#254 Hypertension Update with Dr. Wanpen Vongpatanasin

February 1, 2021 | By Deb Gorth

No More Pressure when Managing High Blood Pressure

Listen as our esteemed guest Dr. Wanpen Vongpatanasin, @DrWanpen (UT Southwestern) discusses the nitty-gritty of blood pressure monitoring and hypertension treatment.  We review the thresholds for HTN diagnosis and how to accurately measure blood pressure levels at home and in the office.  Dr Vongpatanasin shares the latest guideline recommendations for first line pharmaceutical therapies as well as her pearls about how to treat special populations.

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Credits

• Produced by: Deborah Gorth and Isabel Valdez, PA
• Written by: Deborah Gorth 
• Infographic and Cover Art: Edison Jyang
• Hosts: Stuart Brigham, MD; Matthew Watto, MD, FACP; Paul Williams, MD, FACP   
• Editor: Molly Heublein, MD (written materials); Clair Morgan of nodderly.com
• Guest: Wanpen Vongpatanasin, MD

Sponsor: ACP’s MKSAP18

MKSAP® is the most trusted resource for lifelong learning and Board prep for internal medicine physicians and residents. Learn more at www.acponline.org/curb2021.

Sponsor: Provider Solutions and Development

Provider Solutions & Development is a community of experts dedicated to offering guidance and career coaching to physicians and clinicians throughout their entire career journey. With exclusive access to hundreds of opportunities across the nation, reach out today to begin the search for your perfect practice: www.psdrecruit.org/curbsiders.

Sponsor: VCU Health CE

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.

Time Stamps

00:00 Sponsors, Intro, disclaimer, guest bio

03:20 Guest one-liner

05:50 Sponsor – ACP’s MKSAP 18

07:05 Case from Kashlak; Defining hypertension and treatment thresholds

10:43 Measuring blood pressure (at home, in the office, validatebp.org)

16:46 Wrist BP cuff

19:50 Home monitoring and ambulatory BP monitoring; What time to take BP medication

31:23 Sponsor – Provider Solutions and Development

32:10 Approach to treatment; Combo pills; How to titrate meds

42:20 Treating resistant hypertension; hyperaldosteronism; Isolated systolic hypertension

52:04 Take home points and Outro

Hypertension Pearls

1. Hypertension is the presence of sustained elevated blood pressure, defined by the 2017 ACC/AHA Guidelines as systolic blood pressure (BP) ≥ 130mm Hg and/or a diastolic BP ≥ 80 mm Hg.
2. Even high normal or pre-hypertension patients have a higher risk of morbidity/mortality, and people who achieve blood pressure control in the lower range have better cardiovascular outcomes. 
3. Both masked and white coat hypertension are associated with an increased risk of cardiac events and target organ damage as compared to normotensive individuals, though not as high as patients with sustained hypertension.
4. Not all automated blood pressure machines are created equal. Check for their accuracy at validateBP.org. 
5. Wrist blood pressure cuffs do not provide reliable comparisons to upper arm (brachial) cuffs.
6. For first line treatment of hypertension, consider starting a combination pill of two medications at low dose (ACE-i/ARB+CCB).
7. Consider work up of primary hyperaldosteronism if the patient has resistant hypertension even if the patient doesn’t have hypokalemia.

Hypertension Updates Show Notes:

Hypertension Defined

Hypertension is the presence of sustained elevated blood pressure, recently defined by the 2017 ACC/AHA Guidelines as systolic blood pressure (BP) ≥ 130mm Hg and/or a diastolic BP ≥ 80 mm Hg.  These numbers are lower than the ACP/AAFP guidelines, the  JNC 7 Report, and the International Society of Hypertension, which all consider hypertension a blood pressure pressure ≥ 140/90.

High normal or pre-hypertension patients have worse outcomes, and those who achieve blood pressure control in the lower range have better cardiovascular outcomes (Lewingston et al 2002, SPRINT,  Bundy et al 2017). 

White coat hypertension is elevated blood pressure in the clinician’s office but normal blood pressure at home.  Masked hypertension is elevated blood pressure at home but normal blood pressure in the clinic.  While they do not carry the same risk as sustained hypertension,  masked hypertension and white coat hypertension are associated with an increased risk of cardiac events and target organ damage as compared to normotensive individuals (Tientcheu et al 2016).

Measuring Blood Pressure

It is important to consider best practices to measure an accurate blood pressure, and a single elevated or normal reading does not rule in or rule out hypertension (2017 ACC/AHA Guidelines; Table 8).  In Dr. Vongpatanasin’s office, they measure seated BP 3 times after five minutes of rest and average the values plus check a standing blood pressure.  These blood pressures are measured using an automated machine, which is preferred over manual blood pressure readings.  Manual blood pressure cuffs need to be calibrated,  and the human interpretation of manual readings can introduce more error (Myers et al 2011).  However, not all automated machines are created equal, and more expensive does not mean better.  The fidelity of an automated machine can be checked at validateBP.org. 

Home Monitoring

Automated blood pressure machines make at home patient monitoring easier via intermittent self measurements or a 24 hour ambulatory BP monitor (which automatically checks a patient’s BP every 15-30 minutes over a 24 hour period).  Home blood pressure measurements are more closely related to left ventricular mass than in-clinic measurements (Schwartz et al 2020 and Rader et al 2019). There now are CPT codes for interpretation of out of office BP readings (99473 and 99474 Berg 2019).  When interpreting home measurements for medication titration, be aware home BP readings are lower than office readings (2017 ACC/AHA Guidelines; Table 11).  Another advantage of ambulatory 24 hour blood pressure monitoring is that nighttime readings are more accessible, and nocturnal BP readings have stronger prediction of cardiovascular events (Kario et al 2020).  Accurate at home readings are likely to become increasingly more important with the continued prevalence of telemedicine.   Dr Vongpatanasin finds it helpful to perform 24 hour ambulatory bp monitoring on patients with autonomic dysfunction and primarily supine hypertension to get a better sense of their overall risk (Lodhi et al 2019). 

Wrist Cuffs

Wrist and upper arm blood pressures are different; using intra-arterial sequential measurement in the same individual radial systolic BP is 5.5 mm Hg higher than brachial systolic BP with >20% of individuals having a difference of >10 mm Hg (Armstrong et al 2019). There is currently no validation procedure to translate radial blood pressure to brachial blood pressure, and at home measurement using wrist BP cuff can be unreliable (Casiglia et al 2016).

Treatment

Choosing a Target

The first step of treating hypertension is choosing a blood pressure target. For most patients, including high cardiovascular risk patients, that target should < 130/80 (2017 ACC/AHA Guidelines). Although the SPRINT trial suggested that a target SPB < 120 mmHg is better than < 140 mmHg in reducing cardiovascular events in hypertensive patients (SPRINT), careful BP measurement minimized the potential white coat or alerting reaction. A recent analysis showed that SBP was 7 mmHg higher in the SPRINT participants randomized to the intensive arm, when BP was measured in the real world office setting outside of the research context (Drawz et al 2020). In other words, BP measured in the research setting of 120 mmHg is correlated with BP of 127 mmHg when measured in the real world, which makes the target systolic BP goal of <130 mmHg proposed by the 2107 ACC/AHA guideline a very reasonable goal that is supported by SPRINT. However,  coexisting orthostatic hypotension should be considered (the SPRINT trial excluded patients with a standing systolic BP ≤ 110). In geriatric patients, the best target blood pressure may be more relaxed when balancing lifetime risk and polypharmacy concerns (Aronow 2020, Agarwala 2020).

Pharmaceuticals

After lifestyle modification, the first line pharmacological therapies for hypertension are Angiotensin Converting Enzyme Inhibitors/Angiotensin Receptor Blockers (ACEi/ARBs), Thiazide Diuretics, and Calcium Channel Blockers (CCBs) (2017 ACC/AHA Guidelines). The ISH Hypertension Practice Guidelines suggest starting with low dose combination therapy (ACEi/ARB + CCB). Dr. Vongpatanasin notes that starting with ACEi/ARB + diuretics are also very reasonable in some patients. There is evidence of stronger benefit from using half dose of two medications rather than full dose on one medication, with lower side effects.  Full dose (ie 50mg of hydrochlorothiazide) tends to have more side effects with less significant benefit (Bennett 2017, Jaffe 2013).  

Special Circumstances

Although the first priority is ensuring that the patient can consistently take their medication, patients with nocturnal hypertension or reverse dipping may benefit from nighttime dosing.

For patients with autonomic failure and supine hypertension, Dr Vongpatanasin suggests using a shorter acting medication at night time.

Dr Vongpatanasin suggests an alpha blocker would be a 4th line option in a patient with bradycardia.  In a patient with tachycardia, using a beta blocker or a combo beta-alpha blocker like carvedilol could be a good choice.

In patients with isolated systolic hypertension and a low diastolic BP  (wide pulse pressure), Dr. Vongpatanasin tries to avoid beta blockers, because slowing HR will increase stroke volume exacerbating the high pulse pressure. In the SPRINT trial those with DBP < 65 mmHg also benefited from lowering systolic pressure suggesting that there is not a large detriment to low diastolic – (Beddhu et al 2018). 

Hyperaldosteronism

Consider hyperaldosteronism in patients who have treatment resistant hypertension (patients uncontrolled on three standard HTN medications) even if they do not have hypokalemia (Rossi et al 2006).  To screen for hyperaldosteronism test plasma aldosterone and renin concentration, if renin is suppressed even on multiple HTN medications this is consistent with hyperaldosteronism (Wolley and Stowasser 2017).  If blood pressure control cannot be managed with the above first line medications, mineralocorticoid receptor antagonists like spironolactone should be used.  Beware of the anti-androgenic effect of spironolactone in men; this is less of an issue in women. Eplerenone has lower anti-androgenic side effects, and so Dr Vongpatanasin suggests using this in younger men, though it requires higher mg to mg dose and BID dosing.

Links*

1. Parasite the movie
2. Mr. Theo Z. Hyde’s recipe for cauliflower rice.

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on our Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

Goal

Listeners will learn the nuances of hypertension outpatient measurement and management. 

Learning objectives

After listening to this episode listeners will…

1. Define hypertension
2. Identify why we treat high blood pressure
3. Characterize masked HTN and white coat HTN
4. Discuss the nuances of measuring blood pressure and when to use home monitoring or 24 hour ambulatory monitoring. 
5. Define clear blood pressure targets for a given patient
6. Develop an approach to treating hypertension in the outpatient setting
7. Anticipate the negative side effects of antihypertensives
8. Identify a strategy for escalating blood pressure medications
9. Recognize the when to treat hypertension in the hospital

Disclosures

Dr Wanpen Vongpatanasin reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Gorth DJ, Valdez I, Vongpatanasin W., Williams PN, Brigham SK, Watto MF. “#253 Hypertension Update with Dr. Wanpen Vongpatanasin”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date February 1, 2021.