welcome to another MedCram lecture we're going to talk about hypertension
guidelines and specifically the new guidelines that just came out in
November of 2017 in comparison to the JNC seven guidelines that are now 14
years old they came out in 2003 so let's get started so the first thing that I
want to do is I want to give you a sense about what's happened between these two
periods of time and to do that I'm gonna split the screen into two areas and on
the Left we're gonna have JNC 7 and now we're gonna have the 2017 guidelines
here on the right I want to kind of break this up into the systolic blood
pressure just for clarity so here at the bottom we're going to have 120 and then
as we move up we'll have 130 and then even as high as 160 now I'll add the
diastolic numbers in a moment but I think the guidelines are easier to
remember initially with just the systolic numbers in JNC 7 they said
that anybody less than 120 was going to be okay in terms of a systolic blood
pressure and that was considered to be normal
when they hit 120 all the way up to 140 that was considered to be what they
called it was kind of a weird term but they called it pre hypertension and this
was supposed to be a yellow light kind of like a traffic light that occurred
here at 140 and this was supposed to give pause to people who had blood
pressures between 120 and 140 and then they went out full and said okay you
have hypertension Stage one if you're between 140 systolic
and 160 systolic so this was definitely red light area here and that was known
as stage one and then things got really bad
up here if you're above 160 and that they called stage 2 so the thing about
JNC 7 was that you had this normal range which is where they knew you have
to be to make sure that you didn't have an increased probability of having
morbidity from hypertension like stroke or coronary artery disease and then
there was this kind of gray zone where it was pre hypertension and they
recommended the kind of diet lifestyle changes and things to try to get that
down because they knew there was an increased risk but they really didn't
call hypertension hypertension until you hit this magic number of 140 and I'll
put here in small 140 over 90 because that was a key area so what's with the
new guidelines well the new guidelines also agree and they've kept it this way
that less than 120 is normal no question about it however for the first time
they've gotten rid of pre hypertension instead of pre hypertension they still
have this yellow zone here but they're calling it elevated so between 120 and
130 now whereas before that was pre hypertension they're now calling it
elevated blood pressure now between 130 and 140 they're now saying you have high
blood pressure and they're calling that stage one basically anything above that
is stage two so you can see very clearly here that they've condensed the strata
and made them lower which means that for any given blood pressure you're going to
see that people are going to be ruling in for hypertensive disease still 120 is
the cutoff but you can see for people for instance in this range this 130 to
140 whereas before they had pre hypertension now they're gonna be having
hypertension so this is the new standard here it's the 130 and I'll put here in
small in terms of diastolic this is really 130 over 80
so anything more than 130 over 80 so the 140 over 90 is out the new blood
pressure is the 130 over 80 however however this range between 140 and 130
they're not recommending medications or pharmacology here right off the bat what
they're recommending it for is a subsection of these people who are
between 130 and 140 and who are they recommending it for the recommending it
for people who already have coronary artery disease and if you think about it
these people with coronary artery disease should already be
on medications anyway but then the other people are those with at least a 10%
risk of coronary artery disease that they don't already have it
so what they're trying to do here is they're trying to institute medications
earlier in select people and the other thing that they're really trying to do
is they're trying to take these people who were pre hypertension before and it
had a connotation that you're not quite there yet and they're telling them no
you're elevated you have elevated blood pressure and we're hoping here that
you're going to start thinking about diet and lifestyle which is really where
they're trying to push this is instituting diet and lifestyle early so
they have some interesting things to say about that because some studies have
come out since 2003 about that particular thing they had some
recommendations as well and actually they came with the actual reduction in
blood pressure that could be associated with each of these reductions so they
said that there was about a 4 to 5 millimeter of mercury and that may sound
small but you have to remember that at any particular drug is anywhere from 7
to 10 so this is not that weak in terms of its effect but if you wanted a 4 to 5
millimeter reduction in blood pressure got to do a low sodium diet increase
dietary intake of potassium exercise and limit alcohol intake for a man less than
2 and for a woman less than or equal to one drink but at the same time what they
found was that if you wanted to have an 11 millimeter of mercury drop decrease
sodium intake decreased saturated fats increased fruits and vegetables and
increase grains they had the same recommendations that they've had in the
past regarding the four different categories of medications the ACE ARB
the beta blocker the calcium channel blocker and the diuretics they said that
all of these are first-line agents to use except the beta blocker so not a
first-line agent of course beta-blockers would be great
if the patient has concomitant coronary artery disease again as they've said in
the past that you should not use ace and AR bees together but that wouldn't be
good to watch out for them if there is increased potassium because all of these
increase potassium so you want to be careful of that they also said that in
african-americans you want to use the calcium channel blocker or the diuretics
they seem to work better in african-americans and this is what
they've said in the past in terms of diuretics even though a lot of people
use hydrochlorothiazide the actual studies have been with chlorthalidone
it's once daily there is some evidence that it actually is more efficacious and
again the recommending chlorthalidone unless of course the GFR is less than 30
in which case thiazide diuretics don't work very well when the GFR is thirty
then you switch to lasix and lasix is also a good option for patients with low
ejection fraction from heart failure preoperative issues they've talked about
before you don't really want to stop a beta blocker if a patient's going into
an operation so the recommendations haven't changed much in terms of the
medications that are taken and if you want more information on all of those
types of medications and more make sure you watch our video on hypertension but
what's really changed is the classification and this will result in
about 46 to 47 percent of adults in the United States as having hypertension
which means that they would have a blood pressure that is elevated or greater
than 120 and that's pretty significant portion of people in the United States
to be deemed as having elevated blood pressure but again this is under the
guise of getting on things more early and treating that there are explanations
out there for these new guidelines and I encourage you to look those up thanks
for joining us