New Hypertension Guidelines

NEW U.S. Hypertension Guidelines & Patient Recommendations

N.R. Florea, N. Nazarian, A. Basmadjian

University of Southern California School of Pharmacy

On November 13, 2017 the American College of Cardiology and the American Heart Association released the new high blood pressure guidelines (J Am Coll Cardiol. 2017 Nov 13. doi:10.1016/j.jacc.2017.11.005). The definition of adult hypertension was reset from the long-standing threshold of 140/90 mm Hg to a blood pressure at or above 130/80 mm Hg. Overnight the epidemiology of adult hypertension changed drastically, with thirty million new Americans now being classified as hypertensive, the prevalence of hypertension jumping from 32% to 46%, and a total national hypertensive population of 103 million patients in the United States. In addition, the guidelines defined “elevated blood pressure” as a systolic pressure of 120-129 mm Hg and a normal diastolic of less than 80 mm Hg. These new definitions left a mere 42% of American adults now classified as normotensive.

Of the 106 total recommendations held within the new guidelines, the following are perhaps the most significant:

1. New classification of Stage 1 hypertension as a blood pressure at or above 130/80 mm Hg for all adult patients

2. New blood pressure goal of less than 130/80 for all adult patients including the elderly, as well as those with diabetes and chronic kidney disease

3. Emphasis on using some form of out-of-office blood pressure measurement to confirm the diagnosis

4. Use of risk assessment when deciding whether to treat certain patients with medications. *A risk assessment calculator can be accessed at: http://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/

5. Emphasis on lifestyle modification:  

a. For those with elevated blood pressure (systolic pressure of 120-129 mm Hg)

b. As only endorsed intervention for those with hypertension of 130-139 mm Hg but below a 10% risk for a cardiovascular disease event during the next 10 years on the American College of Cardiology’s online risk calculator.  *The risk calculator can be accessed at:  http://tools.acc.org/ascvd-risk-estimator-plus/#!/calculate/estimate/

6. Recommended lifestyle modifications to include

a. Weight loss

b. Following a DASH diet

c. Reducing sodium

d. Enhancing potassium

e. 90-150 minutes per week of physical activity

f. Moderate alcohol intake

7. Emphasis on team-based management

a. American Heart Association and American Medical Association management strategy and tools via the Target:BP program.  The Target:BP program can be accessed at: https://targetbp.org/

b. Implementation of Target:BP program utilizing of Pharmacists, Nurses, Nurse Practitioners, Dieticians and other clinicians to allow more frequent and focused care.

c. Providing a clear, detailed, and current evidence-based plan of care

How Do the New Hypertension Guidelines Affect You?

With the new hypertension guidelines that were introduced by the American College of Cardiology and the American Heart Association, lifestyle modifications can be a crucial contributor to reaching your blood pressure goals now, more than ever. Taking a step back, hypertension is a significant risk factor for coronary artery disease and stroke, the leading causes of death and disability worldwide. At Choice Care concierge medical practice, we want all our patients to be on track and concurrent with the new guidelines. Here are some recommendations we are making for patients like you who may be struggling with keeping on track towards their blood pressure goals:

1. Regular aerobic exercise (90-150 minutes per week)

   1. Walking, Cardio classes, swimming, biking, running

2. Reducing your sodium intake (<1,500mg of sodium per day)

3. Reducing your alcohol intake

   1. No more than one “standard” drink per day.  In the United States, one “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12 oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12% alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol)

4. Cutting down on your smoking habits

5. DASH diet

   1. What is the DASH diet? DASH = Dietary Approaches to Stop Hypertension - A diet low in total and saturated fat, red meat, sugar, sugary drinks, and refined carbohydrates, but high in fruits, vegetables, whole grains, fish, poultry, and low-fat dairy products. Examples: Switch white bread with whole wheat bread, use 1% fat milk instead of whole fat milk, use olive oil instead of butter. What is it aimed at improving? It has shown to lower patients’ weight, heart rate, risk of type 2 diabetes, C-reactive protein, apolipoprotein B, and homocysteine. It is correlated with lowering the occurrence of heart failure, all cause mortality, and stroke. 

6.  Reducing your consumption of total saturated fat(1,3)

Along with making these changes in your lifestyle, it is very important for you to assess your progress by frequently monitoring your blood pressure. A lot of patients have found benefit in keeping a log of their blood pressures as they start to implement these new lifestyle modifications. In addition to keeping a log, it is vital to make sure that your blood pressure readings are accurate. Here are a few techniques you can use in order to make sure that your blood pressure is correct:

• Measure BP in a quiet environment

• Try not to speak

• Make sure your feet are flat on the floor (no crossed legs!)

• Make sure you are calm and relaxed

• Make sure you are sitting with your back supported

• Make sure the cuff is placed at mid-arm (2-3 cm above the elbow)

• Make sure your arm is at heart level

  • If your arm is elevated above your heart, your reading might be lower than it should

  • If your arm is below your heart, your reading might be higher than it should

• Try to take blood pressure before you drink your coffee in the morning. However, if you have had coffee prior to your blood pressure screening, try to wait a little until the coffee jitters subside.3

Due to the high volume of patients in traditional clinics, blood pressure readings in such clinics are prone to error. This often leads to misdiagnosis and mismanagement of hypertension for a lot of patients. At Choice Care we make it our number one priority to avoid such errors. We make sure to give each and every patient our complete undivided attention and take the proper precautions when it comes to screening all of our patients.

Medication management goes hand in hand with monitoring the progression of a patient’s blood pressure status. It is in this setting where patients have shown benefit when consulting and following up with a pharmacist when it comes to what medications they are taking, how they are taking them, and how frequently they should be taking them.2 Our pharmacists at Choice Care have the ability to perform medication therapy management and use the necessary tools and knowledge to implement timely screening and effective prevention initiatives.

Visit us at choicecaredoctors.com so we can start developing a personal treatment plan to help you reach your blood pressure goals today.

References:

1. Nicoll R, Henein MY. Hypertension and lifestyle modification: how useful are the guidelines? British Journal of General Practice. 2010;60(581):879-880. doi:10.3399/bjgp10x544014.

2. Pharmacist's Role in Hypertension Management. Canadian Pharmacists Association. https://www.pharmacists.ca/cpha-ca/assets/File/education-practice-resources/Translator2014V8-1EN.pdf. Accessed February 9, 2018.

3. 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. Journal of the American College of Cardiology. https://ac-els-cdn-com.libproxy2.usc.edu/S073510971741518X/1-s2.0-S073510971741518X-main.pdf?_tid=1a35c670-0de6-11e8-ad38-00000aacb361&acdnat=1518214437_e85f4d05b5e584404cdcc3db9f308184. Accessed February 9, 2018.