Narrator - Dr. Abel  00:00
Welcome to HelixTalk, an educational podcast for healthcare students and providers, covering real life clinical pearls, professional pharmacy topics and drug therapy discussions.

Narrator - ?  00:11
This podcast is provided by pharmacists and faculty members at Rosalind Franklin University, College of Pharmacy.

Narrator - Dr. Abel  00:17
This podcast contains general information for educational purposes only. This is not professional advice, and should not be used in lieu of obtaining advice from a qualified health care provider.

Narrator - ?  00:27
And now on to the show.

Dr. Sean Kane  00:31
Welcome to HelixTalk. Episode 71 I'm your co host, Dr. Kane. I'm Dr. Schuman, and

Speaker 1  00:36
I'm Dr. Patel, and today we're introducing, obviously, the very hot topic, which is holy hypertension guidelines, holiday edition.

Dr. Sean Kane  00:44
And today we're talking about the newest updates to the I guess we're going to call it JNC 8.1, guidelines, the new 2017, ACC/AHA and a number of other organizations, guidelines to the update from JNC seven.

Speaker 2  00:59
And so this is something, again, that I know when it came to our facility and speak to you guys, is at our facility. This was huge news over the last couple weeks when the the guide on came out about, you know, what a changing of practice will be and as well as you know, how does it compare to JNC seven in terms of who supports it, as well as what the document says? So I'm excited about getting into it. Dr, Patel, can you lead us in? Absolutely.

Speaker 1  01:20
Well, first, I did not know how to tackle this, because the executive summary, they're calling it a summary. It's alone 114 pages. So thanks to one of our colleagues here who introduced me to this 28-page document that has, like the most important flow diagrams and the charts to consider maybe can use as a pocket guide. So we have a link for that PDF available as well. But basically, like we introduced the topic, this seems to be from what the authors of these guidelines are saying, a true update to the JNC seven guideline that was published in 2003 so the question really here is, what was that 2014 article that was published in JAMA.

Dr. Sean Kane  02:01
And really that was a panel member report only. It was not the full JNC eight update. It did not affiliate itself with any particular organization. It was just a panel of members. And really their purpose was to review evidence from randomized, controlled trials that were published since JNC seven was published in 2003 and it was not meant to be a comprehensive review. And you can really see that in the length of the document, it isn't 200 and something pages. It's something like 10 pages. The problem that we have here now is, what do we call this new thing? That is the update to JNC seven, given that we've kind of called this 2014 document, JNC eight,

Speaker 1  02:41
well, we kind of don't have an answer for that as to what we're gonna call it, but if you kind of read the preface of the new guidelines, they said that the the guideline is comprehensive enough that it reflect changes since the JNC seven that was published in 2003

Speaker 2  02:56
and I think that's an important thing to know, because when we talked about this episode, a number of you or This issue, a number of years ago, on a previous podcast, we talked about one of the things they said was, we don't in JNC eight, or what formerly JNC eight, is we don't want to get into things like cardiac disease. They said, we'll defer to ACC and other cardiac guidelines for management those diseases. So we had, again, a very small picture of a certain snippet of the population who these the jnca would apply to. And so now I believe what we're looking at is a more global perspective, looking at multiple bodies who are feeding into this document. So the breadth of it is much bigger in terms of who's supporting. Am I correct there? Absolutely.

Speaker 1  03:31
And let's be clear that 2014 guidelines that came out, not all clinicians agreed with the recommendation. And there was, there was a lot of debates and discussion over certain blood pressure goals, especially in the elderly. And so this guideline really looks at, like you said, Dr. Schuman, all the sub population, special population, and addresses the issues and globally.

Dr. Sean Kane  03:52
So Dr. Patel, in this very large document, certainly there's a number of things that we could talk about, and we could take a long time to do that, but in the interest of our listeners, what are some of the big changes that the audience should know about that came out of this 2017, update of JNC.

Speaker 1  04:11
So we, in order to understand the updates easily, we kind of segregated things into maybe six main components as to what are the changes in blood pressure measurement that includes also defining the blood pressure. What are the emphasis on screening of the hypertension as well as comorbidities? What are the new changes in non-pharm recommendations as well as pharm recommendations, looking at the new blood pressure goal and also summarizing the kind of the follow up and the monitoring and kind of approaching patient holistically. So that's how we were going to progress. So first thing, first measurement of blood pressure. I mean, this is very big. They're saying to use two averages of the in office blood pressure reading over two different locations to. Classify a blood pressure. But on top of that, they're saying we should also include home based blood pressure monitoring or ambulatory blood pressure monitoring to diagnose the hypertension, and really to understand that this is not a masked hypertension, or not a white coat type of hypertension,

Dr. Sean Kane  05:17
with the thought that as you get your blood pressure taken by a nurse or someone in a clinic that you your blood pressure goes up because you're worried about what the number is, versus at home, maybe you don't have that response, yeah.

Speaker 2  05:29
And I think about again, in my clinic, which we're dealing with a lot of anxiety and depression, is all right, you got somebody who may be running late for various reason. They're running up the stairs to the appointment, they're huffing and puffing, they're nervous, or they're frustrated or they're anxious, you sit down, you check the blood pressure, it's high. Everyone panics. You sit down and yell the patient. You put on new medication on versus again, having a discussion, seeing what is their baseline, versus, you know, the idea about that's getting a continuum, versus simply a snapshot that may or may not be indicative of where they're sitting the rest of the day and the rest of the week when they're not in your clinic.

Speaker 1  06:00
And for whatever lent this, new guidelines have been out. I heard from some of my colleagues that they love this approach. This decreases some chances of polypharmacy, prescribing medications prematurely, and then really allows patients to be part of a decision whether they actually have this diagnosis or not.

Dr. Sean Kane  06:20
So what are some of the ways that that blood pressure can be monitored at home?

Speaker 1  06:24
Then basically they're asking clinics to loan some blood pressure monitors the patients and then have a series of blood pressure checked over the seven days and return the log back to the office. And then there will be a comparison of what their in office blood pressure is like versus what their home blood pressure has been doing. So for example, if the in office blood pressure is high, but the home blood pressures are doing just fine, more likely that there is some white coat hypertension showing up. If the in office blood pressures are good, but the at home blood pressures are high, they are considering this as something called masked hypertension.

Dr. Sean Kane  07:00
So then once we decide on that typical number for a patient, historically, we use terms like pre hypertension that some people have beat up that term a little bit because it's scary for a patient that you almost have this disease, but not quite. So how did they end up classifying the blood pressures and the newest update?

Speaker 1  07:19
Yeah, so I guess the classification is a little bit different. And then they moved up some of the numbers and the thresholds for this diagnosis or classification, so no more pre hypertension. We're calling it elevated blood pressure, and that's now defined as systolic blood pressure of 120 to 129 previously, that number was 120 all the way to 139

Speaker 2  07:40
and then stage one, it looks like it's now defined as the systolic blood pressure between 130 and 139 again, shifted down from 140 to 159 in the past.

Speaker 1  07:50
And so that leaves stage two as being the systolic of greater than 140 instead of greater than 160 and diastolic of greater than 90 instead of that greater than 110 that we used to have per the older guidelines. So really, then the concern is, because we're moving all the thresholds up, are we going to put patient on medications early on too? And the answer is kind of No, the medications still resume according to new recommendation at stage one. And then we'll talk a little bit more as we go through when to introduce non-pharm and pharm recommendations.

Dr. Sean Kane  08:25
Dr. Patel, I think that's actually a really important point, because if someone walked into a clinic with a blood pressure of 122 over 78 122 is above that threshold of normal, they would be classified as elevated blood pressure category, but they wouldn't be indicated for treatment at that point, even though they carry the label of elevated blood pressure, absolutely right?

Speaker 2  08:44
And plus, there's that also idea about getting more than one simple vision. So again, it's the idea about really trying to get away, it sounds like from that snapshot mentality.

Speaker 1  08:53
So we are defining the blood pressures a little bit differently, right? But then they're focusing so much on making sure that we're not just looking at primary hypertension, but we're looking at secondary hypertension, causes and comorbidities that can lead to having hypertension. So again, making sure that we're screening for secondary hypertension and causes such as obstructive sleep apnea, making sure we're screening for other comorbidities such as insulin resistance, and not just check their blood pressure in the clinic, but if they have it, or if they have elevated blood pressure, go ahead and do thyroid screen. Go ahead and do the fasting blood glucose as well.

Speaker 2  09:29
And again, I couldn't agree with that more, because again, getting us out of the sidewalk approach where we see each disease that is separate, but here we're looking at the impact of the kidneys and other medications. And if somebody's withdrawing on a medication or, oh, you know, too much or too little, what does that do? I'm thinking holistically about how these disease states work together. Then you say, Oh, you've got this disease that your blood pressure is high, therefore we have a med for this one, separate than this one and separate from this one.

Dr. Sean Kane  09:53
And of course, the other recommendation is to think about modifiable CVD risk factors. So in someone who has dyslipidemia, are you thinking about smoking? Are you thinking about their diabetes control? Are you thinking about their cholesterol, obesity? There's a number of other things that we think about that may or may not play a direct or indirect role in their hypertension management that should be thought about when you're dealing with their hypertension.

Speaker 1  10:16
Like you said, Dr. Kane, the modifiable risk factors are more like lifestyle-related risk factors as well. So correcting those things kind of leads us into talking about the non-pharm recommendations that the guidelines have looked at, and they actually gave this non-pharm recommendation task to a prevention committee in itself. So they've examined the non-pharm recommendations in very detail, and if you look at the table and chart, they're very granularly defined. For patients who have elevated blood pressure (less than 130/80), those non-pharm measures should be applied — and remember that when you introduce pharm therapy the non-pharm recommendations are intended to continue.

Speaker 2  11:04
it looks like there's a new recommendation to really to work on increasing the amount of dietary potassium as part of an antagonistic effect with sodium. I've been spending so much time talking about sodium, so saying 3500 to 5000 milligrams per day of foods that are high on potassium, spinach, bananas, sweet potatoes, things like that. That's great. So now we don't have to worry about sodium anywhere, right?

Dr. Sean Kane  11:24
Not quite. So they do have recommendations regarding sodium restriction, and this, to me, is one of the most controversial areas of the 2017 update, their optimal goal of sodium intake is less than 1.5 grams, or 1500 milligrams. Now that is one of the most restrictive sodium intake recommendations I've seen to date, and this has always been a huge issue in terms of whether that is a safe amount for patients and whether that correlates to improved outcomes or not. Not to mention the fact that that amount of sodium restriction is incredibly difficult to maintain for a patient. So with that said, they do have the caveat in the 2017 update, saying that even if you reduced it by a gram a day of your sodium intake, that that has a good effect on your blood pressure, let alone if you can get to a lower goal,

Speaker 1  12:16
sodium, potassium. But then what about the weight? Right? So in previous guidelines, they said that you can get up to five to 20 millimeter mercury blood pressure reduction if you lose 10 kilograms. Now, if I'm explaining it to a patient, 10 kilograms may seem like a very over reaching goal. So what they have done it to simplify it, they've said, we're gonna give you one millimeter mercury reduction in blood pressure per every kilogram weight loss that occurs, and that's a little bit more realistic. You know, your patient always may not need 10 kilo weight loss, and some people will need more than that. So what about those patients? So this equation kind of helps them calculate as to how much weight loss that they would need in order to achieve the proper goal.

Speaker 2  12:56
And then kind of speaking to some of the realism in these recommendations, they also went and looked at physical activity, and not just emphasizing aerobic exercise, which, again, can be very difficult for somebody to get off the couch into, that, you know, aerobic exercise. So they're also mentioning isometrics and dynamic resistance. So types of it, again, is that if you have something that's preventing you, you know, a bad knee, or something else that's preventing you from getting out and doing a lot of vigorous aerobic exercises, at least we can get up, we can do some strength training. We can do isometrics, you know, some, you know, limited body areas, and work on exercising certain limbs or certain muscles, just to start with, until we get the person to where they can do a little bit more involved

Speaker 1  13:35
types of exercise. It's fascinating, like, how granular these recommendations are, because when I saw isometric versus dynamic, I literally had to look it up what these exercises would define as. So if a patient is embarking on a physical activity, it would be a good idea to have a physiatrist or a personal trainer kind of give them examples of what kind of different exercises they need to move in.

Dr. Sean Kane  13:58
I think one of the things that everyone looked at when these 2017 guidelines first came out was, what are they saying about blood pressure goals when on treatment? And this was really the thing that was kind of the main meat of the 2014 Jama JNC eight update was that they redefined blood pressure goals, and kind of talked a little bit about blood pressure treatment, but most of their impact dealt with blood pressure goals. So, Dr. Patel, what did we come up with in the 2017 update in terms of blood pressure goals?

Speaker 1  14:30
I like the New York guidelines because they're not only looking at that surrogate marker, which is a plain old blood pressure number, but they're attaching that to what is the 10 year risk score for cardiovascular disease for that particular person. So with that being said, for most patient, the blood pressure goal is less than 130 over 80. Okay, so this is a full circle. We used to have this number. I remember teaching diabetes, and Ada had recommended this goal for most of its patient and to realign the. Things with other organization. It brought it up to 140 over 90. We'll see what ADA does. But these guys definitely brought it down to less than 130 over 80. Except if you have an individual who doesn't have clinical ASCVD but has a 10‑year risk score of less than 10% we would allow them the same goal while using a higher threshold (treatment threshold >140/90). The recommendation for a BP goal of <130/80 is strong for most individuals, but for those with an ASCVD score <10% and no other ASCVD risk factors or comorbidities, less‑intensive initiation may be reasonable.

Speaker 2  15:53
them as well. I think that's interesting, because again, it's looking like it's going to be very nuanced, because I think about a lot of times we will have to look at the burden of the medication. And so again, just as we've talked about with the different things about intensive sugar amount management, maybe it is, what is? What are we getting for that extra 10 points reduction on the systolic and dash dog, versus the side effects of these medications? Risk of hypotension, falls, all these other concerns which can be concerned again, especially, I'm assuming as we talk about the elderly individuals.

Dr. Sean Kane  16:21
So Dr. Patel, to your point about that kind of low‑risk patient who has a low risk of ASCVD and doesn't have current ASCVD — for example a 35‑year‑old with borderline hypertension — that patient may not require a more aggressive BP goal, whereas most people older than 40 have an ASCVD score that increases with age. So most typically, you're going to be getting closer to that 10% on many of these patients.

Speaker 1  16:52
Anyway, yeah, and then we really can't calculate an ASCVD score if the patient is younger than 40, so I think that kind of ties along with this recommendation as well.

Dr. Sean Kane  17:01
So another recommendation in terms of blood pressure goals, deals with patients who have had a recent stroke. Historically, the guidelines recommended all the way up to blood pressure goals of less than 220, over 120, in the acute setting of a stroke, for a variety of reasons, but the long story short is worrying about regulation of blood flow to the brain being impaired. This auto regulation being impaired, and whether, if you drop them too quickly over too short of a time that you could make their stroke worse by not perfusing the brain adequately. So right now, these guidelines recommend that if you have a patient who just had a stroke, who is not on any antihypertensives prior to their stroke, that you can begin therapy a few days after their stroke, only if their blood pressure is high, being greater than 140 over 90, which isn't that high, and then having a target blood pressure goal, just like everyone else of less than 130 over 80. And they recognize that in this setting, it's a really unique patient population. We just don't have a lot of good comparative data to justify a more aggressive approach to them, but certainly in the longer term, Hypertension is one of the biggest risk factors for stroke, and that's one of the reasons why we're not really sure what to do with them.

Speaker 2  18:10
And then lastly, as I think I mentioned, I'm glad to see that they're trying to be careful about how we treat older individuals, again, because of that medication burden and side effect burden. So what they've said here is that for older individuals greater than or equal to 65 years of age who do have hypertension and a high burden of comorbidity, you know, again, other states, whether it's diabetes CAD as well as limited life expectancy, using a mixture of clinical judgment, patient preference and then really a team based approach to determining your intensity. And so with that, it looks like we're talking about a fairly subjective range that can be considered for those individuals, which, again, I kind of think a little bit back to a 1c guidelines that we use for managing blood sugars.

Speaker 1  18:50
Yeah. So comparing to that 2014 update in JAMA, the goal for the elderly that's defined as greater than 65 years of age was less than 150 over 90. Now this guidelines are saying it's going to be the same, but as you said, Dr. Schuman, look at the other factors and kind of individualize the therapy a little bit better.

Dr. Sean Kane  19:10
And of course, I think we just have to mention the fact that now that JNC 2017 has updated their diabetes blood pressure thresholds, again, the ADA guidelines for diabetes are now discrepant from what JNC 2017 is showing so well. It'll be really interesting to see if the ADA holds their ground with their less than 140 over 90 recommendation, or if they go back to the old lesson, 130 over 80 recommendation.

Speaker 1  19:36
And there are a lot of speculation as to how these guidelines came up with the goal of less than 130 over 80. As we know, the SPRINT trial had come out with a systolic goal of less than 120 but these guidelines did not keep that goal. They kept it less than 130 on the systolic. And we know that patients with diabetes were not included in the SPRINT trial, right? So the ADA is going to be in a product. Met, and then we'll definitely see what they have to say in January of 2018,

Dr. Sean Kane  20:04
and I think we'd be remiss not to say that we did have diabetes only blood pressure trials historically that were done where they compared more or less aggressive blood pressure goals, and those were negative trials indicating that a more aggressive blood pressure approach to those diabetics was not better. So I don't know what will happen. And even regardless of what the guidelines say, you can't say that it isn't going to be controversial. Whether it's the 130 or the 140 someone's going to disagree, because we don't have great data that is definitively showing one approach or the other.

Speaker 2  20:35
So to change the subject, one of the things that are on the same subject is looking at the medications. There was some talk, again with the 2014 guidelines about, you know, changing around some of the preference and order of medication. So Dr. Patel, what do we have in terms of the hot items to start with for blood pressure management?

Speaker 1  20:51
Absolutely. So talking about, you know, pharmacologic interventions, just like the previous guidelines, they're saying they should be done along with the non-pharm recommendation, but really they've defined it as to who would need the pharmacologic therapy. So they're saying that for secondary prevention — patients who have had an ASCVD event and have BP >130/80 — pharmacologic therapy is indicated. For primary prevention, a 10‑year ASCVD risk >10% plus BP >130/80 makes a patient a candidate for pharmacologic therapy. If that risk score is greater than 10% and their blood pressure is greater than 130, over 80, they are candidates for pharmacologic therapy.

Dr. Sean Kane  21:31
Now, Dr. Patel, I think this is one of the most important points of the guideline update in terms of who are we treating? So it's not just a matter of, are you above your goal or not, it's when you initiate pharmacologic drug therapy for the patient. So maybe we can just reiterate that one one more time, because I think it's so important for the audience, absolutely.

Speaker 1  21:49
And I would like to also reiterate that that we're not just looking at a blood pressure number, we are looking at the cardiovascular risk associated as well. So if your patient has had a cardiovascular event, meaning has had a clinical ASCVD and their blood pressure is greater than 130 over 80. We are giving them pharmacologic therapy for secondary prevention of any of those ASCVD events. If the patient has a 10‑year ASCVD risk score of greater than 10% so they are at risk of getting an event and their blood pressure is elevated greater than 130/80, they will be given pharmacologic therapy for primary prevention.

Dr. Sean Kane  22:28
and not to throw a monkey wrench in it, but it's ironic that our lipid guidelines picked seven and a half percent as an ASCVD threshold. These hypertension guidelines pick 10% we're absolutely splitting hairs, and I fully recognize that, but it's coming from the same society that came up with the lipid guidelines. And one came up with a threshold of seven and a half. This one came up with 10%

Speaker 1  22:49
it's a very interesting observation, and I got to find out as to why there is a difference in these numbers,

Dr. Sean Kane  22:57
so in terms of our initial drug regimen. So if you do meet one of the two criteria that you just mentioned, Dr. Patel, one big thing from that JAMA 2014 / JNC8 update was the fact that they said thiazides aren't the only game in town. If you want, you can pick a thiazide, you can pick a calcium channel blocker, an ace or an ARB. If you're African American, maybe avoid the ace in the ARB, unless there's some other compelling reason. Do we stick to that? Or did we come up with a new, first lane therapy for hypertension?

Speaker 1  23:25
You bet we stuck to that. All right, good. So for a stage one hypertension, they're saying any one of the medications, either from calcium channel blocker, thiazide diuretic, ACE or ARB, would be a go.

Dr. Sean Kane  23:40
So really, no update from the 2014 JAMA article in terms of first line therapy. Did they make any comment about adding two drugs at once? Because that was not present in the Jama update. Yeah, if

Speaker 2  23:50
I remember, there was some debate about again, as you optimize one versus add another, and trying to figure out the additive, the band of additive benefits versus the additive side effects. So hopefully we've got some clarity there.

Speaker 1  24:00
Yeah, absolutely. So if your patient's blood pressure is falling under that stage two criteria, or if the blood pressure is more than 20 on the systolic and 10 on the diastolic above the goal, then they're saying, really start out with two different medication from any of this four first class medication we talked about. So again, two different medications started at the same time, if your patient's blood pressure is in the stage two category,

Speaker 2  24:24
and that, I think, is, again, a pretty significant change right there, as far as getting the green lettuce or two medications at once. And that's going to be an important education piece for providers and patients alike.

Dr. Sean Kane  24:33
So one of the big updates that I noticed in the guidelines was the recommendation of preferring chlorthalidone as a diuretic because of its long half life and proven reduction for cardiovascular disease risk and a multitude of different randomized, controlled trials. Now this is important, because current practice is that we love hydrochlorothiazide and we rarely prescribe chlorthalidone. And there's a number of different reasons for that. One. One reason is that hydrochlorothiazide, it didn't used to be this way, but it's cheaper. Chlorthalidone is an ancient drug that used to be on a $4 list and things like that, and now it runs about $20 a month, which isn't a lot, but if you can get hydrochlorothiazide for half or quarter of the price, sometimes that is a big decision maker,

Speaker 1  25:17
Yeah, and especially when they're saying that, to increase adherence you should try combination drug therapy. We know chlorthalidone is not available in combination as much as hydrochlorothiazide is. So, throwing in some confounders, it's going to be tough to select chlorthalidone over hydrochlorothiazide, but they're definitely putting more emphasis on it.

Dr. Sean Kane  25:39
So the data is there. The issue is cost. It's combination therapy. It's also adverse effects. So it's a more potent thiazide it works better, which means that you get more side effects. So because of that, patients don't tolerate it as well. But again, it's a better thiazide diuretic, so they're recommending it. Whether our practice will change, I think is to be seen. I'm fairly skeptical that it will change, but it's great to at least see the guidelines recognize that most of the thiazide data is not with hydrochlorothiazide.

Speaker 2  26:08
All right, so then the next point of interest is the editor, what is the role of the beta blockers? That was something again, the 2014 guidelines kind of deferred and said, we're not really going to get to those. That's a cardiac thing. We're kind of more focused on primary hypertension. Dr. Patel, where are the beta blockers? Are they back? Are they still gone?

Speaker 1  26:24
No, they're still not the first line. Unless your patient has coronary artery disease or a heart failure, which is the reduced ejection fraction heart failure in those patients, they're saying consider beta blockers. But otherwise they shouldn't be the first line blood pressure reduction medications. Unlike the 2014 guidelines, you know, with this, this newer version, the compelling indications are back again. So all the recommendations and the flow diagrams are organized based on whether your patient has CKD, whether your patient has diabetes, whether your patient has reduced ejection fraction, heart failure. So with the interest of time, we're not going to go over all the little details, because most of the recommendations have stayed the same, but it's nice to see that the compelling indications are back and the medications are organized accordingly.

Dr. Sean Kane  27:11
And just for emphasis, as you said, Dr. Patel, these aren't new recommendations for heart failure, for example, they're just reiterating what most of the guidelines already say about those disease states and kind of packaging it into one spot, which is kind of nice, yeah, absolutely.

Speaker 1  27:26
What is worth mentioning, however, is the treatment of resistant hypertension. And if the patient has primary aldosteronism, for those patients, they're particularly recognizing the mineralocorticoid type — spironolactone or eplerenone for treatment.

Dr. Sean Kane  27:43
One thing that really stood out to me is that they did have specific updated recommendations about treating hypertension in pregnancy. We already covered this when we talked about methyldopa in a previous episode. But unlike in previous guidelines, where methyldopa was the drug of choice for pregnancy and hypertension, they now recognize basically three options that are equally efficacious. So they recognize methyldopa, nifedipine (typically nifedipine XL), and labetalol as options, and they equally prefer all three. From my perspective, methyldopa has a slightly worse adverse‑effect profile. We again covered that previously. So from my point of view, Most pregnant patients are more likely to be on labetalol or nifedipine XL for their hypertension.

Speaker 1  28:27
And I think it's a great change in this guideline in particular, talking about other special population, as you said, Dr. Kane earlier, for African American patient. For initial therapy, we should go for either thiazide diuretic or calcium channel blocker over either ARB or ACE. But what they did specify for African American patients, that these patients may need two or more medications to get their blood pressure under control.

Speaker 2  28:53
And again, going back to one of the things we talked about, is the idea about, you know, potentially starting two medications or that being okay is still keeping an eye on ways to improve adherence, and one of the recommendations here was to go with once daily regimens, or at least to consider them as a way of improving adherence, versus something you have to take two times a day or three times a day, and then the idea, if possible, to combine regimens rather than separate them. So again, that goes back to our recent discussion about chlorthalidone, again, a great medication. But if we are looking for a medication that kind of a one pill once a day type of regimen, we still think the HCTZ–lisinopril combo is somewhat an attractive one, and that may suppress some of the chlorthalidone prescribing for that reason.

Dr. Sean Kane  29:33
So Dr. Patel, we figured out what to do in terms of classification. We figured out how to treat it, both with non pharmacologic and pharmacologic therapy. We set the patient up for success, and then what do we do after that?

Speaker 1  29:46
So the important thing is to make sure we are following up with the patient appropriately, and we are monitoring that blood pressure properly. So this guideline actually recommends on what's the interval for that monitoring. So let's say you had a patient with blood pressure of. Less than 130 over 80, didn't start any medication, but we put them on a diet plan or exercise plan on non-pharm, we will ask them to come back in the clinic for reevaluation of the blood pressure within three to six months and follow up sooner rather than later. Maybe your your follow up was like the older guideline thing, but now it's a little bit sooner. Let's say there are on antihypertensive medication and continuing the non-pharm after starting the medication. They're saying, one month follow up for the in office blood pressure measurement for individuals who have normal blood pressures during their physicals and stuff, reassessing in one year is just okay. They're saying, in addition to doing blood pressure monitoring in office, the titration of the medication, the assessment whether new medication needs to be added on or not, can also be based on home blood pressure monitoring. We're not going to go in detail. There is a whole protocol that they have developed on how a patient should do self monitoring of blood pressure, what tools they need to be provided, how they need to measure it, what tools the clinic needs to have, how they need to manage the entire process. They're also emphasizing that the better quality outcomes are achieved when we're applying more team based management. And woo hoo for pharmacists. They've actually mentioned that clinicians such as physicians, nurses and pharmacists should be part of a comprehensive team to attack the issues of blood pressure in the primary care setting. And interestingly enough, Dr. Schuman, you probably deal with a lot more on the VA basis, that they're emphasizing use of telehealth technology to do more follow ups during patients in person visits actually to see a provider.

Speaker 2  31:45
Yeah, really quickly. One of the things I've noticed is a lot of them, just like similar blood pressure, is we have nurses that will call and set up with a patient to do the monitors and get the readings. Providers will co sign me to the note, and then I get ready to do my visit. I've got 1020, days with the blood pressure readings. For me, I call the patient, and I'm rather than gathering their data beforehand, I prep for the patient, look over the readings, and I have a recommendation for it right when we get on the phone, and there's more time for them counseling than just to kind of have to get the information and on the phone figure out what to do with it.

Speaker 1  32:13
There you go. You had a snippet of telehealth visit preparation. All right. So to summarize, I know we covered a lot of different changes, and went through some snippets of it like I said, the guidelines are actually more intense and exhaustive. So to kind of summarize what we discussed on, some of the more important changes in this new guidelines are that the blood pressure goal is back to less than 130 or 80 for most patients, including your patients, who are older in age greater than 65 so keep in mind that this is something different than the previous guidelines.

Speaker 2  32:46
And then another thing that was emphasized is non pharmacologic recommendations. If your blood pressure is less than 130, over 80, really emphasize some of the other diet and lifestyle modifications, increasing the amount of potassium in the diet while decreasing the amount of sodium. Is a big one, focusing on goals of one millimeter mercury (mmHg) reduction in blood pressure per every kilogram, other than these big, grand goals. And then physical activity doesn't always have to be running a marathon, starting out with isometrics, focusing on your hand motions and hand strengthening resistance, dynamic resistance. And then maybe aerobic exercise.

Dr. Sean Kane  33:20
And then for me, one of the big take home points was when you give drug therapy to a patient for their hypertension. So if you have someone who has never had an MI, stroke, or any other ASCVD event, but their risk is above 10% and BP is >130/80, that's when you initiate drug therapy. If someone has had any prior ASCVD event, initiate therapy when BP >130/80.

Speaker 1  33:47
And another big thing to focus on is the therapy for those who falling under the stage two hypertension, that would be the systolic blood pressure of greater than 140 and diastolic blood pressure of greater than 90 for those patients, they're recommending starting off with two different medications of the any of the first class medication like the calcium channel blocker, thiazide ACE inhibitors or angiotensin receptor blockers. So that's a that's something different than the previous guidelines.

Dr. Sean Kane  34:17
So I think that wraps up today's discussion on the 2017 JNC update, or whatever we'd like to call it. I would definitely encourage the listeners to go to our show notes at HelixTalk.com this is episode 71 to get links to these both pocket guides in the full guidelines and all their glory, because there's a lot here, and we were only able to touch on some of the big key points that really stuck out to us. We're also on Twitter at HelixTalk, we love five star reviews in iTunes, so with that, I'm Dr. Kane, I'm Dr. Schuman,

Speaker 1  34:46
and I'm Dr. Patel, and as always, study hard.

Narrator - Dr. Abel  34:49
If you enjoyed the show, please help us climb the iTunes rankings for medical podcasts by giving us a five star review in the iTunes Store. Search for HelixTalk and place your. You there

Narrator - ?  35:00
to suggest an episode or contact us. We're online at HelixTalk.com thank you for listening to this episode of HelixTalk. This is an educational production copyright Rosalind Franklin University of Medicine and Science.