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High Blood Pressure

When doing vitals during a patient evaluation would it be a surprise to anyone to find a patient has hypertension?

Of course not. Hypertension is extremely common. In fact it is estimated that worldwide 41% of those between 35 and 70 are hypertensive. Additionally, less than half of them aware they have the diagnosis. (1) The incidence of hypertension goes up with age with about 50% being hypertensive between 60 and 69 years of age and about 75% in those 70 or older. (2)   We know we have to take the diagnosis seriously since hypertension is a risk factor for coronary artery disease, heart failure, chronic kidney disease, intracranial hemorrhage, TIAs, stroke and even cognitive impairment. (3) The question now becomes what is the best way to manage these patients.

Beginning in the late 70’s a committee was convened with representing stakeholders involved with the treatment of hypertension. This was the first “Joint National Committee (JNC)” and their recommendations are considered the standard. Since then 7 other JNCs have convened reviewing the current literature and publishing their recommendations. The latest or 8th JNC published their recommendations in 2014. (4) This group had expertise in primary care, geriatrics, cardiology, nephrology, nursing, pharmacology, evidence based medicine, epidemiology, informatics and guidelines development.

The JNC does tailor recommendations to different patient population, but as doctors who generally don’t treat hypertension, but routinely treat patients with hypertension let me boil down the recommendations to a few statements:

• All hypertensive patients should receive counseling on lifestyle modification.
• In patients 60 or older, refer patients for pharmacological treatment if their systolic pressure is at or above 150 and/or the diastolic is at or above 90.
• In patients less than 60 the systolic threshold is 140 and the diastolic remains at 90.
• In patients with disorders such as chronic kidney disease and diabetes, effective treatment for hypertension is more critical.

Lifestyle modifications include weight reduction, the DASH eating plan, reduction of sodium, increased physical activity and limiting alcohol consumption. A handy patient resource can be found at this website: https://www.nhlbi.nih.gov/files/docs/public/heart/hbp_low.pdf

The majority of patients will require concurrent management that you will generally handle with a referral. There are a few patients where more aggressive action is required. You should consider getting a patient to the ER if their systolic is above 180 and/or their diastolic is above 110 particularly if they have symptoms like severe headache, dyspnea or edema. (5) On the other end of the spectrum patients with systolic pressure between 120 and 130 or diastolic pressures between 80 and 90 are considered pre-hypertensive. (6) These patients should be monitored and given lifestyle modification counseling.

High blood pressure is an issue for a large number of our patients. Fortunately there are number of good quality guidelines available to aid in the decision process.

1 – Chow CK, Teo KK, Rangarajan S, Islam S, Gupta R, Avezum A, Bahonar A, etal; PURE (Prospective Urban Rural Epidemiology). Prevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-, middle-, and low-income countries. JAMA. 2013 Sep 4;310(9):959-68.

2 – Chobanian AV, Bakris GL, Black HR, et al; National Heart, Lung, and Blood Institute, National High Blood Pressure Education Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003 Dec;42(6):1206-52

3 – DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 – .Record No. 113862, Hypertension [Updated 2015 Aug 24 10:25:00 AM] Accessed at http://www.dynamed.com/ Registration and login required.

4 – James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, etal. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014 Feb 5;311(5):507-20.

5 – Hebert CJ, Vidt DG. Hypertensive crises. Prim Care. 2008 Sep;35(3):475-87

6 – US Dept. Health and Human Services. https://www.foh.hhs.gov/NYCU/hypertension.asp. Accessed: 2016 Jan28.

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