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Hypertension is one of the most common clinical conditions worldwide. Since 2017, international and US authorities have lowered the threshold for hypertension from 150/90 to 130/80 resulting in an increase prevalence from 30% of the USA population to 47% for the disease. The decision to lower the threshold is based on findings in clinical studies showing a strong correlation at lower BP elevations with common clinical conditions such as Coronary Artery Disease, Myocardial Infarctions (heart attacks), Atherosclerosis and strokes. Blood pressure (BP) can be assessed at home by the patient after physician counseling and this data can be used to guide initial management. The age-old sphygmomanometer and stethoscope are replaced by the Electronic Oscillo Metric device in and out of the office environment. This type of device is easier to use, especially for patients at home and is more accurate and consistent with subsequent measurements. These devices eliminate user bias, because they eliminates human hearing from the equation and the results are less individually user dependent. When hypertension is borderline or mild in the office, patients are often instructed to obtain serial BPs at home for 1 -2 weeks. Often, BP in the office or clinic is higher than when taken at home due to an anxiety causing mechanism known as “White Coat Hypertension” which frequently occurs in the office setting.
At the age of 18 and above, patients are assessed once a year if healthy or twice a year if hypertension is found or suspected, when there are comorbid conditions, older patients (>65), when there is a strong family history and when there are predeterminant risk factors that include Obesity, family history or genetics, race and ethnicity, kidney disease, physical inactivity and Diabetes. Medications associated with hypertension include stimulants, antidepressants, decongestants, oral contraceptives, especially estrogen. Conditions such as adrenal hyperplasia and Cushing’s disease, hyper / hypothyroid state and others. Complications of chronic or untreated hypertension are ischemic or hemorrhagic stroke, Heart Failure, Atherosclerosis, Coronary Artery Disease. In fact, persistent hypertension is thought to be the most prominent preventable cause leading to premature cardiovascular disease, more so than cigarettes.
In the office and at home, blood pressure should be taken with the appropriate size cuff. A validated Oscillo metric device should be used. The patient ideally should be relaxed and seated for 5 minutes.
Once hypertension is diagnosed and unless the condition is exceptionally high (BP 180/110) in an asymptomatic subject or a less elevated BP above 150/90 for instance, but with comorbid conditions and symptomatology suggesting “End Organ Damage”. The initial treatment begins with counselling and behavioral/diet modification. Briefly, the diet should be well rounded and include protein in the form of chicken, fish and sometimes a lean cut of red meat is OK, vegetables or fruit and complexed carbohydrates in the form of natural grain, beans or potatoes. Processed, canned foods should be avoided due to high Sodium content. Empty calories found in white bread, white rice, and especially candy, cakes, simple sugar, and deserts should be minimized or avoided if possible because they can lead to weight gain and obesity. Obesity is a risk factor for hypertension. Patients are advised to read nutritional labels. Physical activity in the form of aerobic, dynamic, and / or Isometrics type exercises, at least ½ hour per day is more than encouraged and it is essential for overall good health. As stated before, inactivity is a risk factor for Hypertension. Exercise activity also decreases stress, weight gain and directly and independently reduces resting BP. In addition, there are stress relieving activities like Mindfulness, and Yoga. Adequate sleep, (seven hours or more per night) is important because it helps to reduce stress, BP, and weight gain. Your doctor will counsel you and discuss these concepts with you during your office visit. It is important to note that modifications can be applied in small increments at first and the goals can be lowered at first and increased gradually over time to prevent discouragement. Your physician will sit down with you and help you hash out an effective plan.
If or when the above interventions are not sufficient, medications are prescribed. The human body controls and maintains normal blood pressure through three main mechanisms. The autonomic pathways, the Rennin Angiotensin pathway which involves the kidneys and the lungs, and the adrenal and endocrine system. Today most initial medications work by blocking these pathways. There are medications that work by directly dilating blood vessels and others work by causing the kidneys to excrete more salt and water. This class of medication is called diuretics. Often the provider will start the patient on a combination of two medications that work synergistically through separate pathways.
A short discussion about hypertensive emergencies and urgencies should follow. As a board-certified Emergency Physician, with over 30 years’ experience, I am an expert at managing Hypertension from the other end of the spectrum. The category of Hypertensive Emergency and Hypertensive Urgency requires a different approach than in an office setting. Further detail is beyond the scope of this article but one of the advantages that an emergency physician brings to clinical office practice is the ability to recognize, stabilize and transfer a patient to a higher level of care when it is indicated.
Andrew G Grossman, MD, FACEP,