The "100 Questions on Clinical Practice of Hypertension Guidelines" was launched, focusing on clinical practice issues, answering questions, and helping hypertension diagnosis and treatment|World Hypertension Day

Hypertension is one of the most important and interventionable risk factors for cardiovascular and cerebrovascular diseases, and it is a "silent killer" that threatens human health. According to the "China Cardiovascular Health and Disease Report 2022", it is estimated that there are 245 million people suffering from hypertension in mainland China, and the prevention and treatment of hypertension is urgent. World Hypertension Day is celebrated on May 17 every year, and today is the 20th World Hypertension Day, with the theme of "Measure your blood pressure, Control it, Live Longer".

On the occasion of World Hypertension Day, the "100 Questions on Clinical Practice of Hypertension Guidelines" compiled by the Beijing Association for the Prevention and Treatment of Hypertension and the Hypertension Alliance was officially launched, from blood pressure measurement and diagnostic evaluation, antihypertensive treatment strategies, antihypertensive treatment goals, non-drug treatment of hypertension, hypertension drug treatment, hypertension device treatment, treatment of hypertension in special populations, hypertension combined with clinical diseases, refractory hypertension and secondary hypertension, Ten aspects of risk factor management and follow-up of hypertensive patients answered the relevant questions encountered in clinical practice.

Introduction to "100 Questions on Clinical Practice of Hypertension Guidelines".

"100 Questions on Clinical Practice of Hypertension Guidelines" is a collection of questions and answers on hypertension management, and as an auxiliary tool for the latest hypertension guidelines, it is aimed at clinicians of hypertension and related disciplines to answer relevant questions encountered in clinical practice.

In recent years, new research, new drugs, and new treatments have emerged, which have enriched the connotation of clinical management of hypertension on the one hand, but also brought a lot of confusion to everyone. In order to answer questions, the Hypertension Alliance and the Beijing Hypertension Prevention and Treatment Association collected the practical clinical questions raised by 204 young doctors across the country, condensed 100 "questions and answers", and 96 hypertension experts across the country analyzed these "questions and answers" respectively, and finally 10 editors-in-chief and deputy editors-in-chief conducted the final review and compiled into a book. This procedure guarantees the accuracy and clinical applicability of the Q&A.

This handbook is edited by Professor Zhang Yuqing from Fuwai Hospital, Chinese Academy of Medical Sciences; Professor Deng Yuxiao from the First Affiliated Hospital of Nanchang University, Professor Jiang Weihong from the Third Xiangya Hospital of Central South University, Professor Li Li from Beijing Tongren Hospital Affiliated to Capital Medical University, Professor Liu Min from Henan Provincial People's Hospital, Professor Shu Yan from Sichuan Provincial People's Hospital, Professor Wang Qiongying from the Second Hospital of Lanzhou University, Professor Xi Yang from Peking University People's Hospital, Professor Xu Jianzhong from Ruijin Hospital affiliated to Shanghai Jiao Tong University School of Medicine, and Professor Zu Lingyun from Peking University Third Hospital served as deputy editors-in-chief (in alphabetical order of surname).

Professor Zhang Yuqing introduced that the "100 Questions on Clinical Practice of Hypertension Guidelines" not only provides answers to clinical questions, but also contains detailed explanations and suggestions, which are convenient for medical workers to better understand and apply, so as to better help deal with hypertension and related clinical conditions. This is a practical handbook tailored for physicians in hypertension and related disciplines to help physicians find standardized and individualized treatment options to better manage patients with hypertension.

On the occasion of World Hypertension Day, Yimaitong has excerpted part of the content of "100 Questions on Clinical Practice of Hypertension Guidelines" for readers.

1. For patients with different grades of hypertension, how reasonable is the general hypertension target time after they start to use drugs to lower blood pressure? Is there a difference in the time required for different grades of hypertension?

Analysis:

According to the requirements of hypertension-related guidelines in China and abroad in recent years, the time to achieve blood pressure should be 4 weeks to 12 weeks, but none of the guidelines determine the time to reach the target according to blood pressure classification.

In clinical practice, for most patients with hypertension, it is recommended that the goal should be achieved within 4 weeks; In older patients, patients with severe coronary or bilateral carotid artery stenosis, and poorly tolerated drug therapy, the time to blood pressure target can be extended as appropriate, but the time to target blood pressure should also be controlled within 12 weeks. For patients with hypertensive emergencies (aortic dissection, acute coronary syndrome, hypertensive encephalopathy, eclampsia, etc.), blood pressure should be smoothly and rapidly lowered to target blood pressure within 24 to 48 hours. All in all, the time to reach blood pressure varies from person to person.

At the same time as the patient starts drug antihypertensive therapy, it is also necessary to take into account the patient's health education, that is, to improve the lifestyle and reasonably avoid possible factors that affect blood pressure, to follow up the patient regularly and adjust the treatment plan in time according to the patient's blood pressure.

2. Different patients respond significantly to different types of antihypertensive drugs for different CCBs, so how to evaluate and understand which type of CCB is more suitable for patients before treatment?

Analysis:

CCB drugs can be divided into dihydropyridine and non-dihydropyridine according to their structural characteristics, and the drugs used to lower blood pressure are mainly dihydropyridine CCBs, which are divided into long-acting and short-acting drugs. Because short-acting drugs need to be taken multiple times and have certain adverse effects on the heart, they are currently mainly used in emergency hypertensive patients without potential risk of heart failure. Long-acting dihydropyridine CCBs are recommended for most patients with hypertension, especially those with cerebrovascular disease, renal insufficiency, variable angina, and isolated systolic hypertension in older adults. Amlodipine or felodipine is recommended first in hypertensive patients with cardiac insufficiency, if it must be used. In addition, non-dihydropyridine calcium antagonists have a certain negative effect on cardiac conduction, which is suitable for hypertensive patients with supraventricular arrhythmias, and should be used with caution in patients with atrioventricular block.

3. What are the benefits of low sodium salt for people with high blood pressure? Who should not be given low-sodium salts?

Analysis:

Excessive sodium and potassium intake, as well as a low potassium-to-sodium ratio, are important risk factors for the development of hypertension in mainland China. Modestly reducing sodium intake and increasing dietary potassium intake can help lower blood pressure.

Results from cohort randomized controlled trials in mainland China in stroke patients, patients at high risk of stroke (SSaSS study), and older people (DECIDE-salt study) showed that low sodium potassium-rich salts significantly lower blood pressure, reduce stroke, and reduce the risk of cardiovascular events and death compared with regular salt.

Patients with renal failure, adrenal insufficiency, or spironolactone are not likely to use hyposodium because these patients are more likely to develop hyperkalemia.

4. Patients with high blood pressure should not eat chili peppers, so as not to cause blood pressure to rise? Is this statement correct?

Analysis:

This statement is incorrect. Chili pepper not only does not cause blood pressure to rise, but also has a certain antihypertensive effect, so it is beneficial for patients with high blood pressure to eat chili pepper in moderation.

Among people who did not drink alcohol, those who ate spicy food daily had a 28% lower risk of developing high blood pressure than those who never ate spicy food. In women, those who ate spicy food more than three times a week had a 12% lower risk of developing high blood pressure than those who never ate spicy food, and the more times a week they ate spicy food, the more significant the drop in systolic and diastolic blood pressure. Studies have found that spicy eaters reduce salt intake by 2.5 grams per day compared with those who do not like spicy food, and SBP and DBP are 6.6 and 4.0 mmHg lower respectively.

The manual points out that eating chili peppers not only has a mild direct antihypertensive effect, but also helps to reduce the patient's need for table salt and indirectly plays a hypotensive effect. In addition to this, eating chili peppers can also promote the excretion of sodium, which also helps to lower blood pressure. A recent meta-analysis also found that people who love spicy food may live longer and have a lower risk of dying from diseases such as cardiovascular disease and cancer.

5. Can exercise treat high blood pressure?

Analysis:

Regular exercise is beneficial in both preventing and treating high blood pressure. Exercise for the purpose of treatment in patients with hypertension is not only an increase in daily physical activity, but more importantly, an active exercise intervention. Specific exercise interventions include: (1) aerobic exercise: There is strong evidence that aerobic exercise can reduce blood pressure by 5-7 mmHg in adults with hypertension. Among low, moderate, and high-intensity aerobic exercise, moderate-intensity aerobic exercise has the best antihypertensive effect. (2) Resistance exercise: The antihypertensive effect may be comparable to or even greater than that of aerobic exercise. Resistance exercises are not used to increase muscle strength, but rather to achieve exercise therapy through very light strength training. (3) Meditation and breathing training: It can alleviate or even relieve various causes of hypertension caused by psychological stress, cervicogenic cardiovascular disease, poor posture and posture.

(4) Flexibility training and stretching training: comprehensive training of joint mobility and muscle strength is a simple and safe exercise treatment method to eliminate fatigue, improve daily activity ability, and delay aging.

6. How is refractory hypertension diagnosed? What tests are needed? How should lifestyle interventions be made in patients with treatment-resistant hypertension?

Analysis:

Refractory hypertension is called refractory hypertension when blood pressure remains above target levels in the office and outside of the office (including home blood pressure or ambulatory blood pressure monitoring) after at least 4 weeks of treatment with adequate and reasonable doses of 3 antihypertensive drugs (including a thiazide diuretic) that are tolerated and appropriate, or at least 4 drugs are needed to achieve blood pressure targets.

First, out-of-office blood pressure measurement (home blood pressure measurement and ambulatory blood pressure monitoring) should be used to rule out the white coat blood pressure effect and occult hypertension. At the same time, look for the causes of poor blood pressure control and coexisting disease factors. In addition to assessing the patient's adherence, rationality of antihypertensive drug use, use of antihypertensive drugs, poor lifestyle/obesity, and volume overload (inadequate diuretic therapy, high salt intake, progressive renal insufficiency), comorbid disease conditions such as diabetes, dyslipidemia, chronic pain, and long-term insomnia and anxiety should be evaluated by completing biochemistry.

After the above factors have been ruled out, screening for secondary hypertension should be considered, including renal disease (renal parenchymal hypertension, renovascular hypertension), endocrine diseases (primary aldosteronism, pheochromocytoma/paraganglioma, Cushing syndrome, hyperthyroidism, etc.), cardiovascular disease (aortic regurgitation, aortic stenosis, etc.), and obstructive sleep apnea syndrome (OSAS).

Patients with treatment-resistant hypertension should be treated with ongoing therapeutic lifestyle changes, including:

Weight loss: 5-10% weight loss in overweight and obese adults; Strive to keep body mass index below 24 kg/m²;

Salt restriction: sodium chloride intake should be controlled below 5 g/d;

Reasonable diet: DASH diet and Chinese heart healthy diet and spicy diet;

Alcohol restriction: Alcohol restriction is <10 g/d (women) and <20 g/day (men) or daily alcohol consumption < 15 g/d;

Exercise: at least 30 minutes of moderate-intensity exercise at least 5 days a week, mainly aerobic exercise, supplemented by anaerobic exercise;

Reduce psychological stress and improve sleep: ensure 7-9 hours of sleep per day;

Mitigating environmental triggers: Avoid factors such as cold, noise, air pollution, etc.

7. Why should diastolic blood pressure not be controlled too low in patients with coronary heart disease and hypertension?

Analysis:

Hypertension is one of the most important risk factors for coronary heart disease, and the two are often coexisting. The risk of cardiovascular mortality is significantly increased when hypertension is associated with coronary artery disease. Patients with coronary heart disease and hypertension need to control blood pressure more strictly, and emphasize the need to achieve target blood pressure. However, it is important to note that the effect of blood pressure on patients with coronary heart disease is U-shaped, so it is not always better to control blood pressure as low as possible.

Under normal circumstances, the blood supply to the coronary arteries occurs during diastole, so it is not recommended to lower the diastolic blood pressure. When diastolic blood pressure falls below a certain level (J point), the blood supply to the myocardium decreases, which can increase the incidence of cardiovascular and cerebrovascular events in patients with coronary heart disease. The INVEST study shows that the J-point of diastolic blood pressure is 70 mmHg, so do not let it fall below 70 mmHg during the blood pressure lowering process. In general, according to domestic and international guidelines and clinical practice, it is generally recommended that patients with hypertension and coronary heart disease reduce their blood pressure to below 130/80 mmHg, preferably not less than 70 mmHg, if tolerable.

This article was reviewed and published by Professor Zhang Yuqing

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