High blood pressure: what good care looks like

What high blood pressure is, in plain language

Blood pressure is the force of blood pushing against your artery walls. It is written as two numbers: systolic (the pressure when your heart beats) over diastolic (the pressure between beats). High blood pressure, or hypertension, means that force stays too high all the time.

Most people feel nothing at all, which is why it is often called a silent condition. Over years, the extra pressure damages the inside of blood vessels and forces the heart to work harder, raising the risk of heart attack, stroke, heart failure, kidney disease, and vision loss. It usually cannot be cured, but it can almost always be controlled with lifestyle changes and, for most people, medicine.

What the current guidelines recommend

The main guideline is 2017 ACC/AHA Guideline for High Blood Pressure in Adults, which lowered the definition of high blood pressure to 130/80 mmHg or higher (previously 140/90). Under this guideline, blood pressure is grouped as normal (under 120/80), elevated (120 to 129, and diastolic under 80), stage 1 hypertension (130 to 139 systolic or 80 to 89 diastolic), and stage 2 (140/90 or higher). Medicine is recommended for stage 2 at any risk level, and for stage 1 when you already have cardiovascular disease, diabetes, chronic kidney disease, or a calculated 10-year cardiovascular risk of 10 percent or higher. The general treatment goal for most adults on medicine is a blood pressure under 130/80.

The treatments, and why each one is recommended

Lifestyle changes come first for everyone, and stay important even after starting medicine: a lower-sodium eating pattern such as DASH (rich in fruits, vegetables, whole grains, and low-fat dairy), regular aerobic exercise, weight loss if overweight, limiting alcohol, and stopping smoking. These changes alone can lower systolic pressure by 5 to 11 mmHg.

When medicine is needed, four drug classes are considered first-line and are similarly effective at lowering pressure and preventing heart attacks and strokes:

• Thiazide-type diuretics (chlorthalidone, indapamide, hydrochlorothiazide): help the kidneys remove extra sodium and fluid.
• ACE inhibitors (lisinopril, enalapril) or ARBs (losartan, valsartan): relax blood vessels and are preferred when you also have diabetes or chronic kidney disease with protein in the urine, because they protect the kidneys directly. The two classes are never combined together.
• Calcium channel blockers (amlodipine, felodipine): relax the muscle in artery walls.

Most people with stage 2 hypertension start on two medicines from different classes at once, because a single drug rarely reaches goal on its own and starting with two gets you to target faster.

What guideline-based care looks like at a visit

A good clinician measures your blood pressure the way the guideline specifies: seated, back and feet supported, arm at heart level, after 5 minutes of quiet rest, using the average of two or more readings on two or more occasions. A single high reading in the office is not enough to diagnose hypertension. Home blood pressure monitoring or a 24-hour ambulatory monitor is often used to confirm the diagnosis and rule out "white coat" readings that are only high at the doctor's office.

At follow-up visits, expect your clinician to review your home readings, check for side effects, and order basic labs (kidney function and potassium) a few weeks after starting or adjusting an ACE inhibitor, ARB, or diuretic. If your pressure stays high despite three medicines from different classes at good doses, including a diuretic, that is called resistant hypertension and should prompt a search for a treatable cause and consideration of a fourth medicine such as spironolactone.

Why choosing a guideline-based clinician matters

The SPRINT trial, a large randomized study, found that treating to a lower systolic target (under 120, versus under 140) reduced heart attacks, heart failure, stroke, and death from cardiovascular causes by about a quarter, and reduced death from any cause by close to a third. Because blood pressure has no symptoms, the only way to know it is controlled is to measure it and treat it to target, not to treat based on how you feel.

Questions to ask your doctor

1. Which guideline do you follow for high blood pressure, and what year is it from?
2. Which of the recommended treatments am I on, and if not, why not?
3. What targets are we aiming for, and how will we track them?
4. What should make me call you before my next visit?
5. Do you sell any supplements or compounded medicines? (A guideline-based clinic does not.)

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