g of pure alcohol, which is

typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually

about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).

Nonpharmacologi-

cal InterventionDose Approximate Impact on SBP

Hypertension Normotension

Weight loss Weight/body fat Best goal is ideal body weight, but aim

for at least a 1-kg reduction in body

weight for most adults who are

overweight. Expect about 1 mm Hg for

every 1-kg reduction in body weight.

-5 mm Hg -2/3 mm Hg

Healthy diet DASH dietary pattern

Consume a diet rich in fruits,

vegetables, whole grains, and low-fat

dairy products, with reduced content

of saturated and total fat.

-11 mm Hg -3 mm Hg

Reduced intake

of dietary

sodium

Dietary sodium Optimal goal is <1500 mg/d, but aim

for at least a 1000-mg/d reduction in

most adults.

-5/6 mm Hg -2/3 mm Hg

Enhanced intake

of dietary

potassium

Dietary potassium

Aim for 3500–5000 mg/d, preferably

by consumption of a diet rich in

potassium.

-4/5 mm Hg -2 mm Hg

Nonpharmacological

Intervention

Dose Approximate Impact on SBP

Hypertension Normotension

Physical

activity

Aerobic ● 90–150 min/wk

● 65%–75% heart rate reserve

-5/8 mm Hg -2/4 mm Hg

Dynamic resistance ● 90–150 min/wk

● 50%–80% 1 rep maximum

● 6 exercises, 3 sets/exercise, 10

repetitions/set

-4 mm Hg -2 mm Hg

Isometric resistance ● 4 × 2 min (hand grip), 1 min rest

between exercises, 30%–40%

maximum voluntary contraction, 3

sessions/wk

● 8–10 wk

-5 mm Hg -4 mm Hg

Moderation

in alcohol

intake

Alcohol consumption In individuals who drink alcohol,

reduce alcohol† to:

● Men: ≤2 drinks daily

● Women: ≤1 drink daily

-4 mm Hg -3 mm

*Type, dose, and expected impact on BP in adults with a normal BP and with hypertension.

†In the United States, one “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of

regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12%

alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).

Hypertension: Stage 1

130-139 mm Hg or 80-89 mm Hg

• Assess 10 year risk of ASCVD using ASCVD

risk calculator

• If risk <10%, start with healthy lifestyle

• If risk >10% or known CVD, DM or CKD, start

with lifestyle changes and BP lowering

medication

Hypertension: Stage 2

≥ 140 mm Hg or ≥ 90 mm Hg

• Healthy lifestyle changes

• Start two BP lowering medication of different

classes

• Reassess after 1 month

Choice of Initial Medication

COR LOE Recommendation for Choice of Initial Medication

IASR

For initiation of antihypertensive drug therapy, first-

line agents include thiazide diuretics, CCBs, and ACE

inhibitors or ARBs.

Choice of Initial Monotherapy Versus Initial Combination Drug Therapy

COR LOERecommendations for Choice of Initial Monotherapy

Versus Initial Combination Drug Therapy*

I C-EO

Initiation of antihypertensive drug therapy with 2 first-line

agents of different classes, either as separate agents or in a

fixed-dose combination, is recommended in adults with stage

2 hypertension and an average BP more than 20/10 mm Hg

above their BP target.

IIa C-EO

Initiation of antihypertensive drug therapy with a single

antihypertensive drug is reasonable in adults with stage 1

hypertension and BP goal <130/80 mm Hg with dosage

titration and sequential addition of other agents to achieve the

BP target.

2017 Hypertension Guideline

Age-Related Issues

COR LOERecommendations for Treatment of Hypertension in

Older Persons

IA

Treatment of hypertension with a SBP treatment goal of less than

130 mm Hg is recommended for noninstitutionalized ambulatory

community-dwelling adults (≥65 years of age) with an average SBP

of 130 mm Hg or higher.

IIa C-EO

For older adults (≥65 years of age) with hypertension and a high

burden of comorbidity and limited life expectancy, clinical judgment,

patient preference, and a team-based approach to assess risk/benefit

is reasonable for decisions regarding intensity of BP lowering and

choice of antihypertensive drugs.

Racial and Ethnic Differences in Treatment

COR LOE Recommendations for Race and Ethnicity

IB-R

In black adults with hypertension but without HF or CKD, including

those with DM, initial antihypertensive treatment should include a

thiazide-type diuretic or CCB.

I C-LD

Two or more antihypertensive medications are recommended to

achieve a BP target of less than 130/80 mm Hg in most adults with

hypertension, especially in black adults with hypertension.

Pregnancy

COR LOERecommendations for Treatment of Hypertension in

Pregnancy

IC-LD

Women with hypertension who become pregnant, or are planning to

become pregnant, should be transitioned to methyldopa, nifedipine,

and/or labetalol during pregnancy.

III:

HarmC-LD

Women with hypertension who become pregnant should not be

treated with ACE inhibitors, ARBs, or direct renin inhibitors.

How can I use this in my

practice?

• 130/80 is the new 140/90

• Encourage out of office BP checks

• Encourage healthy lifestyle

• Calculate ASCVD risk for stage 1 HTN

• Consider 2 medications first line for Stage 2 HTN

Question

Based upon the 2017 ACC/AHA guidelines for hypertension, a 75 y/o male with history HTN and Diabetes has an average BP 170/80 and pulse rate of 78? What would you recommend for treatment of this patient’s hypertension?

A. Carvedilol 6.25 mg po BID

B. Lisinopril 10 mg po QD

C. Amlodipine 5mg QD and Lisinopril 10mg po QD

D. Metoprolol 25mg po BID and HCTZ 25 mg po QD