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Guidelines fall short in diagnosing labile hypertension, addressing adherence
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CHICAGO — There are a number of gaps in the 2017 American Heart Association/American College of Cardiology hypertension guideline that cardiologists may not be aware of, presenters said at the Cardiometabolic Health Congress.
The topics include home vs. office BP measurements; medication and lifestyle adherence; and lastly, labile hypertension, according to the presentations.
Integrating guidelines and addressing the gaps
In his presentation, Raymond Townsend, MD, professor of medicine at the University of Pennsylvania, discussed gaps in how clinicians align home vs. office vs. ambulatory BP measurements.
“What does a 130 mm Hg systolic/80 mm Hg diastolic in the office look like on a home monitor? The AHA/ACC guidelines would say it looks like 130/80 at home,” Townsend said in his presentation. “What does it look like on the daytime of an ambulatory BP monitor? With this one-size-fits-all approach, it says 130/80 there as well. When you go to the tail end of this section of the guidelines, you’ll find about 10 or so references for this particular section. The references support the actual recommendation saying it’s a good idea to do these things, but the references don’t honestly address where these numbers came from.”
Townsend referenced a previous study published in Hypertension that assessed the reasoning behind the ACC/AHA guideline on ambulatory and home BP monitoring thresholds.
Healio previously reported on these findings in March.
“When we looked at daytime systolic BP and the 24 hours systolic BP measured by ambulatory BP monitoring in these highly adherent participants, we found that the difference between their daytime systolic BP and office systolic BP was an issue in SPRINT,” Townsend said. “In the more intense group, there was a 7- or 8-mm difference in systolic BP on the ambulatory monitor, which was higher outside the office, and there’s a smaller delta in the daytime systolic BP on the ambulatory monitor compared to the 27-month data inside the office, which was about 136. ... Even in research, they don’t line up perfectly at 130 office, 130 home and 130 ambulatory. There’s still some work that needs to be done.”
Adherence to treatment
Cardiology Today Editorial Board Member Michael A. Weber, MD, professor of medicine at SUNY Downstate College of Medicine, suggested several methods to improving patients’ adherence to hypertension treatment that included:
- simplify their hypertension treatment by using combination products (a strong recommendation of the ACC/AHA Hypertension guideline);
- increase and improve communication with patients via phone calls, emails, text messages, etc;
- get patients’ spouses, children, parents and other family involved in treatment; and
- get patients engaged in managing their own treatment by making them aware of their BP targets and encouraging them to check BP at home.
“We, of course, think about the problem of patients not reliably taking their medicines and following the lifestyle recommendations we hope will be valuable in managing the hypertension. Clearly, we worry most about this issue are when patient’s BP is not well controlled,” Weber said in his presentation. “We know there are a number of reasons why BP isn’t at its target and sometimes it’s because patients intrinsically have very difficult-to-treat hypertension, but far more often it’s because they have a white-coat BP effect in the office or simply are not being adherent to their prescribed therapy.”
Labile hypertension
Labile hypertension is not adequately addressed in the guidelines, Aldo J. Peixoto, MD, professor of medicine and clinical chief of the section of nephrology and co-director of the hypertension and dysautonomia program at the Yale School of Medicine and Yale New Haven Hospital Heart and Vascular Center, said during his presentation.
“The term labile does not exist in the current ACC/AHA guidelines, but we all see this and I certainly get lots of referrals for this,” Peixoto said. “There are three major clinical syndromes of ‘fluctuating’ BP, one in which the BP is labile, but it is high and every time that the BP deviates from normal, it’s toward a high blood pressure level (pheochromocytoma and related syndromes); one in which BP oscillates between hypertension and hypotension in an unpredictable manner (eg, baroreflex failure and autonomic dysreflexia); and one in which BP changes predictably from high to low based on posture (neurogenic orthostatic hypotension complicated by supine hypertension).”
Peixoto stated that a diagnosis of labile hypertension starts with ruling out pheochromocytoma. In the absence of pheochromocytoma, labile hypertension can be caused by “pseudopheochromocytoma syndromes,” which are often driven by psychological stress and may be associated with disorders of other systems including the endocrine system, where it may be due to hyperthyroidism, adrenal medullary hyperplasia or carcinoid; the neurologic system, where it may be a symptom of complex migraines, diencephalic seizures, brain tumors, lateral medullary neurovascular contact or baroreflex failure; psychiatric comorbidities such as anxiety, panic and PTSD; drug complications such as sympathomimetics and withdrawal from clonidine and tizanidine; or problems related to sleep-disordered breathing or sleep deprivation. – by Scott Buzby
References:
Bakris GL, et al. Hypertension guidelines: Gaps you weren’t told about. Presented at: Cardiometabolic Health Congress; Oct. 10-13, 2019; Chicago.
Muntner P, et al. Hypertension. 2019;doi:10.1161/HYP.0000000000000087.
Muntner P, et al. Ann Intern Med. 2015;doi:10.7326/M14-2803.
Disclosures: Peixoto reports no relevant financial disclosures. Townsend reports he was an investigator on the SPRINT trial and reports no other relevant financial disclosures. Weber reports he is a consultant for AbbVie, Ablative Solutions, Boston Scientific, Johnson & Johnson, Medtronic, Novartis and ReCor and receives research grants from Ablative Solutions, Astellas, Boehringer Ingelheim, Boston Scientific, Johnson & Johnson, Medtronic, Novartis and ReCor.