hypertension ABPM, not use HCTZ

The point of this email is to present some of the new literature on hypertension, which could impact clinical practice.  The summaries below are quite brief, but lots of info in the articles.

 

NICE  (National institute for health and clinical excellence, in the UK, which sends out recommendations for many clinical issues -- well-researched and probably less influenced by pharmaceutical money, etc -- see htn nice recs 2011 and htn nice recs summary 2011 in dropbox).  These are very thoughtful guidelines with some major changes over JNC here (though rumor has it that a revised JNC is on the near horizon). A few very notable changes:

 

--hctz should not be first line, and that in general, ccb's be used first line in people over 55yo and in african-caribbean patients, while ace/arb's be used in under 55yo non-african descent (use with care for women who might become pregnant, though there was an article suggesting that ACE-I not so bad in early pregnancy -- see htn ace-i early in pregnancy bmc 2011 in dropbox). There was a very interesting review (see htn hctz metaanal meserli am j cardiol 2011 in dropbox), which argues that there are no efficacy data on low dose hctz and that high dose is dangerous (studies found inc in sudden cardiac deaths). Also much less decrease in ambulat bp monitoring on hctz low dose than on other meds -- e.g. office BPs are ok with hctz (short-acting effect), but bp increases later so that 24-hour monitoring finds higher blood pressure on hctz. The advice to not use hctz applies as a single agent, not in combo with ace-i or betablocker, where hctz augments the effect of these synergistically. Chlorthalidone seems much better than hctz, as suggested in the messerli meta-analysis and supported by NICE, if one wants to use diuretic as first agent.

 

--should relax target BP in older (>80yo) to 150/90, on an individualized basis (I have many older patients who need target even higher than this, or they become dizzy and risk falling -- either because of autonomic dysfunction leading to orthostatic hypotension, or orthostasis when they decrease their fluids some days or sweat more….)

 

--strong support for using ambulatory blood pressure monitoring for diagnosis of htn. Dovetails with review article (see htn ambulat bp monitoring metaanal bmj 2011 in dropbox), suggesting that pretty much anyone with office bp>140/90 should get one. (if severe htn, such as in the 180/110 or higher range, then treat).  Bottom line: strong literature that 30% of patients with office htn have normal ambulatory bp, several articles reinforce that cardiac endpoints correlate with ambulatory bp and not office bp (see htn masked nejm 2003 in dropbox, with impressive figure 2 and htn refractory salles archintmed 2008 in dropbox). both of these last articles find no relationship between office blood pressure and cardiac events.  the refractory htn article (defining pts as higher than goal of 140/90 on 3 meds at full dose,including a diuretic) found that 40% of patients labeled as refractory are actually well-controlled as assessed by ambulat bp. Both NICE and the meta-analysis note that ambulatory bp monitoring may be difficult or unacceptible for some patients, and that home-based monitoring (and perhaps checking in the local pharmacies) may be adequate -- but limited data.)