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Tag: blood pressure

New Guidelines for High Blood Pressure

According to a joint statement issued Monday by the American Heart Association and the American College of Cardiology, nearly half of all adult Americans will be considered to have high blood pressure under new guidelines. “The numbers are scary,” said Dr. Robert M. Carey, professor of medicine at the University of Virginia and co-chair of the committee that formulated the new guidelines.

The nation’s leading heart experts state that tens of millions more Americans will now meet criteria for the condition of high blood pressure, as the redefinition is now a reading of 130 over 80, down from 140 over 90. The number of adults with high blood pressure, or hypertension, will rise to 103 million from 72 million under the previous standards—meaning that 46% of U.S. adults will be considered hypertensive.

Carey states that the reformulation stems from the recognition that blood pressure considered ‘normal’ in the past—or ‘pre-hypertensive’—actually placed patients at significant risk for heart disease and death and disability, as medical evidence confirms that people with high blood pressure in the 130-139 range carry a doubled risk of heart attack, stroke, and heart and kidney failure. “The risk hasn’t changed. What’s changed is our recognition of the risk.”

Nevertheless, the report’s authors predict that few of those who fall into the new hypertensive category will require medication. Rather, the hope is that many with early stages of the condition will address it through lifestyle changes, including weight loss, diet improvements, increased physical activity, less alcohol and sodium consumption, and lowered stress. “An important cornerstone of these new guidelines is a strong emphasis on lifestyle changes as the first line of therapy. There is an opportunity to reduce risk without necessarily imposing medications,” said Richard Chazal, the immediate past president of the American College of Cardiology.

High blood pressure is the leading cause of death worldwide, and the second-leading cause of preventable death in the United States, after cigarette smoking. Hypertension is often a precursor for cardiovascular disease, strokes, severe kidney disease, and other disorders that kill millions annually. Thomas R. Frieden, the former director of the U.S. Centers for Disease Control and Prevention who now runs a global health initiative that focuses on heart disease and stroke, has called hypertension “the world’s most under-addressed preventable health problem.”

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Increases in Pediatric Hypertension

More children and teens are likely to be categorized as having abnormal blood pressure during their annual wellness visits, based on new recommendations released this week by the American Academy of Pediatrics.

High blood pressure is mostly a “silent” condition, with no visible symptoms. Yet it can have long-term health consequences, including cardiovascular disease. The new guidelines, aimed at prevention, were published Monday in the journal Pediatrics. They include new diagnosis tables based on normal-weight children.

The academy convened a 20-person committee to update the previous guidelines, issued in 2004, and develop new evidence-based recommendations. As part of its work, the committee reviewed nearly 15,000 articles focused on diagnosis, evaluation and early management of abnormally high blood pressure in children and teens.

An estimated 3.5% of all children and teens in the United States have hypertension, according to the guidelines. “The prevalence of 3.5% is based on fairly recent large-scale screening studies,” said Dr. Joseph T. Flynn, lead author of the guidelines and a professor of pediatrics at University of Washington. In the past, the percentage of children diagnosed with high blood pressure was lower, he said: “based on previous studies, maybe 1% to 2%.”

The cause of hypertension depends on the age group. “In infants and very young children, we worry about an underlying cause like kidney disease,” Flynn said. With older school-age children and teenagers, the cause is more likely to be primary hypertension, sometimes called essential hypertension, “where there’s no specific problem,” he said. “This is like adults.”

Obesity does contribute to higher blood pressure, yet the physiological mechanisms causing high blood pressure are very complicated, and not all kids who are overweight or obese are hypertensive, while some normal-weight kids may be.

“If, for example, a child is known to have kidney disease or heart disease, then they would be at higher risk for hypertension. Another group would be kids whose parents have hypertension,” Flynn said. The guidelines include updated blood pressure tables based on normal-weight children for more precise classifications of hypertension. As a result, more children will be categorized as needing treatment.

“Untreated, we believe that high blood pressure in a child will lead to high blood pressure when that child becomes an adult, so that would potentially lead to an increased risk of cardiovascular disease later in life,” Flynn said, adding that untreated hypertension can also cause heart and kidney damage. The new guidelines are aligned with those for adults, according to Flynn. “The blood pressure levels that are concerning in adults would also be concerning in an older teenager,” meaning those age 13 and older. “It simplifies things for doctors,” he said.

The major thing parents need to know is that their children should have their blood pressure checked when they see a doctor, Flynn said. Also, know that hypertension can be managed with lifestyle change: for example, more exercise or changing the diet. Sometimes, though, the condition requires medication. Another change in the new guidelines is an emphasis on confirmation of the diagnosis.

“Ambulatory blood pressure monitoring is a procedure in which the person wears a blood pressure cuff for 24 hours, and their blood pressure is measured periodically over 24 hours,” Flynn said. “This is very important in children because there’s a very high rate of what’s called white coat hypertension, where blood pressure is high in the office (due to fear of doctors) but not at home.”

The new recommendation is that ambulatory blood pressure should become standard practice in children after any abnormal in office reading, Flynn said. Dr. Sophia Jan, director of general pediatrics at Cohen Children’s Medical Center in New Hyde Park, New York, said the rationale behind the new guidelines makes sense. With evidence that there may be consequences for kids whose high blood pressure is not treated at lower thresholds, it makes sense to treat them earlier than in the past, said Jan, who was not involved in the new recommendations.

What she would tell parents is that “we’re not doing anything majorly different. We’re still going to check your child’s pressure when he or she comes for wellness child visits. That’s what we’ve done always in the past.” What’s new is that “we may be quicker to recommend that you and your family help your child engage in lifestyle changes if your child’s pressure is within a threshold that is lower than in the past. “Everyone’s loath to put kids on medicines if you don’t have to, but we may need to get there a little bit faster than we have traditionally in the past,” Jan said.

“As doctors, we recommend these lifestyle changes, yet in reality, it requires partnership with schools and public health agencies,” she said. “We in the pediatric community did not necessarily appreciate to what degree kids were starting to exhibit what is traditionally thought of as an adult condition. Kids can show early signs of organ damage and increased risk for cardiovascular disease despite the fact that they’re young.”

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USPSTF Recommends ABPM to Confirm Hypertension Diagnosis and Yearly Screening for Higher Risk Groups

In an update to their 2007 reaffirmation recommendation statement, the US Preventive Services Task Force (USPSTF) finalized Grade A recommendations for blood pressure screening of adults. The use of ambulatory blood pressure management (ABPM) is recommended to confirm a diagnosis of hypertension outside of the clinical setting before treatment begins. (The exception to this recommendation is for cases in which therapy should begin immediately.) Further, adults 40 years of age and older and those at higher risk should undergo screening every year after a normal blood pressure finding; others can be screened every 3 to 5 years.

In response to public comments that were received after the draft version of the recommendation statement was released in December 2014, the USPSTF acknowledges there are barriers to implementing their recommendation of utilizing ABPM due to availability and affordability. In response, their final recommendation is “to include home blood pressure monitoring (HBPM) as an alternative method for confirmation of a diagnosis of hypertension when ABPM is not feasible.”

To learn more, plan to attend the Hypertension and Cardio-Renal Syndrome session at the 10th Annual CMHC on Friday, October 23, and read more on the USPSTF recommendations here.

Screening for high blood pressure in adults: US Preventive Services Task Force Recommendation Statement. Ann Intern Med. Published online 13 October 2015 doi:10.7326/M15-2223.

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