4 August 2020
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Take the (blood) pressure down

Dr Ross Walker
30 October 2019

Over the past 50 years, there has been an enormous emphasis on cholesterol as a major risk factor for heart disease. Although I am not suggesting that cholesterol is unimportant, the reality is that hypertension or high blood pressure, is the most important cardiovascular risk factor.

In people over the age of 60, hypertension is more the norm than the exception and many people are taking antihypertensive medications. Unfortunately, it has been estimated that up to 50% of people with hypertension don’t even know their blood pressure is high and 50% of people who are aware they have high blood pressure still don’t have adequate blood pressure control.

In a study published a few years ago known as the SPRINT trial, 9,000 people with hypertension were followed for three years. Half were targeted to 140/90 whilst the other half were targeted to 120/80. It is important to understand that the blood pressure readings obtained in this trial were taken with a person sitting quietly in a room by themselves for five minutes, measuring their own blood pressure on an automated machine. This was not the typical doctor’s office hypertension where most blood pressure levels are obtained. The participants in the trial whose blood pressure was 120/80 had a 30% reduction in heart attack, stroke, sudden cardiac death and heart failure compared with those who could only achieve blood pressure readings of 140/90.

When you think of treatment of blood pressure, however, you immediately think of medications. Tragically, homo sapiens are a sorry lot and there is no doubt that if more effort was put into the non-pharmacologic aspects of blood pressure management, people would be a lot better off. But, people continue to swallow a variety of antihypertensives and not put much effort into their lifestyle changes. If anyone with hypertension could lose anywhere between 5-40 kg, depending on their starting weight, their blood pressure levels would plummet.

There are 5 keys to the nonpharmacologic management of hypertension

1. Weight loss

2. 3-5 hours per week of moderate exercise

3. Avoid sugar and salt

4. Keep your alcohol intake to below 3 standard drinks per day

5. Manage stress as well as any human being can possibly do in this rather stressful modern world

Two recent studies regarding pharmacologic management of hypertension have just been released. The first published in the LANCET reviewed just under 5 million people in 4 different countries who were initiated on blood pressure treatment. In just under 50% of cases, the most commonly prescribed first line treatment were ACE inhibitors, which includes drugs such as Coversyl and Tritace and the variety of generics available around these. Only 17% of cases were commenced on diuretics. But, when the data was analysed, there was a 15% reduction in heart attack, heart failure and stroke in the people commenced on diuretics compared with ACE inhibitors. Interestingly, the ACE inhibitors also appeared to cause a much more significant rate of side effects. Interestingly, the calcium channel blockers were the least effective of all of the major groups of diuretics. The calcium channel blockers include drugs such as amlodipine, verapamil and diltiazem.

The next trial from the European Heart Journal looked at the timing of blood pressure therapy. The trial followed just over 19,000 adults in Spain in both men & women, average age 60, and with a follow up of 6 years. Each person had a yearly 24 hour BP monitor. The study demonstrated around a 45% reduction in death from all cardiovascular events including heart attack, stroke and cardiac failure in those patients who were given the blood pressure pills at night as opposed to those who took their blood pressure pills in the morning.

When analysing this trial, it was important to understand that the average length of blood pressure treatment was around 8 years and the initial blood pressure control was in the relatively adequate range with 50% not dropping their blood pressure during sleep. This to me is a key risk factor for hypertension. If your blood pressure does not drop whilst asleep, this is a marker of very established hypertension, which requires at least nocturnal blood pressure treatment and possibly even twice daily treatment to cover stressors during the day and also the lack of blood pressure dropping at night. The key message here is that managing blood pressure in all people is vital and frankly as a cardiologist, I don’t care what treatment works, including non-pharmacologic or pharmacologic, as long as you’re achieving blood pressure levels that keep you around 120/80 for most of the time and it is demonstrated that your blood pressure drops at night, as seen on a 24 hour blood pressure monitor.

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