All right.
Now, we’re going to discuss hypertension,
which is one of the most common diagnosis in my practice.
And unfortunately,
across the United States,
hypertension is getting more common as our population ages and also gets heavier.
So, it’s really important to understand hypertension,
its diagnosis and management.
And that’s exactly what we’re about to do.
So, let’s start with a case.
I’ve got a 51-year-old female,
no past medical history and taking no medications.
Good for you.
But her blood pressure today is 146/90 and her pulse is 86 bpm.
The rest of her physical examination is unremarkable.
So, what's the next best step in her care?
Should we talk about lifestyle changes and recheck her blood pressure in one to two weeks?
Or we should start her on a thiazide diuretic?
Start an ACE inhibitor or angiotensin receptor blocker?
Or is her blood pressure actually within normal limits,
and therefore,
we can just see her next year for another wellness examination?
What would you choose?
Now, the answer is A.
And it's pretty clearly A in this case
because remember that the diagnosis of hypertension requires
a blood pressure reading of 140/90 mm or more on at least two separate occasions.
Now, the number may be a little bit controversial.
You'll see different recommendations from different groups,
but 140/90 is generally the consensus now,
and it’s certainly the consensus
broadly that it has to be measured on at least two occasions.
So, it's best if the patient can do some testing at home.
Home blood pressure is more correlated than office blood pressure
with cardiovascular events like stroke and myocardial infarction
and if they can vary the time, morning and night, on both arms.
In terms of practicality and can a lot of patients do that?
Some can, some cannot.
You want to see a blood pressure
that's high in both your office setting and the home setting. That’s validating.
And one thing we can do as physicians is there is some value in doing both sitting and standing
blood pressure in both arms in the office.
And that gives a slightly truer reading,
and therefore, a higher accuracy for their future risk of cardiovascular events.
So, remember that among patients who are older than 60 years,
and this is a controversial idea,
but it's part of what the Joint National Commission 8
recommended for blood pressure
that their blood pressure can be allowed to increase up to 149 mmHg safely.
Certainly, we see older adults getting in trouble
with too aggressive a treatment of blood pressure.
And particularly, in my practice, patients over 80 years old,
those who might be a little bit more frail,
who may be 61 years old, but they may be 41 years old, if they’re very frail,
I get nervous about trying to push their blood pressure towards those normal
120 systolic levels and they may be allowed to go up a little bit.
That said,
I've got 85-year-olds who are very vital and active.
And for them, I maintain that blood pressure target of less than 140.
So, it's really I think up to you and your individual patient.
The age provides a basic guideline,
but it's more about the risk of pushing your patient too low with their blood pressure
for that individual patient and how frail they are.
Now, and the JNC 8 no longer recommends that the
systolic blood pressure be treated at less than 130 mmHg among
patients with diabetes or with chronic kidney disease.
So, the 140/90 or below standard fits all,
except for older adults for JNC 8.