Journal Article | Cardio-Metabolic

February 20, 2020



Paul Whelton and Robert Carey

Introduction:

Hypertension or high blood pressure (BP), defined as a systolic BP of 130 mmHg or higherand a diastolic BPof 80 mmHg or higher, is a major growing health concern around the world. It is the most common risk factor for cardiovascular disease and it affects nearly two-thirds of adults aged 60 years and older. It exerts a substantial public health burden on cardiovascular health status and healthcare system across the globe. Research shows that more than half of cases of deaths from coronary heart disease are associated with hypertension and approximately 1/4 of all cardiovascular events are attributable to hypertension.

 

High blood pressure has a higher prevalence in developed countries and it has been linked to a stressful lifestyle. Smoking, alcoholicbeverage drinking, low levels of physical activity, and alterations in eating habits play vital roles for developing hypertension. Individuals with subclinical or those with clinical coronary heart disease have higher risks of poor health outcomes in relation to inadequate blood pressure control. The American Heart Association (AHA), in 2017, released a scientific statementon the treatment of hypertension and the prevention and treatment of coronary heart disease.

 

 

Relevance:

 

Hypertension should be treated earlier with lifestyle changes and for some patients, medications can be startedat a blood pressure of 130/80 mm Hg and higher rather than the previous set point at 140/90 mm Hg. This is according to the first comprehensive new high blood pressure guidelines released after more than a decade. A 21-member panel formed by The American Heart Association (AHA) and the American College of Cardiology (ACC) writing committee has published new guidelines for detection, prevention, management, and treatment of high blood pressure in adults.

 

Objectives:

The primary aim of the study is to impart knowledge on the 2017 guidelines for diagnosis, prevention, evaluation, management, and strategies to improve control rates during treatment of high blood pressure in adults.

It also aims to summarize key recommendations in the following areas, namely: BP classification and measurement,BP thresholds and cardiac risk estimation to guide drug treatment, screening for secondary hypertension, non-pharmacologic therapy,treatment goals for patients with diabetes mellitus, chronic kidney disease, and advanced age,choice of initial drug therapy, resistant hypertension, and strategies to improve hypertension control.

Highlights:

Recommendations from the 2017 Hypertension Guidelines:

 

  • The normal BP is set less than 120 mm Hg (systolic) and less than 80 mm Hg (diastolic).
  • Elevated BP is a BP of 120 to 129 mm Hg systolic and less than 80 mm Hg diastolic.
  • Stage 1 hypertension is a BP of 130 to 139 mm Hg (systolic) or 80 to 89 mm Hg (diastolic)
  • Stage 2 hypertension is a BP of 140 mm Hg or more (systolic) or 90 mm Hg or more (diastolic).
  • The new guideline eliminates the category of prehypertension which was used for blood pressures with a systolic BP between 120-139 mm Hg or a diastolic BP between 80-89 mm Hg from the previous guideline.
  • The impact of the new guideline is expected to be greatest among younger people. The prevalence of high blood pressure is expected to triple among men under the age of 45 and double among women under the age of 45.
  • Blood pressure levels should be based on an average of two to three readings on at least two different occasions.
  • The guidelines recommend the use of BP readings out of the medical office to confirm the diagnosis of hypertension and titrate therapy. Patients should consider weekly readings, especially after changes in treatment and before clinic visits.
  • The use of ambulatory 24-hour BP monitoring is particularly recommended in the evaluation for white coat and masked hypertension.
  • The diagnosis of white coat hypertension should prompt surveillance for sustained hypertension and the diagnosis of masked hypertension should prompt consideration of antihypertensive therapy.
  • Medication for stage 1 hypertension is recommended if a patient has a previous history of a cardiovascular event such as heart attack or stroke or if the patient is at high risk of heart attack or stroke based on age, the presence of diabetes mellitus, chronic kidney disease, or atherosclerotic risk after risk estimation.
  • The patient’s plan of care must include identification of socioeconomic status and psychosocial stress as risk factors for high blood pressure.
  • By lowering the definition of high blood pressure, the guidelines recommend earlier intervention to prevent further increases in blood pressure and the complications of hypertension.

Conclusion:

Blood pressure control is an important and cost-effective way to reduce hospitalizations and cardiovascular events, such as stroke and myocardial infarction. Medications such as anti-hypertensives can delay or prevent the development of hypertension and recent clinical trials have demonstrated that maintaining blood pressure of 140/90 mm Hg may reduce the risk of cardiovascular events. Given the benefits of successful clinical intervention, the high cost of treating cardiovascular disease, and the aging population, control of BP among adults, particularly among those at high risk for coronary artery disease, needs to be a national priority.

Reference:

Whelton, P. and Carey R. Prevention, Detection, Evaluation, And Management of High Blood Pressure in Adults: Synopsis of the 2017 American College of Cardiology/American Heart Association Hypertension Guideline. Annals of Internal Medicine. March 6, 2018

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