The New Hypertension Guidelines and My Decision to Treat Now

February 26, 2018

It has been a little over a month since the new guidelines came out for the diagnosis and treatment of hypertension in adults.

As is well-reported through the ACC and a variety of other media outlets, hypertension is now categorized as follows:

• Normal: Less than 120/80 mm Hg;
• Elevated: Systolic 120 – 129 mm Hg and diastolic less than 80 mm Hg;
• Stage 1: Systolic 130 – 39 mm Hg or diastolic 80 – 89 mm Hg;
• Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg.

While these changes are expected to affect an even higher percentage of U.S. adults, perhaps the greatest meaning of the new definition will be imparted upon the younger individuals, those less than 45 years old.

And I am one of them.

A lot of people, including physicians, are always surprised to hear this news when I speak up. I think this is because – outwardly – I do not play the part; I am not too far off from 30-years-old, eat a lot of fruits and vegetables, exercise frequently and would otherwise appear to be (and am) quite healthy.

The truth is that the numbers do not lie; I have maintained nearly identical blood pressures for the better part of the past four years. Yes, the scientist in me has been has required that I keep track. And, yes, I have been doing everything I have learned through this and previous guidelines to ensure I am getting the most accurate figures possible.

Additionally, like a lot of my generational peers, I knew that my family history, while not ragingly positive, certainly could not be ignored forever. I figured I would need to start medication at some point. My unspoken plan was to wait a few more lifetime milestones: I would treat my blood pressure somewhere around age 40, and then start an aspirin and statin about another ten years down the road, all else remaining relatively equal.

The kicker for me was what the 10-point drop in the new definitions imply; now, a consistent diastolic blood pressure of 90 mm Hg puts me all the way up into Stage 2 hypertension. As soon as I read the November headlines, I knew it would be tough to stick to the original plan, and I feel OK about it.

I spent the first two weeks attempting to be very honest with myself and taking on some lifestyle modifications. I read food labels, quit salting foods, pumped up the aerobic activity a bit, re-verified the readings on my home blood pressure and made my intentions known to my immediate family and co-fellows, who would help keep me accountable. At the end those two weeks, my very honest conclusion was that it would be extremely difficult to reliably keep up this level of diligence.

Ultimately, I decided it was time to start a medication.

At that point, I spent a good deal of mental energy deliberating over what agent I would go for. I quickly began to see how ready I was to offer these drugs to patients – including the obligatory but cursory discussion of side effects – but how reluctant I was going to be taking something myself. (The adage is true: doctors definitely make the worst patients).
In the past week or so, I have moved on to the monitoring phase, where I do my best to attempt not to react like a Type A cardiology fellow and instead do what my primary care doctor suggests. I try to focus on being diligent about monitoring my blood pressure and taking my medicine, while hopefully not losing track of the lifestyle modifications that play a big role in stabilizing whatever gains I have made. I hope that a second agent is not needed, though the cards may be stacked against me.
I look at myself and consider that these are the behaviors I continually ask of my patients. Now, I am quite literally getting a dose of my own medicine.
So, why write this article?
Most importantly, my goal is that this piece might be a reminder that the things we recommend to our patients, even a suggestion as commonplace as taking a pill every day, are not always so easy to perform. Additionally, as providers, it is important to remember that it can be scary for a patient to think about anything that might compromise a brighter future for his or her cardiovascular health.

When it comes to the management of high blood pressure, put it this way: we are arguing that the only successful approach is through a long-term management strategy, and the stakes are high.

Until the time the hypertension guidelines changed, serving to alter my thinking and affect the choice to finally treat my hypertension with medication, I maintained an emotional discrepancy with my patients in this arena. It is the difference of understanding that something potentially harmful exist, and actually getting to experience it firsthand.

For me, hypertension became personal.

The author wished to keep his or her identity anonymous.