Merck Manual

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Treating Patients with Hypertension—Commentary

02/09/17 George L. Bakris, MD, University of Chicago School of Medicine;

Most people don’t know that high blood pressure poses serious health risks. Hypertension is a “silent killer” – it often presents with no recognizable symptoms but is responsible for approximately 1,100 fatalities among American adults every day.

One in three adults in the U.S. has hypertension. However, only about 54 percent of hypertensive adults have their blood pressure levels under control, according to the Centers for Disease Control and Prevention.

It’s up to medical professionals to emphasize the importance of reducing high blood pressure with patients while also identifying effective treatment methods and staying current on the most recent recommendations.

Goal blood pressure in treatment of hypertension

There has recently been some disagreement in the medical community about the target blood pressure in the treatment of hypertension. In 2014, the Eighth Joint National Committee (JNC 8) shifted the target BP to less than 150/90 mm Hg for most people over the age of 60. For patients younger than 60 or those with diabetes or chronic kidney disorder, the JNC 8 recommended treating patients to a target of less than 140/90.  

However, in 2015 the Systolic Blood Pressure Intervention Trial (SPRINT) showed that a lower BP target may be better in certain groups. In this trial, more than 9,000 patients over the age of 50 and at risk of coronary artery disease (defined as age  > 75, clinical cardiovascular disease, chronic kidney disease, or Framingham risk > 15%) were randomized to intensive (SBP < 120) or standard (SBP < 140) blood pressure treatment. Patients with diabetes or history of stroke were excluded. The trial found that the intensive treatment group had a decreased risk of the primary end-point (myocardial infarct, acute coronary syndrome, stroke, heart failure, and cardiovascular death). The number needed to treat to prevent one primary outcome was 61 and the number needed to treat one death was 90. A subgroup analysis of the SPRINT study in patients > 75 years confirmed the lower rate of cardiovascular events and death in the older population.

It’s also important to note different blood pressure measurement methods can produce results that vary enough to impact treatment targets. In the SPRINT study, the measurement methodology was different than what’s used by physicians treating patients in clinical practice. Physicians need to be aware of these differences in measurements, especially when prescribing medication that could reduce blood pressure to the point of creating adverse effects. In general, goal systolic blood pressure ranges for patients measured in clinical settings should be 5 to 10 mm Hg higher than the rates outlined in SPRINT. For more on measurement discrepancies, read this commentary in the online journal Circulation.

Based on the SPRINT study, some doctors recommend treating to a blood pressure target of less than 125 to 130 mm Hg (if BP is measured by standard manual office readings) or 120 to 125 mm Hg (if BP is measured with an automatic digital monitor) in most patients with hypertension. This includes patients meeting the criteria of those in the SPRINT study. In addition, some clinicians also believe the SBP should be less than 125 to 130 mm Hg in some patients with diabetes, for example, those with diabetic nephropathy and proteinuria.

The benefits of the intensive BP treatment strategy should be weighed against the risks. Risks include worsening kidney function, syncope, and electrolyte abnormalities. Physicians should work collaboratively with patients to pursue an individualized treatment protocol that minimizes side effects.

Treating hypertension

Lifestyle changes are of course a crucial component of controlling blood pressure. Lifestyle changes include regular physical activity, weight reduction, DASH diet and restriction of sodium and alcohol intake.

If lifestyle changes are not sufficient, antihypertensive therapy is necessary. At least 75 percent of patients will require two or more drugs to achieve blood pressure targets. The Manual outlines drugs that have been shown to be effective in reducing blood pressure.

When determining medication to prescribe patients, it’s also necessary to look at what lifestyle changes they’re likely to make. Renin–angiotensin system blockers, for example, will be considerably less effective in patients who cannot reduce their salt intake.

Talking to patients about controlling hypertension

Finding time during office visits to detail the dangers of hypertension is difficult for many physicians. However, patients need to be educated. Clearly communicating why hypertension is the silent killer is an effective way to motivate patients to commit to lifestyle interventions. Many individuals have a close family member who has died of heart failure or a stroke, which can also be a powerful motivator.

It’s also a good idea to have a nurse or physician’s assistant call patients a few weeks after starting a new treatment. It shows patients you’re committed to their improvement and gives you an opportunity to make sure the patient is correctly following the treatment.