Understanding Blood Pressure

• Hypertension is defined according to the American Heart Association (AHA) guidelines.
• Cardiovascular complications associated with hypertension can be identified.
• Blood pressure goals are determined based on patient-specific presentations.
• Lifestyle modifications can be recommended for managing hypertension.
• The effectiveness of lifestyle modifications for hypertension can be described
• A treatment plan (pharmacologic and/or non-pharmacologic) can be created for patients with hypertension.
• Appropriate monitoring and follow-up plans can be recommended for patients with hypertension.

Introduction

• Hypertension (HTN) is persistently elevated blood pressure (BP).
• Hypertension is often asymptomatic
• This can delay seeking medical help
• This can lead to medication noncompliance
• Most patients remain asymptomatic until their blood pressure is very high
• Symptoms include throbbing headaches, fatigue, and shortness of breath.
• Hypertension is a significant risk factor for cardiovascular diseases (CVD)

Classification

• Most patients have essential (primary) hypertension
• The cause is unknown
• Linked to environmental factors.
• Reasons can be identified for secondary hypertension.
• Renal diseases
• Hormonal issues
• Structural problems
• Pregnancy, drugs, and sleep apnea can be secondary causes

Drug-Induced Hypertension

• Drug-induced hypertension retains sodium and water.
• NSAIDs like Ibuprofen and Naproxen can cause hypertension
• Decongestants like Pseudoephedrine can cause hypertension
• Glucocorticoids like Methylprednisolone can cause hypertension
• Stimulants like Methylphenidate, Amphetamine, and Cocaine can cause hypertension
• Psychotropic agents like Venlafaxine can cause hypertension
• Immunosuppressants like Cyclosporine and Tacrolimus can cause hypertension
• Chemotherapeutic agents like Bevacizumab can cause hypertension

Physiologic Regulations of BP

• BP is regulated by:
• Humoral mechanisms
• Neuronal mechanisms
• Peripheral autoregulatory mechanisms operated by the kidneys
• Vascular and endothelial mechanisms
• Electrolytes

Pathophysiology

• Blood pressure (BP) is determined by cardiac output (CO) multiplied by systemic vascular resistance (SVR).
• Cardiac output (CO) calculated by stroke volume (SV) multiplied by heart rate (HR)
• Hypertension can be caused by increases in either cardiac output (CO) or systemic vascular resistance (SVR).
• CO and/or SVR increase due to:
• Increased fluid volume from sodium intake or renal sodium retention
• Renin-angiotensin-aldosterone system (RAAS) activity
• Sympathetic nervous system activity
• Endothelial dysfunction
• Genetic mutations.

Factors Affecting BP

• Age
• Gender
• Genes
• Physical inactivity
• Salt intake
• Obesity
• Stress
• Alcohol consumption

Arterial BP Measurement

• Pressure is measured in millimeters of mercury (mm Hg) within the arterial wall.
• Systolic BP (SBP) is the peak value during cardiac contraction.
• Diastolic BP (DBP) is achieved during cardiac relaxation when heart chambers are filling.
• Blood pressure (BP) is reported as SBP/DBP.

Evidence-Based Guidelines

• Recommendations are based on the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults.
• The guidelines come from a report by the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, published in the J Am Coll Cardiol 2018;71:e127-e248.
• Guidelines from the 2023 European Society of Hypertension for the management of arterial hypertension published in J Hypertens 2023;41:1874-2071 will be discussed.

Prevalence and Incidence

• About 70 million American adults have hypertension.
• Only 52% of people with hypertension have their blood pressure at goal
• In 2013, over 360,000 American deaths included hypertension as a primary or contributing cause.
• High blood pressure is a risk factor for cardiovascular morbidity and mortality

Hypertension vs. CV Morbidity and Mortality

• A strong correlation exists between blood pressure >115/75 mm Hg and cardiovascular (CV) morbidity and mortality.
• This includes stroke, myocardial infarction, heart failure, and kidney failure
• Cardiovascular deaths are reduced by antihypertensive therapy.
• A 20 mm Hg increase in systolic blood pressure (SBP) and a 10 mm Hg increase in diastolic blood pressure (DBP) over 115/75 mm Hg doubles the risk of major cardiovascular and stroke events.

Benefits of Lowering BP

• Stroke incidence is reduced by 35-40%
• Myocardial infarction is reduced by 20-25%
• Heart Failure is reduced by 50%
• Anti-hypertensive medications can save lives

CVD Risk Factors

• Modifiable risk factors: can reduce cardiovascular (CV) risk if changed
• Fixed risk factors: difficult to change; even if changed, may not reduce CV risk
• Modifiable risk factors include current cigarette smoking, secondhand smoking, diabetes mellitus, dyslipidemia/hypercholesterolemia, overweight/obesity, physical inactivity/low fitness, and unhealthy diet.
• Relatively fixed risk factors include chronic kidney disease , family history, increased age, low socioeconomic/educational status, male sex, obstructive sleep apnea, and psychosocial stress.

BP Measurement

• Proper measurement of BP includes:
• Correct cuff size
• Proper patient positioning.
• Ask about smoking, taking caffeinated beverages, or consuming alcohol within 30 minutes.
• Patients should rest for 5 minutes before measurement
• A second/third measurement should be taken within one minute intervals.
• At least two independent measurements are required for hypertension diagnosis.

Patient Assessment

• Includes blood pressure monitoring at home,
• Assess patient's knowledge about the disease and medications,
• Take a medication history (adherence, non-Rx medications),
• Order basic labs

Laboratory Parameters to Consider

• Complete Blood Count (CBC)
• White blood cells
• Hemoglobin
• Hematocrit
• Platelets
• Chemistry Panel
• Sodium
• Potassium
• Chloride
• Bicarbonate
• Blood urea nitrogen (BUN)
• Serum creatinine
• Glucose (fasting)
• Additional electrolytes
• Calcium
• Magnesium
• Phosphate
• Serum Enzyme Tests
• Alanine aminotransferase (ALT)
• Aspartate aminotransferase (AST)
• Alkaline phosphatase
• Gamma-glutamyl transferase (GGT)
• Other Serum/Blood/Plasma Tests
• Activated Partial Thromboplastin Time (aPTT or PTT)
• Albumin
• Vital Signs
• Blood Pressure (BP)
• Heart Rate (HR)
• Temperature (T)
• Respiratory Rate (RR) Lipid Panel
• Cholesterol
• Triglycerides
• HDL Cholesterol, direct
• LDL Cholesterol

Dx

• Most patients will report no symptoms Referred to as "silent killer"
• The average of two or more measurements taken during two or more clinical encounters is required to diagnose HTN
• Blood pressure (BP) averages are used to establish a diagnosis and classify the stage of hypertension

Question

• True or false: Essential hypertension has no symptom. The answer is true.
• OTC drugs such as Pseudoephedrine can raise blood pressure.

Classification of BP

• Normal BP: Less than 120/80 mm Hg
• Elevated BP is 120-129 mm Hg systolic and less than 80 mm Hg diastolic
• Stage 1 HTN is 130-139 mm Hg systolic or 80-89 mm Hg diastolic
• Stage 2 HTN: ≥140 mm Hg systolic or ≥90 mm Hg diastolic
• Hypertensive crisis is ≥180 mm Hg systolic or ≥120 mm Hg diastolic
• If systolic and diastolic values yield different classifications, the highest category determines classification

Guideline Differences: 2017 ACC/AHA vs. 2023 ESH

• The Hypertension Definition cut off: ≥ 130/80 in 2017 ACC/AHA, and ≥ 140/90 in 2023 ESH.
• Top-line medications include thiazides, ACEI/ARB, CCB as individual consideration but do not combine.

Other Classifications of BP

• White coat hypertension: Higher in a clinical setting but normal in out-of-office settings
• Affects an average of 13% of patients
• Masked hypertension: Controlled office BP but uncontrolled BP in out-of-office settings.
• Hypertensive crises are defined as BP ≥ 180/120 mm Hg.
• Hypertensive urgency: Significantly elevated BP without acute or progressing target-organ damage, including symptoms like headache, shortness of breath, and epistaxis.
• Hypertensive emergency: Significantly elevated BP with acute or progressing target-organ damage, such as hypertensive encephalopathy, intracerebral hemorrhage, acute MI, acute left ventricular failure with pulmonary edema, and unstable angina.

Other Classifications of BP

• Resistant hypertension patients fail to achieve BP control despite adhering to full doses of three medications, one of which is a diuretic
• Causes: Volume overload, drug-induced factors from NSAIDs, oral contraceptives, corticosteroids, non-adherence, inadequate doses, obesity, and excess alcohol intake.

Overall Treatment Goal

• Reduce BP to the target goal, reduce HTN-related CVD morbidity and mortality
• Prevent ischemic heart disease, cerebrovascular events, end-stage renal disease and vision loss

BP Goals

• Treating patients with HTN to achieve a target BP is a surrogate goal.
• Reduce BP to goal does not guarantee prevention of hypertension-associated complications.
• Reduction in BP is correlated with lower risk of CV complications.
• Targeting goal BP value to determine the need for drug therapy titration and regimen modification

BP Thresholds and Goals for Pharmacologic Therapy

• Clinical CVD is defined as stroke, myocardial infarction, angina, or heart failure.
• 10-Year ASCVD risk is the risk of developing atherosclerotic cardiovascular disease in the next 10 years.
• Clinical CVD or 10-year ASCVD risk ≥ 10%: BP Threshold is ≥130/80 with a goal of lowering to less than <130/80 mm Hg.
• 10-year ASCVD risk < 10%: BP Threshold of ≥140/90, BP goal of less than <130/80 mm Hg.
• In older persons (≥65 years), the BP threshold is ≥130 systolic, with a BP goal of <130 systolic

Prevent Calculator

• Predicts the risk of getting CVD in 10 years
• https://professional.heart.org/en/guidelines -and-statements/prevent-calculator
• Takes into consideration kidney function (eGFR) and metabolic status (BMI)
• Updated January 2024 by American Heart Association

HTN Treatment

• Includes non-pharmacologic and pharmacologic interventions

Algorithm to Treat HTN

• Normal Blood Pressure: <120/80 mm Hg; promote optimal lifestyle habits.
• Elevated Blood Pressure: 120-129/<80 mm Hg; recommend lifestyle modifications, reassess in 3-6 months.
• Stage 1 Hypertension: 130-139/80-89 mm Hg Individuals who had a Clinical ASCVD, diabetes, CKD, or 10-yr ASCVD risk score ≥ 10%: recommend Lifestyle modifications and prescribed medication Individuals without the risk factors had a Clinical ASCVD, diabetes, CKD, or 10-yr ASCVD risk score < 10%: recommend Lifestyle modifications
• Stage 2 Hypertension: recommend Lifestyle modifications and prescribed medications, reassess in 1 month.

If no compelling indication:

• Monotherapy with an ACEi, ARB, CCB, or thiazide; reassess in 1 month.
• Two-drug combination using an ACEi or ARB with CCB or thiazide; reassess in 1 month.

Avoid Clinical Inertia

• Start with lifestyle modifications and monitor
• If no improvement start pharmacological therapy

Non-Pharmacologic Treatments

• Physical activity
• Alcohol consumption
• Smoking cessation
• Diet

Life-Style Modification

• Lifestyle modifications can provide small-to-moderate reductions in systolic blood pressure (SBP).
• All patients with hypertension (HTN) should be prescribed lifestyle modifications.
• Lifestyle modifications should never replace anti-hypertensive drug therapy.

Non-Pharmacologic Recommendations

• Aim to achieve ideal body weight or a 1-kg loss in overweight patients
• DASH diet is needed Rich in fruits, vegetables, whole grains, and low-fat dairy Reduced total and saturated fats
• Reducing salt intake Optimal goal of <1500 mg/d Aim to reduce by at least 1000 mg/d in most adults
• Enhanced intake of dietary potassium Aim for 3500 - 5000 mg/d through sources, such as fruits, vegetables, low-fat dairy, selected fish and meats, nuts, and soy products
• The Aerobic activity 90 -150 min/wk
• Moderate alcohol consumption <2 drinks per day for men; less than or equal to 1 drink per day for women

DASH: Dietary Approaches to Stop Hypertension

• Low in saturated fat, cholesterol, and total fat
• Emphasizes fruits, vegetables, grains, and low-fat dairy products
• Reduced red meats, sweets, and sugar-containing beverages
• Rich in magnesium, potassium, calcium, protein, and fiber
• 2.4 g sodium per day of intake is required

More Questions

Questions about stage and recommendation for medication/ life style changes

Pharmacotherapy- Recommendations

• With stage I hypertension, if ASCVD risk is ≥ 10%, initiate pharmacotherapy with preferred first-line agents. If ASCVD risk is <10%, then recommend lifestyle modifications at first
• In second stage hypertension, regardless of ASCVD risk, initiate pharmacotherapy
• Initiate 2 first line agents of different classes
• First line preferred classes of drugs; thiazide diuretics, CCB and/or, ACE1/ARB

Pharm Pearls

Preferred drug classes that can be combines- Thiazide and RAAS medications Diuretics + ACEI work well together In black patients; thiazides or CCB can be started In patient with heart/ renal failure: start with ACE/ARB, BB

Pharmacotherapy (No Compelling Indication)

• Primary Agents
• Thiazide or Thiazide-type Diuretics
• Calcium Channel Blockers (CCB)
• Angiotensin Converting Enzyme Inhibitors (ACEI)
• Angiotensin Receptor Blockers (ARB)
• Secondary Agents
• Loop diuretics
• Potassium-sparing Diuretics/Aldosterone antagonist Diuretics Direct Renin Inhibitor
• Beta Blockers (BB)
• Alpha-1 Blockers
• Central Alpha-2 Agonists
• Direct Vasodilators

Test your knowledge of systolic and diastolic blood pressure. This quiz covers the correlation of blood pressure with cardiovascular health. Learn about hypertension prevalence and the impact of blood pressure reduction.