Are you on the right blood pressure medications?
When the American College of Cardiology and the American Heart Association changed the definition of hypertension in 2017 from anywhere above 140 over 90 to anywhere above 130 over 80, it meant that roughly half of the population in the United States had high blood pressure, instead of the 32 percent under the previous guidelines.
While more people are now considered to have hypertension, it has not necessarily translated into more people on prescription drugs. Lifestyle changes are still recommended for those in the first stages of hypertension, according to the American College of Cardiology (ACC) and the American Heart Association (AHA) (see below).
But, unfortunately, sometimes lifestyle interventions aren’t enough to control high blood pressure. When that is the case, a medication is necessary to cut your risk of heart attack and stroke.
There are many different classes of drugs with a variety of individual medicines in each class. Deciding which one works best can be complicated, according to cardiologist Lawrence McAuliffe, MD, at Cape Cod Healthcare Cardiovascular Center in Hyannis.
The three drugs recommended most frequently, he said, are:
- A diuretic
- Angiotensin II receptor blockers (ARBs)
- Non-dihydropyridine calcium channel blocker
However, every treatment strategy is patient-specific, said Dr. McAuliffe.
“The choices need to be tailored to the individual patient.”
For example, even though diuretics are often a first line of treatment, giving a person with kidney dysfunction or high creatinine levels a diuretic would be harmful to their kidneys. An ARB is also not be recommended for these patients, he said.
“Every medication has a downside and, with diuretics, its urination,” he said. “Most people will have a urination natriuretic effect (excretion of sodium in the urine) initially and then, with a lot of patients, it levels off. They don’t notice that they are urinating more.”
A diuretic also would not be appropriate for a patient with a fast heart rate because it may reduce their total body fluid volume, which, in turn, may result in an increased heart rate.
“I may choose a beta blocker (which slows the heart rate) for that patient,” Dr. McAuliffe said. “Or, if a patient has a history of vascular disease or coronary disease or stroke, those are patients who would benefit from beta blockers as well.”
For those who are newly diagnosed with hypertension, and whose condition is in the initial stage, lifestyle interventions are the first line of defense. The interventions recommended by the ACC and AHA recommended include:
- Weight loss, if needed to achieve a healthy BMI
- A healthy diet rich in fruits, vegetables, whole grains legumes, nuts, fish and low-fat dairy products, with a reduction in saturated and total fat, processed foods, red meat, refined carbohydrates and sugar
- Reduction of dietary sodium with an optimum goal of less than 1,500 mg a day
- Enhanced intake of dietary potassium by eating foods rich in potassium
- Increased physical activity to at least 150 minutes of aerobic exercise a week or 75 minutes of vigorous activity a week
- Moderation of alcohol, with men drinking no more than two drinks a day and women drinking no more than one drink a day
- Smoking cessation
For those who do need medication to control their condition, cardiologists do not prescribe Angiotensin-converting enzyme (ACE) inhibitors any more because they are not recommended under the current American College of Cardiology (ACC) and the American Heart Association (AHA) guidelines.
“Too often they are either not as effective as their cousin ARBs or patients develop side effects, namely a dry cough that people get on ACEs,” Dr. McAuliffe said. “Or, they can cause swelling in the tongue, lips and throat called angioedema. So, as a first line of therapy, most of us no longer use ACEs; we’ll just go directly to an ARB.
I never change anybody on an ACE that’s working. I just don’t start anybody on an ACE anymore.”
Despite the change in guidelines, a lot of patients are in fact being prescribed ACE inhibitors as a first line of treatment. A recent study published in The Lancet, using data from 4.9 million people revealed that ACE inhibitors are the most commonly prescribed first-line medication for hypertension. Doctors prescribed them for 48 percent of the patients and diuretics were the first line of treatment for only 17 percent of the patients in the study.
The study highlighted the fact that ACE inhibitors have many more side effects than thiazide diuretics, which is one of three types of diuretics that also include types known as loop diuretics and potassium-sparing diuretics. Each type of diuretic affects a different part of your kidneys the diuretic that is prescribed depends on the condition being treated. The study also illustrated that thiazide diuretics were linked to 15 percent fewer heart attacks, heart failure hospitalizations and strokes.
In many cases, patients do better on low doses of a couple of medications, Dr. McAuliffe said. That can maximize effectiveness while keeping the risk of side effects lower. The AHA recommends a single pill combination agent like a calcium channel blocker and a diuretic or an ARB and a diuretic. Unfortunately, they cost more to produce and the higher expense means that not all insurance companies will cover them.
“Theoretically, every patient gets a regimen that should be tailored to their needs in what will predictably be the best effect with the least side effect and the highest chance of compliance,” Dr. McAuliffe said. “But again, you have to be patient specific.”