Let’s Not Forget the Silent Killer: Hypertension

Background

The prevalence of hypertension continues to rise in the United States, contributing to increasing cardiovascular-related deaths. According to the CDC, hypertension was a primary or contributing cause of about 691,095 deaths in the US in 2021.¹ Approximately half of US adults are diagnosed with hypertension or are taking prescription medications for hypertension.¹

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The incidence of hypertension varies between different racial and ethnic groups, with the most prevalent being non-Hispanic Black adults followed by non-Hispanic White adults, non-Hispanic Asian adults, and Hispanic adults.² The management of hypertension contributes to the ever-increasing health care cost burden, with about 650 million hypertensive medication prescriptions filled each year, and this amounts to about $29 billion in total health care spending.²

Hypertension is defined as persistent average blood pressure (BP) of 130/80 mm Hg or higher on 2 or more occasions or office visits.^4,5 Table 1^4,5 shows the classification of hypertension based on average BP measurements in a clinical setting. Patients with hypertension commonly present asymptomatically, leading to delays in seeking medical help and, ultimately, the diagnosis of hypertension. This delay in initiating hypertensive therapies predisposes patients to develop other cardiovascular diseases such as stroke, myocardial infarction, heart failure, peripheral artery disease, coronary artery disease, atrial fibrillation, and chronic kidney disease.^4,5 Hypertension is sometimes referred to as the “silent killer” because patients are asymptomatic, and if not adequately treated, are at increased risk for myocardial infarction, stroke, heart failure, and renal failure. According to the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) clinical practice guideline for managing hypertension, the recommended target blood pressure is less than 130/80 mm Hg.

Individuals can be predisposed to hypertension due to the presence of risk factors such as family history/genetic disposition, obesity, physical inactivity, smoking, excessive alcohol use, male gender, age over 65 years, stress, and unhealthy diet consisting of high sodium and low potassium. Other risk factors for developing hypertension can be attributed to uncontrolled comorbid conditions such as chronic kidney disease, type 2 diabetes, and dyslipidemia.

According to the United States Preventive Services Task Force, adults 18 years and older should be screened for hypertension with an office BP measurement and another BP measurement should be obtained outside the clinical setting for a confirmatory diagnosis. This confirmatory BP measurement could be from a home BP monitoring device or a wearable ambulatory BP device. Annual screening is recommended in individuals 40 years and older or in those at higher risk for hypertension. Adults aged 18 to 39 with normal BP readings and without increased risks of hypertension can be infrequently screened every 3 to 5 years.¹³

Prevention of hypertension is paramount to avert cardiovascular complications such as stroke, myocardial infarction, and heart failure. About 37 million US adults with hypertension are uncontrolled with a BP reading of 140/90 mm Hg or higher.¹ Some preventive measures to avoid hypertension or lower high blood pressure include weight management, dietary changes, physical exercise, and reduced alcohol intake.^6,8,12

According to the 2017 ACC/AHA guideline for managing hypertension, weight loss of 1 kg results in a 1 mmHg reduction in blood pressure. A heart-healthy diet consisting of fruits, vegetables, whole wheat, and low-fat dairy is called the Dietary Approach to Stop Hypertension (DASH) diet. This DASH diet helps prevent hypertension and maintain normal blood pressure. Intake of sodium should be limited to less than 1,500 mg/day, and consuming potassium-rich foods such as bananas, beets, and cooked spinach should be enhanced.^4,9 Physical activity should be incorporated into daily routines, and it is recommended to achieve at least 150 minutes of moderate-intensity aerobic activity per week or high-intensity aerobic activity for 75 minutes per week. Aerobic activities include walking, running, swimming, dancing, or other strength-building activities such as weightlifting. Alcohol consumption should be limited to less than 2 drinks per day for men and less than 1 drink per day for women.

Medication Management

Four classes of medications are recommended as the first-line therapies for the treatment of hypertension in addition to lifestyle changes: thiazide diuretics, angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARBs), and calcium channel blockers (CCBs).^4,5 These first-line medications have the benefit of reducing clinical events. Other second-line agents include loop diuretics, potassium-sparing diuretics, aldosterone antagonists, and beta-blockers (BB). Direct-renin inhibitors, alpha-1 antagonists, and central alpha agonists are antihypertensive agents that are rarely prescribed.

Medication management can be initiated with one first-line agent, although some patients may require 2 or more agents to control their BP. The hypertension stage can be a determining factor in the number of agents used at medication initiation; for instance, stage 2 hypertension would require 2 medications from different classes of first-line therapies.^4,5 Treatment options can be selected based on other comorbid conditions, as listed in Table 2.^4,5

Monitoring

Home BP monitoring is essential to managing high blood pressure. Following the appropriate steps during BP measurements is vital for accurate readings.¹⁰ Patients can bring their record of home BP readings to their physician for a comprehensive overview of how well-controlled their BP has been and whether medication titrations are required. BP measurement is recommended twice daily, in the morning, before taking any antihypertensive medications and food, and in the evening. Home BP monitoring facilitates early diagnosis of hypertension for patients with risk factors.

Pharmacists’ Role

Through extensive patient education on the importance of medication adherence, pharmacists are instrumental in reducing the progression of other cardiovascular diseases such as stroke, myocardial infarction, heart failure, peripheral artery disease, and chronic kidney disease. Pharmacists can engage in collaborative practice with physicians and other health care team members to provide medication therapy management. Pharmacists should educate patients on how to manage medication adverse effects and recommend dietary modifications.

Patients' self-monitoring of blood pressure at home is preferred because this can improve motivation and yield treatment success. Additionally, pharmacists are best suited to educate patients on accurate BP monitoring steps.² Pharmacists are a reliable resource for guidance on selecting safe OTC medications for common conditions like cough, cold, and pain without increasing the risk of worsening a patient’s hypertensive condition.

Conclusion

Although hypertension is a silent killer, high blood pressure can be controlled with proper medication management, including medication adherence and lifestyle changes. Pharmacists play a vital role in identifying and equipping high-risk patients with preventive strategies to mitigate the development of hypertension. In addition, pharmacists are knowledgeable about the various antihypertensive medications, potential adverse effects, guideline-directed therapy recommendations, and optimal medication choices for co-morbid conditions.

References

1. Facts about Hypertension. Centers for Disease Control and Prevention. July 6, 2023. Accessed January 11, 2023. https://www.cdc.gov/bloodpressure/facts.htm

2. Health and Economic Benefits of High Blood Pressure Interventions: Power of Prevention. Centers for Disease Control and Prevention. January 27, 2023. Accessed January 11, 2023. https://www.cdc.gov/chronicdisease/programs-impact/pop/high-blood-pressure.htm

3. Brown M. Why is Blood Pressure Important and How to Monitor From Home. Performance Therapies. October 18, 2021. Accessed January 11, 2023. https://ptforhealth.com/why-is-blood-pressure-important-and-how-to-monitor-from-home/

4. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Journal of the American College of Cardiology. 2018;71(19):e127-e248. doi:10.1016/j.jacc.2017.11.006

5. Unger T, Borghi C, Charchar F, et al. 2020 International Society of Hypertension Global Hypertension Practice Guidelines. Hypertension. 2020;75(6):1334-1357. doi:10.1161/HYPERTENSIONAHA.120.15026

6. US Department of Health and Human Services, National Institutes of Health, National Heart Lung and Blood Institute. Primary Prevention of Hypertension: Clinical and Public Health Advisory from the National High Blood Pressure Education Program National High Blood Pressure Education Program. November 2002. Accessed January 10, 2024. https://www.nhlbi.nih.gov/files/docs/resources/heart/pphbp.pdf

7. First WHO report details devastating impact of hypertension and ways to stop it. News release. World Health Organization. September 19, 2023. Accessed January 10, 2024. https://www.paho.org/en/news/19-9-2023-first-who-report-details-devastating-impact-hypertension-and-ways-stop-it

8. Hypertension. World Health Organization. March 16, 2023. Accessed January 10, 2024. https://www.who.int/news-room/fact-sheets/detail/hypertension

9. James PA, Oparil S, Carter BL, et al. 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427

10. Merschel M. Monitoring blood pressure at home can be tricky. Here’s how to do it right. American Heart Association News. May 23, 2022. Accessed January 10, 2024. https://www.heart.org/en/news/2022/05/23/monitoring-blood-pressure-at-home-can-be-tricky-heres-how-to-do-it-right

11. National Institutes of Health. DASH Eating Plan. December 29, 2021. Accessed January 10, 2024. https://www.nhlbi.nih.gov/education/dash-eating-plan

12. American Heart Association. Life’s Essential 8 Fact Sheet. 2022. Accessed January 10, 2024. https://www.heart.org/en/healthy-living/healthy-lifestyle/lifes-essential-8/lifes-essential-8-fact-sheet

13. United States Preventive Services Task Force. Recommendation: Hypertension in Adults: Screening. April 21, 2021. Accessed January 10, 2024. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hypertension-in-adults-screening#fullrecommendationstart