The Curbsiders Internal Medicine Podcast

#77 Hypertension Guidelines Showdown

10 snips

Jan 8, 2018

Dr. Mary Ann Forciea, a leader in geriatric medicine and chair of the ACP hypertension guidelines, shares her insights into blood pressure management for older adults. She discusses the nuances of measuring blood pressure properly and the significance of different target goals. Dr. Forciea also highlights how guideline development works and the importance of critically evaluating them. Key topics include the role of ambulatory monitoring, managing frail patients, and the differential recommendations from the ACP and ACC/AHA guidelines.

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ADVICE

Standardize BP Measurement

Standardize blood pressure measurement: have patients sit quietly for five minutes with feet on the floor and back supported before recording.
Prefer validated upper-arm oscillometric devices and check cuff accuracy by bringing the home monitor to clinic periodically.

ANECDOTE

Surprise About Home Monitor Algorithms

Mary Ann Forciea learned there are three BP monitor types: mercury, aneroid, and oscillometric.
She was surprised automated home monitors calculate systolic/diastolic from mean arterial pressure algorithms.

ADVICE

Confirm Office Readings At Home

Use home or ambulatory blood pressure monitoring to confirm office readings and detect white-coat hypertension.
Ask patients to take twice-daily home readings for 2–3 days if ambulatory monitoring isn't available.

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Ease the tension around blood pressure goals in older adults and get inside the hypertension guidelines released by the ACP and ACC/AHA in 2017 with the sagacity of Dr. Mary Ann Forciea, MD, MACP, Professor of Medicine at University of Pennsylvania. We cover: how to properly measure blood pressure, how to diagnose hypertension, blood pressure targets, why BP goals differ by society, how to guidelines are written and how to interpret them with a critical eye, plus a hot take on the 2017 ACC/AHA guidelines. Dr. Shreya Trivedi joins as cohost. Special thanks to Hannah Abrams for her wonderful infographics and to Dr Trivedi for compiling our show notes.

Time Stamps

00:00 The setup
02:15 Disclaimer
03:32 Picks of the Week
08:13 Getting to know Dr Forciea
13:35 Broad overview and a clinical case of geriatric hypertension
14:45 Brief history on BP targets
18:05 How do you measure a blood pressure? What type of monitors are available?
22:13 How to standardize BP in the office?
23:55 Ambulatory BP monitoring
24:55 Home blood pressure monitoring
26:11 Standing blood pressure readings and orthostatic hypotension
27:53 How guidelines are written
30:51 Evaluating evidence quality and strength of recommendation
32:35 Timeline and process for guideline generation
34:27 How to read guidelines with a “critical eye”
36:15 Return to our case of uncontrolled hypertension
38:25 Blood pressure targets from ACP guidelines and BP management in frail older adults
40:33 Counsel patients on BP targets
42:25 Low diastolic blood pressure
45:35 SPRINT and the ACP BP guidelines
48:58 Take home points from Dr Forciea
50:07 HTN targets and pay for performance in clinical practice
51:45 Curbsiders recap the ACP guidelines
53:45 Matt and Paul recap the AHA guidelines
54:47 AHA definitions of hypertension
56:15 Diagnosing hypertension and how to measure a blood pressure
60:35 Choosing a blood pressure monitor and HBPM
62:29 Blood pressure goals in ACC guidelines
66:08 Non-pharmacologic measures
69:15 Will we follow these new strict targets?
72:45 Outro

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