5MinuteConsult Journal Club
Treating “Mild-Moderate” Hypertension
Hypertension. 2021;77:00–00; https://www.ahajournals.org/doi/pdf/10.1161/HYP.0000000000000196
The American Heart Association has published a Position Statement on the initial management of “mild-moderate” hypertension and hyperlipidemia. It supports “lifestyle only” as the initial treatment. On the plus side, they give a detailed discussion of what lifestyle changes should be encouraged, and their anticipated benefits. What they are somewhat vague about are the “mild-moderate” levels.
The AHA’s 2017 guidelines dropped the silliness of “prehypertension,” but added, in its place, “elevated blood pressure” for systolic blood pressure (SBP)=120 to 129 mmHg with diastolic blood pressure (DBP) <80 mmHg, and reduced the threshold for diagnosing stage I hypertension to SBP=130 to 139 mmHg or DBP=80 to 89 mmHg. The paper implies these two categories AND an ASCVD score </= 10 should be treated with lifestyle interventions.
What are the recommended changes? Nothing new: 50-300 minutes/week of moderate intensity exercise or 75=150 minutes/week of vigorous intensity exercise WITH resistance exercise >/= 2 times per week. Added to the list is weight loss, and dietary changes: high levels of fruits and vegetables, whole grains, low fat dairy, seafood, nuts/legumes, and reduced red/processed meats, refined grains, and sugar sweetened foods/drinks.
My initial response to this was “no kidding!”; we know just using a pill does not lower an individual’s risk very much; changing their lifestyle is the key to living longer and better. Yet, I have tempered my snark. This is a national organization that has finally said “don’t give a pill first.”
The “pill” to treat early hypertension, hyperlipidemia and prevent type 2 diabetes is a change in behavior. Hard to do, but if we try, our NNT at improving outcomes is as low as 4. This beats the 100+ for using meds for moderate hypertension. If I feel I need to write an Rx, I would hope we can soon use an SGLT2 inhibitor or GLP1 agonist. These agents promote weight loss, improve lipids and CV risk, AND with a 5% weight loss, lower blood pressure. Thanks, AHA for joining the right side of healthcare.
For mild to moderate blood pressure, the initial treatment is increasing activity, and changing diet.
More from 5MinuteConsult
Contributed by Frank J. Domino, MD, June 30, 2021