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- [00:03]
A
Welcome to the first of our three part special series focused on hypertension. Hypertension is one of the most common and important risk factors that we all diagnose and treat every day in the office. In fact, the American College of Cardiology American Heart Association's 2025 guidelines, which came out just about a year ago, reaffirmed, and I'm going to quote here, hypertension is the most prevalent modifiable cardiovascular disease risk factor and is the leading cause of death and disability worldwide. It is serious. Hypertension is associated with an elevated risk for total cardiovascular disease, coronary heart disease, heart failure, peripheral vascular disease, kidney disease, ischemic and hemorrhagic strokes, dementia and cognitive impairment. And on today's podcast, we're going to discuss assessment and management. In part two, we'll discuss uncontrolled and resistant hypertension, which is a lot more common than we often think it is. And then in part three, we'll look at some common and challenging cases. There were important changes in the American Heart Association ACC 2025 guidelines and we're going to make sure that we cover those changes. I'm your host, Dr. Neal Skolnick, professor of Family and Community Medicine at the Sidney Kimmel Medical College of Thomas Jefferson University. And this special edition of Diabetes, Obesity and cardiometabolic update that is formally diabetes core update is sponsored by AstraZeneca. Joining us to discuss the updated guidelines today is Dr. Manish Rajpal. Dr. Rajpal is a board certified nephrologist and hypertension specialist trained at the Cleveland Clinic. He has extensive research experience in renovascular hypertension, hypertension in kidney transplantation and cardiorenal interactions. He is a reviewer for the Journal of the American Society of Hypertension. Welcome, Manish.
- [02:33]
B
Thank you. Thank you. Dr. Skolnick. Thank you for having me. And thank you for bringing attention to hypertension. Believe me, we have been dealing with hypertension for a long time, but we need to do better. So I truly appreciate being here and adding to it.
- [02:48]
A
Thank you, Manish. It's so interesting. You're so right that we've been dealing with this for a long time and we've still got a ways to go. And one of the things that's impressed me as a primary care clinician, because we see this all the time, is that just like so many things we see all the time, we become used to it. This is true. Right at home. We don't value our family members the way that we should because they're always there, right? We need to value them. And the same with hypertension, we don't attach the importance to it because we're so used to treating it. And can you remind us of the degree of effect that we can have when we treat hypertension correctly?
- [03:38]
B
Yeah. So hypertension, you know, is just a number. And by the way, even though I say it's just a number, that has been the bone of contention between various guidelines ever since I started training. We moved from JNC7 to JNC8 and then Accaha took over in 2017 and then finally updated in 2025. And the bottom line is, yes, we need to control blood pressure to a certain number, which, by the way, spoiler alert is less than 130 by 80, preferably less than 120. Please keep that preferably less than 120 in your mind. And it is important because with every 10 point reduction, we do reduce the risk of MACE, cardiovascular dementia, ESRD. So this number and sticking to this number is very important. All that talk about this is my patient's normal blood pressure does not stand a chance, especially after the newer data in Sprint Accord and various Chinese studies have shown itself. So yeah, that's what I would.
- [04:51]
A
That's what I. Yeah, no, you're so right. I hear so many patients say, well, my pressure is always this. I don't have to worry, worry. And well, yes you do if it's elevated. Now you mentioned for every 10 millimeter drop there's an improvement. I remember hearing something like for every 20 millimeter increase in systolic blood pressure, there is a roughly doubling of cardiovascular outcomes. You mentioned the 10 millimeter drop if someone goes from, let's say 150 to 140 or 140 to 130. Is there a sense of the degree of improvement that one has with just that 10 millimeter of mercury improvement?
- [05:34]
B
Yeah, so. So every 10 millimeter mercury drop is important not just for the heart, brain, kidney, but also for longevity. And again, since that is the new buzzword on all the podcasts, everybody wants to live forever. So if you do want to live forever, please reduce your heart risk, cardiovascular risk by 20% by dropping your systolic blood pressure by 10. Reduce your chronic heart conditions, reduce your strokes by 27%, reduce your heart failure risk by 28% and reduce your all cause mortality by 13% for every 10 millimeter. And I do emphasize that. Why? Because when a patient first shows up, you know, doctors try to do the right thing. They will prescribe the first medication and then therapeutic inertia creeps in. You know, we are bad at prescribing the second medication. And by the way, we are really bad at prescribing the third medication. And neither the patient nor the doctors want to prescribe that medication. And if, say, for example, your patient shows up at, let's call it 160 and you do the right thing and you bring them down to 140, don't be complacent, you still have 20 millimeter mercury that you can drop, provided the patient can tolerate it. And that is a very important 20% provided, you know, I mean, there's so much to gain with that. So please know these numbers, that these numbers are important and these numbers are directly proportional to how well you are sticking to the guidelines.
- [07:14]
A
You know, it's interesting. I was surprised and I've, you and I both have been doing this a while when I went back and looked at the literature and saw the numbers you just went over that they apply not just moving from 160 to 150 systolic, but equally from 150 to 140, 140 to 130. That percent drop is something that we in cardiovascular outcomes, in stroke risk is mind boggling and higher than we commonly think think that it is. Let's move on now to classification of blood pressure using the 2025 guidelines to guide us. Can you go over the classification?
- [07:58]
B
Yes. So all of us have this sense that our blood pressure is normal. So please, anybody who's listening, go home, relax, put your oscillometric blood pressure machine on, press the button. If you do not get less than 120 and less than 80, you are not normal. Okay? And most of us who work in medicine, it is highly unlikely that you will be normal. All right? And so then say, for example, you don't get that less than 120 and less than 80. So essentially you want 119 by 79 to be normal. Correct. Or lower. But let's say even one of those are not met, that automatically puts you at higher blood pressure. Now if you, you're not exactly hypertension till you are above 130 or above 80 and 130 to 139 and 80 to 89 will put you in stage one hypertension. After that, 140 to 149 or above 90 will put you in stage two hypertension. And then finally there is uncontrolled hypertension. The reason we, we divide it into stages is because we want to figure out whether I give you one blood pressure medication off the bat or two blood pressure medications off the bat. And these readings have to be two visits apart, by the way, for you to get those medications. What do you do if your blood pressure is between 120 to 130 systolic and diastolic is still less than 80, this is your only chance where you can just go, go about with lifestyle modifications without really dealing with a pill. Everybody wants to say, hey, let me do a better lifestyle. I'll stick to less alcohol, less, you know, increase exercise, better dash diet, and so have you. So, so 120 to 130 is your window to do all of that. Once you are above 132 visits in a row, you are, or you should at least get one medication and then you try to do better. Now, I said something about adding one or two medications right off the bat for stage one and stage two hypertension. There is one more important caveat we added to that, and that is your prevent score, which is your ACCAHA calculator. You can just plug it in into any calculator you use. And this has included uacr, urine, albumin, creatinine ratio. So we finally nephrologists have convinced the cardiologist that urine is important. And by the way, it is very important. And we have included that in the score. If you are at a higher score in that, then that promotes more stricter blood pressure control and quicker introduction of blood pressure monitoring. So I connected the stages of hypertension with the treatment and I'll be happy to go over anything again if needed.
- [11:04]
A
Yeah, we'll talk more about that in a little bit. And I'm glad that you mentioned the prevent calculator because we really are moving. We have moved away from the old ASCVD calculator that all of us were used to is often still in our electronic health records. People go to their iPhones to pull it up. We should be using now the prevent calculator. And I want to come back in a minute to that 7.5% risk that you talked about. But can you go over for people why we've moved from the old ASCVD calculator to the new prevent calculator in calculating risk.
- [11:46]
B
So the newer score actually includes a more comprehensive approach rather than focusing on purely the heart. You know, now it is going to be heart, kidney, cardio, metabolic and obesity all built in together. We all know diabetes increases cardiovascular mortality, but believe me, nephrologists have been trying to convince the world that EGFR and UACR are actually even better predictors of cardiovascular mortality. And believe me, all These patients show up with everything all mixed in one and not really one or the other. So essentially our problem is metabolic and lifestyle induced. Initially I can say that. But we have to go beyond just lifestyle modification. We want to be able to, to predict the risk and treat them appropriately and aggressively enough. So this score is more about ground reality of where we are and how aggressive we need to be.
- [12:53]
A
Yeah, it's interesting that ground reality of where we are is so important in that score because it's based on a more modern cohort than the old ASCVD score. It's based on something like 3 million people's data in there as opposed TO I think 20,000 in the old one. And as a result of that, partly because we are better now at controlling risk factors than we were 20 to 30 years ago, that 7.5% on the Prevent calculator roughly equates to 15% which was, if I recall the entry criterion risk to the sprint trial equates to roughly 15% in the old calculator. And it's an important cutoff because as you said above 130, according to the new guidelines, everyone gets a medicine right away unless they have a prevent calculated risk less than seven and a half percent, in which case they're given three to six months of. Let's try some lifestyle approaches because lifestyle is still foundational and medicines are, are course critical. Can you give us a sense before we go into treatment, both lifestyle and medicines? You mentioned that goal having changed from the old 140 to the current 130 and you mentioned a few trials. But I want to make sure that our listeners understand the strength of recommendation, the strength of the evidence that has shifted from what many of our listeners who might be over 40, 40 years old remember as a goal. People remember the 140 systolic goal and in fact it's still in some of the guidelines out there. The International Society of Hypertension, the AFP still has that. But can you clarify why? The American College of Cardiology and the AHA guidelines are pretty clear that a systolic of 130 is what they recommend.
- [15:05]
B
So I hate to say it, that the cardiologists are right, being a nephrologist myself, but, but the point is the sprint study that came out, I think it was 2015 when it came out. This is around the time where we were all confused with the JNC8 and they actually, I mean you, you mentioned 140. They, they actually upped, upped it a notch for people above 60 and trust me. You know, people who are close to 60 don't consider themselves that old. And for them the blood pressure goal was even higher without really any strong evidence. But then we have the sprint trial from 2015, which was the non diabetics, which were split into a tighter control less than 120, and then slightly lesser control less than 140. And it clearly showed a 25% reduction in cardiovascular event and 27% reduction in all cause mortality. And there was a slight increase in hypotension, syncope and aki, but the benefits outweighed the risk by far. By the way, we also had a few Chinese studies, the Step trial or the Esprit trial, which also showed that intensive control was better. Everybody likes to quote the accord trial from 2010, which was your type 2 diabetics. And those did not show a reduction in primary composite endpoint, but the stroke risk was reduced by 41%.
- [16:40]
A
Wow.
- [16:41]
B
Now, now these are the important randomized control trials. We also have observational and meta analyses, especially the enlightened study, more than 240,000 patients, and that clearly showed that there was increased mortality 1.3 times, 1.8 times Michigan, 2.2 times stroke, 2.5 times progression to dialysis, and also an increased risk of dementia for people who were not less than 130 by 80. So enough risk for us to try to mitigate an enough benefit that we can actually aim to have. So I would say these are a few studies that anyone wants to look up.
- [17:25]
A
Thanks for going over things in such detail because I think it's really important for our audience to, to recognize the strength of the evidence behind that recommendation. We'll talk in a moment about what labs to get once someone has established hypertension. But before we do that, can you just touch on the place of home blood pressure monitoring? Yeah.
- [17:47]
B
So home blood pressure is the most important blood pressure and it is equal to, in my opinion, ambulatory blood pressure monitoring. ABPM or office blood pressure, which all of us rely on and we all try to be as good as we possibly can, is the worst blood pressure that we can actually check. So again, that does not mean you stop checking your office blood pressure. You should still do that. But make the patient come in, let them rest in a quiet room for five minutes, have them seated, both feet on the ground, back supported, and put the blood pressure on the non dominant arm, press the button and get one or two or three readings, whatever your office protocol is. And that could be a reasonable blood pressure. But what you want your Patient to do is have. Have a similar oscillometric device at home, preferably a arm cuff, not a wrist in my opinion. And then follow the same protocols. Don't watch the news while you're trying to do that, or don't be yelling at your neighbor and then give it five minutes to check your blood pressure and write it down. It has to be done similar time of the day. Don't check it at work, don't check it if you have to run out of the house or you're getting already getting late. Because remember, blood pressure is a moving target and it will change depending on what you're trying to achieve at that time. You know, don't check blood pressure right before you're going to run a marathon. So it does matter what you're trying to do at that time.
- [19:21]
A
Yeah, no, those are really important points and it adds a lot to our ability to assess things. So we have a patient, they have elevated blood pressures on two separate occasions. It correlates with their home blood pressures. What labs are recommended at this point?
- [19:37]
B
So a regular cmp, which will include kidney panel, which will include electrolyte sodium, potassium is very important. Please add a urine albumin creatinine ratio to it. We are really bad at ordering the most simple test that can be done, which is a uacr. What that will give you is more important than what your blood test will give you. And why do I say that a UACR will predict any damage to the kidney and in return to the heart much before your blood test will catch up to it. Now, I mentioned the electrolytes. Why? Because we use medications which tend to alter these electrolytes. So it is very important to catch them right at baseline and utilize appropriate medications to bring blood pressure down based off of those.
- [20:32]
A
Excellent. I was so thrilled when I saw the UACR as a clear recommendation in the guidelines. We've been waiting for that and it's so critically important. Let's go on now to treatment. What are the recommendations for initial treatment? Let's start with what are the lifestyle things on the menu? How much effect might one get from lifestyle? Then we'll go on to medicines.
- [20:59]
B
So I want to clarify that we are just talking primary hypertension. If by the way, we are thinking of secondary hypertension, which we might, depending on patient's age or unreasonably high blood pressure, based on what we see or hear here, and low potassium, we may want to check aldosterone, renin, and so on and so forth. But that I think can be a topic for another day. In terms of lifestyle, lifestyle is the most important thing by far. It is more important than any medication. And this should be part of our daily lives, right, right from childhood and we should try to inculcate that in our children and elderly and you name it better. Increased protein in diet, a reasonable control of salt, increase in physical activity, especially intense physical activity. Of course, quit smoking if you are smoking and also minimize alcohol. Now, weight reduction. For every kilogram of weight drop, you will drop your systolic blood pressure by one point. So weight reduction is equally important. And if you like to think about pounds, you can do the math. It's 2.2 pounds per kilogram and then, then moving on to sleep apnea. Sleep apnea is the best non pharma pharmacological thing that you can do to try to reduce blood pressure. And once you have achieved all of this, you can figure out how many more millimeters of mercury you have to drop. Now, I present it as steps, but these are not steps. These are all to be done at the same time.
- [22:46]
A
Time.
- [22:46]
B
I'm not going to wait for my patient to lose 20 pounds in two years before I give them a pill. So, you know, if you need to lose weight, please start that journey today. If you need a cpap, go, go see a sleep doctor right away. And here is another blood pressure medication.
- [23:02]
A
Yeah, it's, it's so critically important. It's something we need to emphasize and something that's hard to do. I'm just thinking, as I say that of someone I saw who I once said the, the best thing you could do is diet and exercise. He looked at me and said, doc, I don't deserve the best. Do you have any medicines? Which leads us to medicines. Can you go over initial treatment with medicine? So we've done lifestyle either at the same time of starting medicines for people at higher risk. For those, as we said, with a Prevent score below 7.5%, we can for three to six months really work hard on lifestyle. If they don't achieve it, we go to medicines. Talk to us about initial treatment with medicines.
- [23:51]
B
Absolutely. And you know, just like everybody else, I like hearing podcasts, both medical and non medical and somehow in most non medical podcasts, they make us believe that it's either this or that. I mean, whoever said that you don't have all options available to you at the same time and, and I would much rather prevent my heart, kidney, brain today, plus, you know, try to do better with my lifestyle and lose the weight and build the muscle and so have you? But the point I want to emphasize is please don't think of medication as an enemy. Think of blood pressure as the enemy. Now, that being said, per guidelines, we have the best medications that we want to start right off the bat. And these are our thiazide diuretics, our ACEs and ARBs and our calcium channel blockers. These are medications that we want to utilize as our first line medications. And then we have to mix and match these. Not everybody can get a thiazide diuretic. I live in an area where most of my patients are above 80 and almost everybody seems to be hyponatremic there. So I may not be able to utilize a thiazide diuretic even though I may want to in those patients. ACEs and ARBs are still gold standard in nephrology and most patients, unless they are allergic to it or get angioedema with it, I would want to put them on an ACE and ARB at a reasonable dose. I tend to gravitate more towards arbs now because I don't want to deal with the cough, even though it happens in a small percent of patients. And then finally, we have calcium channel blockers. Both amlodipine and nifedipine work great. They do have a little side effect of lower extremity edema and an even smaller side effect of gum hypertrophy. But these are my three top blood pressure medications that I utilize. If my patients are consistently two visits in a row above 140, they will end up getting two right off the bat.
- [26:00]
A
That makes a lot of sense and that's really helpful. You mentioned therapeutic inertia earlier and a critical thing is the decision about how long should we wait to see people back. How do you approach that?
- [26:16]
B
I utilize the National Kidney foundation and the chronic kidney disease guidelines to target my follow up visits. Usually patients who show up with any amount of ckd, I will tend to see them a little sooner. But what I don't want is I bring them too soon. I want to give them time to get accustomed to the medication. If there is a slight drop in GFR, up to 25 to 30% with better blood pressure control, I would much rather that resolves before I bring them in for another blood test. So almost every three month follow up till I get to my target will be what I would aim.
- [26:58]
A
That's great. And it's really consistency that always gets us results. I think it was Ovid that said dripping water can hollow out a rock. Not because of its strength, but because of its persistence and you know, bringing people back and when they come back doing something is so critical. That issue of therapeutic inertia, we, we all see it. It's partly the patient who says I don't want to have medicine added today there was traffic on the way to the office or something else. And we don't want to argue with our patients. But while we shouldn't argue, we need to be clear to change those medicines when people are not to goal. Which brings us as we're getting toward the end of our podcast, so we've seen someone, we've added a medicine, they're doing better, maybe we've now added, they're on two medicines and they've improved. But what are the definitions of uncontrolled hypertension and then separately resistant hypertension?
- [28:10]
B
The resistant hypertension criteria is something that we have already tried at least three blood pressure medications which include a thiazide diuretic. And these are our tougher to control patients. These patients may be very heavily aldosterone dependent hypertension which ends up causing various end organ damage. By the way, I'm still not talking secondary hypertension. So they may not meet the criteria for primary hyperaldo but they may still be Aldo dependent. So those are our resistant hypertension patient. Uncontrolled hypertension is the same class of people. They're just on two blood pressure medications which includes a diuretic. They may also have some degree of Renin Aldo mismatch. Now just to mention that the Renin Aldo system is an excellent life saving system that we were given. But when Aldo decides not to listen to Renin, that's when we deal with primary hypertension. So I do want to bring that to everyone's attention. Now what can we do for these resistant or uncontrolled hypertension? We want to make sure that we are not letting go of our original idea of trying to get them to less than 130 or less than 120 provided our patient can tolerate it clinically.
- [29:39]
A
Yeah, and that's so important. And you know, there are no perceptions unless they're conceptions. And what I mean by that is I think we see uncontrolled hypertension often but we almost don't notice it it until we realize those definitions that you went over. And if we look at the literature, is there anything in the literature that informs us about how common uncontrolled hypertension is or resistant hypertension?
- [30:09]
B
Yeah, once, once we identify hypertension and we have added more than two medications, 50% of our hypertensive Patients will actually be uncontrolled. And we are always making excuses, both as doctors and patients on why not to add another medication. Oh, my patient is old. Oh, what if they get orthostatic? What if they fall and break a hip? I do understand that those are very valid concerns, but even more valid is the cardiovascular, metabolic, renal risk, which is happening as we speak. So hypertension management is not a sprint, it is a marathon. If a patient comes to me with resistant or uncontrolled hypertension, I tell them it's going to take me a year to get them perfect and I am going to keep chipping at that blood pressure with either lifestyle or CPAPs or a weight reduction or adding or subtracting medications. But I will get them controlled, preferably to per guidelines to reduce their cardiovascular and renal risk. So just keep chipping at it while one medication or lifestyle at a time and try to achieve your goal.
- [31:20]
A
Yeah. And it's so important, and in a way we've now set up, we've teed up what we're going to talk about in our second of part of this series, which is where we're going to really focus on an approach to uncontrolled and resistant hypertension. We are about out of time. Manish, any final thoughts for our listeners?
- [31:45]
B
Yes. So I really appreciate you putting your important time in arranging this podcast. It is really important that our physicians, our apps, and even our patients have an access to real medical knowledge. One person asked me, hey, why do doctors have to become podcasters? And the answer is, because podcasters have become doctors. So please, thank you for putting out real information which people can hear and decide for themselves. And our job as clinicians, most importantly, is to put data and information out there for people to choose what's best for them.
- [32:27]
A
So well said. Dr. Manish Rajpal, thank you so much for joining us.
- [32:32]
B
Dr. Skolnick, it was my pleasure and thanks for having me.
- [32:36]
A
And to our listeners, thank you for joining us for this special edition of Diabetes, Obesity and cardiometabo metabolic disease updates. Discussing hypertension. This is part one where we discussed an overview. In part two, we will discuss uncontrolled and resistant hypertension. And then in part three, we will be discussing some common and also challenging cases. This special series of diabetes, obesity and cardiometabolic disease updates has been sponsored by AstraZeneca for the American Diabetes Association. I'm Dr. Neal Skolnick. Till next time, stay safe and keep learning.