Initial Treatment of Hypertension

Aug 24, 2023

Initial Treatment of Hypertension

This Harvard Medical School Continuing Education video examines these key questions: Does a diagnosis of hypertension always necessitate pharmacological intervention? What nonpharmalogical interventions are available? Who can benefit from medications to lower blood pressure?

Dr. Michael Honigberg, MD, a cardiologist at Massachusetts General Hospital, reviews evidence-based nonpharmacological approaches to hypertension treatment, such as diet and exercise interventions. Drawing from the 2017 ACC/AHA guideline recommendations for pharmacotherapy, he outlines how to determine whether a patient is a suitable candidate for antihypertensive medications, and how to prescribe them.

This video was peer reviewed by Dr. Jonathan Salik, TMD, MHPEd, Instructor of Medicine, Massachusetts General Hospital; and Dr. Sugantha Sundar, MD, Assistant Professor of Anesthesia, Beth Israel Deaconess Medical Center, to validate the quality and accuracy of the content.

00:00 | Introduction
00:43 | Non-pharmacological interventions to lower blood pressure
03:46 | Determining for whom pharmacotherapy is indicated
05:01 | Prescribing guideline-recommended anti-hypertensive medications

References:
GBD 2018 Disease and Injury Incidence and Prevalence Collaborators. Global Burden of Disease Study, Lancet. 2018;392(10159):1683-2138.

Notice: At this time, the content in this video is not accredited.

Content

0 -> [MUSIC PLAYING]

2.898 ->

5.798 -> MICHAEL HONIGBERG: Hi, I'm Dr. Michael Honigberg.

7.84 -> I'm a cardiologist at the Massachusetts General Hospital

10.57 -> in Boston, Massachusetts.

12.37 -> Today we'll be talking about a topic that's

14.35 -> fundamental to the practice of primary care, the treatment

17.23 -> of hypertension, with a focus on the 2017 American

20.86 -> College of Cardiology/American Heart Association guidelines.

25.09 -> In today's video, we will review evidence

27.13 -> based nonpharmacologic interventions to lower

29.98 -> elevated blood pressure.

31.67 -> Next, we will identify individuals

33.46 -> for whom pharmacotherapy to lower blood pressure

36.37 -> is indicated.

37.57 -> Finally, you'll understand how to prescribe

39.94 -> guideline-recommended antihypertensive medication

42.1 -> therapies.

43.93 -> The complications of chronically elevated high blood pressure

47.47 -> include atherosclerotic cardiovascular diseases,

50.47 -> such as ischemic heart disease, stroke, and peripheral artery

53.8 -> disease, aortic aneurysm and dissection, heart failure,

58.09 -> and chronic kidney disease.

60.25 -> On a global scale, elevated blood pressure

62.95 -> is the most common risk factor for death and disability

65.53 -> worldwide.

67.54 -> The 2017 ACC/AHA guidelines defined

71.11 -> four categories of blood pressure-- normal blood

74.08 -> pressure, elevated blood pressure, stage 1 hypertension,

77.59 -> and stage 2 hypertension.

79.78 -> Nonpharmacologic interventions are recommended

82.48 -> for individuals with elevated blood pressure

84.64 -> and both categories of hypertension.

87.92 -> What are some of these nonpharmacological blood

90.08 -> pressure lowering interventions?

91.76 -> First, weight loss.

93.89 -> The best goal, ideally, is to work toward ideal body weight

97.19 -> but this is infeasible for many patients.

100.16 -> The guidelines recommend initially

101.6 -> targeting 1 kilogram reduction in body weight for most adults

104.96 -> who are overweight.

106.69 -> You can expect roughly 1 millimeter

108.79 -> per mercury reduction in blood pressure for every one kilogram

112 -> reduction in body weight.

114.23 -> Second, dietary modification.

116.65 -> Several randomized trial-supported heart

119.29 -> healthy diets are available, including

121.39 -> the Dietary Approaches to Stop Hypertension, or DASH, diet.

125.35 -> In general, we recommend that patients

127.09 -> consume a diet rich in fruits, vegetables,

129.889 -> whole grains, and low content of saturated fat.

133.66 -> This can be even more effective for blood pressure

136 -> when paired with sodium restriction.

138.4 -> An ideal goal, from sodium intake standpoint,

141.37 -> is less than 1,500 milligrams per day.

144.01 -> At the very least patients should

145.84 -> aim to decrease their daily intake by 1,000 milligrams

149.17 -> from baseline.

151.46 -> Next is potassium supplementation.

154 -> Guidelines advise that patients aim

156.01 -> for at least 3,500 milligrams per day of potassium intake,

160.21 -> ideally through dietary sources rather than medications.

164.56 -> Good sources of dietary potassium

166.6 -> include fruits, vegetables, low-fat dairy products,

170.47 -> fish and lean meats, nuts, and soy products.

174.35 -> Note that potassium supplementation is not

176.32 -> recommended for individuals with chronic kidney disease or those

179.65 -> using medications that interfere with renal excretion

182.62 -> of potassium.

184.96 -> Increased physical activity.

187.48 -> Aerobic exercise, resistance training,

190.09 -> and isometric exercise, such as planks, all lead to reductions

194.47 -> in blood pressure.

195.79 -> Guidelines recommend targeting 150 minutes

198.67 -> per week of moderate or greater intensity aerobic exercise,

202.66 -> both for blood pressure and overall cardiometabolic health

205.6 -> and wellness.

207.37 -> And finally, alcohol moderation.

210.28 -> Guidelines recommend no more than two

212.86 -> standard-sized alcoholic beverages per day

215.29 -> for men, and one per day for women, although some evidence

219.37 -> that either lower targets or thresholds might be

222.22 -> beneficial for overall health.

225.69 -> How do you decide whether the patient you're seeing

228.09 -> requires pharmacotherapy in addition

230.7 -> to nonpharmacologic lifestyle modification?

233.85 -> Start with the blood pressure categorization--

236.7 -> elevated blood pressure, stage 1 hypertension,

239.49 -> or stage 2 hypertension.

241.88 -> For patients with elevated blood pressure,

243.98 -> the guidelines recommend starting

245.9 -> with nonpharmacologic interventions, lifestyle

248.45 -> modification, and reassessing in three to six months.

252.05 -> Conversely, for patients with stage 2 hypertension,

255.35 -> the guidelines recommend a combination

257.209 -> of nonpharmacologic interventions

259.13 -> and the initiation of blood pressure lowering medication.

263.24 -> For stage 1, it depends.

266.25 -> Does the patient have established

267.86 -> cardiovascular disease, diabetes, or an estimated

271.49 -> 10-year risk of a cardiovascular event greater than

274.19 -> or equal to 10%?

275.75 -> If not, the guidelines advise that it's

277.82 -> reasonable to trial nonpharmacologic modifications

281.12 -> or interventions, and reassess in three to six months.

284.27 -> If the answer is yes, the guidelines

285.98 -> recommend starting medication in addition

288.59 -> to nonpharmacologic approaches.

291.17 -> Based on randomized trials like the SPRINT trial,

293.57 -> most patients deserve a typical blood pressure

296.48 -> goal less than 130 over 80 millimeters of mercury.

301.07 -> You've decided that your patient warrants pharmacotherapy.

304.46 -> What medication should you start?

307.13 -> Many different antihypertensive medications

309.38 -> are available to clinicians.

311.51 -> The guidelines endorse these four categories shown here

315.23 -> as very reasonable first-line approaches to managing blood

319.1 -> pressure--

319.94 -> the thiazides, angiotensin-converting enzyme

323.18 -> inhibitors or ACE inhibitors, angiotensin receptor blockers

327.23 -> or ARBs, or the calcium channel blockers.

331.22 -> And the typical daily doses and dose frequencies

334.49 -> of several commonly used agents are shown here.

337.88 -> Comorbidities can help guide selection of particular agents

341.06 -> to use.

341.87 -> For example, beta blockers are also commonly used

344.84 -> to treat blood pressure in patients with underlying

347.36 -> cardiovascular conditions, such as coronary heart disease,

350.85 -> heart failure, or arrhythmia.

353.24 -> Refer to the 2017 ACC/AHA hypertension guidelines

356.93 -> for a more complete list of blood

358.43 -> pressure lowering medications.

361.01 -> Should you start with one drug or combination drug therapy?

365.48 -> The guidelines advise consideration

367.79 -> of two-drug combination therapy up front for patients

371.09 -> with stage 2 hypertension if the blood pressure

374.15 -> is greater than 20 millimeters of mercury

376.52 -> above the systolic goal, or 10 millimeters of mercury

379.88 -> above the diastolic goal.

381.59 -> Be sure to select drugs from two different pharmacologic

384.68 -> classes.

385.97 -> Note that ACE inhibitors and ARBs should not

388.64 -> be prescribed together.

390.47 -> Combination therapy can be prescribed

392.18 -> as a fixed-dose combination pill or as two

395.03 -> separate prescriptions.

397.43 -> In summary, in this video, we reviewed

399.5 -> evidence-based nonpharmacological

401.42 -> interventions to lower blood pressure, reviewed

404.3 -> how to identify individuals for whom pharmacotherapy to lower

408.11 -> blood pressure is indicated according to guidelines,

411.35 -> and learned how to prescribe guideline-recommended

413.72 -> antihypertensive medications.

417.86 -> Thank you for watching us today.

419.43 -> I hope you found this video educational.

422.5 ->

Source: https://www.youtube.com/watch?v=23NSzQLa5Ug