Uncontrolled high blood pressure: the old “silent killer” is still alive and well

Uncontrolled hypertension is a significant risk factor for stroke and heart attack, and lifestyle modifications such as diet and exercise, along with proven supportive drug therapies, are essential for the prevention and management of cardiovascular disease.

In a commentary published in American Journal of MedicineResearchers at Florida Atlantic University's Schmidt College of Medicine are warning healthcare professionals that an ancient “silent killer” is alive and well.

“Healthcare providers need to be aware that hypertension is one of the most common, serious and growing conditions we see in our patients,” said Stacey Rubin, M.D., senior author and assistant professor of medicine in the FAU Schmidt College of Medicine. “Healthcare providers need to manage blood pressure urgently and keep in mind that sudden cardiac death accounts for 50 percent of cardiovascular deaths and is the first symptom in approximately 25 percent of cases. Additionally, in 76 percent of stroke patients, the first symptom is the stroke itself.”

The authors point out that controlling hypertension is effective and, at least in theory, easy. Prior to the landmark Hypertension Detection and Tracking Programme, a study carried out in the US in the 1970s, only around 50% of patients were aware of their hypertension. Of these, only 50% were actively treated. Of that group, only 50% were effectively treated. In other words, only one in eight patients were effectively treated.

Currently, these figures indicate that 54% are aware of their high blood pressure, 40% are actively treating it, and 21% are actively controlling it. Many countries around the world have developed guidelines, all of which tend to emphasize the need for strict control. According to the most recent guidelines from the American Heart Association and the American College of Cardiology, healthy individuals should have a systolic blood pressure of 130 millimeters of mercury (mmHg) or less and a diastolic blood pressure of 80 mmHg or less.

“By these updated definitions, hypertension affects approximately 45 percent of the U.S. adult population,” said co-author Panagiota “Yota” Xantas, PhD, professor and chair of the Department of Population Health and Social Medicine at FAU's Schmidt College of Medicine. “Another clinical challenge is the metabolic syndrome, which includes central obesity, high triglycerides, low high-density lipoprotein cholesterol, high fasting glucose and hypertension.”

The authors warn that in the United States, the world's most obese society, metabolic syndrome is a major risk factor for heart attack and stroke.

“We believe that angiotensin-converting enzyme inhibitors, or the more powerful next generation of receptor blockers, are the first-line treatments for patients with metabolic syndrome,” said co-author and corresponding author Charles H. Hennekens, MD, the Sir Richard Doll Professor, senior academic advisor and professor of preventive medicine in the Department of Population Health and Social Medicine at FAU Schmidt School of Medicine. “These drugs have a positive effect on heart attack, stroke and kidney disease, the other major consequence of leaving high blood pressure untreated.”

Positive lifestyle changes, such as losing weight, being more physically active, and reducing salt intake, have been shown to be effective in managing blood pressure. For people with blood pressure above 130/80, these lifestyle changes, combined with medications, can safely and effectively lower blood pressure. If blood pressure remains above 140/90 despite these lifestyle changes, medications are usually initiated.

The authors suggest that both healthcare professionals and patients should be aware of fluctuations in blood pressure from day to day and from morning to night. This complicates effective treatment as healthcare professionals must create algorithms for each patient. In addition, patients must actively monitor their blood pressure. For this reason, the American Heart Association and the American College of Cardiology recommend Omron blood monitors, which are used to measure blood pressure levels at home.

“Healthcare providers should advise patients to measure their blood pressure every morning and evening and prescribe or adjust the dosage of certain medications accordingly, based on the average of three measurements taken approximately five minutes apart,” Hennekens said. “While hypertension remains uncontrolled in the U.S. and around the world, healthcare providers may be able to 'eradicate this ancient silent killer' by paying close attention to these issues.”

Co-authors are Barry R. Davis, MD, PhD, professor emeritus of biostatistics and data science at the University of Texas at Houston School of Public Health; high school and pre-med student Jared Greenwald; second-year FAU medical students John Dunn and Alexandra Matarazzo; and second-year FAU medical student Katerina Benson.

Hennekens served as the coordinating center principal investigator (PI) for both Phase I and Phase II of the landmark National Heart, Lung, and Blood Institute (NHLBI)-funded Multicenter Randomized Trial of Hypertension Prevention. Davis served as the coordinating center PI for the landmark NHLBI-funded Antihypertensive and Lipid-Lowering Multicenter Randomized Trial of Heart Attack Prevention.