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Tis the Season to Be…Hypertensive?

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Twelve days after Thanksgiving, six days before the start of Hanukah, 19 days before Christmas, and 20 days before the beginning of Kwanzaa. Today, December 6th, puts us smack in the middle of the Holiday season. The time of year when just about every newspaper, magazine, website and TV and radio station begins rolling out their tips and tricks for keeping stress down, maintaining proper diet and exercise routines, and starting the New Year off right. While these can often be helpful and full of sage advice, they’re not always foolproof.

In fact, this year for many Americans, some heath pitfalls may be unavoidable – specifically, high blood pressure, which tends to climb during the winter.

Last month at the American Heart Association (AHA) Scientific Sessions 2017 in Anaheim, CA, the AHA and American College of Cardiology (ACC) released a new cache of hypertension guidelines, which sparked quite a bit of stir. Under the new guidelines, roughly 31 million more Americans will be considered hypertensive and at higher risk for heart attack and stroke, and in many cases it means a significant increase in the number of patients being prescribed blood pressure medication.

“My biggest concern with the new recommendations is that a guideline is not a substitute for clinical judgment,” said Raymond Townsend, MD, director of the Hypertension Program at Penn Medicine. “If these recommendations are embraced and incorporated into workflows, I think it will require clinical practices to more carefully measure blood pressure so that we don’t over treat.”

Under the new recommendations, the number of women under the age of 45 with hypertension will double, and the number of men in the same age range with high blood pressure will triple. With these new standards, it’s also been noted that 103 million Americans will be considered hypertensive, up from 72 million based on previous guidelines. Since they were released – in a standing-room-only session at the Scientific Sessions – the New York Times has covered the potential impact fairly extensively. In their first piece, which noted that high blood pressure will now be defined as 130/80 (up from 140/90) the Times called this change the “the first official diagnostic revision since 2003,” which comes as a result of increasing data showing that maintaining a lower blood pressure significantly reduces a patients risk of heart attack and stroke.

 “Large population studies suggest that the best blood pressure to have is 115/75 mmHg, so even 130 mmHg for the upper number is above that value,” Townsend said. Townsend, along with Jordana Cohen, MD, MSCE, an instructor of Medicine in the division of Renal-Electrolyte and Hypertension, penned an editorial about the guidelines – “The ACC/AHA 2017 Hypertension Guidelines: Both Too Much and Not Enough of a Good Thing?” – which was published on Monday in Annals of Internal Medicine.

While there is much debate over whether this change is beneficial for the whole population, it did have a positive impact for older Americans. The Associated Press  (AP) reported that the guidelines would improve recommendations for those over 65. In a 2014 change to the guidelines, standards for this older population relaxed a bit, and encouraged the use of medication only when their blood pressure climbed above 150.

High blood pressure is directly linked to the risk of heart disease, and specifically heart attack and stroke, so lowering it seems to make sense. In fact, as the Times noted, reducing blood pressure is only second to cutting smoking in the list of things that can directly and most significantly improve cardiovascular health. 

“I do think it was necessary to show that doing something, like medication treatment, had more benefit than harm. I also think the new guidelines are right to emphasize that it isn’t just BP that matters, but the ‘setting’ in which it occurs – that is, patients with high cholesterol, or prior heart disease or stroke, or peripheral vascular disease, etc.,” Townsend added.

But despite these known positive impacts of lowering blood pressure, one has to wonder how easy is it to do, specifically for those who were considered “normal” even just a month ago. And, does this mean more people are at risk for heart disease, not only because of other risk factors, but simply because these guidelines cast a wider net of people to catch?

“Technically the answer is yes, this would mean more people are identified as ‘at risk’ for heart disease,” Townsend said. “For the reasons above (heart disease, peripheral vascular disease, etc.), the risks from elevated blood pressure alone are small, but definite.  It’s when you add other factors that the effect of high blood pressure really kicks in – such as stress, diet, age, and genetics, among others. That said, it’s important to keep in mind that a heart attack is not as strongly related to blood pressure as something like heart failure, since the lining of the heart’s arteries is where the issue lies for heart attack. That lining is very sensitive to things like cholesterol, diabetes and cigarette usage, which are all linked to elevating blood pressure.”

Though Townsend may not favor every facet of the guidelines, he does believe that clinicians will likely be able to get most people to the new goal. But, he noted, it will come “at the ‘cost’ of more medication and more lab testing to monitor for drug side effects.”

In the AP story, Steven Nissen, MD, of the Cleveland Clinic also expressed concern around the use of more medications for more patients, particularly older patients: “Some more vulnerable patients who get treated very aggressively may have trouble with falls because too-low pressure can make them faint.” As he alludes, this may open up another set of issues for patients. Though many blood pressure medications now come in a generic form, which takes out some of the cost concerns, medication can have side effects – dizziness and falls, like Nissen mentioned – as well as impacts on the interactions with other drugs, and implications on other organs in the body.

“The risks of more medications are relatively well understood,” Townsend said. “There is likely to be more low sodium and low potassium levels in the blood from more potent diuretic usage. There is also likely to be more acute kidney injury, reflected by an increase in the creatinine in the blood. This happens because the lower level of blood pressure achieved by more aggressive blood pressure reduction can place the kidneys at greater risk to abruptly lose function if something happens to lower blood pressure further – like a gastrointestinal illness with vomiting or diarrhea.”

The general consensus here seems to be to prescribe cautiously and focus on what lifestyle changes can be made for those patients who need to lower their blood pressure slightly to get down to the “normal” range. But, this most effective treatment can also be the biggest barrier to change. Townsend noted that consuming less salt and more potassium is helpful – provided the patient does not have an existing kidney disease – as is losing weight and increasing light exercise.

Townsend, and Cohen, by way of the Annals editorial, ultimately stress that having blood pressure checked at the very least every other year for folks who are under age 40 years, and annually for those older than 40 years and those with conditions like diabetes, obesity, peripheral vascular disease, and kidney disease, among others. And unfortunately, Townsend added, “those with a family history of high blood pressure, those who are overweight, those with diabetes, and those with kidney damage, of African descent, and, sadly, those who have passed their 60th birthday are some of the most ‘at risk’ people for future hypertension.”

Ultimately, Townsend said, “we have had a steady flow of patients with high blood pressure in the Hypertension Program at Penn, but we most often see patients with conditions that can be difficult to manage with existing medication, or who are uncontrolled despite taking multiple blood pressure medications. Though the current guidelines do not specifically state that they are to be universally applied, I believe that those who audit our patients’ charts in the future will find that even blood pressure specialists like those in our group will struggle to achieve the BP control goals using the new guideline values.”

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Views expressed are those of the author or other attributed individual and do not necessarily represent the official opinion of the related Department(s), University of Pennsylvania Health System (Penn Medicine), or the University of Pennsylvania, unless explicitly stated with the authority to do so.

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