Hypertension Management: Translating the New Guidelines Into Practice

The new hypertension guidelines issued in late 2017 by the American Heart Association and American College of Cardiology will likely change how practitioners measure and manage blood pressure, said F. Wilford Germino, MD, FACP, FASH, at the 2018 Cardiometabolic Risk Summit (CRS) in San Antonio, Texas.

The new guidelines, which lowered the threshold for hypertension to 130/80 mm Hg, have implications for both ambulatory blood pressure monitoring (AMBP) and self-blood pressure monitoring (SMBP), he explained in his presentation.

Dr Germino, who is affiliated with the Department of Internal Medicine at Rush Medical College in Chicago, Illinois, and the Department of Internal Medicine at DuPage Medical Group, discussed the importance of adhering to proper technique and related protocol outlined in the new guidelines.

"The vast majority of BP measurements performed in this country are done with either poor/improper technique or an inadequate number of readings," Dr Germino told Consultant360.

Common errors, including improper cuff size, arm placement and positioning, talking during a measurement, and use of a nonvalidated device could interfere with the accuracy of BP readings.

The frequency of these errors in US medicine is problematic because these readings, which are often done incorrectly, are used to make a diagnosis of hypertension and drive treatment decision-making, he explained.

With this in mind, he emphasized in his presentation that clinicians should:

• Ensure that BP measurements are taken properly and multiple times with a validated device.

• Encourage, teach, and observe patients in proper technique, and then use that information in their BP management.

• Incorporate numbers from SMBP readings into patients’ BP management in ways that include treatment dosage adjustment.

• Remember that β-blockers are no longer considered first-line therapeutic option for most patients with hypertension.

• Target lower BP goals in patients with a higher cardiovascular disease risk, with considerations for older systolic BP (SBP) patients who may not tolerate medication adjustments to reach the target SBP.

In addition, Dr Germino discussed the numerous pharmacologic and nonpharmacologic treatment recommendations for hypertension. In his discussion of pharmacologic options, he emphasized the importance of using combination therapies early in hypertension, as well as promoting patient adherence to antihypertensive therapy.

"Using combination therapies for those who are 20/10 mm Hg above their goal reduces pill burden, allows for titration, results in earlier achievement of the BP goal, and probably leads to better adherence by the patient who is monitoring their BP," he said. "Seeing a response to therapy affirms the benefits of the treatment."

"Additionally, one can titrate the treatment dosage higher if there is an insufficient response before the next visit, if warranted, thereby achieving the target BP goal earlier in the condition," Dr Germino added.

Among the best proven nonpharmacologic options he discussed were weight loss among patients with overweight or obesity, a heart-healthy diet such as the Dietary Advances in Stop Hypertension (DASH) diet, dietary sodium reduction, dietary potassium, and physical activity.

—Christina Vogt

Reference:

Germino FW. How do the new hypertension guidelines change your practice? Presented at: Cardiometabolic Risk Summit 2018; September 14-16, 2018; San Antonio, TX.