Under newly issued directives from an American College of Cardiology (ACC) and American Heart Association (AHA) joint task force, blood pressure readings of 130/80 mm Hg to 139/89 mmHg are categorized as stage 1 and readings of 140/90 mm Hg or above are categorized as stage 2 hypertension.
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“This means that instead of one in three U.S. adults having hypertension, nearly one in two will now be classified as having hypertension,” says nephrologist George Thomas, MD, at Glickman Urological & Kidney Institute.
The new guidelines are based in large part on data from the 2015 Systolic Blood Pressure Intervention Trial (SPRINT), which showed that targeting lower blood pressure (to a goal of less than 120 mm Hg systolic) reduced heart attack, stroke or death in higher-risk older adults.
New Blood Pressure Guidelines
Correct measurement technique is imperative
The new guidelines emphasize proper blood pressure measurement technique. This includes using the right cuff size, proper positioning, having the patient sit quietly for five minutes before taking a reading to help avoid “white coat hypertension” as well as taking several readings to determine a more accurate blood pressure.
Physicians should consider using an automated oscillometric blood pressure monitor that takes multiple readings, with the patient alone in the room. The new recommendations stress the need for out-of-office blood pressure readings to confirm measurements made in clinic. Patients can take readings at home or undergo ambulatory blood pressure monitoring.
“Correct blood pressure measurement is essential,” Dr. Thomas states. “You can’t treat it if you don’t measure it correctly. The new guidelines emphasize self-monitoring of blood pressure and increased patient involvement in the management of their hypertension. Physicians need to help patients learn to monitor BP at home.”
The new guidelines will likely result in more Americans being prescribed antihypertensive medication, Dr. Thomas points out. However, he agrees with guideline authors who stress that nonpharmacological lifestyle changes should always be emphasized.
“Our focus should not be to simply prescribe antihypertension medication,” he says. “We need to strongly emphasize attempting lifestyle modifications – a low-sodium diet that includes limiting processed foods, weight management, physical activity and limiting alcohol use. All of these are proven methods that help improve blood pressure control.”
In patients with stage 1 hypertension who have low cardiovascular risk, lifestyle modifications should be attempted for at least three to six months.
When medications are prescribed, physicians must take an individualized approach and monitor patients carefully, Dr. Thomas says, noting, “Not all patients will tolerate lower blood pressure levels, which can create electrolyte imbalances or other side effects that some find intolerable. In these patients, targeting a lower goal BP that is best tolerated without significant side effects would be reasonable.”
Special considerations for BP management in CKD
The new guidelines lower the threshold for chronic kidney disease (CKD) patients as well. Joint National Committee (JNC) 8 panel guidelines, released in 2014, set a blood pressure goal of less than 140/90 mm Hg for CKD patients. Now, based on the SPRINT trial, in which about 30 percent of participants had CKD (with eGFR between 20 and 60 ml/min/1.73 m2), the goal has been lowered to less than 130/80 mm Hg.
The JNC 8 panel also recommended relaxing blood pressure goals for patients 60 years or older from 140 mm Hg systolic to less than 150 mm Hg. Again, the SPRINT data contradicted that recommendation, which the new guidelines reflect.
6 takeaways for physicians
1. More diagnosis of hypertension/more awareness means we can “catch it early,” helping reduce cardiovascular risk burden.
2. Tightening BP goals may require more medications and therefore more side effects and intolerances; this will require closer monitoring.
3. Lifestyle modifications, a relatively neglected area, will come more into focus now.
4. Remind patients that making even small lifestyle changes can impact blood pressure and improve overall health.
5. Encourage patients to monitor their BP at home. Frequency of monitoring should be decided in conjunction with the treating physician.
6. BP goals and management still need to be individualized based on multiple factors.
Dr. Thomas concludes: “The bottom line is that guidelines are guidelines; they provide a standard framework within which to work. My belief is that we should try to help our patients get as close to the lower blood pressure goals as is safely possible, while remembering that some patients may not tolerate an aggressive approach. Management must always be individualized.”