Hypertension

Hypertension is a common condition encountered in the outpatient setting and responsible for a significant portion of the mortality and morbidity from cardiovascular disease (CVD). The harms of hypertension are so well recognized today that it is hard to believe medicine did not emphasize the importance of treating high blood pressure (BP) until the second half of the 20th century. In this section, we will cover the following: 

• Blood Pressure and Mortality

• Guidelines

• Diagnosis and Treatment

• Resistant Hypertension

Blood Pressure and Mortality

(Reprinted from The Lancet, Age-Specific Relevance of Usual Blood Pressure to Vascular Mortality: A Meta-Analysis of Individual Data for One Million Adults in 61 Prospective Studies. The Lancet 2002, with permission from Elsevier.)

Guidelines

History

In 1977, the Joint National Committee (JNC) on Detection, Evaluation, and Treatment of High Blood Pressure sponsored by the National Heart, Lung, and Blood Institute (NHLBI) published the first guideline on hypertension. As shown in the chart below, over the course of the next four decades, many landmark clinical trials continued to shape our understanding of hypertension management and optimal blood pressure.

Ultimately, it is important to individualize the approach to hypertension management when deciding treatment options and goals. For each patient, consider these factors:

• underlying conditions

• age

• cardiovascular risk

• treatment preferences

• potential for adverse medication effects

(Source: Lessons in Uncertainty and Humility — Clinical Trials Involving Hypertension. N Engl J Med 2016.)

In 2015, the Systolic Blood Pressure Intervention Trial (SPRINT) showed a mortality and cardiovascular benefit in patients with a high risk of cardiovascular disease but without diabetes or stroke when treated to a target systolic BP of <120 mm Hg versus <140 mm Hg. However, some experts expressed concern regarding the generalizability of these findings because of the way in which BP was measured in the study — a mean of three measurements after the patient was seated for 5 minutes of quiet rest — potentially leading to lower readings than in typical practice. Notably, in the intensively treated group, the average achieved systolic BP remained above 120 mm Hg and was associated with more hypotensive adverse effects.

Current Recommendations

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 

In 2017, the American College of Cardiology (ACC), American Heart Association (AHA), and nine other societies published the current guidelines. These guidelines are heavily influenced by the results of the SPRINT trial and redefine BP categories and hypertension as follows:

The 2017 ACC/AHA guideline also incorporates 10-year risk of arteriosclerotic cardiovascular disease (ASCVD), as defined by the ASCVD risk estimator, into the treatment decision-making process. In brief, the recommended treatment algorithm is as follows:

Some experts have expressed concern that the 2017 ACC/AHA guidelines will lead to the diagnosis of many more patients with hypertension and lead to excessive, unnecessary treatment. Ultimately, it is important to consider the guidelines along with the risks, benefits, and preferences of the individual patient when deciding treatment options and goals.

2020 International Society of Hypertension Global Hypertension Practice Guidelines 

These international guidelines define hypertension as follows:

• grade 1 hypertension: a systolic BP of 140−159 mm Hg and/or diastolic BP of 90−99 mm Hg

• grade 2 hypertension: ≥160 systolic and/or ≥100 diastolic following repeated examination

2021 Screening for Hypertension in Adults U.S. Preventive Services Task Force Reaffirmation

Recommendation Statement: The 2021 USPSTF screening guidelines recommend that all adults be screened for hypertension in the office setting. In adults aged 18-39 years who do not have risk factors for hypertension, screening every 3-5 years is acceptable. However, in adults who are older than 40 years or who have risk factors for hypertension (e.g., Black, previously elevated BP, overweight or obese), then screening should be annual. Blood pressure measurements should also be obtained in the ambulatory setting for confirmation before initiating antihypertensive treatment.

Diagnosis and Treatment

Measuring Blood Pressure

The first step in treating hypertension requires properly measuring BP. Key points for accurate BP measurements include the following:

• Diagnosis of hypertension should be based on the average of two or more properly measured readings at two or more follow-up visits after the initial screening visit.

• The patient should sit quietly for 5 minutes if possible before measuring.

• Use the right size cuff for the patient’s arm.

• Check BP in both arms at the first screening and use the arm with the higher reading for subsequent measurements.

• Consider ambulatory BP monitoring in patients who might have white coat hypertension (e.g., high BP only in a health care setting), which is associated with minimal increased risk of CVD.

• In contrast, masked hypertension (normal office BP with elevated ambulatory BP) is associated with a risk of CVD and all-cause mortality similar to sustained hypertension. Although the data for screening and treatment of masked hypertension are still not entirely clear, the ACC guidelines recommend ambulatory BP monitoring in patients not on antihypertensive medication who have consistent office BPs of 120-129 mm Hg systolic or 75-79 mm Hg diastolic or in patients who — despite being treated for hypertension and have office BPs at goal — still have end-organ damage consistent with potentially untreated hypertension or are at high risk for ASCVD.

Lifestyle Interventions

All patients should start with lifestyle interventions to reduce blood pressure, including the following:

• weight loss

• the DASH diet

• dietary sodium reduction

• potassium supplementation

• regular exercise (at least 150 minutes of moderate activity a week)

• restricted alcohol use (two standard drinks per day for men and one per day for women)

Medications

The following table lists first- and second-line agents recommended in the 2017 ACC/AHA guideline, with specific notes for different classes.

Resistant Hypertension

Patients who have uncontrolled BP despite taking three antihypertensive medications including a diuretic or who need at least four medications to reach their goal are considered to have resistant hypertension. Make sure that these patients are adhering to their medication regimens, have accurate BP measurements, make lifestyle changes, and stop taking any interfering drugs or substances (e.g., alcohol, caffeine, NSAIDs, sympathomimetics). True resistant hypertension along with the following clinical features should prompt a workup for secondary causes:

• severe hypertension

• abrupt-onset hypertension

• worsening of previously controlled hypertension

• disproportionate target organ damage to degree of hypertension

• onset of diastolic hypertension in those aged ≥65

• unprovoked or excessive hypokalemia

  • age <30 (can still have primary hypertension)