The current HEDIS measures on blood pressure control tell us the “goal” is a systolic BP of <140 mmHg and a diastolic BP of <90 mmHg. Seems like a no brainer, right? It was, until recent publications began to call this goal into question.
A recent study found, for adults over age 50, having a diastolic of >90 mmHg might not increase mortality if the systolic is <140 mmHg (J Gen Intern Med. 2011 July; 26(7): 685–690). And, in those under 50 years, a diastolic over 90 mmHg increases risk.
Confused? A 2012 Cochrane Systematic Review of 9,000 patients found no benefit to treating “Mild Hypertension” which was defined as Systolic BP of 140-159 mmHg and Diastolic BP of 90-99 mmHg. And, the relative risk of an adverse event was 4.8 (Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD006742).
For those with Type 2 Diabetes, the best outcomes from the ACCORD trial were found when the treatment goal was a systolic BP of <140 mmHg (N Engl J Med 2010;362:1575-1585), rather than the previous treatment parameter of <130/<80.
So what is a busy provider to do? First, make sure your patients really have hypertension. A 2011 study of those classified as having resistant hypertension (needing 3 or more meds to control BP) found 1/3 of the patients had white coat hypertension (Hypertension. 2011; 57: 898-902). If insurers won’t cover 24 ambulatory BP monitoring, have the patient buy an inexpensive automated BP cuff, check their pressures twice a day, keep a log, and after collecting data for 1 week, mail it in.
Next, don’t hold the salt. Yes, I said DO NOT hold the salt. A Cochrane review says most people who restrict salt obtain very little BP benefit (Cochrane Database Syst Rev. 2011 Nov 9;(11):CD004022). Salt restriction in Whites with hypertension reduces the BP by 5/<3 mmHg, Blacks <6/<2.5 mmHg. Asians with systolic BP get the best benefit at 10/<3 mmHg reduction. What about the DASH diet? This was a 30 day trial of a variety of interventions; no idea of its true efficacy.
What lifestyle changes really make a difference? Aerobic exercise, just 20 minutes each day for 5 days a week, improves BP control AND lowers CHD risk. Smoking cessation. And 2008 meta analysis says meditation, practiced daily, is also effective (Am J Hypertens. 2008 Mar;21(3):310-6).
Hypertension is an important disease; do not take it lightly. But, diagnose and treat it appropriately, and your patients will live happier, and longer.
– Frank J. Domino, MD