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5MinuteConsult Journal Club 

Treating “Mild-Moderate” Hypertension

Reference


Hypertension. 2021;77:00–00; https://www.ahajournals.org/doi/pdf/10.1161/HYP.0000000000000196

Study Summary


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.

Conclusions


For mild to moderate blood pressure, the initial treatment is increasing activity, and changing diet. 

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Contributed by Frank J. Domino, MD, June 30, 2021
 
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