New Recommendations for Managing Hypertension

Dr. William White with a participant in a trial that studies out-of-office blood pressure as a predictor of cognitive and functional decline. (Chris DeFrancesco/UConn Health Photo)
Dr. William White, chief of the Division of Hypertension and Clinical Pharmacology at UConn Health and a nationally recognized expert, discusses the latest information on treatment goals for high blood pressure. (Chris DeFrancesco/UConn Health Photo)

SHARELINES

Dr. William B. White of the Pat and Jim Calhoun Cardiology Center at UConn Health specializes in clinical pharmacology, hypertension, and vascular diseases.
Dr. William B. White of the Pat and Jim Calhoun Cardiology Center at UConn Health specializes in clinical pharmacology, hypertension, and vascular diseases.

This Heart Month, Dr. William B. White, professor and chief of the Division of Hypertension and Clinical Pharmacology at the Pat and Jim Calhoun Cardiology Center at UConn Health and the immediate past president of the American Society of Hypertension, shares the latest information on high blood pressure.

Hypertension, or high blood pressure, is the leading attributable cause of death in the world – why? First, it is very common in adults, and when untreated, hypertension is associated with several untoward outcomes, including heart attack, heart failure, and stroke – all of these cardiovascular events may lead to death, particularly heart failure.

The goals of therapy for hypertension have been very controversial, until 2015. Based on the results of a remarkable study called the Systolic Blood Pressure Intervention Trial (SPRINT), it is likely that the new treatment goal for adults over 50 years of age will be reduced to a blood pressure level of about 125-130/80 mmHg, when measured in the medical care environment (by a doctor or nurse). SPRINT showed a 25 percent reduction in major cardiac outcomes and death when patients were treated more aggressively than previously, to a level of about 120/80 mmHg.

The debate over the past several years regarding treatment goals for middle-aged people may have diverted attention from the bigger picture. Despite decades of efforts and regardless of the goals, hypertension is still under-treated worldwide, including in the United States. Recent studies have shown that nearly 30 million adults in the U.S. between the ages of 60 and 79 have systolic blood pressures (the top number) that are higher than 150 mmHg. People with these blood pressure levels are clearly at increased risk for complications. Specialists in the field like myself and my colleagues at UConn Health hope that the SPRINT results will stimulate renewed efforts to achieve more intensive blood pressure control.

What is the most appropriate therapy for hypertension?

There are many choices of medication therapy for hypertension – management guidelines from the U.S. and Canada recommend either an angiotensin-converting enzyme (ACE) inhibitor, an angiotensin receptor blocker (ARB), or a calcium channel blocker (CCB) as first-line therapies. Virtually all guidelines, with the exception of those from the United Kingdom, also recommend a diuretic, often referred to as water pills, as a potential initial therapy. Due to concerns of metabolic disturbances associated with thiazide diuretics (particularly elevated blood glucose), some groups believe that in the absence of heart failure diuretics be used as second-line therapy for black patients and third line in other ethnic groups. However, an older diuretic – chlorthalidone – was a fundamental part of therapy in the SPRINT study, so it is likely that the long-acting diuretics will remain as first-line therapy in most, if not all, future guidelines.

UConn Health is unique in having the only hypertension specialty group in Connecticut since the early 1980s. Our team also includes Dr. Meryem Tuncel-Kara, an expert in hypertension and kidney diseases; and Dr. Beatriz Tendler who specializes in hypertension and endocrine disorders. In our practice, patients receive expert evaluations for underlying causes of hypertension using technologies such as ambulatory blood pressure monitoring, ultrasound with Doppler to evaluate heart and kidney issues, and specialized laboratory testing for endocrine causes of hypertension.