Dr. Loh: The updated hypertension guidelines

When it comes to assessing risk of developing cardiovascular disease, which is the leading cause of death in the developed world, your doctors fundamentally sort out what known risk factors may be in play in your particular circumstance. As I have written on many occasions, cardiovascular risk factors are generally divided into two general categories, those that are nonmodifiable and those that are modifiable.

The nonmodifiable ones are mostly genetically based, but fortunately many of their manifestations are modifiable through the knowledge advances that have accrued by testing the impact of lifestyle changes like diet, exercise, and weight loss. Also, there have been significant alterations in the trajectory of cardiovascular diseases induced by medications that have been validated in clinical trials.

Knowledge of these risk factors is not enough, however, since any intervention must be done to the degree that has been demonstrated to make a significant difference. This is why, for example, doing exercise or being on a given course of medications per se is not enough to derive the benefit; one needs to do enough exercise and be on the right amount medications to get to the target therapeutic goals. All that then raises the question: what are those targets one should strive to achieve to get the positive effect, and how do doctors know what to recommend?

You may have noticed that over the years, these guidelines change. The cynics say that the prior doctors’ recommendations were wrong and that they’re moving the goal posts and you should not trust what they say. These people are, of course, idiots. What is occurring is that new information is developed that is compelling enough to have experts, subject to the foibles of being human despite their acknowledged experience in that discipline, say that the new treatment goals should be adjusted. And, as in most human endeavors, political (in the broadest sense) considerations may create disagreements between bodies of even these august experts.

But unlike in our current political environment, medical professionals, working on the best available evidence, try to bridge these differences to close the gaps that may confuse patients and their doctors as to what exactly is the best course of action, for now. The disparities in recommendations like optimal lipid, blood sugar, or blood pressure targets have been the consequence of the results of new clinical trials using better and often more potent medications capable of more effectively treating those conditions of interest. Balanced against those results are the increased cost and potential adverse effects. No wonder that different expert bodies may vary in their suggestions.

There are too many expert panels for me to review in a single column, but recently there has been a blending of the European and American guidelines on blood pressure goals which have somewhat merged the recommendations to more closely resemble each other. This makes it easier for not only the doctors, but the patients as well, to know if their blood pressure is where it should be.

As with many cardiovascular targets, lower values in genetic or lifestyle induced elevations of risk markers have been carrying the day. So the American and now the European blood pressure experts are recommending that the optimal goal for most patient should be the well recognized systolic of 120 to 129 mm of mercury and diastolic of 70 mm of mercury. And high blood pressure worthy of initiating medications if lifestyle changes are not sufficient after about three months are systolic BPs of 140 or greater, or diastolic BPs of 90 or greater. This leaves an intermediate range systolic BPs of 120 to 139, and diastolic BPs of 70 to 89, now simply called “elevated BP” where doctors may want to start medications but patients may be reluctant to do so.

Here the recommendations remain a bit out of sync, but not excessively so. The European guideline suggest that the clinician do a formal calculated risk estimate using a standard and validated risk estimator that factors in other extant cardiovascular risk factors, and if the patient falls into a higher risk category, medications be recommended. The American recommendation is to more formally recommend lifestyle changes and if after a certain period of time the blood pressure remains out of the optimal range, then pharmacologic options be suggested. Of course, frail or very elderly patients need special consideration to avoid creating new problems when trying to solve these old problems.

It should be noted that there are more defined recommendations for exercise now in place, so it’s not just “you should exercise more” or the prior recommendation of 2.5 hours of vigorous exercise per week.” The recommendation is now 75 minutes of vigorous exercise per week and use of light weights two to three times per week. And, in the absence of significant kidney disease, an encouragement of potassium supplementation may also help with BP management.

Increasingly, it is apparent that there is an interaction between many of these risk factors, often as a result of the effect of new knowledge of medications, such as the GLP-1 stimulators and SGLT-2 inhibitors that I have written about in prior columns. So even if one does not have diabetes, the use of these medications can have a positive impact on weight, blood pressure, kidney function, reducing risk of heart failure, and diabetes.

Plus new and novel therapies, both pharmacological and surgical, are being evaluated, for the more refractory hypertension cases.  We are bringing some of these to our community if you would like to learn more.

Whatever one’s cardiovascular status, you are your best advocate. So optimizing your diet, exercising regularly, achieving your desired weight, taking your medications reliably, and knowing your biometric numbers, including your blood pressure, are the things that allow you to take charge of your own health under the supervision of your caring clinicians.

Irving Kent Loh, M.D., is a preventive cardiologist and the director of the Ventura Heart Institute in Thousand Oaks. Email him at drloh@venturaheart.com.

This article originally appeared on Ventura County Star: Dr. Loh: The updated hypertension guidelines