High blood pressure: please don’t lose your head

Xavier Bayona
 

Although I am sure that we well know the difference between a risk factor and a disease, I allow myself the license to start this post by defining them. Risk factor (hypertension, hypercholesterolemia...) is that situation that has been related to the development of a disease (maybe the disease never develops despite having one or more risk factors), while the disease is the alteration in the organism's state or of any organ that interrupts or disrupts vital functions, affecting the state of health (ischemic heart disease, embolism...).

Since Julian Tudor Hart, in an article published in the British Medical Journal in 1993 after following a cohort of hypertensive patients for 21 years, concluded that the basis of treatment is the detection of hypertension and that the most important measures are hygienic-dietary and working from the community, countless articles have been written. But the essence of management remains: detect it, decrease sodium intake, increase physical exercise, abandon toxic habits and if they do not achieve the desired objectives, start pharmacological treatment.

In different posts on this blog, certain trends and recommendations have been highlighted that move away from Right Care and the prevention of overdiagnosis and overtreatment. And it’s that the bias is often incurred to universalize recommendations from populations of higher risk and apply them to others of much lower risk such as the Mediterranean. This is the case of the latest 2017 ACC/AHA recommendations on the diagnosis and management of high blood pressure, in which the current threshold for the diagnosis of high blood pressure is lowered to figures greater than or equal to 130/80.

Various authors have carried out critical analyzes of the latest 2017 guide. In this sense, G Bakris and M Sorrentino, in the New England Journal of Medicine, conclude that, generically, in people who don’t have a high risk of cardiovascular disease, it seems more reasonable to continue defining high blood pressure with measurements greater than or equal to 140/90, and that risk determination is a factor aimed at establishing treatment goals, taking into account different concurrent situations such as kidney failure, diabetes or others.

But, before the conclusions, Bakris and Sorrentino make a series of reflections among which I would like to highlight:

1. There seems to be a consensus that pressure self-monitoring improves controls and decreases adverse effects.

2. Lowering the cut-off level for the diagnosis and treatment of hypertension (up to 130/80) in the American population would increase the number of hypertensive patients by over 30 million and over 4 million new patients with treatments compared to previous guidelines. It would go from 32% of the hypertensive population to 46%. Thus, pre-hypertension would be considered hypertension.

3. First-line treatments should also consider the benefit of hypertensive patients in hyper-adrenergic situations with beta-blockers.

4. The literature shows in sufficient quantity that sodium restrictions below 2,300-2,400 mg daily do not affect blood pressure.

5. It doesn’t seem reasonable to have the same treatment objectives at 30 and at 80 years of age when the compliance of the arteries causes the reading of these blood pressure figures to rise preferentially in systolic pressure, the predominant form of high blood pressure from the epidemiological point of view.

As a last reflection, we should bear in mind that the recommendations of the guidelines are not always based on the best evidence and that they are often based on the consensus of experts who are part of the working group who may have conflicts of interest. In Spain, in relation to this matter, I only have been able to read some reflections in a blog (No Gracias), but I have not found positions in this regard (reasoned reflections) of working groups of scientific societies of primary care, internal medicine or cardiology that can bring light on the controversy.

Although we must be attentive to the recommendations of the experts, we must also be critical and sensible. We must be alert and keep in mind that lowering the diagnostic threshold changes the substrate of the risk factor or the disease, and this alone would force us to seek recent evidence. Every day there are fewer patients to whom we can apply the exact results produced by clinical trials, especially in multi-chronic situations, and we have to be skilled in prioritizing situations while maintaining an open dialogue with our patients and their families to give coherence and value to the objectives we want to achieve.