A Road Map and a Full Tank for Hypertension Management: Thank You, ASH 2013

A strange thing happened to the future of hypertension management in December, 2013. As we have already reviewed the long-anticipated JNC 8 (the operative being long) arrived, and left me frankly unsatisfied. (See JNC 8 part I; JNC part 2) It was like an appetizer without any subsequent portions.

Almost simultaneously, the American Society of Hypertension, in collaboration with the International Society of Hypertension, also produced a hypertension update-Clinical Practice Guidelines for the Management of Hypertension in the Community.¹ I would compare this product to a main course for healthcare professionals who treat hypertension on a regular basis.

Although there is agreement between JNC 8 and ASH-for example, the new target blood pressures for persons over age 60 and an overall simplification of targets for disparate groups-there is a more substantive “vehicle” in the ASH update for reaching the many other clinical destinations. Here are some highlights for primary care:

Consider a delay in medication initiation in individuals with stage 1 hypertension (140 to 160/90 to 99 mm Hg). The definition of hypertension was also simplified-reduced to 2 blood pressure readings over target, 1 to 4 weeks apart.

Initial work-up should include: a K+, a fasting glucose, a BUN/creatinine, a lipid profile, a hemoglobin, liver function tests, an ECG, and a urine albumin.

History and physical are emphasized: use a BMI and waist circumference routinely, ask about NSAID use, palpate the left ventricle, perform a fundoscopic, and examine the jugulars.

Start 2 antihypertensive drugs from the “get go” in those with stage 2 hypertension (>160/100 mm Hg).

Direction for treating resistant hypertension is provided. Spironolactone is mentioned with specific caveats for hyperkalemia. But alternatives are included (eplerenone and other classes).

Ambulatory and home monitoring of blood pressure are discussed in specific context.

Warnings are included about the relativley poor cardioprotection offered by beta blockers compared with other classes and about a heightened risk for insulin resistance.

Clear cut choices for medications are provided: for black persons with hypertension, initiate therapy with a calcium channel blocker or thiazide; for white persons, use an ACEI or ARB and thiazide for the first 2 agents.

Obstructive sleep apnea is identified as an important comorbidity with hypertension and as a likely cause of resistance to therapy.

There now, I feel better regarding content. JNC was transparent about the utilization of evidence-based data for their report, but there was very little evidence included after 2008. There is still a place for consensus when all the evidence is not available, particularly in dealing with resistant hypertension for 2014.

What's still missing All beta blockers are not created equally. Is there not yet enough evidence to demote atenolol and favor carvedilol over metoprolol after measuring a fasting glucose and BMI? Since spironolactone has been effective in resistant hypertension, but limited by hyperkalemia, when will stacking diuretics (spironolactone + chlorthalidone, for example) find a role? We have some nouvelle cuisine to sample, but there is more to come. Bon appétit!

References:

• Weber MA. Schiffrin EL, White WB, et al. Clinical Practice Guidelines for the Management of Hypertension in the Community: A Statement by the American Society of Hypertension and the International Society of Hypertension. J Clin Hypertens.December 17^th, 2013 [epub ahead of print].