Hypertension: What Clinicians Need to Know

Podcast Transcript

Announcer: Welcome to Cleveland Clinic Cardiac Consult brought to you by the Sydell and Arnold Miller Family Heart and Vascular Institute at Cleveland Clinic. In each podcast, we aim to provide relevant and helpful information for healthcare professionals involved in cardiac, vascular and thoracic specialties. Enjoy.

Interviewer: I'm here this morning with Dr. Luke Laffin. He's a staff cardiologist in our Preventive Cardiology section. He is also a clinical specialist in hypertension so we're very excited to have him here and talk about the hypertension guidelines. They came out at the end of 2017. How have they really impacted your practice or how has your practice changed?

Dr. Laffin: Great well, thanks for having me on at first. I think the main thing about the hypertension guidelines is that it really hasn't changed practice necessarily for most physicians but it really now aligns with what clinicians have been doing for many years.

There's five main things that I feel like the hypertension guidelines really expounded upon or built upon. One was just the idea about managing or excuse me, measuring blood pressure properly. There's a nice section in the guidelines just talking about what size cuff people should be using, how they should be measuring blood pressure in the office but at home as well.

The second point would be the emphasis on home blood pressure monitoring. It's been something that we've been doing in clinic for many years and having patients do and send us their numbers. Now, we have more and more data to suggest that home blood pressures can often times be more useful than just your once every six month in the clinic blood pressure.

The other things that the guidelines really reflected was they created new definition for what is elevated blood pressure and what is hypertension. Really, that reflects that we want to be a little bit more aggressive in our higher risk patients with decreasing blood pressure and getting below certain targets. We've been doing that probably over the past three years or so based on more recent data from large blood pressure trials such as the SPRINT Trial.

Then also this idea about treating blood pressure or targeting lower blood pressures based on cardiovascular risk specifically, 10-year cardiovascular risk and your likelihood of having things like strokes, heart attacks. This is something that's not new to cardiologists or primary care docs because we've been doing that for lipid therapy and cholesterol lowering therapy but now we've transitioned it more to the blood pressure realm.

Then finally the one thing that probably has changed my practice a little bit but again we were doing it was a focus on rather than just starting one pill at a time or one drug at a time, we've moved more towards using combination therapy so, one pill with two or three different medication.

Interviewer: In a lot of the discussion that came out after the guidelines, people talked about, "Oh, more people are going to be on medications now because they lowered the thresholds." Have you seen that or is it similar to what you saw before?

Dr. Laffin: I think it's probably more similar to what we saw before. Generally, the people that maybe on slightly more medicines or higher doses of medicines are those patients at higher risk because we are targeting lower blood pressures. I think it's important to remember that with all the controversy that surrounded the guidelines and labeling patients that are now 130/80 or higher as having stage I hypertension that really unless you're high risk for cardiovascular events, the focus is not on adding pharmacological therapy but it's doing those things that will lower blood pressure without medicine so focusing on weight reduction, dietary sodium reduction, and things like that more than anything else, proper sleep hygiene. Those all have a beneficial effect on lowering blood pressure.

Interviewer: You mentioned placing people on two medications. There's a lot of choices between one medication, two medications, and now even at ESC they talked about the benefits of those dual, one pill having two medications in them. How do you choose the right medication for the patient?

Dr. Laffin: It's definitely something that we have to think about carefully and consider. When it comes to combination therapy, I think the thing to remember is that all the different classes of blood pressure medicines tend to have or they can have synergistic effects with each other. It's been shown that a moderate dose of two medications is probably more efficacious and better for you in the long run than just the high dose of one. We have to take that into consideration.

The other benefit to combination therapy is it's easier to take. It's easier to convince patients to take one pill that may have two or three medicines in it versus taking three pills that are three different medications. That helps.

Really, the nice thing about antihypertensive medications is that even these combination therapies are not cost prohibitive. We're not talking $100 a month or anything like that. They're generally quite affordable.

The one block that sometimes patients have is saying, "Well, yeah your blood pressure isn't that high but we're going to start you on two medications as one." It's important to explain that to patients that really were looking for a synergistic effect. We might be able to get away with one but it's probably better to have moderate doses of both.

Interviewer: Are there certain patient populations where certain types of drugs or classes of drugs would be better suited for different patients?

Dr. Laffin: There definitely is. The main two determining factors that I use when I'm treating patients is thinking about the age of the patient and then any comorbidities that they may have. For example, there's some that are self-evident to all physicians. Patients with chronic kidney disease, stage III or greater, they should be on a blocker, the renin angiotensin system and then often times we'll need another class of medication to control their blood pressure as well. Often times, a diuretic in combination works well. Cardiology patients that I see more regularly often times, they'll have compelling indications for a medication class called beta blockers. Now that's if they have heart failure with reduced ejection fraction. The pumping function or they have LV systolic dysfunction. Then similarly if they have arrhythmias that we need to control, beta blockers can be a good choice or if they've recently had a myocardial infarction.

Then when we talk about age. One thing when I'm seeing patients that are maybe newly diagnosed hypertension or it's gotten worse as they reach 75 or 80 years old, is to remember that those patients tend to have stiffer blood vessels and so they tend to respond a little bit better to calcium channel blockers, our amlodipines, nifedipines, et cetera.

Interviewer: Speaking of the elderly, I know again with the guidelines coming out there was concern over too low, too high you know for risk related to safety risk even for elderly patients. Do you change your thresholds for these patients or ... ?

Dr. Laffin: You definitely have to be aware of them. The data that changed the blood pressure guidelines the most significantly was the SPRINT blood pressure trial. They enrolled in a group of patients that were elderly. You could be over 75 and they did show a benefit. But, this was a relatively robust 75-year-old. What we run into trouble with is again these stiff blood vessels. What happens as we age is that rather than seeing the diastolic blood pressure go up, it tends to decrease. We get the separation between the systolic and diastolic blood pressure. We have to be aware that we don't want to drop the diastolic pressure too low. The data is still a little bit conflicting about how low to go but, we generally use around 16 millimeters of mercury that we don't want to go under that level.

With respect to other side effects, we do also have to be cognizant that elderly people don't tend to drink as much fluid so certain medications, their effect can be potentiated when we're dehydrated. Example. ACE inhibitors and ARBs tend to we have more potency. It's important to explain to them to make sure you stay hydrated et cetera and reduce the risk for things like acute kidney injury.

Those are the main thoughts on that.

Interviewer: It sounds like these guidelines truly are guidelines and you really have to create an individualized plan for the patient. You really have to look at the whole picture.

Dr. Laffin: You definitely do and that's why it's important to discuss it with your physician about what works best for you. One thing that works for your neighbor may not be the right thing. There is trade offs with trying to target lower blood pressures and that was clearly shown in the trials that were done. In the long term, I think most patients and most physicians would say, "We'll tolerate the occasional episode of lightheadedness or a little bit lower blood pressure for a reduced risk of strokes, heart attacks and heart failure in the future."

Interviewer: You mentioned home blood pressure monitoring. I know as physicians today you are bombarded by ways the patients communicate with you and different information that you're getting in all the time. As a clinician, how are you using the data from home blood pressure monitoring to help titrate meds or help control blood pressure in your patients?

Dr. Laffin: I think it's very important and it's actually essential in my practice to doing that. It's paramount.

What I typically do especially when I see a new patient, most of the patient I see have a resistant hypertension. They are taking at least three blood pressure medicines without controlled blood pressure or at goal blood pressure. What I have them do is send me their numbers via our electronic medical record or via email just so we can have a better sense of what they are two or three weeks after the visit. We're not waiting three months till we see them again to actually address these.

It's very important to monitor blood pressure at home. When medication changes are made I typically recommend checking blood pressure at least three or four times a week. In the patient that's been on a stable dose of maybe one or two blood pressure medicines, it's very reasonable to only check a couple of times a month. That has been shown to be a decent marker of what your blood pressure is generally.

Interviewer: Okay, the last, I often get this question as a nurse that patients want, you mentioned lifestyle change. You see a patient, they come in and everything's out of control. As they start losing weight, and start eating better controlling their sodium but you have them on this medication regime, how do you titrate or change things. They always say, "Can I come off my meds now?"

Dr. Laffin: Yeah, yeah, it's a very common question at the first visit and every subsequent visit actually. What I tend to tell patients and the data supports this is that blood pressure management is 70% lifestyle, 30% medication.

Coming back to the guidelines, they have a really great chart in there talking about the non-pharmacological strategies to lower blood pressure. For example, the DASH diet which is a low sodium, more Mediterranean focused diet that's been shown to reduce systolic blood pressure in hypertensive patient by about 10 millimeters of mercury. You couple that with weight loss which is shown to, if one reaches their ideal weight, decreased blood pressure by about five millimeters of mercury. Then someone that's exercising regularly similarly you're going to get about a five to eight millimeter of mercury difference. If you put all those together you're getting almost 20 millimeters of mercury or more in decrease in blood pressure.

If a patient comes to me and they're overweight, sedentary, on a high sodium diet, I say, "Yeah, we might be able to come off blood pressure. You might not have to do more than lifestyle." That's in contrast to the patient that maybe is 75, elderly, in good shape, watching their sodium already, then that's really a consequence of stiff blood vessels and then years of stiff blood vessels and just that accumulation of years. They may need blood pressure medicine for the rest of their life and that's okay. We say, "Do the lifestyle modifications and then we'll try, and keep you at one or two medicines and not have to do anymore."

Interviewer: Well thank you for talking to us this morning. I think you provided clinicians with a lot of great tips with how to manage patients with high blood pressure and also how to incorporate the guidelines into their practice.

Dr. Laffin: That's wonderful. Thanks for having me.

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