{"id":906,"date":"2013-08-19T14:55:30","date_gmt":"2013-08-19T18:55:30","guid":{"rendered":"http:\/\/blogstemp2.wpengine.com\/?p=906"},"modified":"2015-06-04T14:24:51","modified_gmt":"2015-06-04T18:24:51","slug":"managing-hypertension","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/general-medicine\/index.php\/2013\/08\/managing-hypertension\/","title":{"rendered":"Managing Hypertension – Not as Easy as It Once Seemed"},"content":{"rendered":"
\"\"

Target a blood pressure < 140\/90 mmHg in everyone, but be rational in the medications you choose to get there.<\/p><\/div>\n

Hypertension…<\/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’t make life any easier.<\/p>\n

I soon realized a little more finesse was required of the internist-in-training. JNC-7 didn’t 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’s 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’s 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’t 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’s 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’s as a house officer. CCB’s 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’t 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’s. While this study doesn’t 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