Healthy Life Webinar 1. What to do about hypertension?
Monday 22 June 2020. 4pm UK time
Professor Bernard Cheung, University of Hong Kong
Hypertension is a very common disease worldwide, affecting a large proportion of the adult population. Hypertension develops early in the cardiovascular disease continuum that culminates in coronary artery disease and heart failure. The last few years saw the publication of several international hypertension guidelines. The JNC VIII in 2014 cautioned against too aggressive lowering of blood pressure in the elderly, some of whom do not tolerate drug therapy well. The AHA/ACC guideline in 2017 went the other way and defined hypertension (stage 1) as a blood pressure of 130/80 mmHg or greater. At a stroke, many more people in the general population are classified as hypertensive.
Most of these people with stage 1 hypertension are obese with only mildly elevated blood pressure and a low annual risk of cardiovascular events. The latest ISH guideline, published in May 2020, set out essential targets (for resource-poor countries) and optimal targets. Non-pharmacological treatment is suitable for the whole world, for poor countries as well as for developed countries where obesity is a huge problem. Weight control, a healthy diet (such as DASH), salt reduction, physical activity and drinking less alcohol all help to lower blood pressure. When a person can do all these successfully, blood pressure is more easily controlled and less medication is needed. These nonpharmacological measures are especially powerful if instituted in the young, before hypertension develops.
Medicines and other ways to treat high blood pressure
Professor Albert Ferro, King’s College, London.
Where lifestyle measures have not been sufficient to control hypertension, or in cases of severe hypertension, the next stage in treatment is to institute antihypertensive medication. Drugs remain the bedrock of hypertension management, although international guidelines differ in their precise recommendations as to how they should be used. In the UK, the 2019 NICE (National Institute for Health and Care Excellence) hypertension guidelines are used, and their recommendations are based on age, ethnicity and presence / absence of diabetes; and these will be reviewed in this webinar, including the NICE recommendations on which drugs to use in cases of resistant hypertension (persistently raised blood pressure despite three drugs including a diuretic). A number of device therapies are also under investigation at the moment, and they offer potential attractions, including circumventing lack of adherence (which is a particular issue in hypertension management, both with lifestyle measures and drugs) and in the case of some devices the theoretical potential for long-term effectiveness. However, these all remain experimental at present as their real-world efficacy as well as their place in clinical utility remain to be defined.
Specialist hypertension clinics have an important place in management of certain defined groups of hypertensive patients: those with young-onset hypertension (under age 40), those with resistant hypertension (as defined above), those with severe hypertension with or without target organ damage, and those with other clinical features suggesting the possibility of a secondary cause. In these patients, primary aldosteronism is a common underlying cause (approximately 15% prevalence) which should routinely be screened for, as it can be specifically treated either by surgery or medical management with aldosterone antagonism. Phaeochromocytoma is much less common, and investigation for this is only really indicated if there are other clinical features to suggest it as a possibility. Investigation for, and treatment of, renal artery stenosis is not routinely indicated or useful, except in specific clinical scenarios. These will all be reviewed in this webinar.