Editor's note: China is a country with high blood pressure, and hypertension is the primary risk factor for cardiovascular events. Therefore, good blood pressure management is the key to reducing cardiovascular events. So, how to lower blood pressure to achieve better standards? How to do the whole journey management of blood pressure well? Recently, at ACC 2021, we invited Professor Suzanne Oparil of the University of Alabama at Birmingham to share her views on relevant issues.
International Circulation: In recent years, the United States, Europe, China, and international hypertension guidelines have been updated one after another. Would you please share us the similarities and differences in the overall blood pressure management concepts of these guidelines?
Professor Suzanne Oparil : The guidelines are similar in one important aspect in that they emphasize that lowering blood pressure is important for a large proportion of the population, whether it is in China, Japan, US or Europe. The question is, how low to go? The US has been the most aggressive probably, relying on evidence from randomized controlled trials, particularly the most recent SPRINT (systolic blood pressure intervention) trials, which showed that in patients who were carefully screened and carefully followed for an average of 3.5 years, being randomized to a systolic blood pressure goal of 120mmHg was better than to a goal of 140mmHg in preventing all kinds of cardiovascular outcomes – a composite of stroke, myocardial infarction, heart failure, deterioration in kidney function and death. It is important to note that the clinical trial setting is a little bit different from the ordinary patient setting. In the clinical trial, the patients had been enrolled for several years, with visits every three months and they were familiar with their coordinator, so were very relaxed in the clinic. It was easy to obtain a blood pressure close to 120mmHg. In a busy clinical practice where you are in a hurry and the patient is in a hurry and may have other complaints, it is very difficult to do that. On that basis, the ACC/AHA Guidelines Committee in 2017 recommended a target of 130/80mmHg, in contrast to the old 140mmHg, because the SPRINT trial had shown that getting lower is better. In other settings where the background is different and the clinical trials do not apply, it may be reasonable to have a less aggressive goal. It is possible to do harm by lowering blood pressure too much.
International Circulation: What is your opinion about the role of home blood pressure monitoring in the prevention and treatment of hypertension?
Professor Suzanne Oparil: I think it is very important out-of-office. Instead of calling it home BP monitoring, I would call it out-of-office blood pressure monitoring. Its measurement is very important, because the office setting can be very artificial. Some patients can be very nervous. There is the white coat phenomenon where results are falsely elevated. If you measured clinic blood pressure only you would be treating too aggressively and could cause harm. Then there is masked hypertension, which is more serious. Masked hypertension means your blood pressure is elevated out-of-office but is under control whatever the control level is in the office. Those patients would be missed if we only used in-office pressures. It has been shown that those people have bad outcomes. So it is important to have some out-of-office blood pressure measurement. The question is how to do it. Some people say we need ambulatory blood pressure monitoring with the cuff on for 24 hours measuring blood pressure every half hour or fifteen minutes. That’s nice, but it is very expensive and some patients don’t like it because they can’t sleep very well. It is better if you can teach the patient to buy a good blood pressure cuff and then measure their blood pressure when they relax, sitting for five minutes, not talking, not drinking coffee or tea, not arguing with a spouse, so you can get an idea of what the blood pressure is doing. That is very valuable. Some studies have shown that home blood pressure measurement by a reliable patient is better than ABPM (ambulatory blood pressure monitoring). So it is very important, but it is an educational challenge and there is the cost of buying the machine. We need to work out exactly how we are going to do it, exactly what kind of equipment is going to be used, and exactly what sort of schedule we have. Now that we have the pandemic, I see patients one day a week, all day, and many of them cannot come to the office because they haven’t been inoculated against COVID-19. We are doing home visits, so the only measurement I have is what the patient records. So this is very important to get into the education system and it is a great question.
International Circulation: How to manage the whole process of blood pressure? Would you please share us your opinion？
Professor Suzanne Oparil: If the whole process means the natural history, I think that even young people and children should have their blood pressure measured by their provider. It has been shown that blood pressure tracks. If it is high as a child or adolescence, you are going to develop high blood pressure when you get older. The other hint is if you have a strong family history with parents and grandparents with high blood pressure, then you will probably inherit it. What you can do about it is try to avoid those factors that make hypertension worse, i.e. eating salty and fatty foods, weight control (obesity in the US is a huge problem as a contributor to hypertension), also physical activity is much underrated. It is known that if you are active, you stimulate nitric oxide production in the blood vessels as blood flows past the endothelial cells. That is a vasodilator. So physical activity as well as diet are important in the prevention of hypertension, and in the potentiation of the drugs. If we know you have high blood pressure, we don’t send you away on drugs to do whatever you want. You should continue to be physically active, continue to keep weight down and continue to eat a healthy diet. All of those things are important throughout your lifetime from the time you are a child till the time you are 90 years old. So this is a great question too. It is the whole process. People are often very afraid of their diagnosis. It can be managed. In most cases, we can keep people from dying. The major complication is no longer stroke or heart attack, it is heart failure, because people are living longer with high blood pressure and they get heart failure with preserved left ventricular ejection fraction.
International Circulation: To achieve blood pressure management around the world: how do you make the most of limited options?
Professor Suzanne Oparil: Well, that’s a great question. There are studies, and I am collaborating with one of them, in underdeveloped countries like Puerto Rico and related Caribbean islands, where there are programs to screen the population so they don’t need to go to a doctor. There are screening programs for the people by healthcare workers paid for by grant, and if they are found to be hypertensive or borderline hypertensive, they are encouraged to have a better diet, to do more exercise and use inexpensive, frequently fixed dose medications that can be very helpful. In poor countries, this population-based approach is very important. You can’t expect someone to go to a doctor who charges US$50 plus medication plus other expenses. We do need population-based approaches. That is true not only in poor countries, but also within the US, the richest country. For example, I am involved in a study in rural Alabama, which has a large African-American population and lower socio-economic status, and people also live in the countryside. We are trying to make their healthcare workers more conscious of the guidelines and how to manage blood pressure and how to use electronic health records and so on. Also how to get patients more adherent to a regimen. It is a team type of approach. The other thing is that there are not enough physicians with a doctoral degree in the world to do this, so we need other healthcare workers like nurses and interested laypeople who are willing to work with patients but without medical training to participate in this at very low cost. There have been lots of different approaches looked at and that are needed in order to bring everything under the umbrella of good blood pressure control.
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