{"id":38085,"date":"2013-08-29T08:00:47","date_gmt":"2013-08-29T12:00:47","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?post_type=voices&p=38085"},"modified":"2013-08-26T17:07:10","modified_gmt":"2013-08-26T21:07:10","slug":"managing-hypertension-not-as-easy-as-it-once-seemed","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2013\/08\/29\/managing-hypertension-not-as-easy-as-it-once-seemed\/","title":{"rendered":"Managing Hypertension \u2013 Not as Easy as It Once Seemed"},"content":{"rendered":"

CardioExchange welcomes this guest post from\u00a0Dr. Paul Bergl<\/strong>, Chief Resident at the University of Chicago Medical Center.\u00a0This piece originally appeared on the NEJM Journal Watch blog, Insights on Residency Training<\/a>.<\/em><\/p>\n

\"blood-pressure2\"<\/a><\/p>\n

Hypertension\u2026<\/p>\n

As a medical student, I never really understood the fuss over it. Practicioners had an excellent and concise guide in the JNC-7<\/a> to handle all of the major aspects of this disease. The JNC-7 guidelines were algorithmic, and a helpful table of compelling indications for antihypertensive agents couldn\u2019t make life any easier.<\/p>\n

I soon realized a little more finesse was required of the internist-in-training. JNC-7 didn\u2019t tell the whole story. My attendings all had slightly different opinions on the optimal strategies for control, and these approaches might contradict my antihypertensive gospel.<\/p>\n

Hydrochlorothiazide was replaced by chlorthalidone after a preceptor noted, \u201cAll of the important studies on thiazides were done with chlorthalidone.\u201d After adopting its use, I found another internist who advised, \u201cChlorthalidone just causes more hypokalemia. There\u2019s no reason to believe HCTZ is inferior.\u201d So, back to HCTZ. Soon after, I learned that calcium-channel blockers were a preferred option for isolated systolic hypertension\u00a0in elders. \u201cDiuretics just make older patients dizzy, dehydrated, and hyponatremic.\u201d And the advice continued to accumulate in the form of these little pearls.<\/p>\n

To complicate matters further, various societies and expert-written guidelines also had a slightly different take on the ideal systolic and diastolic pressures. I was becoming dizzy myself. Do I target a systolic blood pressure of 130 mm Hg in patients with diabetes? Or was that patients with CKD? Or is the diastolic blood pressure more important? And does it really matter?<\/p>\n

Well, if JNC-8 looks anything like the Eurpoean Society of Hypertension\/European Society of Cardiology joint guideline<\/a>s that are so nicely summarized in Joanne Foody\u2019s NEJM Journal Watch article<\/a>, we can all breathe a sigh of relief. As Dr. Foody highlights, these guidelines emphasize a more universal blood pressure target of 140\/90 mm Hg and a greater focus on global cardiovascular risk. I haven\u2019t gotten through the whole document, but I was also glad that these guidelines allow for more lenient control in elders. And these guidelines are not<\/b> at all prescriptive in the choice of antihypertensive medications.<\/p>\n

A brief report<\/a> in Physician\u2019s First Watch on a common class of antihypertenisves also caught my eye this past week.\u00a0Staff writer\u00a0Amy Orciari Herman reported on the recent JAMA Internal Medicine article<\/a> by Christopher Li et al showing an association between long-standing calcium channel blocker (CCB) use and risk for breast cancer.<\/p>\n

The article gave me pause for one major reason: I really fell in love with CCB\u2019s as a house officer. CCB\u2019s struck me as an affordable, convenient, and efficacious antihypertensive class. Amlodipine in particular seemed to promise worry-free prescribing to this young physician. Patients liked the once-daily dosing and small pill size. Since amlodipine required no periodic electrolyte checks and side effects are uncommon, I would gladly discharge a patient from the hospital on it. If the patient was lost to follow-up, I probably wouldn\u2019t be on the hook for an adverse drug effect.<\/p>\n

Or maybe I will be. This population cohort study suggests an elevated risk of breast cancer with CCB\u2019s. While this study doesn\u2019t prove causality, it should make us all a little more circumspect about the antihypertensives we choose.<\/p>\n

In the end, these articles gave me a chance to reflect on what we ought to teach residents about managing hypertension. I expect I will keep my teaching simple in the coming years:<\/p>\n