Hypertension Guidelines Explained Clearly – 2017 HTN Guidelines

Hypertension Guidelines Explained Clearly – 2017 HTN Guidelines


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