Hypertension Treatment Updates

Listen in as our expert panel breaks down what every clinician needs to know about the 2025 hypertension guidelines. You’ll hear them discuss what’s changed, some controversies, and other practical takeaways to optimize blood pressure management for your patients.

Special guests:

• Michael E. Ernst, PharmD; BCGP, FCCP, AHSCP-CHC
  • Clinical Professor
  • Department of Pharmacy Practice and Science, College of Pharmacy; and, Department of Family & Community Medicine, Carver College of Medicine
  • The University of Iowa
• Catherine G. Derington, PharmD, MS
  • Assistant Professor of Medicine
  • Division of Cardiology
  • University of Colorado School of Medicine

You’ll also hear practical advice from panelists on TRC’s Editorial Advisory Board:

• Craig D. Williams, PharmD, FNLA, BCPS
  • Clinical Professor of Pharmacy Practice
  • Oregon Health and Science University
• Andrea Darby-Stewart, MD
  • Associate Director, Honor Health Family Medicine Residency Program
  • Clinical Professor of Family, Community & Occupational Medicine
  • The University of Arizona College of Medicine - Phoenix

None of the speakers have anything to disclose. 

This podcast is an excerpt from one of TRC’s monthly live CE webinars, the full webinar originally aired in May 2026.

🏷️Use code mt1026 at checkout for 10% off a new or upgraded subscription.

TRC Healthcare offers CE credit for this podcast. Log in to your Pharmacist’s Letter, Pharmacy Technician’s Letter,or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.

Claim Credit

The clinical resources related to this podcast are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights: 

• Chart: Meds That Can Increase Blood Pressure
• Checklist: Measuring Blood Pressure Checklist
• Chart: Hypertension Goals in Adults
• Algorithm: Treatment of Hypertension
• Chart: Management of Severe Hypertension in Adults

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Transcript

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Introduction

Catherine G. Derington 0:07

That historical start low go slow approach that I was taught and used for many years is no longer evidence-based. And so the guideline is really challenging us to think about starting two meds at once. And when you do, using it in one pill.

Michael E. Ernst 0:53

The concept I want everyone to think about is that when we have a goal, at least with blood pressure, we tend to treat it as a floor. You know, we're happy to get down to it and kind of close to it. You know, I think that perhaps we should be thinking about the goal as more of a ceiling and that we don't want to spend a lot of time over it.

Narrator 0:53

Welcome to Medication Talk, an official podcast of TRC Healthcare, home of Pharmacist’s Letter, Prescriber Insights, and the most trusted clinical resources. On this episode, listen in as our expert panel breaks down what every clinician needs to know about the 2025 hypertension guidelines. You'll hear them discuss what's changed, some controversies, and other practical takeaways to optimize blood pressure management for your patients. Our guests today are Dr. Catherine G. Darrington, a clinical pharmacist and assistant professor at the University of Colorado School of Medicine, Division of Cardiology, and Dr. Michael E. Ernst, a clinical professor at the University of Iowa College of Pharmacy, and certified hypertension specialist. You'll also hear practical advice from panelists on TRC's editorial advisory board, Dr. Andrea Darby Stewart from the University of Arizona College of Medicine, Phoenix, and Dr. Craig Williams from the Oregon Health and Science University. This podcast is an excerpt from one of TRC's monthly Live CE webinars. Each month, experts and frontline providers discuss and debate challenges in practice, evidence-based practice recommendations, and other topics relevant to our subscribers.

CE Information

CE Narrator 2:00

And now the CE information.

Narrator 2:04

This podcast offers continuing education credit for pharmacists, pharmacy technicians, physicians, and nurses. Please log in to your pharmacist letter, pharmacy technician's letter, or prescriber insights account, and look for the title of this podcast in the list of available CE courses. None of the speakers have anything to disclose. Now, let's join TRC editors and clinical pharmacists, Dr. Steven Small and Sarah Clockers, and start our discussion.

What’s the Biggest Change in the 2025 Hypertension Guidelines?

Sara Klockars 2:37

So let's get into our content for today's program and talk about some of the changes with hypertension management. Now that the updated 2025 guidelines for managing high blood pressure have been out for a while, it's been about eight years since our prior guidelines, and many things have changed. So to start us off, what's the single biggest aha or change with these guidelines that every clinician and practice needs to know? I would love to hear from each of the panelists. What's your biggest takeaway? So, Andrea, can you start us off?

Andrea Darby Stewart 3:12

What I really appreciated was the reminder to consider secondary causes of hypertension and particularly primary hyperaldastronism. I talked to our residents about that on a regular basis. And I think that if we look, we will find and we will be better able to manage a certain percentage of our patients' hypertension.

Catherine G. Derington 3:34

Yeah, I completely agree with that, Andrea. Something that I get pinged about to talk about all the time that I think is a big aha from the guidelines is that the guidelines are now highly encouraging that we use two or more medicines to treat patients for hypertension from the very beginning of their hypertension treatment journey, and that those medicines should be prescribed in a single pill combination. The previous guidelines were a little bit more wishy-washy than the current ones are. And so that's a big thing that I think we should be taking home.

Michael E. Ernst 4:04

I think we have to acknowledge the use of the prevent calculator, replacing the pooled cohort equations as at least I think is a really big change. You know, there's been criticism of the pooled cohort equations in the past in terms of their overestimation of risk. And so I think the prevent calculator is a big improvement there. And I also wanted to point out one other thing, too, that I think, because I had tough time sort of thinking about this one, but the hard stop for lifestyle modifications for the lower risk patients, you know, in the previous guidelines just talked about, you know, implementing the lifestyle modifications and then kind of reassessing. But in the in the latest guideline, now we have a hard stop at three to six months, which I think is really important for combating some of the therapeutic inertia that we see with hypertension.

Craig Williams 4:52

They'll give you a, I think, a good aha and a and maybe bad aha. My inpatient head-on, the good aha, I think these guidelines finally kind of codified some language around potentially we're harming patients by doing our short acting as needed blood pressure treatments, especially in the hospital for asymptomatic, severely elevated blood pressure numbers. So that's been a long evolution, but the previous guidelines didn't come out and say outright like we should probably not be doing this. And these guidelines now give a class three harm reading to treating asymptomatic elevated numbers. And really it applies across settings, but especially to those of us on the hospital side. I think my kind of badaha on the on the ambulatory side, I have no objection to the number of 130 as a systolic goal as it's been determined in the trials. But you know, I'm over 50 now and have my share of interactions with the healthcare system. I've never had a blood pressure checked in the clinic in the way these clinical trials do. I think they could have incorporated some recognition of the fact that most clinics just don't have the bandwidth to measure blood pressures the way clinical trials do. And maybe these numbers should be thought about a little bit differently in some of those busy primary care settings.

Sara Klockars 6:06

These are all great points, and I'm hopeful we'll touch on each one of these today.

When Should You Screen for Secondary Causes of Hypertension?

Sara Klockars 6:11

So, Katie would love your thoughts on what are some common conditions that may trigger you to screen for secondary causes in patients.

Catherine G. Derington 6:24

Yeah, absolutely. And the guideline really gives a great set of tables around screening for secondary causes. I think it's tables 10 and 11. So I'm just going to cover some of the higher ticket items, greater prevalence kind of things. But when I say patients in clinic, there's so many different phenotypes of people we see. I mean, hypertension affects so many US adults in our country that whenever we're talking to a patient, we're noting their history, we're talking about their background, if we hear an element that feels unique or notable compared to our norms, it might be worth considering whether there are secondary causes at play. So this could be things like hypertension among patients less than 30, or very abrupt onset or acceleration of hypertension, significant family history of heart disease or stroke. These are helping us think about what could be happening that we're not able to measure yet correctly, but there's something else going on potentially. Also, like target organ damage in relation to someone's age. It's not normal for young people to be having heart attacks or strokes, but it's happening more often, or at least we're detecting it more often. Something else that comes up a lot in today's day and age is thinking about obesity and looking beyond that BMI number, thinking about visceral adiposity and abdominal circumference, because 25 to 50% of patients with hypertension have obesity and obstructive sleep apnea. And obstructive sleep apnea requires entirely different management strategies beyond just putting them on an antihypertensive pill. Chronic kidney disease comes up all the time and is a huge element to think about in our management. So beyond looking at patients who have diabetes, thinking about those who have a history of urinary frequency or an incontinence or elevated serum creatinin or abnormal urinalysis, those patients should potentially be worked up for additional causes of their hypertension, specifically chronic kidney disease. And I know we'll talk a lot about primary aldosteronism. And I think this is one of the both roses and thorns of the guidelines. It's a huge driver of secondary hypertension. However, it's hard to screen. Screening's rare. And I think some of the screening tools that we have are kind of hard to implement in everyday practice. So, but when we have someone who has resistant hypertension, we're throwing all the things we can that work for most people and it's just not working for this patient. Okay, let's think about primary aldosteronism and see how it works up for this patient. And I think obviously as a pharmacist, it's important to bring this up, but it's really important we look at medications that people are taking and then also evaluate their history for substance abuse, whether that substance is alcohol, but also nicotine, and then things like cocaine or methamphetamine use, of course. But many of the medications that elevate blood pressure are over the counter. They don't often show up in patients' medication lists at home because they only use them as needed, or even forget that they're in their closets at home. So this is things like pseudoephedrin, which we use for coughs and colds all the time, or NSAIDs for pain like ibuprofen and neproxin. There's very many antacid products over the counter that contain sodium. So it's really an important practice to do a thorough med rec with each visit. It's really important to know what patients are doing at home and how that's impacting how we're seeing them in the clinic right in front of us. Someone brought up herbals earlier, and I think that's becoming more and more important as patients are reaching outside of our traditional healthcare system to find treatments that work for them. I've had at least two patients in the last month bring in herbal supplements, and I'm looking through and doing some research, and it has Mahuang in it, which contains ephedrine and alkaloids and obviously elevates blood pressure. So those are things that can easily be talked about with a patient and not remedied per se, but at least addressed by doing a thorough med rec. Another important thing, especially for our early younger patients, is the importance of vaping and how much nicotine is contained in those products. I don't think always that the labeling is very accurate in describing how much nicotine is in those products, but when we have someone who's younger and in front of us who is reporting that they do vape, we need to consider whether that nicotine content is contributing to their elevated blood pressure. There's a lot of things to think about.

Sara Klockars 10:47

Thank you. That was an excellent overview.

What is Primary Aldosteronism and Who Should Be Screened?

Sara Klockars 10:50

And just briefly, I would love to jump back to primary aldosism. We've talked about it some already, but can you just briefly review what this is and who are you screening in your practice, Katie?

Catherine G. Derington 11:05

Yeah, absolutely. So primary aldosteronism is a condition where we have high blood pressure because we have high aldosterone production. And that aldosterone production is out of whack and not responding to the normal ways that we would correct electrolytes. And if we remember back to anatomy and physiology days, aldosterone is a really important hormone to regulate sodium and volume status. So when that level is high, we see high blood volumes, we see sodium retention, we see suppressed renin, and we have excessive potassium excretion. So the patient who is in front of you, you don't know that they have primary aldosteronism, but they may be presenting with resistant, difficult-to-treat blood pressure, particularly in younger patients. Sometimes they have low serum potassium values, but not all the time. And then a good proportion of the time they have obstructive sleep apnea. And these are important things to think about because those with primary aldosterinism have significant higher risks for cardiovascular events, twofold higher risk for heart failure, 2.8 fold higher risk for stroke, fourfold risk of aphib. So this isn't, you know, a benign condition. It's something we really need to think about a screening early. And as Andrea said earlier, if you look for it, you will find it. 10% of patients with hypertension have this condition, but we suck at screening. Less than 2% of people who could be screened for this condition are screened. And we know that screening is cost-effective, but it's fairly complicated. We have to look for the ratio between aldosterone and renin in the plasma after correcting electrolyte abnormalities and after removing meds like sporonolactone for four to six weeks. The confirmatory tests are like sodium loads or adrenal CT scans, adrenal vein sampling. Those are not fun tests, not easy to get scheduled for. So we have to think practically. And how these results are interpreted to diagnose primary aldosteronism are changing over time, which is why you'll see conflicted guidelines that don't always agree. And I think this will change a lot in the future. I work in an FQHC. We do very little, if any, screening for primary aldosteronism. Not saying that's the right thing to do, obviously, but it's really worth doing some work in our clinic to potentially identify a champion who could evaluate different workflows or processes that could codify how we look for these patients. Because as Andrea said, if you look for them, you will find them.

Prevent Risk Calculator vs Pooled Cohort Equations

Sara Klockars 13:34

Let's talk a little bit about the risk and thresholds and goals associated with blood pressure. We talked briefly about the prevent risk calculator. So would love to hear, Katie, how does this differ from the prior pooled cohort equations?

Catherine G. Derington 13:52

The prevent risk calculator is so much better than PCEs in a lot of ways. The major advantage of the prevent risk calculators is that we can look at risk for heart failure. We can look at risk of ASCBD or a combined version of those, which is termed total CBD. With the pooled cohort equations, we could only look at ASCBD. Prevent also can be used in patients as young as 30. So we can start thinking about risk earlier than the pooled cohort equations, which had a lower cutoff of 40 years old. PREVENT gives us 30-year risk of events, so we can start thinking about longer-term horizons. The pooled cohort equations kind of gave us back of the envelope lifetime risk that wasn't actually grounded in some statistical modeling. So that's a huge advantage of PREVENT, especially when we're talking about treating patients earlier and younger in their disease course. I'm really passionate that PREVEN removes the race predictor. We know that race is a social construct and not a biologic one. What they've replaced that with is with a zip code personalized estimator that uses area deprivation index. And that's not perfect, but it's better than introducing the racial bias with using a race variable in the modeling. And then the last thing that I think is really important is that PREVENT allows us to incorporate more indicators of the cardiokidney metabolic spectrum. So we can incorporate albumin to creatinin ratio or A1C. And so it allows us to think about risk more comprehensively than the PCEs let us do. The place where PREVENT comes in is if you have a patient in front of you who does not have a history of cardiovascular disease. So we're looking at primary prevention patients. They don't have a history of diabetes or CKD, so fairly uncomplicated hypertension, and they have stage one hypertension, so systolic 130 to 139 or diastolic 80 to 89. So if you have a patient like that, the guideline is telling us to calculate their 10-year prevent total CVD risk score. If you do that and the number comes out to seven and a half or higher, you should initiate medication immediately at the time of diagnosis. We're not doing a trial of lifestyle modification in these patients first. Although, of course, that's extremely important and should be a part of our treatment. We are initiating medication right away.

Sara Klockars 16:08

Great discussion about the role of prevent.

Why Do Blood Pressure Classifications Matter?

Sara Klockars 16:11

Wanted Mike to touch a little bit on the blood pressure classifications. So we have the different categories. And why do these classifications matter clinically? And are you using it to drive treatment decisions?

Michael E. Ernst 16:28

Yeah, thanks. So I think going back to our conversation, the classifications are important because when we have to make treatment decisions, you know, like many conditions need to stage the severity of it or the risk associated with it. When you look at the algorithm, and Katie talked about the role of prevent and, you know, where that fits in and when we decide to start treatment or not, you know, obviously staging the blood pressure, we've got to start there as part of this. So I mean, if you're stage two, you don't even really need to do the prevent calculator because the guidelines recommend that, you know, you're going straight to, in most cases, fixed dose combination of two agents. Whereas the individuals in stage one sort of fall in that continuum of risk, you know, some may be a lower risk, some some may be higher risk. So so I guess in a nutshell, these stages matter because they're really driving the decisions about whether we're going to start antihypertensive treatment, whether we're going to start with one drug or potentially two, or whether we're going to just keep an eye on things and promote lifestyle modification for a period of time and reassess.

Sara Klockars 17:36

Thank you. It's another piece of the puzzle.

What Blood Pressure Goal Should We Target?

Sara Klockars 17:39

Craig would love to hear, you know, what's the recommended blood pressure goal?

Craig Williams 17:44

Still, I think the main crux of these guidelines is when do we treat and then what do we use? And the when to treat portion, I think if you ask 10 clinicians, uh you've got 10 like variances on the answer. And I'll I'll defer back a little bit to our discussion of it. It is a bit uh of an individual decision because our patients think of their own risk as kind of differently. And uh, if you're having a discussion with someone who uh is currently smoking and rides a motorcycle without a helmet, then they probably think about risk than uh the next patient who buckles up the seatbelt every time they get in the car. So uh so it gets tough. And we just had that nice discussion of the goals. I think there's still room to argue, you know, is a systolic of 122 really an elevated uh number? And is a systolic of 132 the way most of us can see those in our clinics, a hypertensive number that warrants therapy. So to answer the question on the guidelines, they really codified around the under 130 as a systolic goal. And I think that's perfectly fair if that blood pressure is measured the way it's measured in clinical trials. And I think you have a mix of panelists here today. And if you work in a clinic that does a really careful job measuring that blood pressure in that clinic, and these trials often get three blood pressures each clinical trial visit and average at, and it's obviously always done with a well-fitted, automated, validated device, and patients are not talking to the person measuring their blood pressure, and they're not on their phone and their arm is supported, and they don't have to go to the restroom. And and then I think important for a lot of us in primary care, the patient not there because you have lower back pain or an abdominal pain that's concerning them. You you almost need kind of a well visit for an adult to get a blood pressure measure the way these clinical trials do. And then if you do that, then I think these are valid numbers. These numbers come from clinical trials. So, and that's a to my mind, so that's a pretty big context for these numbers. So I I honestly am still kind of in the the population number that I can definitely agree with is a systolic goal under 140. We can all agree above that, that's too high. You need to be lower. If you're in the 130s and you're on one or two drugs already, do I intensify therapy to get you under 130? If I do, I hope that was a well-measured pressure and probably an average of a couple pressures, maybe even measured at more than one visit, that you're persistently above that number before I add that third drug or thinking about working you up for secondary hypertension. So it's a long way of saying I don't disagree with these numbers, but I think they're numbers that come from clinical trials, and we don't all practice that way in our in our busy clinical practices.

Michael E. Ernst 20:34

Craig, I would just add too that this is where the importance of you know home readings comes into play as well, because we all know that as you've mentioned, oftentimes readings in the clinic are artificially higher because of just everything that goes on in the clinic. So I think that's important. But the concept I want everyone to think about is that when we have a goal, we at least with blood pressure, we tend to treat it as a floor. You know, we're happy to get down to it and kind of close to it. You know, I think that perhaps we should be thinking about the goal as more of a ceiling and that we don't want to spend a lot of time over it. Now, I think Craig has alluded to the fact that, I mean, everybody's an individual, and there are going to be people that we definitely don't want to be driving blood pressure down to a very tight range. But I think, again, there's so much therapeutic inertia that gets in the way of having better blood pressure control. I mean, it's why our national average is still 50% or thereabouts, you know, depending on what populations you're looking at. But I think it's just worth at least thinking about. Because I do routinely see people in the 130s. And if, you know, we try and make sure we've got carefully taken blood pressures, we try and, you know, validate that with home readings. And if we see that and it's an otherwise reasonably healthy individual, that I think that's one of the best things I can do is in terms of their cardiovascular risk. To try and get them a little bit lower because we've got eight clinical trials that have shown us that blood pressure goals of 130 or less are beneficial.

When to Use Lifestyle Changes vs Medications

Sara Klockars 22:11

I'm going to move us along to treatment because we have a lot of questions to answer for some of our listeners. So I wanted to talk a little bit about lifestyle. The guidelines, as I think Mike alluded to earlier, recommend that three to six months of lifestyle changes before starting meds and lower risk patients. And Andrea, is this realistic in your practice? Or are we setting patients up to fail? When do you skip straight to medications? Can you comment on this?

Andrea Darby Stewart 22:45

Yeah, absolutely. So, no, I believe in hope for all, right? So all of our patients should be given the opportunity to make the changes that will help them not just with their hypertension, but with all kinds of other chronic diseases in their life. And so I basically use shared decision making with my patient. If I'm giving them the diagnosis of a stage one hypertension, I've got some patients who are like, just give me a pill. I'm not going to do any of those things. Okay, let's talk a little bit about the medication and what that might mean for you. And you're comfortable you can take that every day. Great, let's go for it. But motivational interviewing and trying to figure out, you know, kind of what makes your patient tick, what's important to them. And then helping align their goal for health or wellness to that blood pressure number that seems like a weird number, right? Patients with hypertension don't have symptoms. So why should I take a pill for this? Or why should I change my life? I feel fine, is really the role of those of us who practice primary care. We are there to be coaches to our patients to help them achieve the best health that's available to them. So everybody gets an opportunity. If they say flat out, I'm not going to do lifestyle changes, then we talk about medications.

Michael E. Ernst 24:02

I think a good point to discuss with patients too in that situation is the fact that lifestyle modifications help the medications work better. So I think if someone's motivated to be on less medicine, continuing to address and help them be successful with lifestyle modifications can be really important. One other thing I wanted to add about lifestyle is that we all know the things that we're supposed to talk to our patients about with lifestyle. And I think sometimes that can be overwhelming for patients, or they've heard it before and they've struggled their whole life with weight, for example. Or and I think Andrew kind of alluded to this, but you know, really to some extent being sensitive to, you know, what matters to the patient, talking frankly about how each of these different lifestyle things can affect their blood pressure. And, you know, maybe I don't want to go run a marathon, but I can take the stairs instead of the elevator. Or I mean, there's a lot of ways that we can make a connection with patients in terms of implementing some lifestyle modifications. And the other thing that we'll often do too is show them the numbers in terms of the average effect of, for example, losing a couple of pounds on blood pressure. And I think when you couple those recommendations with that kind of objective information, it becomes very real to patients, like, wow, you know, that's as good as the single dose of a, you know, low dose of a single antihypertensive if I can lose 10 pounds. And that can be a powerful motivator. So I think we can always do a better job of how we discuss, have these conversations. And again, it's always a challenge, right? Because these visits are short and there's not always enough time. So these need to be ongoing and continued conversations over the course of multiple visits for those that are receptive.

Steve Small 25:48

Great thoughts there. And we have a couple audience questions that have come in.

How Do You Choose Initial Hypertension Therapy?

Steve Small 25:52

Katie, we have four meds that are considered first line for hypertension. So how do you pick which one to start first?

Catherine G. Derington 26:01

Yeah, absolutely. And the guideline didn't actually drastically change like these first line classes who are still thinking and reaching for the ACEs or ARBs, obviously, not both of them, calcium channel blockers and phiazide diuretics as first line agents. The question actually is now which two do you start? And that's the recommendation for most patients in the guideline when we're thinking about starting medicines. The reason being is that there's a lot more evidence coming out that it is safer to use low dose combination therapy than it is to use one medicine maximized to its highest dose. We know that side effects are a linear relationship to dose, meaning that no matter how much you ratchet up that dose, you'll increase side effects. And the effect is not the same. So when we can combine multiple meds with complementary mechanisms of action and keep it at a low and safe dose, we should. That historical start low go slow approach that I was taught and used for many years is no longer evidence-based. And so the guideline is really challenging us to think about starting two meds at once. And when you do using it in one pill, there are 28 different single pill combinations for blood pressure that are available in the US market. And nearly all of these are generic and covered by all types of insurances or on $4 drug lists. The guideline has a really great table. I think it's table 14 that lists these out. But these are nearly all the single pill combinations, combine these in different formats. You have ACEs and thiazides, you have ARBs and thiazides, you have ARBs and calcium channel blockers, we have ARG calcium channel blocker thiazide, triple therapy. So there's lots of different flavors of these. I don't typically reach for a beta blocker, and thus there's a compelling reason to do so. That's a bit of a difference from some of the European guidelines, but they just have higher side effect profiles and risks that just make me less likely to reach for them. I like to use long-acting arbs combined with a viazite or a calcium channel blocker. I really like telmasartin, herbosartin, or ulmasartin combined with HCTZ. That long-acting arb helps us ensure coverage over that 24-hour period. And then you just avoid the whole potential for ace cough altogether. Lo sartin is commonly used, but it actually has the porous blood pressure control over 24-hour periods. So I try to avoid it. And especially when the other arbs are generic, I really don't like to use it.

Michael E. Ernst 28:27

I would just add this is a wonderful time to be treating patients with high blood pressure because I'm old enough to remember when none of these first-line medications except for thiozides were available generically. And so we just have so many different options, and we're hitting different mechanisms of action. And to Katie's point about starting low doses of two drugs and a fixed dose combination, there's a great paper in hypertension here earlier this year, which showed the mean reductions with half dose, single dose, and double doses of all the different main classes, the fixed dose combinations. And the half dose of a fixed dose combination will give you, on average, as much or if not more than the full dose or double dose of one of these other agents as a single agent. So it's a great time to be treating high blood pressure, in my opinion.

Craig Williams 29:25

The only thing I'll add, Steve, is that I think, you know, I don't think there's three drugs or four drugs. I don't really see a need to have ACE numbers on this list necessarily anymore. Now that we're in the generic ARB era, is Mike said, I'm old enough to remember when those were branded agents and it was ACENIBERS first because they were cost effective. But as Katie alluded to, you'll have fewer adverse effects in a population if you go ahead and use the ARB as your RAS blocker. And so that's kind of our approach. So we think of this as three drugs ARBs, CCBs, and thiazides. And I would love to see head-to-head trial of Lusartin versus any other ARB for long-term outcomes. I'm still pretty agnostic on, you know, Lusartin as a first-line agent. I don't object to it, and everyone's very comfortable using it. And we've always got good data for it compared to other classes of drugs. So, but it's a good point. And uh I loved NH to fund that study, but I don't think I'll see it in my clinical lifetime.

Do GLP-1 Agonists Lower Blood Pressure?

Steve Small 30:18

And we're getting another audience question now. Do GLP1 receptor agonists lower blood pressure? Katie, could you help us answer that one?

Catherine G. Derington 30:28

Absolutely. And the answer is yes, I do. Obviously, the primary ways that these drugs lower blood pressure is from weight loss. There's a general rule of thumb that you can expect one millimeter of mercury reduction in systolic blood pressure for every one kilogram of weight loss. That's not a perfect rule. Of course, there's like dose-dependent effects and things, but it's a good general one to think about. But outside of weight loss, GLP1s have other mechanisms that lower blood pressure too. They actually induce natrioresis in the kidney. They lower circulating angiotensin. They cause release of nitric oxide, which causes vasodilation. There's actually also evidence to show that they penetrate the blood brain barrier. So they can reduce catecholamine release and reduce catecholamine receptor expression. But in total, these direct effects only reduce systolic blood pressure by two to four millimeters on their own outside of the weight loss. So not huge, but they do affect blood pressure. This is super interesting, I think, an evolving area of the literature. And the guidelines actually acknowledge this. They say that patients who have a BMI of 27 or higher who might be a candidate for a GLP1, that the GLP1 will actually be probably an adjunct to reduce their blood pressure. And I think practically for many insurances, we're seeing that hypertension can be used as a part of the justification or rationale for prescribing a GLP1. So when we're thinking about this in clinic and we have a patient who's starting one of these, we should be aware that if they have hypertension and we're already treating them with meds, we may need to modify that regimen if they're starting or increasing the dose of a GLP1. And something I'm seeing more and more, and actually I'm fairly concerned about, and I don't think is talked about much, is that patients are increasingly getting these medications outside of the bounds of our normal healthcare system. They're buying them online from systems like HIMS or hers or Roe. I mean, the ads are everywhere for those of us who are on social media. You can get them at your local like spas or aesthetic companies. So we need to also be asking patients if they're using these, even if we don't see them in their chart and if we didn't prescribe them ourselves, because it affects a lot of what we do downstream.

Do Supplements Help Lower Blood Pressure?

Steve Small 32:42

Really great points. What supplements can help lower blood pressure? Some audience members have mentioned magnesium, some garlic, some even beetroot. Uh any thoughts there?

Craig Williams 32:54

Unfortunately, there's there's no supplements that we can recommend with any confidence that certainly reduces cardiovascular outcomes or even consistently lowers blood pressures in a way that we can recommend. So there's nothing in the guidelines, no supplements that the guidelines recommend. And we alluded to earlier, there's a couple in the guidelines that can potentially raise blood pressure a bit. So it's definitely something like with the GLP1 scase, ask your patient what they're using and get a list. If patients say they're using something, again, that's a great gateway to have a conversation on. I'm glad you want to lower your blood pressure and reduce your risk. Let's talk about what we can do to do that.

Sara Klockars 33:32

Thanks, Craig. And

Hypertensive Emergency vs Severe Hypertension

Sara Klockars 33:34

then one last question for you, Katie. Can you briefly review the differences between hypertension emergencies and severe hypertension?

Catherine G. Derington 33:43

Yeah, and this has changed a lot over the last few years. So it's good to review. Right now, the defining feature is really the presence of target organ damage. In both situations, you have a super high blood pressure greater than 180 over 120. The thing that distinguishes them is in a hypertensive emergency, we have acute target organ damage. We're looking at stroke, heart attack, acute kidney failure, or even some other like neurologic manifestations like encephalopathy, things like that. And those patients need to be acutely admitted into the hospital to carefully manage and monitor them and lower their blood pressure slowly. On the other hand, if you have a severe hypertension patient who comes in with that same blood pressure greater than 180 over 120, we're not using that hypertensive urgency anymore if they don't have acute target organ damage and they're not symptomatic. These patients can be managed in the outpatient setting. We can either reinstate a therapy that they stopped or something and address adherence there, or we can ratchet up their therapy and intensify. I appreciate these differences, but I think in reality, a lot of our patients fall into a gray zone in between the two where they have a high blood pressure, but maybe have more non-specific symptoms like chest pain or headache. And the guideline doesn't really address what to do in this more gray zone, but extremely common circumstance. And it's of course left up to clinical discretion. But in the guideline, it seems the emphasis is on encouraging providers to think about patients and managing them on the outpatient instead of just referring them to the ER simply because they have high BP.

Craig Williams 35:23

Yeah, honestly, I I've got to kind of live through iterations of these guidelines and see this evolve. And because if I've had a foot in the inpatient side, yeah, I've watched a lot of interest. And I think a lot of academic healthcare centers have kind of already adopted this approach. We don't use anywhere near, certainly the IV hydrolosines have pretty much disappeared from our service, and even the occasional oral clonidines have pretty much disappeared from most kind of academic hospital practice settings. But it's still nice to see this more codified in the guidelines. The big takeaway for me from this is asymptomatic, severely high blood pressure doesn't need therapy. And yeah, Katie makes good points on what we define as either symptomatic or signs of disease that define an emergency. Like things like protonuria, if you don't know what the patient's urine protein was six months ago or a year ago, it's it's hard to know what to make of that and just kind of one acute measurement. And symptoms can be vague, as Katie alluded to. So we're being much more narrow on what symptoms could actually be from high blood pressure and and what could be from like headache famously is really doesn't associate very well with elevated blood pressures. And most of us get a headache, it's not because we have severely high blood pressure. So we're being much more narrowed, narrow in what symptoms would should we look for in the hospital setting. And then general, just be comfortable with really high numbers that don't need an acute intervention. And I think that was a nice change in this guideline, is saying it's okay to be comfortable with a really high number if there's no attributable symptoms or signs. Just yeah, restart outpatient therapy or or start potentially an initial oral therapy. Don't reach for those IV bags of things we used to use 10 years ago.

Conclusion

Narrator 37:09

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