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I am going to talk to you now about stage I hypertension and what is an indication for beginning drug therapy, all of this presumes that you have measured the blood pressure repeatedly over several months, that you have counseled the patient about life style issues, you have made sure they are not on oral contraceptives, that they are not taking 14 ibuprofen a day, that they are doing reasonably what they can in terms of their dietary salt and alcohol intake. If the patient has a blood pressure of greater than 140/90 for more than a month, and they have something wrong with their heart, kidney or brain, or they have diabetes, they ought to be on a pill. If they have this kind of a blood pressure over this period of time and despite life style counseling, you cannot eliminate their other cardiovascular risk, they ought to be on antihypertensive medication. Other cardiovascular risks we talked about earlier, hyperlipidemia, diabetes, smoking or bad family history. Those are people with stage I hypertension 140/90 or more sustained on multiple readings who ought to be on medicine. IF the patient is officially elderly, 65 and they have sustained elevation of their systolic blood pressure over 150, that is systolic hypertension on multiple readings over at least a month time, the day to show that treating their blood pressure significantly reduces their risk and the last category is very difficult, people with stage I hypertension, they have no other risk factors, they don’t have end organ disease, they have this slightly elevated blood pressure that is slightly into the hypertensive range, it is very difficult to know what to do with those patient’s. Two things are reasonable, it is reasonable to work with them for a year on exercise, losing weight, whatever it is you choose to do and some physicians will choose to treat those patient’s. My own recommendation to you is to talk about it in a straight forward manner with the patient, and get their preferences. Some of our patient’s don’t want to take pills under any circumstances, and under the circumstance, avoidance of medication is a reasonable choice. On the other hand, people are more inclined to take medications they are worried about their blood pressure and when offered the choice, will take the pills, and those people I suggest you ought to give the medication.
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This slide deals with the issue of how low to go when you start treating somebody with high blood pressure, this is from a recent study in the Lancet which deals with that issue and the bottom line is somewhere around 135 to 140 and somewhere around 80 to 85 in terms of the diastolic. Get the blood pressure below 140 and get the diastolic somewhere between 80 and 85, that appears to be the place where risk of cardiovascular events is optimized. You will notice in these slides that reducing the systolic blood pressure to lower levels does not reduce the risk and lowering blood pressure to lower diastolic levels does not reduce the risk, whether or not the risk of a cardiovascular event goes up here, if you get the blood pressure too low is an issue we don’t have time to talk about, remember 135/85 approximately, that is your target.
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If the patient is elderly, this may or may not be possible, it may well be when the patient stands up, they are dizzy, so you may have to compromise, but 140 is a reasonable target, or slightly below for an elderly patient. The pharmaceutical industry has provided us with maybe 300 medicines for high blood pressure, maybe 300, so this is every bit as daunting for you as prescribing oral contraceptives is for me. So I am going to try to distill this into something manageable, these are the categories of antihypertensive agents. Fortunately, you don’t have to know all of that. What this slide shows is that all of the classes of antihypertensive agents, diuretics, alpha blockers, beta blockers, calcium channel blockers, and ACE inhibitors all lower blood pressure at starting doses exactly the same amount, they re all equally effective. Quality of life, impact of these drugs on how the patient perceives their life. Bottom line of this slide, all the same. Patient’s on diuretics do not feel quality of life any worse than patient’s on alpha blockers or beta blockers or calcium channel blockers, so that’s point two. Point three is, the cost, and this is a major differentiator of the classes of antihypertensives, diuretics are down here at the bottom, generic hydrochlorothiazide, $8.00 a month to the patient and if you choose to give the patient what the drug reps are trying to sell you, then you can get the patient to spend $40.00 a month instead of $100.00 a year they will be spending $500.00 or $600.00 a year for the same degree of blood pressure lowering effect and the same impact on their quality of life, and the vast majority of the data that we have about the benefit of antihypertensives is in diuretics and beta blockers. All you need to know is about diuretics and beta blockers.

If it’s your sense that the patient’s diet is very highly laden in salt, it is a reasonable thing to ask them to try to reduce their sodium intake to a reasonable level. This does not mean that you should ask the patient to eat cardboard three times a day, which is what heart failure diet tastes like, what we’re saying is no added salt, avoid things that have lots of salt in them, anything in a bag, anything in a can that doesn’t say no salt, prepared meats, salt at the table, those are things which the patient should be counseled to try to reduce if at all possible. There is some evidence that eating large quantities of foods and vegetables which are high in potassium is a way to lower blood pressure a bit, but it’s also a good thing because it’s a good cardiovascular healthy diet because it’s low in fat. Moderation of alcohol intake to no more than that which you personally drink per day is a reasonable thing to do,smoking can’t be a good thing and Matt talked about fat. That is lifestyle modification, very difficult to do, most doctor’s don’t like to do it, my own recommendation to you in our office is to have your nurse trained to do most of these things and refer your patient’s to them, or connect yourself with some sort of counseling center in which people can get cardiovascular lifestyle counseling.
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After you do that, and you decide that your patient might need medicine for high blood pressure, I am going to suggest to you that you can do this, you can do the vast majority of drug therapy of stage I hypertension and I am going to show you why you might want to do it, and how you might want to do it. First, it’s important to know that medicines work. Here is the evidence, trials of low dose diuretics, that’s 12.5 or 25 mg of hydrochlorothiazide, and beta blockers demonstrate important substantial clinically significant decreases in strokes heart attacks, heart failure and dying from one of these things, there is no doubt about the data. Interestingly enough, the biggest benefit is in old people. We used to have this misguided notion that old people with stiff vessels with tiny holes in the middle of them needed high blood pressure to get the blood to their brain, that was a really stupid idea, that was just about as dumb as it gets. What the data shows is that people who are older, have the highest risk of all these things and because in fact, they have the highest risk of them, when we lower their blood pressures even modestly, the absolute reduction in their risk is much greater than the absolute reduction in their risk in somebody who is young and has elevated blood pressure. The message here is, don’t write it off just because the patient is old. That is the patient who you absolutely want to treat. Treatment of 90 middle aged people for five years presents one major cardiovascular event, but you only have to treat 30 elderly patient’s for five years to prevent that same event and the reason is, is because of the much higher absolute rate or risk in older folks, and this gives you some sense of cost effectiveness issues, five years total outpatient cost, doctor, laboratory, medicines to prevent one major event, about $100,000 if you are using a diuretic, and if you try to use something that the drug representative is pushing on you on a daily basis, it will cost a half million dollars, implications, obvious.
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The physical examination is not complicated. The blood pressure needs to be measured reasonably, not through a sweater, not when the patient is standing, not after the patient has just been rushed into the room because you are running 30 minutes late in your office.Two or more blood pressures using an appropriate size cuff, make sure that you measure it in the opposite arm, particularly important in older patient’s who might have arteriosclerosis. If the patient has arteriosclerosis and has blockage of say their left subclavian artery, so the blood pressure in their left arm is lower than the blood pressure in the right arm, and you measure only the blood pressure in the left arm, and let’s say it’s 140/90, and you forget to measure the blood pressure in the right arm which is 160/100, you have not done a good thing because, which blood pressure is the heart exposed to. Which blood pressure is the brain exposed to, it’s the higher blood pressure, so you use the blood pressure which is the higher blood pressure. You look for evidence of neck bruits, heart failure, a big thyroid gland which is a rare cause of hypertension, is the heart bit, which is not a good thing, abdomen bruits, enlarged kidneys and are there poor pulses suggesting end organ disease. Again, the history and the exam are designed to answer three questions, primary secondary hypertension, end organ disease, and other cardiovascular risk factors. All of those questions ought to be answered by the time you finish with this list. A simple urinalysis to look for kidney disease, a serum potassium to screen for rare endocrine disease, increased aldosterone secretion but it also serves as an important baseline measurement because we are going to be giving most patient’s with stage I hypertension who need therapy diuretics, a serum sodium, glucose to look for other cardiovascular risk factors, serum creatinine to look for kidney function. Serum sodium is another baseline function because sometimes diuretics will cause hyponatremia. Cholesterol is to look for other risk factors, JNC recommends a complete blood count on all patient’s with chronic hypertension, I don’t know why. I can think of no good reason to do that.
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The 12-lead electrocardiogram is to look for left ventricular hypertrophy or on rare occasions, evidence of a myocardial infarction that was not picked up in the history, a chest x-ray is not indicated. It is a terrible test for heart disease and unless the patient has symptoms, you need not do it. So the list is relatively small, again, focused on looking for end organ disease, secondary hypertension. If you decide that the patient has sustained elevations of their blood pressure, and after the appropriate focused history, exam and laboratory tests tell you as it will the vast majority of the time, that the patient has essential or primary or, yes you have elevated blood pressure and we have to idea why, then you have to start thinking about what you’re going to do about it. Here are the things you should start to do about it in every patient, no matter what the level of their blood pressure is. Some of these things are very difficult to do, I would suggest that if you don’t do them, then you are not doing a good thing for the patient and you are certainly not meeting reasonable standard of care, so you have to at least try to do most of these things. If somebody is grossly overweight, that is a major contributor to high blood pressure and it is reasonable to either counsel them or send them to somebody who can counsel them. That almost always involves increase in physical activity which is, in the vast majority of patient’s a very good thing for all sorts of reasons in addition to their hypertension.
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Hypertension is an asymptomatic disorder. It is very much like hypercholesterolemia, the vast majority of patient’s who have stage I or II hypertension, cannot feel their blood pressure, despite what they tell you.The reason that hypertension is an important problem, is not because elevated blood pressure causes people to be sick, the reason it is an important problem is because it causes arterial and atherosclerosis. It is important for the same reason that hypercholesterolemia is an important problem. Caring for the patient with hypertension without caring for their other cardiovascular disease risk factors is not an adequate management of the patient. How do we answer those three issues? First, an appropriate history and these are the key questions; does the patient have a family history of essential hypertension; if the relatives, the mother, father, grandmother and two sisters had essential hypertension onset at age 43 and your patient has elevated blood pressure at age 45, it’s a genetic disorder, we know it is and the patient probably does have essential hypertension. Knowing how high the blood pressure is and how long the patient has had it is very important. The patient who has never had an elevated blood pressure, who walks into your office for the first time with an elevated blood pressure of 143/95 is very different than the patient who tells you, for 30 years my doctors have been telling me that my blood pressure is between 140 and 150/90 to 100, two very different patient’s who require very different types of evaluation. If the patient tells you they have been on antihypertensive medication, you name it, Atenolol, Procardia and it made them sick, that’s important information because that is not medicine you want to prescribe to the patient, they won’t take it, even though you might think it’s the right medicine. If the patient says, I was on hydrochlorothiazide and it lowered my blood pressure, no it didn’t make me sick, I just ran out of medicine that might be a pill you want to consider because it worked in that patient, so take advantage of the history. If patient’s main caloric intake is out of a cellophane bag, as many of our patient’s diets are, that might raise their blood pressure. American diets are highly laid in salt and some portion of patient’s with chronic hypertension have salt sensitive hypertension, maybe 30%.
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The problem is, you can’t tell which patient’s have salt sensitive hypertension. So understanding the patient’s diet is important in guiding them about life style modification, reasonable life style modifications. More than four drinks of alcohol per day activates sympathetic nervous system and can cause sustained elevations in blood pressure. Really, the only symptom suggestive of secondary hypertension are pheochromocytoma, we talked about that. Vast majority of other diseases don’t cause symptoms with the exception of rare endocrinopathies which I am not going to address. Stress is an important epidemiologic feature of chronic hypertension, my own personal bias as a primary care physician, it is important for us to understand the context of our patient’s lives. If somebody is working two jobs and they have lots of stress at home, and on the job and they have elevated blood pressure, those things may well be linked. It may not be that you can fix their psychosocial or economic issues, but understanding them, I think, helps us care for the patient. If the patient is on oral contraceptives, large doses of nonsteroidal anti-inflammatory agents or appetite suppressants, those things might raise their blood pressure. Oral nasal decongestants for upper respiratory infection do not elevate blood pressure.

I would also caution you about this circumstance being particularly common in hospitalized patient’s. Just because somebody is in the hospital to have a GYN procedure, very often patient’s will have mild elevations in their blood pressure, please don’t jump to the conclusion that they have sustained elevations in their pressure if they have not had multiple recorded pressures that are elevated.
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Once you have decided that the patient does indeed have multiple readings over 140 or over 90 and that the do have confirmed hypertension, you have through history and physical and a very small set of laboratories, you need to answer three question; does the patient have primary, essential or doctor not smart enough to understand why hypertension, which will be every case in your entire career, save a few, or does the patient have some sort of secondary cause of hypertension, or what internists like to talk about, things like pheochromocytoma, there are a few important things you need to understand for secondary causes. Oral contraceptives are an important cause of secondary hypertension as is large amounts of alcohol intake and less frequently underlying renal disease. I am not going to ask you to think about any weird endocrinopathies, you don’t need to think about those disorders because you will never really see them. If patient’s have symptoms that you think are compatible with a pheochromocytoma , wild fluctuations in their blood pressure, severe unrelenting headaches, unexpected bouts of palpitations and anxiety, that is a patient you might want to refer for workup. It will be a very rare circumstance. The second question you need to answer with a targeted history, exam and laboratory is, does the patient have target organ disease, have they had a stroke, do they have coronary artery disease, or heart failure, or do they have renal insufficiency, easy to answer, and finally there are other cardiovascular disease factors present.

High blood pressure has now been reclassified, no longer do we talk about mild and moderate and severe, we call it stage I, stage II, and stage III, the reason for that is that the vast majority of people with high blood pressure are in this area and on a population level, the vast majority of strokes and myocardial and kidney disease from hypertension is in people who have this stage of disease so the JNC was loathed to call this mild because it causes a lot of disease simply because the incidence of this kind of problem is very high, so although the risk for an individual patient may not be in stage I as high as it is in stage III on a population basis, you should not think of this as mind and therefore not important. It is a very important problem.
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Stage I is 140/90 or above, and that’s really all you need to remember on the slide, that is what hypertension is, 140/90 above, but measured on multiple occasions. Many patient’s who see a physician for the first time have high sympathetic nervous system and have tachycardia, they are sweating and their blood pressure is up a little bit and it is inappropriate for you to label them as having chronic hypertension simply because they are nervous, so the JNC cautions us to confirm elevated blood pressures on at least two visits over a few weeks. I would agree with you that if somebody has a blood pressure of 250/130, and they are having chest pain and are short of breath, and they are in pulmonary edema, that person probably has severe cardiovascular disease, but none of us are going to see that kind of a patient so we really don’t need to worry about that clinical circumstance. The vast majority of the issues we are going to deal with in primary care, are people who have a blood pressure of 148/93 in the office for the first visit, again, nonpregnant patient’s we are talking about here, confirm over the next few weeks to ensure that they do have sustained hypertension and these are just guides and for the most of these patient’s, stage I hypertension, just see the patient again within a couple of months. What I often do is have the patient come back and see the nurse a couple of times and then I will see them a second or third time in one or two months and by that time you will have multiple measurements over several months and then at that point you can make the decision whether or not the patient has sustained elevations in their blood pressure.
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