December 5, 2017

New Hypertension Guidelines: How to Approach Your Patients

Key takeaways for physicians

650×450-Blood-Pressure

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.

Advertisement

Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services. Policy

“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.”

Lifestyle changes

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.

Advertisement

“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.

Advertisement

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.”

Related Articles

Man sitting at kitchen table with blood pressure monitor and pill bottles
March 19, 2024
Should Patients Take Blood Pressure Medications in the Evening to Enhance Cardiovascular Benefit?

Clinicians should individualize dosing practices based on patient risk factors and preferences

Drawing of a pink bulb with two tubes coming out of the top
March 13, 2024
Predicting Post-Op GFR: AI Algorithm Is as Accurate as Clinical Model

Fully-automated process uses preop CT, baseline GFR to estimate post-nephrectomy renal function

Arm of Black patient having kidney dialysis
March 8, 2024
GFR Equations: How Will Eliminating the Race Coefficient Affect Black Patients?

Could mean earlier treatment, but also could have negative effects

Senior at the Doctors
December 29, 2023
Study Assesses the Utility of Renal Genetic Testing in Black Patients

Identifying barriers in the renal genetic assessment of Black patients

GUKI Care Page of Dr. George Thomas and Angela Smith
June 1, 2023
Resistant Hypertension: A Stepwise Approach

Getting patients to their goal blood pressure

urine bottle held by healthcare professionals with latex glove, toxicology test
April 10, 2023
Nephrologist-Led Urine Microscopy Edges Out Automated Technology in Predicting AKI

Study highlights benefits of nephrologist-led urine sediment analysis

23-URL-3773974-CQD-650×450-1
April 3, 2023
New Data Suggest Kidney Diseases With No Known Cause May Be Linked to Viruses

Using sequencing data to identify novel factors linked to kidney disease with unknown origin

650×450-Wang
February 22, 2023
A 3-Year Review of Real-World Experience in the Renal Genetics Clinic

Program plays key role in diagnosis and management of genetic kidney diseases

Ad