Chapters Transcript Video Hypertension: Guidelines and Updates Back to Symposium Hi, thank you everyone for joining us. Um, it's wonderful to have so many people here. There's a reason internal medicine is still 3 years training before fellowship because medicine forms the foundation of everything that we do. So as primary care providers, we are the pillars of health. Before I start, I need to ask Blake a question. Now that I know what to eat for lunch, can I go for a second? I, I don't think that's how it works. OK, so we'll save it for the talk. Thank you. Um, all right, so hypertension. Uh, so hypertension guidelines, uh, I currently have no disclosures. Um, effectively we have a very large burden of hypertensives in this country for a population of around 350 to 400 million people, about 120 million people are hypertensive. Less than 60% are aware they're hypertensive, 50% are receiving treatment, and only about 1 in 20% of the ones who are receiving treatment are at goal. So hypertension and treatment is a very big opportunity, not only to. Reduce the chronic disease burden in a patient, but also to reduce healthcare costs and reduce healthcare disparity because it reduces eventual poor outcome in patients which can include strokes, heart attacks, dissections, or even renal disease. So. Effectively, we had the first set of one set of guidelines in 2017. Since then, it was an eight-year time lag between the update and the most recent update is in 2025. What we're gonna focus on is a pathway to managing patients, as well as a little bit into update. What were the new updates so that we can all be on the same page and we can all provide the same standard of care that we that our patients deserve. So effectively the 2025 guidelines and the 2017 guidelines at a glance, the risk estimate in 2017, we used to use a pool cohort ratio. In 2025, we introduced a prevent uh calculator that's present on the. AHA website and basically takes 10 years and 30 years total cardiovascular disease risk and it also reduces the age cutoff for which we can use the calculators. In the past there was a cutoff of 40 or higher. Now it has been reduced. Um, drug decision threshold has evolved from an understanding of an absolute number to actually a risk-based assessment of a patient. The secondary workup starts earlier. There's more emphasis on home-based or ambulatory-based blood pressure monitoring. There's a change in the concept of hypertensive urgency. How many of us grew up always confusing urgency with emergency? Uh, it always happened to me. So now they've taken urgency and emergency as concepts away, and they've labeled it as severe hypertension versus emergency, and we'll go a little bit into that. And then, of course, there's resistant hypertension and a little bit on renal denervation, which Centera has recently started offering as well. So what are the goals and what are the targets? Normal remains less than 120/80. Elevated starts at 130/80. Stage one, stage two, those standard guidelines, they haven't really changed. Now, a couple of years ago, there was a huge trial that was conducted called the sprint trial. How many, how many of us heard about sprint trial? All of us did. So why did we find that. There was lesser cardiac outcomes with 120 and 80. More strict control led to better cardiovascular outcomes, and yet we decided we should leave it at 1, we should leave the target of threshold to 130, 80. Well, one part of it is because a more strict blood pressure resulted in a little, fewer, more, a few more complications, including hypotension, dizziness, acute kidney injury, metabolic derangements, especially in the older and frail patients. The second concept is, and I'm going to talk about this, this is an opinion, not a guideline-based answer. And from my opinion is that when we target guidelines, when we come up with guidelines, we need a community and a national based approach. And on a national level, if we suddenly have a 12,080 cutoff, the number of hypertensives. Will go through the roof and that will lead to much more cost, much more care usage, and the benefit between 120 and 130 was not found to equate to the cost of, uh, medication and therapy that would be used. So that's where we're at. Um, goals should be individualized. We should always target a 12,080 number when people are on anti-hypertensive therapy. However, we need to be cognizant that frailty, diet, and, uh, other factors like CKD and uh electrolyte derangement always go into personal prescriptions as opposed to a guideline box-based prescriptions of blood pressure medications. So the two terms defined, there's essential hypertension, which we very commonly see, and then there's resistant hypertension. So essential hypertension is basically prim also called primary hypertension, has multiple names, and it's a combination of genetics, lifestyle, the food that we eat, the amount of sodium that we take, and resistant hypertension is defined as when a patient is on. 3, blood pressure medications, and one of them is a diuretic and still not meeting control and. That's when we define resistant hypertension. Once we have a patient of resistant hypertension, the first aspect of evaluation is always confirm your therapy is actually being used, because a lot of times patients may forget pills here or there, they may not take them as they're prescribed, or their out of office readings may be higher or lower than what you're getting in office. So always confirm the diagnosis before escalating or increasing the number of medications. So the Prevent equation replaces the pool of cohort equations, and this is just a summary of what we've talked about. It increases the catchment groups from 3 to 30 to 79 as opposed to 40 to 79. There's a 10 year and a 30-year total cardiovascular disease, MI, stroke, heart failure risk calculation. And it adds a cardio metabolic angle to the whole, uh, paradigm. It includes renal function, statin use, and social drivers of health as opposed to things that were not present. It has migrated a little bit away. From using race in the calculation as well and in the therapy guidelines too, those were a big part in the past. We've migrated away from that because effectively, we want to individualize therapy without making it a race-based therapy. So the prevent equation, what it is, is an AHA tool. Anyone can um access it. I don't have my mouse or else we could have practiced calculating it. Um, how the guideline uses it is basically a 10 year risk factor cutoff. You start medications when people are above 7.5%. If the risk is less than 7.5%, we try to do lifestyle modifications and we start therapy as always if BP. Remains elevated despite lifestyle modifications. The data in the prevent equations is more robust than the older equations. More patients were enrolled. It's, uh, recalibrated with contemporary uh data, so it's just a better equation now. So when do you start medications? There's the high risk adults, there's the lower risk adults, and then there's the stage two antihypertension uh stage two, blood pressure management. Lower risk, uh, is less than 7.5, 10 year risk. Higher risk is more than 7.5 on the equation. Start a medication when you hit 130, 80. Stage 2, 140, 90, start two medications. Now, in the past, we used to say. One of 2 or 2 of 2. What now the guidelines have transitioned to is use a combination upfront. This was great research that came out of New York and the combination pills are much more adhered to as opposed to individual pills. That being said, there's a practical component to this as well, a high dose combination pill versus a high dose individual pill. How do you get a patient to go in and take a combination pill when you're actively trying to titrate their medications? So that's a conversation and once again goes into individualized care. If you believe that the patient is definitely going to end up on two pills, just. Start a combination straight away. But if you feel that there's going to be a titration, what I do is I start, I provide a 30-day script for individual medications, and then I renew them as a combined once I have a fixed dose regimen for each of them. We try to combine ACEs or ARBs along with calcium channel blockers, or a thiazide diuretic to start off with, and then we add the third agent as necessary. There's a lot of focus on, um, let's go back. There's a lot of focus on ambulatory and blood, uh, home-based blood pressure monitoring, and I believe I have a slide on that and we'll talk about that in a few as well. So, what's the role of GLPs and what's the role of SGLT-2s in management of hypertension? So GLPs are great for lowering blood pressure through weight loss. I, um, our clinic recently had a patient who was consistently running 200s, and she was having a lot of complications from it. She could hardly walk 50 ft before she got winded because her pressure was so high. And she would constantly get, keep getting headaches, migraines. She was having blurry vision. Um, she was on 6 different antihypertensives. Uh, she was on furosemide, hydralazine, isosorbide, losartan, and none of them, and even a clonidine patch, and yet it was not able to bring her blood pressure down. So looking at her profile, her BMI was 45. What she really needed was weight loss, appropriate diet therapy, because all these drugs, they were just band-aiding a bigger problem. We started her on GLP-1, and she lost about 50 to. 75 pounds over three months, and lo and behold, her blood pressure came down to 150, 160, and now we're able to control it with lesser medications. So it's remarkable what good blood uh what good weight control, diet changes can actually do to your patients. SGLT2 inhibitors, they have a very big role in our practice right now. They prevent kidney disease. They reduce the risk of kidney disease. They reduce the risk of, um, cardiac, uh, events. They are very. Mild in lowering the blood pressure. So if you're going to start them on uh SGLT-2 inhibitors, I wouldn't consider them as an anti-hypertensive agent. I would use purely antihypertensive agents and an SGLT2 inhibitor, and then titrate the anti-hypertensive agent at the same time. So out of office blood pressure monitoring has taken a much greater role in the current guidelines and practice because it helps us confirm diagnosis. How many of us have seen patients come to us? I have a headache 3 times a week. I have, my creatinine has gone from 0.9 to 1.5. My office blood pressure is 160/90, but doc, this is all white coat syndrome. I always get this when I'm in the office. It's happened to all of us in our practice. So to those patients, what's. One of the most important factors is buy-in. We need to convince them that their health is in their hands as much as ours. They're 60% and we're 40%. So convincing them to measure their blood pressure two times a day at home, keeping a log, and then returning it to the office so that we can evaluate. I feel that it has given my patients a little bit of more say and active monitoring in their whole pathology. And then as they become active participants and they see their blood pressures decrease with the new medications, they're actually much more reliably adherent to the changes that you make, as opposed to just saying, here, take the pill, go home, you're going to be fine. So active home blood pressure monitoring with a cuff that's the right size, that goes on the bicep, that doesn't have a wrist cuff, um, those are really important things. And at the end of this, if we're still getting conflicting data, what I tell them is, bring your cuff to the office, we'll measure it in the. Office will use your cuff and do a calibration to see if there's any difference, and that really helps us all have a buy-in and the patients feel I have a say my, uh, my fears are being heard and I'm being taken care of and it also helps us unmask the phenotypes. Stay away from the cuffless or the wearable devices because they're inherently um have risk of being inaccurate. Lifestyle remains first. Um, I'm, we've had a great talk about our diet changes. I'm not gonna, uh, belittle Blake's talk. So lifestyle and diet are paramount and the key to cardio metabolic diseases. If we can fix just one thing in our patients, it should be the diet and exercise, and it would go such a long way in a population standpoint. We screen for primary aldosteronism earlier now as opposed to waiting. So why should we do it? Well, 5 to 10% of all hypertensives have, uh, uh, aldosteronism, and up to 20% of the resistant hypertension subsets do. So who to screen now? All stage two. All resistance and you check your plasma um and your renin and your aldosterone activity and you calculate the ratios. It's a very simple test um just make sure that they're off their aldosterone antagonist medications during this time because those can really affect those um numbers. Um, how do you evaluate, um, resistant hypertension? First of all, we rule out pseudo resistance, and that goes into your blood pressure monitoring, pill counting, making sure they're taking what they're supposed to be taking, contact with the pharmacy, are they picking up their medications as they're. opposed to if all of those boxes are checked, then we work up the second, uh, secondary causes which can be primary aldosteroneism, can be endocrino endocrinopathies, obstructive sleep apnea, pheochromocytoma, thyroid disease, and of course whenever I have a patient who's on 4 or more antihypertensives, I make sure I get renovascular ultrasounds because it, it's. Uncanny how many times we actually find it in patients who actually have renal disease along with hypertension, and we find that it was a simple fix. Renal denervation. Doctor McKechnie has recently started and you can refer patients to him for renal deinnervation, especially if they have resistant hypertension and you're finding it difficult to control with just medications. It's a catheter-based procedure that lates the renal sympathetic nerves. It's a class 2B after a discussion with the patient and making sure that, um, they have been adherent to the medications. So, um, that's another therapeutic option that we have from a cardiology standpoint now. Now, severe hypertension. I want all of us to resist the reflex of sending patients to the ER, and I've been guilty of this too. Um, my patient that we talked about on 6 blood pressure medications, first time she showed up in the office with a blood pressure of 210, straight to the ER, even though she was asymptomatic at that time. But let's resist the temptation to send patients to the ER unless they're really symptomatic. Let's resist, um, a knee-jerk reaction as opposed to treating the patient. So when we have markedly elevated blood pressure over 180 or 120, uh, without any acute changes, they do not need to be hospitalized. They don't need to go to the ER unless they're having active chest pain, vision changes, uh, shortness of breath, pulmonary edema. Treat them with oral medications, bring the blood pressure down, um, slowly, do a close follow-up in the clinic, and if it still doesn't work or if they start to develop symptoms, send them to the ER at that point. Um, there's special populations. There's the diabetics, uh, the CKD patients, um, the patients who have cog, uh, we anticipate to have cognitive issues, uh, pregnant patients, patients who have had recent strokes, patients who have had recent intracranial hemorrhage, all of those patients require special attention. The strokes and the intracranial hemorrhage, that's a separate discussion on its own, so I've left it out. But in CKD and diabetes, try to make sure they're on an ACE and ARB. If, um, the GFR allows with, uh, in conjunct with a nephrologist, try to check albumin urea for all of these patients. More, uh, blood pressure control reduces the risk of poor cognition down the line. So control the blood pressure to target less than 130/80. During pregnancy, 160 or 110 is the cutoff, and 140/90, less than 140/90 is chronic, and we treat them per guidelines along in conjunction with our obstetricians involved in their care. So what do we need to bring to work on Monday morning when we go back from here? The first thing we need to do is start practicing using the prevent uh equation if we haven't. Stage 2 or 140/90, straightaway, start with a two combination, uh, a combination pill. Keep life lifestyle first line therapy in conjunction with a pharmacological therapy. Confirm home blood pressure monitoring. If you're starting somebody on two blood pressure medications, it's reasonable to request that they invest in a blood pressure cuff at, um, and they can pick up any one of them. What I usually tell patients is it doesn't need to have the bells and whistles, a Bluetooth monitor, a Wi Fi, a bird that comes out and tells you when to check, no. All you really need is one that sits on your table that you can use every morning and every night before you go to sleep. Screen patients for secondary causes and don't reflexively treat, um, asymptomatic severe hypertension patients. Give them medications, give them a couple of days, and if you're having trouble, then activate the higher, uh, centers. Um, and that does my, uh, talk. Thank you so much for listening, um. Published June 30, 2026 Created by Related Presenters Manik Veer, MD Cardiology View full profile
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