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August 19th, 2013

Managing Hypertension – Not as Easy as It Once Seemed

Paul Bergl, M.D.

Target a blood pressure < 140/90 mmHg in everyone, but be rational in the medications you choose to get there.

Hypertension…

As a medical student, I never really understood the fuss over it. Practicioners had an excellent and concise guide in the JNC-7 to handle all of the major aspects of this disease. The JNC-7 guidelines were algorithmic, and a helpful table of compelling indications for antihypertensive agents couldn’t make life any easier.

I soon realized a little more finesse was required of the internist-in-training. JNC-7 didn’t tell the whole story. My attendings all had slightly different opinions on the optimal strategies for control, and these approaches might contradict my antihypertensive gospel.

Hydrochlorothiazide was replaced by chlorthalidone after a preceptor noted, “All of the important studies on thiazides were done with chlorthalidone.” After adopting its use, I found another internist who advised, “Chlorthalidone just causes more hypokalemia. There’s no reason to believe HCTZ is inferior.” So, back to HCTZ. Soon after, I learned that calcium-channel blockers were a preferred option for isolated systolic hypertension in elders. “Diuretics just make older patients dizzy, dehydrated, and hyponatremic.” And the advice continued to accumulate in the form of these little pearls.

To complicate matters further, various societies and expert-written guidelines also had a slightly different take on the ideal systolic and diastolic pressures. I was becoming dizzy myself. Do I target a systolic blood pressure of 130 mm Hg in patients with diabetes? Or was that patients with CKD? Or is the diastolic blood pressure more important? And does it really matter?

Well, if JNC-8 looks anything like the Eurpoean Society of Hypertension/European Society of Cardiology joint guidelines that are so nicely summarized in Joanne Foody’s NEJM Journal Watch article, we can all breathe a sigh of relief. As Dr. Foody highlights, these guidelines emphasize a more universal blood pressure target of 140/90 mm Hg and a greater focus on global cardiovascular risk. I haven’t gotten through the whole document, but I was also glad that these guidelines allow for more lenient control in elders. And these guidelines are not at all prescriptive in the choice of antihypertensive medications.

A brief report in Physician’s First Watch on a common class of antihypertenisves also caught my eye this past week. Staff writer Amy Orciari Herman reported on the recent JAMA Internal Medicine article by Christopher Li et al showing an association between long-standing calcium channel blocker (CCB) use and risk for breast cancer.

The article gave me pause for one major reason: I really fell in love with CCB’s as a house officer. CCB’s struck me as an affordable, convenient, and efficacious antihypertensive class. Amlodipine in particular seemed to promise worry-free prescribing to this young physician. Patients liked the once-daily dosing and small pill size. Since amlodipine required no periodic electrolyte checks and side effects are uncommon, I would gladly discharge a patient from the hospital on it. If the patient was lost to follow-up, I probably wouldn’t be on the hook for an adverse drug effect.

Or maybe I will be. This population cohort study suggests an elevated risk of breast cancer with CCB’s. While this study doesn’t prove causality, it should make us all a little more circumspect about the antihypertensives we choose.

In the end, these articles gave me a chance to reflect on what we ought to teach residents about managing hypertension. I expect I will keep my teaching simple in the coming years:

  • Go for 140/90 in everyone; be a little more lax in those with advanced age.
  • Make sure your choice of an antihypertensive is rational.
  • Every drug has side effects and risk; make sure your choice to treat hypertension is rational.

10 Responses to “Managing Hypertension – Not as Easy as It Once Seemed”

  1. karen says:

    yes, definitely. thank you. well put. as a geriatrician, be careful when trying to make things “perfect!”

  2. Loretta S says:

    I sometimes have to take patients off CCBs, especially amlodipine, because of ankle/lower extremity edema. Even on low doses of amlodipine, some of my patients develop edema that is quite dramatic and bothersome. I have found that this problem is more common than I would have expected. I still like amlodipine for all the reasons you suggested, but I have to be alert for edema as a side effect once I prescribe it.

    Love the new Euro guidelines and wonder if the day will ever come that we see JNC8! Thanks for your post.

  3. alfonso e sierra says:

    Could not be so “simple”, apparently we have to worry about providing supervision, maybe messaging could help, and we have to entice the patient to improve compliance.

  4. Ed says:

    “Go for 140/90 in everyone”

    My patient demographic is age 18-30. So my dilemma is: for those patients with repeated elevated BPs who have a systolic in the 145 range or diastolic in the 95 range despite lifestyle modifications, do I resist committing them to 50+ years of taking drugs, or do I miss an opportunity to treat a risk now and prevent its complications down the line?

    What are the data on patients in their 20′s with elevated BP remaining fixed and deserving of a diagnosis of HBP? Has the risk/benefit ratio for treatment starting at that age been studied? Recently I have ordered an echo to see if early LVH was present, using that as a rationale for treatment…

    For those patients with BPs consistently over 150/100, I start treatment. But I am uneasy about those in the 140-150/80-90 range…

  5. Dr D says:

    I believe 140/90 or less is a reasonable target, as long as it does not cause more problems than it solves. Treat the patient first, and only use algorithms and evidence based medicine as a rough framework tailored to the individual patient’s “size and tastes”. Even generic CCB’s can be pricey compared to lisinopril/HCTZ which can be had at Walmart for $4 per month. Always remember, the best treatment for an individual patient is the one that allows them to live better and longer. Studies are based on broad statistical analyses of groups, as is “evidence based medicine or EBM”. What is best for the individual patient may be 180 degrees from “EBM”. Sorting out the correct path is “Art Based Medicine”. I would give it the acronym ABM but it would not be a BM. It would be close to the truth, which is what we seek when treating people, not a statistical model.

  6. Sheldon Ball says:

    1. Ask: Why is my patient’s blood pressure elevated?
    Are baroreceptors in the carotid sinus (or elsewhere) perceiving inadequate pressure to perfuse vital organ(s)?
    2. Is there an opportunity for diet and lifestyle intervention?
    3. Remember the J point mortality phenomenon of diastolic blood pressure.
    Achieving a blood pressure of < 140/90 is fine in a patient with a pulse pressure of 80 years of age) may result in better performance on cognitive measures.

    References:
    1. http://www.anvita.info/wiki/Chronic_Hypertension
    2. http://www.anvita.info/wiki/Diastolic_Blood_Pressure
    3. http://www.anvita.info/wiki/Blood_Pressure_In_The_Very_Old

  7. Saurabh says:

    This was an excellent read. As a clinician, I feel that we have made the business of targeting number a priority rather than reducing cardiovascular risk. A clinician should calculate cardiovascular risk and use RRR to explain how patient’s risk would decrease if they take an antihypertensive medication. For example, if patient’s 5-year cardiovascular risk is 10% (without taking any antihypertensive medicatio) then taking an antihypertensive medication will roughly reduce risk to 7% over the five years (Roughly speaking, all antihypertensives have RRR of 30%; (10%-(10% x 0.3) = 7%). Patient need to understand that we want to reduce their risk of cardiovascular event and not just a blood pressure number, which varies (for excellent discussion about targeting/measuring BP, listen to podcasts by Dr. Mike Allen and Dr. James McCormack: http://therapeuticseducation.org/).

    Some therapeutic pearls from a pharmacist’s perspective: 1) consider starting at low dose of any antihypertensive 2) initiate one antihypertensive at time (combo are worst b/c if patient experiences side effect, it will be hard to figure out which drug caused it) 3) dose at least one antihypertensive at night (MAPEC study – reduces CV risk) 4) make sure to discontinue or evaluate following medications that may be contributing to high BPs – NSAIDS, steroids, pseudoephedrines etc 4) In elderly, a relax target would be somewhere around SBP of 150. In elderly, lows are more dangerous than the highs.

  8. Basheer Farah says:

    Logical words

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