HYPERTENSION, THE SILENT KILLER

This article was written in collaboration with Dr. Suzanne Oparil, M.D. Distinguished Professor of Medicine. Professor of Cell, Developmental and Integrative Biology. Director, Vascular Biology and Hypertension Program. Section Chief of Vascular Biology and Hypertension, at the University of Alabama at Birmingham.

HYPERTENSION, THE SILENT KILLER  

Hypertension is a pervasive problem and affects nearly 50% of the US population including over 90 million adults with uncontrolled hypertension and an estimated 34 million untreated. For an adult 40 years of age without high blood pressure, the lifetime risk of developing hypertension is 93% for African Americans, 92% for Hispanics, 86% for whites, and 84% for Chinese adults. The American College of Cardiology and the American Heart Association has stressed the importance of accurate measurements of blood pressure (BP) using validated devices and multiple readings for the management of hypertension. To measure the BP you can use a BP cuff wrapped around the upper arm and inflated to stop the blood flow of blood in the artery. The first number, called systolic BP, measures the pressure of blood against the arteries during heartbeats. The second number, called diastolic BP, measures the pressure when the heart rests between heartbeats. An average of >2 BP readings on >2 occasions confirmed with out-of-office measurements is usually needed to confirm a diagnosis of hypertension. 

According to the new ACC/AHA Guidelines:

Categories:           systolic BP (mmHg)     and/or     diastolic BP (mmHg)

Normal                  <120                             and         <80

Elevated                120-129                        and         <80

Hypertension

Stage 1:                 130-139                        or            80-89

Stage 2:                  >140                            or             >90

Why is hypertension called the silent killer?

Hypertension or high blood pressure usually has no warning signs or symptoms. Many people don’t know they have it. Measuring BP is the only way to know if hypertension is present or not. With time, high BP can damage the arteries everywhere in the body and can decrease the blood flow to vital organs such as the heart, causing a heart attack and leading to heart failure, the brain, causing a stroke or dementia, the kidneys, causing chronic kidney disease (CKD) and lead to renal failure. Because of the increased pressure in the heart, can increase the risk of atrial fibrillation and stroke. In 2018, 500,000 deaths in the US were attributed to hypertension as the primary problem. Worldwide, since 1990 hypertension-related death has increased by 50% to over 10 million and disability-adjusted life years have increased by 45% and are likely to continue to increase in the future.

Can we lower BP without medications?

In many patients, high BP is related to an unhealthy diet and a lack of physical activity. A healthy lifestyle is a cornerstone for the prevention and treatment of hypertension. The rule of 5 incorporates several elements in the diet and activity that can reduce blood pressure:

1. Decrease the weight by 10 lbs can reduce the BP by 5 mmHg ( 1 mmHg for every 2 lbs lost)
2. Decrease the Sodium intake by 1,000 mg or to <1,500 mg/day can lower BP by 5 mmHg
3. Increasing the Potassium intake by 5 mg/day can lower BP by 5 mmHg
4. 150 minutes of moderate exercise per week can lower BP by 5 mmHg
5. Reduce alcohol intake to <2 glasses/day (<1 glass for women) can lower BP by 5 mmHg

When do we consider medications for hypertension?

In addition to a healthy lifestyle, anti-hypertensive medications are used when the BP is >140/90 or stage 2 hypertension and when the patient is at increased risk of Atherosclerotic Cardiovascular disease (ASCVD >10%) with stage 1 hypertension. Patients are considered at very high risk if they have coronary artery disease already (MI, CAD treated with stents or CABG), Diabetes mellitus and end-organ damage, CKD stage 4, and ASCVD risk of >10%. Patients are considered at high risk if they have familial hypercholesterolemia (LDL > 190), DM, LVH on echocardiogram, and CKD stage 3.

What medications are recommended for hypertension?

Four different drug classes are recommended for the treatment of hypertension. 1) diuretics, particularly the long-acting Chlorthalidone. 2) Calcium channel blockers such as Amlodipine, Nifedipine, Diltiazem, or Verapamil. 3) Angiotensin-converting enzyme (ACE) inhibitors such as Lisinopril, Enalapril, Fosinopril, Enalapril, Captopril, and Benazepril…) 4) Angiotensin receptor blockers (ARBs) such as Olmesartan, Telmisartan, Valsartan, Losartan…

For more severe hypertension (>140/90) and for Black patients, a combination therapy such as a thiazide-Calcium antagonist is usually recommended. In addition, Black patients have more angioedema with ace inhibitors, and ARBs are usually preferred. Asian patients have more ACE-cough-related symptoms and ARBs are also preferred. The consideration of using 1 pill combining 2-3 medications helps with adherence to medical treatment and control of hypertension. 

Beta-blockers are considered in patients with CAD and heart failure. They are as efficacious in preventing cardiovascular events with the exception of stroke. Beta-blockers are also preferred in women during pregnancy. 

Beware of alternative medicine on social media for the treatment of hypertension!

A large number of Health alternatives videos have been promoted on Tiktok for the treatment of hypertension with no scientific data, advertising products for sale in 14% of cases and providing advice by non-health professionals almost 50% of the time. Some of the alternative medicines promoted were herbal supplements, acupuncture, and massage techniques that have not been shown to impact cardiovascular outcomes in recent studies. One such video instructed patients to rub behind their ears, 36 times per day, to control their BP! Our patients often discontinue their medicines due to incorrect information on social media.

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