Transcription:
The New High Blood Pressure Guidelines

Melanie Cole, MS (Host): Well, we’ve recently heard that there are new updated guidelines for blood pressure. Do you even know what blood pressure is, or why it’s so important that we know our numbers? Here to tell us about that today is Dr. Dan Sodano. He’s board certified in cardiology at BayCare Health. Dr. Sodano, what’s the prevalence and burden of hypertension or high blood pressure in this country? What’s different about what we know about it now?

Dan Sodano, MD, FACC, RPVI (Guest): So it’s a very, very good question. With the most recent guidelines updates, what we’re now catching is previously people who would not be diagnosed with hypertension are now being included in the newer guidelines essentially with a lower cutoff of hypertension. So by way of most recent estimation, almost half of the country would be labeled as having hypertension with our new guidelines. It’s very important because in many and all respects it is a silent killer with preferentially leading to stroke. But certainly heart attack, chronic kidney disease are also very prevalent when it comes to the long term effects of having untreated hypertension. So pretty staggering numbers.

Host: Dr. Sodano, in your opinion, is this a good thing? Are you glad they updated these guidelines and made it so that more people now are considered to have hypertension?

Dr. Sodano: Excellent question. I will tell you at first my gut reaction was I was not happy about it, at first. However, I then began to realize that this is actually a good thing. It’s a good thing because it jives with what I practice anyway, which is lower is better. Lower cholesterols and lower blood pressures, and if I was treating diabetes, I’d be aiming for lower A1Cs and glucoses. So lower is better. At first, I was unhappy. I thought that maybe this isn’t a good thing. But as time went on, the months went on, I thought this is actually good because I can then be much more aggressive in my lowering of people’s blood pressures and taking it from there. It does get challenging the older we get. So the older we get, it becomes a lot more of a challenge because now you're dealing with other things, such as falls, passing out. Things like that that can happen in older individuals when you have them on anti-hypertensive medications. So it does get tricky as it gets older, but yes. I'm in favor of the newer guidelines now.

Host: Tell us about who is at risk for blood pressure. And as someone who explains blood pressure to people everyday in my profession, people don’t always even know really what it is Dr. Sodano. They don’t know why it’s important that we even know about blood pressure. So tell us a little bit. Give us a little physiology lesson. What is blood pressure, and who is at risk for hypertension?

Dr. Sodano: Okay. So you have your systolic blood pressure, that’s the top number, and the diastolic blood pressure, that’s the bottom number. So pressure is pressure. That’s the amount of pressure that is felt in the arterial system. The systolic pressure is the amount of pressure that the arteries feel after the heart contracts, okay. The diastolic blood pressure is the pressure that the arteries are under when the heart has relaxed. That’s the in the phase called diastolic. So it’s a measure of almost resistance. So that’s blood pressure in and of itself.

How it’s regulated is not through the major arteries, like your aorta or your carotid artery itself. Although, there’s receptors in there that can mitigate it, but the whole artery itself doesn’t do it. It’s rather done by specialized group of nerve fibers that can be found in the bulb of the carotid artery, the top of the aortic arch, the kidneys, and then of course these small resistance vessels which are too small to be seen with the naked eye. You need a microscope, and they're called arterials. All those things regulate our blood pressure. Note, the heart doesn’t regulate it, but it’s primarily done through feedback mechanisms through the central nervous system and the heart is just told to do what it’s supposed to do. So that’s how blood pressure, what it is and how it’s regulated by the body.

Now, who is at risk? People who are risk to develop hypertension are by and large who are, in no order of importance here: overweight or obese, physically inactive, those who smokes, and those who have a genetic predisposition to hypertension, and also those who really just eat a very poor high fat, high sodium diet. Most of those folks do tend to be overweight anyways. If you take many of those risk factors together and by and large you'll find the hypertensive person. I can't underestimate the importance though of genetics. I've seen plenty of folks who take great care of themselves, but who happen to have hypertension. Genetics are the underlying reason as to why. We call that essential hypertension. Their genetics predispose them to it, and it is what it is. So we just need to mitigate that to the best of our ability with obviously lifestyle modifications and, of course, pharmacotherapy. So hopefully I've answered the question.

Host: You absolutely have. So diagnosis, and I’d really like to get right into non-pharmacologic and medicational interventions for it, but when you're diagnosing it. We go to the doctor, we get our blood pressure checked. We go to the pharmacy and you can get it checked. There’s home kits people can use. When you diagnose it, is one time taking it and it’s high that time. There’s white coat hypertension. How do you know that somebody truly is hypertensive?

Dr. Sodano: That’s an excellent question? And no. It is not through a one time measurement. Actually, it needs to be two separate measurements on different days. That’s important. So I feel that the best way to diagnose blood pressure is in the patient’s own home when you can eliminate the possibility of white coat hypertension. Or possibly when they're sitting in the pharmacy for 10 minutes waiting for their medications assuming they're not annoyed or upset and taking your blood pressure there. The doctor’s office is obviously great as well, assuming that they don’t have white coat hypertension. That can sometime confound the ability to make an accurate diagnosis. I’ll get back to that in a second. But the diagnosis relies on two separate measurements where the blood pressure is greater than 130 systolic over 80 diastolic. That is the diagnosis of hypertension. Whereas when I was in medical school, it was 140 over 90.

Host: Yeah, me too. When I was in graduate school, that’s what we were told. As an exercise physiologist, I always—We practiced, and we took it. So the learning curve for taking it, not so much with the digital now, was certainly a factor as well. Now speak about treatments. If you do determine that somebody has high blood pressure, what is the first line of defense? What are some non-medicational things that you really want people to double down on?

Dr. Sodano: Okay. I would say, and, again, all of these are equally weighted here. So you know the first thing I’ll mention is diet, that doesn’t make it more important than exercise. But yes, cleaning up your diet in a tremendous way. So sodium intake needs to be drastically reduced. If you're eating processed foods, canned soups, fast food, frying lots of things, eating out at restaurants a lot. All of these types of things are going to increase the sodium load to a profound degree where people can be taking thousands upon thousands of milligrams of sodium per day. That’s going to drastically increase your risk of having hypertension. So cleaning up the diet to a significant degree.

Obviously, weight loss. The more weight we lose, and that’s going to be done typically through caloric reduction or a healthier diet and exercise. Weight loss is just as important. If you look at someone’s BMI and they're 32, it’s time to lose a lot of weight. If their BMIs are 22, no weight loss is required. Obviously, exercise, exercise, exercise. I can't emphasize that enough. So the more exercise we get, it is a tremendous vasodilator. It releases endorphins. There’s a profound sense of relaxation after exercise therapy. Exercise is very important. So weight loss, exercise, cleaning up that diet are extraordinarily important.

Host: Now tell us a little bit about the medications. We hear about all of these medications. Beta blockers, ACE inhibitors, diuretics, calcium channel blockers, the list goes on. What is their main goal? What are they intended to do to help lower our blood pressure?

Dr. Sodano: So the intended goal is simply to lower blood pressure. That’s the bottom line. Now, some have different mechanisms. The mechanism are what separates why certain medications are used. So let’s take, for instance, a class of medications called the ACE inhibitors. Wonderful medicine. Great medicine. I can also add in the angiotensin receptor blockers. So ACE inhibitors and angiotensin receptor blockers both work essentially the same way. One skips a mechanism. So what they do is they are very good vasodilators, but they also have an ability to protect the kidney. So in someone who has mild to moderate kidney disease and/or diabetes mellitus, they have not only the ability to lower the blood pressure, but they decrease the amount of pressure in the kidneys. So the kidneys are injured to a lesser degree. The kidneys sense less of a pressure within those organs. So ACE inhibitors have a special set of mechanisms that can protect kidneys in the settings of hypertensive kidney disease or diabetes mellitus with a proteinuria. Very important in those specific circumstances.

You also have the calcium channel blockers. Calcium channel blocks are medications that relax those arterials that we spoke about before. By relaxing the arterials, they dilate. When they dilate, the pressure decreases. A medication that’s used in that circumstance is, it’s called the dihydrouridine class of calcium channel blockers with amlodipine and nifedipine being the two primary medications in that class. Very powerful. Those are first line agents.

Diuretics. The old adage goes when I was back in medical school and it still holds true today. You're not treating hypertension unless you start a diuretic. We should have folks on diuretics if we’re going to really be optimizing their antihypertensive regiment. Diuretics help promote sodium loss. By promoting sodium loss, that decreases the amount of stretch in the arteries and arterials. Very important to be on diuretics in the right patient population. Not everyone needs to. People can be well controlled without them. But here’s the kicker. If you're not controlled on other medications, get them on a diuretic because, again, you're not treating hypertension unless you get them on a diuretic. Very important to have them on diuretics. There’s several that we use. Hydrochlorothiazide, spironolactone, and furosemide. Those are the three main diuretics that we use when treating hypertension.

Next, beta blockers. The trick with beta blockers is that most of them don’t work for blood pressure. They don’t work well I should say. It depends on which one you use. There’s some powerful blood pressure lowering beta blockers that are what we call non-selective. Meaning they’ll inhibit every single receptor that adrenaline will go after. By inhibiting every single receptor that adrenaline will go after, you can have some pretty good blood pressure lowering effect, such as labetalol. Carvedilol also comes to mind as well. They do a good job in lowering blood pressure. The mistake that some physicians make is by turning to medications such as atenolol or metoprolol or propranolol first. Those are excellent medications in congestive heart failure, arrhythmia. Not good blood pressure lowering medications because they target a different receptor.

So beta blockers are complicated. It depends on which one we use. There is one beta blocker that I turn to sometimes first line if it can go through their insurance company because it has powerful vasodilating effects along with some of the effects of being a beta blocker, and that’s Bystolic. A wonderful medication that has the ability to vasodilate and it has some beta blocker properties as well. So of the beta blockers that I use to treat hypertension, Bystolic tends to be the only one because it’s once a day and it has some really good data behind it in terms of blood pressure lowering.

So to review. The main classes of medications are diuretics; ACE inhibitors or angiotensin receptor blockers, they’re both in the same class; calcium channel blockers with dihydropyridine calcium channel blockers being the primary ones; and beta blockers with Bystolic being the best blood pressure lowering medication we have that’s not taken like three or four times a day. Those are your main classes. There are some other medications out there, and people who are severely resistant that you use fourth, fifth, and even sixth line agents. I don’t feel like I need to get into those unless you like me too, but your other classes, those four main classes are the main ones.

Host: What a great educator you are Dr. Sodano. That was excellent information. So clearly stated and you made it so understandable. Those medications can be quite dizzying and confusing. Thank you for clearing that up. Wrap it up for us. Give us your best advice what you would like listeners to know about blood pressure, the new guidelines, why it’s so important to take your medications as prescribed, the know your numbers, and to really double down on that exercise and diet to keep that blood pressure under great control.

Dr. Sodano: Absolutely. The precept is lower the better. How low can you go? We all played that in grammar school. We played limbo. It’s how low can you go? Lower is better. We love low. Low wins. So the new blood pressure guidelines target a lower blood pressure. Let’s look at less than 120 over 80 as what we should be shooting for. In order to keep that number or to get as close as humanly possible, let’s make sure that we’re eating healthy, eating simple, eating well. Fresh fruits and vegetables, freshly prepared items. When we go out to eat, don’t overeat. Take things home. Be responsible. Watch our calories. Know what’s going in. Be healthy and exercise. We’re supposed to be moving out and about in space. We’re not meant to be watching phones and TVs and computers. Get out and about. Get to an exercise class or simply take in this insanely beautiful region of the country that we live in and use all of it to your advantage in getting out and about and absorbing that beautiful sunshine. Keeping yourself moving about in space, and yes, getting your heartrate up if you can by exercising. Then, of course, if we do have hypertension and taking all of that into account, please be vigilant about taking your medications. Know why you're taking your medications. Then just simply stick to the regiment and remember to aim low.

Host: Wow. What a great segment. Dr. Sodano, you are just an excellent guest, a great interview. Thank you, again, for coming on with us and really sharing your expertise explaining blood pressure so well for us and why it’s so important that we do all of these things that you’ve recommended. Thank you again. For more information on BayCare’s heart and vascular services and high blood pressure, please visit baycareheart.org. That’s baycareheart.org. This is BayCare Health Chat. I'm Melanie Cole. Thanks for tuning in.