REBOOT: #509 Fresh Hypertension Guidelines. West Philadelphia Doc Jordy Cohen Keeps Our Hypertension Management Fresh

Summary

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Podcast Summary: The Curbsiders Internal Medicine Podcast

Episode: REBOOT: #509 Fresh Hypertension Guidelines. West Philadelphia Doc Jordy Cohen Keeps Our Hypertension Management Fresh

Date: May 11, 2026
Guest: Dr. Jordana “Jordy” Cohen (Nephrologist, University of Pennsylvania, member of the 2025 AHA Hypertension Guideline Writing Committee)

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Episode Overview

This episode dives deep into the 2025 updated American Heart Association (AHA) Hypertension Guidelines with guest expert Dr. Jordana Cohen. The Curbsiders team, with Dr. Cohen, dissects the new recommendations on diagnosing, monitoring, and managing hypertension in both outpatient and special populations. The discussion covers everything from blood pressure measurement technique to the nuances of medication initiation, incorporating patient risk, new lab workup, technology pitfalls, and the critical shift to combination therapy. Insights on pregnancy, secondary causes, and management in frail, elderly patients round out this episode—which is packed with practical pearls and the latest evidence.

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Key Discussion Points & Insights

1. Why Hypertension Matters

• Cardiovascular Disease, Dementia, & More
  • Decades of data show hypertension directly causes cardiovascular disease, stroke, and dementia.

    “For every 20 mmHg higher systolic blood pressure, you about double your risk of a major cardiac event, which is just so impressive and horrifying.” – Dr. Cohen, [07:16]

  • Lowering BP—even small reductions—meaningfully reduces risk across these outcomes.
  • The concept of "time in target range" applies as with INR or glucose (more time at <120 systolic = lower risk).

    “We see things like time in target range: the more often your blood pressure is less than 120 over long periods of time, the better you do in terms of cardiac risk.” – Dr. Cohen, [07:42]

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2. How to Measure Blood Pressure Properly (and Why it Matters)

• Technique is Critical
  • Patients must rest 5 minutes, feet flat, back/arm supported, empty bladder, no caffeine/exercise/food for 30 minutes.
  • No measurement over clothes; ensure a validated, automated device is used.
  • Avoid manual aneroid devices except in arrhythmias.

    “If we can't do it [the right way], it’s really a random number generator… you can get blood pressure artifacts in both directions.” – Dr. Cohen, [10:09]

• Device Validation
  • Use only devices from validatebp.org; beware misleading claims (many devices are “FDA cleared” but not validated for accuracy).
• Home Blood Pressure Monitoring (HBPM)
  • Grade 1A Guideline Recommendation: Do HBPM in ALL for diagnosis and management.
  • 2 readings AM, 2 readings PM, over at least 3 (ideally 7) days.
  • Combined with clinician follow-up, HBPM yields better control and outcomes.

    “There have been a bunch of trials that have shown that when you combine home blood pressure monitoring with some sort of additional intervention…you end up with much, much better blood pressure control.” – Dr. Cohen, [13:19]

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3. Technology Pitfalls: Cuffless BP Devices

• Devices like smart watches and patches are not clinically reliable.
  • E.g., Apple Watch: Sensitivity 41%, meaning 59% with hypertension won’t get notified.

    “It’s worse than a coin flip. I would so much rather that Apple just sent people a notification saying, please go check in with your doctor…This is actually worse than that.” – Dr. Cohen, [17:42]

• They’re not ready for clinical use, regardless of heavy marketing or FDA “clearance.”
• BP watches struggle with medication changes, skin tone, and are based on insufficient technology.
  • Transparency from device makers is helpful, but clinicians should directly ask about device type at every visit.

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4. Initial Workup for New Hypertension ([26:16])

• Standard Tests:
  • CBC, Basic Metabolic Panel, Lipid Panel, Hemoglobin A1c, TSH
• Added in 2025:
  • Urine Albumin-to-Creatinine Ratio (ACR) (screening for early kidney damage or hidden kidney disease in all hypertensive patients, not just diabetics)
• Cardiac Biomarkers:
  • Not mandatory, but can aid risk stratification.
• Consider checking Renin and Aldosterone in all with BP ≥140/90 (matches European & Endocrine recommendations)—buried in guidelines but important.

“Check everyone now for their renin and aldosterone...less barriers, just check it.” – Dr. Cohen, [74:52]

• Always review for secondary causes: sleep apnea, NSAIDs, alcohol, sodium, ADHD meds, tizanidine, etc.
  • New: Explicitly recommend asking about tizanidine (short-acting alpha agonist) and complete alcohol abstinence ([30:30]).

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5. Treatment: Start Early, Start Strong

• Stage 2 Hypertension (≥140/90):

  • Initiate fixed-dose combination therapy right off the bat ([34:01]).
    • Improves adherence and control
    • Hope: insurance coverage will follow guidelines

• Choosing Agents:

  • Avoid losartan (shorter acting, variable metabolism) and lisinopril (angioedema risk).
  • Dr. Cohen’s favorites (insurance-permitting): Olmesartan/HCTZ or Olmesartan/amlodipine (triple pill available for more control), or Valsartan-based combos.
  • Telmisartan for multi-drug intolerant/elderly (if available in needed combinations).

“Almost every adverse effect from antihypertensives except dizziness is pretty specific to the drug.” – Dr. Cohen, [35:21]

• Titration Strategy:
  • For frail/multidrug-intolerant: prefer adding more agents at low dose vs. maxing out single drugs.
  • Each agent’s benefit plateaus above the median dose, but side effects rise.

“Once you go above the median dose, you’re getting a small increase in blood pressure control relative to a 50% or 100% increase in adverse effect risk.” – Dr. Cohen, [39:36]

• Patient Counseling:
  • BP drugs take at least 2 weeks for full effect. Avoid checking BP obsessively during this period ([42:13]).

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6. Lifestyle & Risk Modification

• For Stage 1 (130-139/80-89) with low 10-year risk (now using Pooled Cohort, replaced by PREVENT calculator):
  • If PREVENT-calculated 10-year risk <7.5%, trial of lifestyle modifications for 3-6 months before meds.
• Lifestyle:
  • Lower sodium, increase potassium (prefer whole foods—potatoes, tomatoes, avocados, leafy greens—over supplements).
    • Potassium-based salt substitutes can be as effective as medications in reducing BP and preventing stroke in population studies ([50:21])—but limited US impact due to processed food intake.
    • Mix salt substitute 50:50 with regular salt for taste, or use other seasonings.
  • GLP-1 agonists lower BP only via weight loss ([53:09]).
• Counseling on Alcohol:
  • Now “abstinence” is the official recommendation.

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7. Management in Special Populations

A) Frail & Elderly

• Guidelines recommend intensive control to <130 mmHg unless clear contraindications
• Asymptomatic orthostatic hypotension not a contraindication ([53:53]).
• Low diastolic BP not directly harmful unless tied to underlying frailty:

  “If you cut it out that way...it’s the frailty that’s causing patients to actually have falls and...worsening kidney function and cognitive function.” – Dr. Cohen, [57:06]

B) Pregnancy

• Chronic hypertension is BP ≥140/90 identified <20 weeks (confirmed at home or in-office).
• First-line agents:
  • Long-acting nifedipine preferred, then labetalol, then HCTZ (with caveats; not for breastfeeding)
• Continue home BP monitoring
• Hand off to OB by 20 weeks (as preeclampsia/eclampsia risk escalates; 30-50% risk)
• Microalbuminuria warrants continuing ACE/ARBs until pregnancy confirmed, with strict counseling ([61:20])
• Aspirin prophylaxis for all with hypertension in pregnancy, starting around 12 weeks ([63:58])

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8. Abandon "Hypertensive Urgency"—Don't Overtreat Severe Asymptomatic Hypertension

• "Hypertensive urgency" as a diagnosis is out—call it chronic severe hypertension without end-organ damage; do NOT rush with rapid-acting medications ([64:40]).
• Treating acutely can cause AKI, ischemia, and higher hospitalization rates.

"Don't treat it as something urgent, don't call it something urgent because...you can potentially cause harm by trying to lower them too quickly." – Dr. Cohen, [65:02]

• Instead, escalate chronic meds, target underlying causes, ensure home BP follow-up.

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9. Secondary Hypertension and Renal Artery Stenosis

• Renal artery stenosis: very rarely requires revascularization—reserved for refractory, rapidly progressive, or cases with recurrent pulmonary edema/ischemia.
• Routine imaging is not needed unless strong suspicion or clues from other workup (e.g., fibromuscular dysplasia in young women, asymmetrical kidneys) ([69:19]).

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10. Major Philosophical Changes in 2025 Guidelines

• ABANDON RACE-BASED TREATMENT RECOMMENDATIONS
  • No more preferential ACE/ARB in non-Black, no more diuretic/CCB preference by race.
  • Aggressively treat all to target; focus on control, not monotherapy choice.

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Notable Quotes & Memorable Moments

• "There's no more race-based recommendations."
  – Dr. Cohen, [72:07]
• "I do really appreciate Apple's transparency... It has a sensitivity of 41%...worse than a coin flip." – Dr. Cohen, [17:42]
• "If we can't [measure BP correctly], it’s really a random number generator." – Dr. Cohen, [10:09]
• "Potatoes—you're telling me to eat more potatoes?" – Dr. Cohen, on patient reactions to potassium-rich foods, [49:33]
• "I was arguing with a lot of senior people who knew more than me to convince them to change their opinions that they've had for a long time." – Dr. Cohen, on writing guideline changes, [74:27]
• "Don't treat it as something urgent, don't call it something urgent..." – Dr. Cohen, [65:02]

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Important Timestamps

• [06:41] – Rationale for aggressive BP control (CVD, dementia, time-in-range)
• [09:46] – High-quality BP measurement: technique, equipment validation
• [13:33] – HBPM standards & best practice
• [17:42] – Apple Watch and the dangers of cuffless tech
• [26:16] – Initial lab workup for new hypertension
• [34:01] – Fixed-dose combo therapy for Stage 2 HTN
• [39:16] – Dosing strategy: low dose + more agents vs. max dose
• [44:16] – PREVENT score and managing Stage 1 HTN
• [48:22] – Counseling on potassium-rich foods
• [53:53] – BP goals in frail/elderly, orthostatic concerns
• [58:56] – Hypertension management in pregnancy
• [64:40] – Hypertensive urgency is NOT a thing—no acute treatment
• [69:19] – When (not) to revascularize renal artery stenosis
• [72:07] – End of race-based recommendations

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Take-Home Points from Dr. Cohen ([74:52])

• Never overlook the importance of how you measure BP; use validated devices and ask about device type at every visit.
• Be skeptical of BP wearables—technology is improving but not ready for clinical use now.
• The AHA now recommends checking renin and aldosterone for all stage 2 hypertension.
• Aggressively treat hypertension in all, regardless of race; focus on control and early, combination therapy.

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Useful References:

• AHA Hypertension 2025 Guidelines
• validatebp.org – AMA Validated BP Devices
• PREVENT Cardiovascular Risk Calculator
• National Kidney Foundation: Potassium Foods List

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Summary Prepared by [Podcast Summarizer]

This summary includes only scientific/clinical discussion and omits ads, intros, and non-content material.

Transcript

[A]

Hey listeners, you're about to hear a Curbsiders classic episode. If you heard it the first time, listen again for that space learning. But if you haven't heard it yet, then you are in for a treat. So without further ado, enjoy and don't forget to check out our [e-mail] curbsiders if you want ad free episodes, bonus episodes, and a whole bunch of other cool stuff. Patreon.com curbsiders hey, before we get to the show, I wanted to remind you to check out our [e-mail] curbsiders if you haven't subscribed signed up yet, sign up now to get ad free episodes, twice monthly, bonus episodes and a whole bunch of other cool [e-mail] curbsiders Paul, I'm not sure if I've said this one before, but I'm going to go for it.

[B]

Great.

[A]

My sister bet me $100 that I couldn't build a working car out of spaghetti.

[B]

I think you've done this one before, so it's going to really hurt that I. I cannot come up with the punchline by myself. You said that's impossible. No, I think I made the same attempt. All right, give me the punchline.

[A]

You should have seen her face as I drove past her pasta.

[B]

Great. Yeah, no, I don't know if you've that one before. The Curbsiders podcast is for entertainment, education and information purposes only, and the topics discussed should not be used solely to diagnose, treat, cure or prevent any diseases or conditions. Furthermore, the views and statements expressed on this podcast are solely those of those and should not be interpreted to reflect official policy or position of any entity, aside from possibly cash, like more hospital and affiliate outreach programs, if indeed there are any. In fact, there are none. Pretty much. We aren't responsible if you screw up. You should always do your own homework and let us know when we're wrong.

[A]

Welcome back to the curbsiders. I'm Dr. Matthew Frank Watto, here with my great friend and America's primary care physician, probably the primary care physician, Dr. Paul Nelson Williams. Hey, Paul.

[B]

Hey, Matt. How are you?

[A]

I'm doing great because we just had a fantastic conversation with our friend and returning guest, Dr. Jordana Cohen, talking about hypertension. The guidelines were updated in 2025 by the AHA and she was part of the guidelines writing committee. So who else would we talk to about this important topic? But Paul, before we talk more about her, what is it that we do

[B]

on Curbsiders Sure, Matt, thanks for asking. As a reminder to you and everybody else, we are the internal medicine podcast. We use expert interviews to bring you clinical pearls and practice changing knowledge. Matt, as you mentioned, we talked to Dr. Jordana Jordi Cohen, who's been on the show multiple times before, though I think we overshot when we get some. It feels like she's been on a million times, but it's only been like this is her third time.

[A]

She says three. I feel like it's been five. So maybe they were three oversized episodes. I don't know.

[B]

That may well be. Yeah. In any case, in case you don't recall, Dr. Cohen is a nephrologist hypertension an epidemiologist at the University of Pennsylvania, where she spends most of her time geeking out about blood pressure. She's a member of the freely filtered podcast team. She is also the principal investigator of several NIH studies investigating the treatment and measurement of hypertension in high risk patients. She has leadership roles related to this with the American Heart association and the American Medical Association. She was a member of the AHA 2025 blood pressure guideline writing committee. In this episode, she teaches us the ins and outs of those guidelines. She talks to us about blood pressure classification, what initial workup looks like, how to treat and based on what the blood pressures are. We talk about secondary hypertension, high blood pressure and pregnancy. The list goes on. We cover a lot of ground in this episode and there's plenty that we left on the table for follow up later on. So without further ado, let's get to it.

[A]

And I did just want to shout out to the great Dr. Deb Gorth, who wrote and produced this episode, couldn't be here for this. Don't feel too bad for her, Paul. Is she still in Paris right now?

[B]

She's still embarrassed right now.

[A]

Yeah, I don't feel bad for her. A reminder that this and most episodes will be available for CME credit for all health professionals through VCU Health at curbsiders.vcuhealth.org Jordi, you're back again. Maybe the fourth time or the fifth time. It's only the third. It feels like we're best friends. Paula, should we just give her the smoking jacket now?

[B]

No, I think it's time.

[C]

No, just invite me back again because we're going to have an infinite amount of stuff that we don't get to. I'm sure.

[A]

Yes, absolutely. You're always welcome on. And in case the audience hasn't heard you before, I think one time you Told us about how you almost lost a toe, but give them a current hobby or interest that you have been enjoying.

[C]

It's always the same. It has something to do with backpacking or hiking. So lately I have a 35 pound, three and a half year old who, you know, intermittently will and won't walk and her legs don't work and so I still have to go backpacking. So she just ends up in the pack. So we just did Shenandoah last week and everybody who passes us sees my husband, who is like a foot taller than me, walking while I'm carrying this like, you know, 40, 50 pound pack and cracking up and making comments about how entertaining it is that I'm the one with the pack. So I don't know, I like it that way.

[A]

They probably think you're just into the new, like, rucking trend where everyone's just carrying around like 10, 20% of their body weight all the time just for. For fun.

[C]

It's pretty great. I felt like it was one of the best workouts I'd had in a while. It also was pretty hilarious because the kid will not walk on flat ground. But as soon as we were at like a crazy rock scramble, she had to get out and do it. So I feel like she is actually my child. I can confirm.

[A]

Yeah, that is, look, I mean, kids can walk when they want to walk, but I went to Italy and we had some little kids with us and the one kid was just not walking and we were all joking around about his step count because everyone's like, oh, I 20,000 steps today. And we're like, this guy's like 200 steps. They were just lugging him everywhere. Well, Paul, we have a lot to get to, so why don't you read our first case from Kashlak and we could get into the fun.

[B]

Matt, I will do that. All right, Jordy. So our first case is Jeremy. He is a 39 year old with no MES medical history, presenting for his first yearly wellness exam in years. After taking the average of two high quality blood pressure readings in the office, you confirm that his blood pressure is 142, 90. So before we get into the details of the new guidelines that are kind of driving this episode, can you just talk to us in broad strokes about why we should care about Jeremy's initial blood pressure reading, why we worry about hypertension at all, and then we can get very gran as we progress through the episode?

[C]

Yeah, we've got decades of fantastic data showing causally that hypertension causes cardiovascular disease. We've got newer data too that hypertension causes dementia. I don't think there is a more patient centered outcome than dementia. No one wants to lose their brain. Obviously strokes are part of the cardiovascular disease risk and so much other risk involved. They increase the risk of CKD progression. So anything we can do to lower blood pressure obviously helps to improve that. And now we have extremely high quality trials that demonstrate the magnitude to which they do that. But for any every 20 millimeter mercury, higher systolic blood pressure, you about double your risk of a major cardiac event which is just so impressive and horrifying.

[A]

Yeah. And doesn't it, I heard someone say I can't remember if this was on the show or something else I was listening to but isn't it even above like 115? That's where it starts to go up. So as you get further and further away from that.

[C]

Yeah, it depends on which literature you look at and how much you sort of trust observational data. A lot of the original data came from actuarial data that they got for life insurance companies to help them determine who they should give life insurance to. And so even back decades ago we saw trends like that. But now that we have better quality data we see things like time and target range, that the more often your blood pressure is less than 120 over long periods of time, the better you do in terms of cardiac risk.

[B]

Oh that's great. So it follows kind of the CGM model of tracking blood pressures.

[C]

Very similar. Yeah, they actually got it. The way that they do the math for it is the way that they figured out what INR ranges were therapeutic. So it's the same type of idea with INR and therapeutic. INR ranges from 2 to 3 being appropriate for anticoagulation. It's the same exact type of math that they do now with blood pressure to show what ranges are associated with the lowest and highest risk.

[A]

Yeah, I thought you were gonna say something about like ambulatory blood pressure monitoring or I wonder where they're getting the readings from to apply the math.

[C]

So this example for instance was done by this guy, Leo Buckley. He's this really cool PharmD who thought about the INR literature and had done it from Sprint and Accord. Like just these repeated blood pressures of patients in trials where we know that these are perfectly performed blood pressures. It's since been looked at in some studies that have gotten longitudinal data from other sources. But it's basically the more data you have, the more you know, the more information you have that links to long term outcomes. So the more values that you have in any person, the more you are able to actually use that information more powerfully.

[A]

Yeah. Because I mean, even if you're taking weekly blood pressures, you just don't know what's happening during the week. Like maybe, maybe the most relaxed they were was when they were getting that blood pressure taken. And the rest of the time their blood pressure just like sky high. So that. That's why I was asking.

[C]

Yeah, definitely.

[A]

Yeah.

[B]

But this feels like a natural segue in terms of how do we get a high quality blood pressure reading and what does that look like? I think the guideline has a nice figure with like eight specific points. But what does that mean in the context of blood pressure measurement?

[C]

Yeah, and obviously I think you guys are pros. And we were talking before the show, Paul, about how you did that perfect blood pressure check of the patient in the exact right position after a five minute rest with their arm at the level of their heart and their legs supported and flat on the floor and their back supported. The things that never happen when we do a routine blood pressure check on an exam table. But that ideally should happen. And the problem being if we can't do it that way, it's really a random number generator because you can get blood pressure artifacts in both directions. So it's incredibly important that we're positioning the patient correctly. We're giving them that five minute rest. They have an empty bladder. We're not trying to measure it over bulky clothing and that we're not doing other things anatomically. We've discovered a lot of medical assistants learn that if you raise the arm up in the air, that lowers blood pressure. So they'll often do that when they get a first high reading to make the next one look better. So lots of things like that to look out for. Also incredibly important to make sure you avoid caffeine and exercise within 30 minutes and even food within 30 minutes of checking the blood pressure and have an empty bladder, which we always have in the nephrology office. But I realize that's not the case in most clinics. And the other really incredibly important aspect of it, which made it to the guidelines, I'm so excited, is that it has to be a very validated blood pressure device. It has to be appropriately validated. So not just googling it and seeing if it says that, that it's validated. Because a lot of abstracts for devices will say this met validation criteria, but it actually didn't. So validatebp.org is the American Medical Association's validated device listing. I'm co chair of the review group that checks the devices to make sure that they are actually valid. And we are the most anal group of reviewers you will ever meet. It's like a 60 point checklist that you're going through to make sure that everything's criteria and it, it's something that I think is all very near and dear to our hearts because we've seen the effects of this inaccurate blood pressure measurement on then causing harm to patients in both directions. You can both under and over treat patients by a bad blood pressure check or not getting enough data.

[B]

It's been such a red letter decade for blood pressure measurement studies. I think there was the cuff size one and then there's one about the arm actually hanging dependent as opposed to being at heart level. And I think there's just a more recent one about even the hand being in the lap is sub is below actually having the arm rested at a heart level like you're supposed to do. So there's been like a billion great studies that have just warmed my heart about just where to put the arm of all things. And I love them all so much.

[C]

And those are all led by Tammy Brady who is my co chair of the validated device listing to give you a sense of nerdiness in the room and then with that too. These validated devices apply both to the office and to home. And so in the office we should be using automated devices. And the guidelines now go far enough to say that we really should be pushing away from using aneroid devices. The only times we should be using those manual aneroid devices are for people with like persistent AFIB or persistent irregular arrhythmia that prevents the automated devices really from working well, otherwise it should be automated. The aneroid devices become miscalibrated very quickly and it's very rare to be able to convince clinical engineering to recalibrate them as often as they need to be. So very important and same thing to make sure that our patients are using those. We should be encouraging home blood pressure monitoring. The guidelines have now shifted to a grade 1A recommendation to be doing home blood pressure monitoring and everyone for the diagnosis of initial hypertension to rule out white coat and also for the longitudinal monitoring and management of hypertension. Because there have been a bunch of trials that have shown that when you combine home blood pressure monitoring with some sort of additional intervention, like someone checking in on you with those readings and making sure that they're acted on that you end up with much, much better blood pressure control. So high quality data for home blood

[A]

pressure monitoring and everyone and these guidelines, they said two blood pressures in the morning, two blood pressures in the evening, and you want to do it for at least three days, ideally seven days. So, I mean, I think that's achievable. And you had told us that years ago. So I think we've. For me, that's been a standard practice to have people do that because it's so hard to get an accurate blood pressure in the office. And my old office had stairs and a lot of people, if they took the stairs and then they walked, like, for them, that was basically like performing intense exercise. And even if they had sat for a few minutes, it would still be high. So I was almost always having to get readings at home and occasionally ambulatory blood pressure if I was really confused as to what was going on.

[C]

Yeah. And the guideline's pushing away a bit from ambulatory blood pressure monitoring. Just acknowledging that it's harder to access. It's still really useful in those situations, especially when you're not really certain you trust the home reading. But patients can do them really well. Even the people that we think can't usually surprise us. And the key is just checking in with them. If you're questioning how well they're doing and just asking them, tell me what you're doing. I also think it's really important that we make sure, though, that we educate patients on the device and it's something that's easy to sort of like, push aside. But I've had so many patients that were using high quality, validated devices and I didn't check in with them for a while, then their blood pressures were changing and I check in with them and I'm like, oh, wow, something different. I have to lower, like your blood pressure medication because you're suddenly becoming hypotensive. Did you lose weight? No. And then I find out that they are using a new blood pressure watch to check their home blood pressure. And they didn't mention that. And it came up in conversation. And now I've learned I have to outright ask every time, are you still using the same device? What kind of device are you using? Because these blood pressure watches, even though they're FDA cleared, even though they're often sold and marketed in this way to make them sound incredibly effective and incredibly accurate, they are not. The data so far is quite, quite bad, still that they're not ready for use clinically. There's one device company that has a patch that's very aggressively marketing to inpatient groups and to hospitals. And they're being used a lot in like, like, by, like, like for sleep studies and for other actual clinical purposes and that their data is not usable for that purpose. And it's really, really scary. So check with your patients. The new Apple Watch, for example, the Series 10 and later Apple Watches now have the ability to do a notification to let you know if you have hypertension. And I do really appreciate Apple because their FDA clearance paperwork is super transparent. But I do have to very briefly mention a couple things about it. One, the reason it got FDA cleared is much like most of these devices is not that they demonstrated that it actually worked to check the blood pressure, but the got FDA cleared is that they claim equivalence to a predicate to a previous device that's been FDA cleared. In the Apple Watch's case, it's an ECG with a machine learning tool that predicts hypertrophic cardiomyopathy. So in the columns that for a typical cuffed blood pressure device where it would say, we promise we're using the exact same motor and the exact same cuff material and the exact same arm circumference and every little detail in this case they wrote, oh, we used photoplethysmography to assess what the blood pressure was next to. We used a 12 lead EKG that was attached to the person. Just unbelievable how it's just night and day in terms of the devices that it was cleared against as being equivalent. But they were very transparent. They did this big what they call a validation study with 2,000 patients, which is much more than what you would ever see. The actual requirement for international standards is 85 patients. But they didn't follow any of the standards. They did their own thing and it was like home blood pressure monitoring in 2,000 patients. They don't tell us how they did their home blood pressure monitoring. That's fine. What I do love is their transparency in saying, oh, and it works great. It has a sensitivity of 41% and a specificity of 92%. So what that means is that of people who actually have hypertension and don't know they have hypertension, 59% will never get a notification telling them that they have hypertension. So it's just going to tell them they're fine. So it's worse than a coin flip. I would so much rather that Apple just sent people a notification saying, please go check in with your doctor every six months for a blood pressure check or once a year for a blood pressure check depending on their risk factors. So this is actually worse than that.

[B]

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[C]

Foreign.

[B]

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[A]

Trying to find this table, Jordi, because I'm pretty sure that it's. Isn't it like 46.7% of people over age 40 have high blood? Like, isn't there some really high number of. It's in the guidelines here?

[C]

It's 46% of US adults of people over the age.

[A]

Like, it can't even do as good as.

[B]

Just as literally the coin flip.

[C]

Perfect.

[B]

I do. One of the things I like about you, Jordi, is your specificity of language, because the phrase what they call a validation study just made me smile.

[A]

We should mention whoopmg, which I think stands for medical grade, also has some sort of blood pressure capability, but you have to use a cuff to sort of calibrate it, which I guess in some degree is better, but I don't know how good the WHOOP is. Have you looked at anything with that one?

[C]

Yeah. So they're all right now, not quite ready for clinical use. Like, they're. They're guesstimating. They're not even guessing or estimating a blood pressure. It's like some. It's this, like, black box of. It's an algorithm that uses AI, so it must be good. But it's good that they're using a calibration, but all it's basically looking at is waveforms that go through your blood vessel without a pressure and looking to see trends of it. And so very similar devices, not that particular one. What they've done is there have been some really cool studies done out in Australia where they'll give people a blood pressure pressure medication, like a new one, and someone, you know, has elevated blood pressure, and they'll have them wear the device, and then they'll also have them check home blood pressures or ambulatory blood pressure monitoring, and they'll show that when they take a new blood pressure medication a week later, their blood pressure's 5, 10 millimeters of mercury better. And the cuffless device is still telling them it's exactly the same and hasn't budged. And so it can't actually, like, interpret, for instance, introducing a new medication or introducing other things that could alter blood pressure. It's having a lot of trouble. A lot of these. All of these devices so far are having a lot of trouble with those issues and also a lot of trouble with artifact from motion and with artifact from other things like skin tone. The Apple Watch did acknowledge that this is a known issue, the skin tone issue. This had been shown with Photo. Most of these devices use photoplethysmography, the same thing as spirometry. We'd seen the data during COVID that there had been this increased risk of occult hypoxemia in individuals with darker skin tone because the spirometers using this technology couldn't really.

[A]

The oximeter, you mean?

[C]

What's that?

[A]

The pulse oximeters.

[C]

You mean pulse oximeters. Exactly. Yeah, sorry, pulse oximeters. And so photoplathysmography is that technology that is sensing the light and it has issues with certain light tones. And so these companies are claiming there's just no issue with skin tone differences with regard to how well the devices work. What Apple had done in their study was they showed the differences by skin tone and there wasn't any in terms of the performance, but they adjusted for race when they looked for the differences across skin tone. And so that's. It's something where you're sort of like, if you look across different races and then you're adjusting for that, you then have dampened away the entire effect that you might see from differences in skin tone. So just a lot of concerns about these in general that I think even the companies that are being really transparent with their data, we're seeing issues. Microsoft had put out their data for open source for people to use because they tried doing a couple less blood pressure device and realized that it's just not. Not feasible. So they just released it into the wild and let whoever wanted to have access to the data and see how it was. And there's this great publication that a group did where they showed that it was no better than just pumping in someone's demographics and just guesstimating their risk of having a high blood pressure from that well.

[A]

So that's why they get this class of recommendation is a three for no benefit and so not ready yet. It would be cool though. I mean, I would love it if there was. You could just constantly have blood data. I think it would be useful to know what people's blood pressure is doing throughout the day and for people to just be able to be diagnosed without having to put a cuff on their arm and have that. Because most people have a smartwatch, not as many people have a blood pressure cuff around that they're actually using.

[C]

Yeah, that's a really good point. And I'm sitting here being this huge naysayer about it. But it's gonna remove a lot of barriers once this works, because I think there are so many people that hate getting their blood pressure checked, have that alerting reflex and that white coat effect from getting their blood pressure checked. I have a lot of patients who even have that at home. And so I do think it's going to open a lot of doors to screening that we didn't have previously, also in people who just never go see a doctor, but we're just not there yet. I'm worried about where we are right now. It's just not ready for clinical use.

[B]

I also think that the people who are invested enough to and have the capacity to get devices that can do blood pressure readings are probably more likely to be seeing die. I think there might be a. We still might be missing important segments of the population, even if the technology does advance where we need it to be. But in any case. So with all that as context, let's bring it back to Jeremy, who I'm going to remind our listeners is the 39 year old gentleman whose blood pressure is 14290 in our office. So if this is confirmed, we have stage two hypertension. So, Jordi, I guess my first question before we get into management, which I know we always have the tendency to jump to, I would love to know what our initial workup should look like for Jeremy. Should we be getting cardiac biomarkers? I saw those mentioned somewhere in the guidelines. What is the standard operating procedures for someone who now has this freshly diagnosed stage two hypertension?

[C]

Yeah, the guideline now has this table of the additional things that we should be checking in everybody. And so the main things they recommend for everybody across the board are a CBC, a basic metabolic panel, a lipid panel, hemoglobin A1C, TSH, and then the new thing that they just added for everybody is a urine protein to creatinine ratio or urine albumin to creatinine ratio. So we should now be checking microaluminuria and hypertensive patients, not just diabetic patients. That's what happens when you have three nephrologists on the guideline committee. But in terms of the cardiac biomarkers, it's sort of still up in the air. They encourage it. They're useful for risk stratification in particular. But I think that because of expense and accessibility of them, it's still not 100% of a recommendation, but they're pushing more towards it.

[A]

So CBC, metabolic panel, you said lipids A1C and then TSH. With the urinalysis and the albumin to creatinine ratio, the idea is to pick up early kidney damage, proteinuria that we might have been missing, or I guess on the urinalysis, you might see red cells like this. Might be some. Is there a glomerulonephritis or something else going on? Is. Can you talk more about the rationale?

[C]

Yeah, that's the idea is either that you've had occult hypertension for a while, that's caused some. That's caused target organ damage, that there's controversy if it does that, or that there is more. An underlying kidney disease that's not been diagnosed and you can catch it in the early stages. And that's what's driving the hypertension. Exactly. We also, for example, see a lot of albumenuria as a result of aldosterone. Aldosterone is quite toxic to the kidneys. And so if it's an aldosterone driven process, then that could be your first clue to it. And it's such an inexpensive, quick test to do that it would be sort of opening doors to then them having additional workup done to make sure that we're not missing why they have the albuminuria.

[B]

And what are we doing with the cbc? I have a reputation for being a monster about that lab. In particular with my residents who like, at a baseline cbc, I'm like, what are we doing here? So now with hypertension I might have to modify my approach and be less of a hateful human being. So what is the intention behind that? One specific.

[C]

My guess is maybe not to give an ACE inhibitor to cause anemia. I really don't know. Like, there are some rare side effects from some antihypertensive medications that I guess maybe you're trying to get a baseline to make sure that they don't worsen. I don't think it's part of any of the diagnostic workup other than maybe polycythemia or like other.

[A]

I think you're looking for maha, Paul.

[C]

Yeah, right.

[A]

I mean, nothing to do with rfk.

[B]

Paul.

[A]

Microangiopathic hemolytic anemia.

[B]

Original MAHA stands for a while. And you're not talking about being a monster.

[A]

Okay, wait, so aldosterone didn't make it in. I know that because we've talked to the adrenal people. They want everybody with definitely with resistant hyper. I guess it made it in for resistant hypertension, but it's not making it into the first round yet?

[C]

Sort of. And this is where it's really interesting. It got buried. But there is a new TUBI recommendation to consider checking Renin and Aldo. And anybody with a blood pressure greater than or equal to 140 over 90, which is stage two hypertension. And so that matches with the European guideline and it's pretty much matching with the aldosteronism guideline, like the Endocrine Society guideline. It's pretty close to that. Like they're basically saying do it in anyone with hypertension. In this case it's saying anybody with like slightly worse hypertension, but pretty much new diagnosis because most people were diagnosing it in the 140s, over 90s, I think. And so I'm pretty excited about that. But it got buried. It didn't make it into like the list of new recommendations. It didn't really make it into any of the press releases. And I'm sitting here like shouting quietly from my rooftop about it.

[A]

All right, so are we. We've been doing that for years thanks to people like you. So we will continue to do that. And the other, I guess we talked about the lab work up here and we've talked about this on previous shows. Thinking about things like sleep apnea, alcohol intake and sodium intake, all these other kind of things. Are they taking any over the counter meds that might be raising their blood pressure? Nsaids, are they on ADHD meds? Those are other things we think of. Anything else on your list of like the workup? We've gone over this many times with

[C]

you, but yeah, the big things I think we've talked about before, they added tizanidine on the list of medications to ask about. So I'm very excited about that. And so as we know, short acting central alpha agonist that behaves like a very sudden clonidine withdrawal. And the other one that was new is that the new lifestyle recommendation is to abstain from alcohol altogether. And so really any alcohol is considered a teaching point to recommend people to cut back.

[A]

I love it. I mean, there's a lot of great non alcoholic beverages out there nowadays. People, I mean, I don't know why everyone is still. I heard the non alcoholic wine is fantastic, Paul. Actually, I haven't heard that. I've heard people say that's terrible. The non alcoholic beer though, it's a

[B]

great time to drink non alcoholic beer. I'm a big believer. And we've said this before on the show, I do think the new diagnosis of hypertension is always such a great chance to go back and revisit the social history because that often gets neglected and kind of parked after you take it initially. So it's a good chance to see if alcohol intake has changed or someone has taken up cocaine in the intervals of your life. Sure. Yeah, of course, yeah.

[A]

One of these days, black licorice for the audience is. Let me see if I remember this. It's. There's some sort of like apparent mineralocorticoid excess that it can kind of mimic. Right.

[C]

Like acid in black licorice. That's imported only from certain countries overseas, not in the us Typically.

[B]

This is like the scorpion sting, specifically in Bora Bora, causing me pancreatitis.

[C]

But I got a call from a colleague about. He was like, is this for real? And he had a patient that was a schoolteacher who had gotten black licorice as her present from her students at the end of the year. Young woman, like in her like 20s or early 30s. And she like binged on it. Cause she was so excited about this wonderful gift from her students. And ended up admitted with Takotsubu cardiomyopathy.

[A]

Oh, no.

[C]

A hypertensive emergency from the licorice.

[A]

Oh, that's terrible. Well, now I feel bad for joking about it, but let's get back to Jeremy. So just to recap, we've given Jeremy some buy in that hypertension is. Is causally linked to cardiovascular disease, including stroke and also now dementia, which is very bad and everyone wants to avoid that. We talked about time in target range, much like we want our INR to be in a target range, much like we want the glucose to be in a target range. You want your blood pressure. The more time you spend in the ideal range, the better. And then we talked about the lab work up here where we're doing the normal stuff that we would get, but the new things would be the albumin creatinine ratio in addition to a urinalysis and then aldosterone kind of got buried. But you're not going to be faulted, at least by the four of us. Three of us, rather. Deb's not here, the three of us for doing that. And then we said tizanidine and clonidine. Don't miss those as like that could be yo yoing the blood pressure if they're taking it, then withdrawing from that. And alcohol, try out some non alcoholic beer. Paul says there's a lot of great stuff out there and from what I've had, it's great as well. So, Paul, where are we at next with our. Where are we going to take things next for Jeremy? Are we in treatment land now?

[B]

Yeah, let's manage this hypertension. So we've confirmed the diagnosis, we've confirmed the stage 2 hypertension with the new guidelines. Anything changed, Jordy? In terms of how we should be managing this or what should be our approach once we commit to actually treating, which I guess is a little bit different than managing.

[C]

Oh, yeah. Yep. The guidelines now match everything I preached in our prior episode. So they're now recommending for a blood pressure greater than or equal to 140, 90. So that stage two hypertension that you start right off the bat with a fixed dose combination, that every single patient should get that ideally. And the hope is that this is gonna. This recommendation will hopefully push all insurers to cover it because right now a huge proportion of insurers cover it. Medicaid, Medicare cover fixed dose combinations. But there are some private insurers that make patients run through hoops to get them. So hopefully this will push that needle a bit to close that gap.

[A]

They've been great. And I've had a lot more success with blood pressure medication since starting the fixed dose combination. And if someone's stage two, it has been my practice to just start them off, off on that because, you know, if someone, a lot of the times I was seeing people 160 over 90 consistently and then you start them on one agent, they're almost never getting to goal with that. So when you start them on two agents and layer on some lifestyle things, you definitely get better results.

[C]

Yeah. And so very quickly, one, a couple of things with that. I think there's always that concern of how are you going to know if they have an adverse effect? Which when it's two, and thankfully almost every adverse effect from antihypertensives except dizziness is pretty specific to the drug. If you have edema, it's the amlodipine. If you have hyperkalemia, it's the ACE inhibitor, ARB and whatnot. And so I think hopefully that we won't have too much of that. The rashes aren't that common and so ideally you can always take a step back and figure out exactly what caused what. But it's really in big, big, big, big trials. They've seen adherence improves, patients tolerate them well. They're not seeing effects from fixed dose combinations. And I think that if we can change the culture, we're gonna see huge differences in terms of patients feeling better about their care and getting faster to goal and then achieving better outcomes.

[A]

Just to talk some specifics about this, and this is stuff that I learned from you. Losartan is a shorter acting arb. It is often the cheapest combination medicine. Like it's coming with either hydrochlorothiazide or I Don't know. Does it come with a calcium channel blocker? Maybe not that one, but that's one that I try not to do, that one. But then one of the other common ones is lisinopril hydrochlorothiazide and we've talked about the risk of angioedema is a real thing that we've all seen many times. So I try to avoid lisinopril nowadays if I can. Can you comment a little bit about that if you have a couple favorite combination go tos for the audience?

[C]

Yeah, my favorite, as long as insurance will cover it, which the vast majority do is Olmesartan HTTZ or Olmesartan with calcium channel blocker with amlodipine. Because then if I'm adding a third drug it comes in a fixed dose combination that's a triple pill combination. And if insurance doesn't cover it, I do the Valsartan combination with either of those. Even though it's not as potent, it's still you get so much bang for your buck in the fixed dose combination that I feel like that's why worth the downside of using a slightly less potent arb. Losartan's really a challenge. It's shorter acting and it's also metabolized differently in different individuals. And those people who are poor who do metabolize it differently can really end up not being as effective and not being as potent. And so you really will more consistently across the board get better outcomes with Valsartan even though it's not as great of an arb. I love telmisartan too. I tend to have it being one that's better tolerated in my older patients. It's sort of my go to when patients have multi drug intolerance tolerances. But it's not available in as many fixed dose combinations so it's a lesser choice for me.

[A]

There is one, I think it's a 5 of amlodipine and 40 of telmisartan. And I think it comes in maybe 10 and 80 or something like that. But for some people it's like a little, it's a little higher than I'd like to start older people at the like a quarter dose, you know, of both agents and sometimes that's hard to do with the combination pills.

[C]

Yeah. And then there was a new one that was I think recently FDA approved but I don't think it's readily available yet. But it was at Telmisartan andapamide Amlodipine fixed dose combination which is I think Going to be a really cool one. The reason being that indapamide is even gentler than HTT and it's a little longer acting and so it's also a really good one for people who are afraid to have their patients on hctz. It's like an nice sort of softer one.

[A]

So Paul, we covered that on hotcakes.

[B]

We did. Can I miss that to get granular, recognizing that there's going to be variability and you're going to treat more frail patients a bit differently in terms of your practice. Are you starting sort of that with the fixed dose combination, fixed doses of that sort of median effective dose, then adding on a third medication if you need to up titrate or do you start at sort of the lower end of the fixed doses and sort of play around with those before adding on a third medication? Or does it really depend on the patient in front of you? But I guess if you could speak broadly to your practice because a lot of people are just not comfortable with this.

[C]

My practice tends to be a lot more multidrug intolerant and super frail patients because I get the patients referred to me who are having challenges in other practices with people who've already done a great job managing them. And so in my practice I'm doing a lot more lower doses adding a drug at a lower dose because the more you keep the drug at or below the median dose, the more bang you get for your buck. In terms of blood pressure control relative to adverse effects, once you go above the median dose, you're getting getting a small increase in blood pressure. Depending on the drug, it's usually somewhere around maybe a 20% increase in blood pressure control relative to a 50% or 100% increase in adverse effect risk. And so I tend to go up in doses in more robust younger people who are proving themselves able to tolerate the drugs without any issues and who I'm not worried about tipping over but in anyone who I'm worried about having adverse effects or any challenges with them, I stay low in some slow.

[B]

Yeah, there's a great paper I think that just came out that I think looked at that exact. Which I'm sure is exactly what you're citing because you're you. But yeah, we should probably also link in the show notes that sort of looked at the combination and the. The benefit that you get with sort of adding additional above the median dose and just how not all that helpful as compared to the side effects. So everything that you just said is what I'm saying. This episode is brought to you by Continuing Education Co. Hey Curbsiders listeners, have you ever chosen a CME conference because the destination only to be disappointed by the education once you got there? That's where Continuing Education company really stands out. They host conferences in places clinicians genuinely want to visit like Hawaii, Alaska, the Florida Keys, Kiawah Island, Nashville and New Orleans. But they pair those destinations with the education that Ashley delivers. Their meetings are structured as half day morning sessions so you get focused practical learning without feeling overwhelmed. And because your afternoons are free, you have time to enjoy the destination and reflect on what you learned, which makes it far more likely to stick. That balance is why so many clinicians attend for the location the first time and then keep coming back for the education. By the way, if destination CME is on your radar, the folks at CEC recommend planning ahead since discounted hotel room blocks tend to sell out and if traveling isn't in the cards right now. Continuing Education company also offers a wide range of online CME options. Options including live webcasts, on demand courses and recordings from recent conferences. It's the same expert faculty and evidence based content just available whenever and wherever fits your schedule. And for Curbsiders listeners, there is a special offer. Use promo code CURB30 for 30% off all online courses and webcasts. That's promo code CURB30for 30% off all online courses and webcasts. See for yourself why Continuing Education company is considered a leading source from a medical education. Visit cmemeeting.org curbsiders to learn more. That's cmemeeting.org curBSiders.

[A]

Jordi, you told us last time just to remind the audience that when you start someone on a new blood pressure agent, you usually tell them I don't want you to go crazy checking your blood pressure for maybe even two weeks, the first two weeks on the new agent. Because I don't expect expect it to have its full effect and I want to give it at least that much time to kind of let things do what they're going to do.

[C]

Exactly. Because these are all long acting drugs. And so I think a lot of patients who say the drug doesn't work for me it's because they're like checking their blood pressure day after they started it or right after they started it and they're not seeing it lower and so they are convinced that it is not working for them. And so I try to make sure that I do that education up front that that has to be a big part of the conversation of this drug will not work right away it may have a little bit of an effect, but the big effect is going to be when you take this drug regularly for at least two weeks. And if you set that expectation up front, you get a lot less failures like that. Because I just think that people have been programmed to expect the sudden effect and sort of that instant gratification of a blood pressure lowering agent. And this is a lot of the patients that get referred to me on the meclonidine hydralazine combination cocktail of these are the only drugs that have ever worked for my blood pressure. So, yes, really important. I usually counsel my patients specifically to start checking your blood pressure two weeks after you've started. So then you get like that third week of blood pressure on it.

[A]

I like it. Well, let's change it up a little bit. Let's say that if Jeremy was in the 130s over 80s for his blood pressure, so not stage two, and he was just like, you know what? I don't want to take a medicine if possible, so how would you handle that? And I know they talk about this prevention, this calculator, the prevent calculator that we talked about on a lipid episode where it's basically replacing the pool cohort equations. Right. And it's this new risk calculator. So can you talk a little bit about that and how you would decide for people that are stage one?

[C]

Yeah. So if you were stage one, it's not as cut and dry because blood pressure looks pretty close to goal. And so somebody like that, I don't want to have true inertia and just ignore them. I want to ask myself, could they benefit from a lower blood pressure? Is this that person who that time and target range of less than 120 is really going to do them a lot of benefit. And so the key to that is looking at their cardiovascular risk. And the prevent scores threshold is now 7.5%. So any score greater than or equal to 7.5% is considered higher risk. And this is in contrast to the old greater than or equal to 10%. This is because the prevent calculator is just calculated differently. And the people that overlap with that old 10% ASCVD risk are the people in the 7.5% risk group. And so there's this really beautiful publication that Sadiya Khan put out about a week after the guidelines came out. And she was the person who developed the prevent equation. And she drew the curves and lets you see exactly what it looked like if you used a 10% threshold for the prevent equation versus the 7.5%. If you use the 10% threshold, you'd end up with this massive additional group of people who really aren't higher risk and won't benefit as much from the intensive blood pressure lowering. So that's why the number is different. I really like the prevent score. The goal of it was to be more generalizable. It's like using a ton more patient information to calculate it. So it's much more applicable to the patients we see rather than some of these equations that are using the perfect patient that was enrolled in these perfect trials. And instead of using race, it's using zip code. Because we've seen this wealth of data showing that your zip code predicts your lifetime risk of heart disease so much more than almost anything else. And so it's using that, it's incorporating those factors that we now know really matter the most. And so I really like it a lot. And that so if your score is greater than or equal to 7.5%, which his definitely won't be based on his age alone, then you would be started right away with a blood pressure greater than or equal to 130 over 80. The other people who sort of automatically hit that bill are people who have diabetes, who have chronic kidney disease, or who already have a history of cardiac disease. So sort of intuitive, those higher risk subgroups, they used to include people over the age of 65 or greater than or equal to 65 in that group of higher risk. But now basically you just have to pump it into the prevents equation and like 95% of 65 year olds are going to make it in, but there's like that woman with the HDL of 100 and the LDL of like 20 naturally who is like 100 pounds and like still running marathons in her 80s, who isn't gon to actually cut that bill and everybody else will. So I think it's just a little more nuanced now in that way. And so with him, he's going to be lower risk. And so the guideline is much more specific now on what to do with these lower risk younger people, which is nice because I think the last one we all sort of were scratching our heads about what to do with them. And it's really specific and says three to six months of lifestyle modifications and then if the blood pressure is still in this range, start medication. And so I really like that because it's very concrete and it's something you can deliver to the patient and say let's try three months of like weight loss. If he Needs it and whatever, like exercising more if he's sedentary, anything that he can do to help improve his blood pressure using lifestyle factors. And if you're seeing some improvement, keep going. And if you're not, then it's sort of a timeline of exactly when to increase it so you're not just watching forever and not doing it anything.

[A]

Paul, I feel like this is what you've been dying to get to. I think we're gonna talk. Should we get into some, like, other things you can do to lower blood pressure besides medication?

[B]

Sure, that would be great. Yeah. So it's. I do note, and I think these are in the last set of guidelines too specifically mentioned about potassium. I know we talked about some things like in terms like avoidance of alcohol intake, which I could talk about for forever in a day. But I would love to hear some of the other things. But I would love to hear specifically how you counsel your patients about this potassium piece, because I feel like I think we said in pre recording, I'll tell patients like, yeah, have a banana or something and moonwalk out the door and hope for the best. But I feel like there's a lot more concrete recommendations in the guidelines and I would love to hear your teaching script as well.

[C]

Yeah, I mean, some people are actually giving potassium supplementation. I'm not going that far, but I love to tell patients to take away the salt and add the potassium. So when you're taking away one thing, you add something back. And most of them are very surprised about the foods that are high potassium because everyone just thinks banana. That's automatically what comes out of everyone's mouth when you hear high potassium. And bananas have a lot of starch and sugar in them and aren't quite as nutritionally beneficial as like, this wealth of other foods that are high potassium that are not as sugary and starchy. And so I usually start more with like tomatoes, potatoes that aren't fried, and avocados are very high potassium. A lot of green leafy vegetables are very high potassium. Obviously we have patients with other medical issues with where these are problems, but I actually take the CKD list of high potassium foods that they wrongly tell patients to avoid that I disagree with. And I take that and I tear off the part of the page where they're telling people to avoid them and I just hand them the list and I circle the high potassium foods and I'm like, these are the ones you should eat more of. So that's my approach. National Kidney foundation has this great list of high potassium Foods on their website. And I use that as my reference of what to add. But yeah, the big ones that I think people are always surprised about are oranges. They are sugary, but they are very high potassium. And I think people are surprised to hear potatoes because a lot of patients love potatoes and they're like, wait, you're telling me to eat more potatoes? So those are the two that I get the biggest wins with.

[A]

People probably should not be slamming these hydration multiplier things that have a gram of sodium and like a bunch of potassium in them. Just do it with like real foods is what I would tell people.

[B]

Specifically mentions the salt substitute, which is potassium based. And I think that even cites a study where you correct me if I'm wrong, but I think the reduction in systolic pressure by like 5 millimeters of mercury and diastolic by like 1 1/2 for patients who made that switch. Is that something that you're telling patients?

[C]

It prevented strokes? Like on a large population level scale, like, it would be. So the backstory is that there were two of these. There was one in China and one in Peru, where they took entire villages where people don't go out to restaurants constantly, like, everything is cooked at home. And they just replaced all the salt they had access to with the potassium based salt substitute. And in these villages, they actually had meaningful prevention of major outcomes. And so this is big. And so, yes, potassium based salt substitutes are efficacious and effective at reducing blood pressure and cardiovascular risk from hypertension, probably as much as a drug. But the problem is in the US we don't cook that much. Most of people's salt is from processed foods, from the jar of sauce that they pour on their home cooked meal, not even thinking twice about it. All of those things that are sort of ingrained in our everyday life. I have so many patients who are shocked when I tell them that cheese has salt in it because they're like. But I didn't add any salt to my cheese.

[B]

The good cheese, though.

[C]

Yeah, and so. Yeah, exactly. Not al. Yeah, there are some cheeses that are lower salt, but. But yeah, it's. It's something where patients are just sort of. It's part of their culture and part of how they've been brought up. And it's just so hard to break that. That said, though, I think it is a great idea to suggest the one thing that the studies did, both trials were really smart about this. They actually did massive taste testing before they started with it because they didn't want people to know that they had a potassium based salt substitute. And, and if the ones that are sold in the US like no salt. And there are a couple of other ones, I think like Morton's has one, like most of the salt brands have a potassium based salt substitute that you can just find on most supermarket shelves. Those are all 100% potassium based chloride salt substitutes. So those taste metallic as heck. And so the issue with them is that patients aren't going to like them as much. So if you get pushback from patients who are trying to use them regularly, the couple of options are either don't use those and just use other seasonings that aren't salt based or mix it. And so the studies had found that there was a ratio of salt to like actual sodium chloride salt to the potassium based salt substitutes that was more palatable. I think it was somewhere around 50, 50. And so I'll usually tell my patients just like throw 50, 50 into a bag and that'll be your salt. Just shake it up. And I've had a few who love that, who do mostly home based cooking and really have that craving for salt, that it does the trick for them.

[B]

I feel like that's a product waiting for you to market at Jordi, just a low sodium salt. This is your chance.

[A]

The other stuff we talked about last time were GLP1 agonists, basically because of weight loss. I don't think they have a direct effect on blood pressure. Right. It's more the effect of the weight loss that causes the lowering of the blood pressure.

[C]

Yeah. There was a great meta analysis in European Heart Journal that had shown that it was, it was perfectly mediated by your weight loss. The amount of weight you lose determines how much blood pressure you lose.

[A]

Okay, so I think we should change the case up again a little bit. Let's say we got Jeremy, he's substituting salt, he's drinking non alcoholic beer, going to the gym. And just in general we really tuned things up and we were able to avoid a medication when he came back. But what if we were seeing a little old lady with mild cognitive impairment and or dementia? Are you gonna be less aggressive in somebody like that? What are the blood pressure goals there now?

[C]

Yeah, so this is I think one of the more controversial parts of the guidelines that I don't know, I haven't again heard about this much from folks cause I think they're not really digging this out as much, but they are recommending going aggressive with these older patients going to less than 130 millimeters of mercury for Just about anyone who's an older patient, unless they really have a contraindication to it. And we used to think of orthostatic hypotension as that contraindication, but now they specifically call out that. There was a meta analysis last year in JAMA showing that in patients with asymptomatic orthostatic hypotension, that intensive blood pressure lowering didn't really cause much harm at all and that they did much better from a cardiovascular standpoint. So I think we're all sort of blown away by that and questioning our reality with that. I, I do it in patients where I really feel comfortable that they would have been in Sprint because we were a Sprint enrollment site. So these were patients that show up to the appointments, that are able to come in regularly, that are able to self manage. I'm a little more cautious about it in really frailer patients that I don't think would have ever met the bill for being in the trials that these goals are based on. I think we need more data to know for sure. In those groups.

[B]

Groups, this feels like the right time to shoehorn in my specific question, where I'm basically just consulting you and not talking about the guidelines. So we're talking about sort of older patients. One phenotype that I've personally have struggled with is the older patient who has this big old pulse pressure. So they have systolic hypertension, but their diastolics are in the 50s or 60s. Maybe their home measurements are a little bit better, but not by much. And I always struggle. How hard do I push without worrying about that diastolic blood pressure and, and sort of what do the data show? And I recognize this is not a. I don't think it's specifically in the guideline, but since I have you here, I would feel foolish not taking advantage. So how should we think about patients like that and what do we do with them?

[C]

Yeah, I see a ton of this because patients with chronic kidney disease, even milder chronic kidney disease, have a lot of very wide pulse pressures because it's caused by arterial stiffness, stiffening of blood vessels from several things. Smoking can do it, diabetes can do it. A life of comorbidities can do it. And so we see a lot of this, obviously, and, and it's really, really hard because intuitively we've been told that if we lower that diastolic too much that we're gonna cause harm to patients. We're gonna hypoperfuse their kidneys and their brains and cause them to fall and cause them to have adverse outcomes. And interestingly, people have now started looking at this with higher quality data and not seeing what we think by anecdote is happening. And so in Sprint, in Accord, in all of these trials, many of which enrolled older patients, for instance, the STEP trial in China enrolled patients in, in 65 to 85. So these aren't like young, really robust patients. These are older patients that are typically the ones with these wide pulse pressures that the cardiovascular benefits from intensive blood pressure lowering didn't differ by your diastolic. So if you had really, really low diastolic blood pressures, you still benefited as much and the adverse effects didn't differ. And so they didn't have more syncope, they didn't have more falls, at least recorded in the patients with lower diastolic blood pressures than the ones with higher, higher. The caveat being that these trials didn't really have patients with diastolic blood pressures in like the 40s. They might have had one or two in the 50s and then a whole lot in the 60s. But we're not thinking about those people with really, really extreme isolated systolic hypertension where like those diastolics are non palp. We're talking about sort of a more moderate range of it. But yeah, lowering the systolic is actually probably beneficial to those patients and you're not causing harm by doing it. And a huge portion of them, the studies that have found that there may be some harm, it seems that it's actually the frailty that's doing it, not the diastolic blood pressure. So low diastolic blood pressures are exceptionally common in people who are frail. And so if you cut it out that way and you look at it by frailty, it's the frailty that's causing patients to actually have falls and to actually have a worsening kidney function and worsening cognitive function from blood pressure lowering. It's not the actual low diastolic blood pressure itself. It's just that it happens to be there more often in people who are too frail to tolerate those things.

[A]

That is a really satisfying answer, Paul. Yes, thank you for that reassurance. Yeah.

[B]

All right, let's move on to a different type of case. Let's talk about Jolene. This is a case that would terrify me. Jolene is a 34 year old primary care patient who comes to your office with the exciting news that she is 16 weeks pregnant. So it means I'm in a blind panic even before checking vital signs. But we unfortunately check Vital signs. We see that her blood pressure is 148, 92, which we confirm with all the right positioning and empty bladders and all the things. Since she is pregnant, my inclination would be to just close my eyes, hope for the best, and make sure that she's seeing OBGYN in the short term. But I guess that's probably not what we're supposed to be doing. So I would love to hear how we should be approaching patients with pregnancy who also happen to be hypertensive and what to do about them, because I think they would probably instill fear in a lot of just general internists.

[C]

She's not on an ACE inhibitor or an arb, so my heart rate has slowed down a little bit. But I think we should make this part of our wheelhouse. I think it's okay for us to feel a bit uncomfortable with pregnancy, obviously, because there's so little testing that's been done to really know what's safe and what isn't. But in somebody like this, we do have really good data. And so I think that it's like not the same like area of uncertainty as many other aspects of pregnancy. And so this woman, if she's presenting this early with a blood pressure in that range, this is now actually considered chronic hypertension. Assuming we confirm that blood pressure, we really trust that's real, or we get some home blood readings that confirm it, that's chronic hypertension. So that's actually really our wheelhouse. And so the only difference is instead of starting this patient on fixed dose combo of our favorite ARB and calcium channel blocker, instead we need to stick with the safe pregnancy blood pressure meds. And so this is exactly the person. Her blood pressure is between 140 to 160 or less than 160. She's the person that we start on a new blood pressure medication and call her chronic hypertension. The ideal is because she is 16 weeks pregnant. I'm starting with nifedipine with long acting nifedipine, the usual one that we'll often use in many of our other patients. And then if that's not enough, I check in again in a week or two, have her checking home blood pressure monitoring. It's been shown to work really well in pregnancy. And then if it's not enough in a couple of weeks, then increase the dose or add labetalol. I will never, ever recommend using labetalol for hypertension in any other setting except for pregnancy. And then in terms of long term management, yes, we'll hand off to OB around 20 weeks.

[B]

Can I ask a tangential question? I don't want to get too far away from the pregnancy, but in patients who have the potential to become pregnant, how does that ever impact your choice of initial antihypertensive? Because I feel like we're seeing so much more blood pressure, so much elevated blood pressure in younger and younger patients because of comorbidities and such. And I know that a lot of. I feel like a lot of folks just love reaching for the ACE specifically or an arb, which I understand. I love them, too. But in younger patients with nasty become pregnant, does that alter your arithmetic or does it influence how you sort of choose agents for initial management of blood pressure? That was something I meant to ask.

[C]

Yeah. This is part of why I love that the microalbumin is part of the initial screening. Because if they have microalbuminuria, I'm keeping them on an ACE inhibitor arb, no matter what, because I really want that person to have their kidneys protected because pregnancy is hard on the kidneys. And so I want them to be on that as long as they can. But to counsel them that as soon as you find out you're pregnant, we should be stopping it, because once you're on it in second trimester, you're in trouble. So if this woman were on an asinibido ARB right now she's in her second trimester, I'd be worried about the risk of teratogenic effects. But as long as you stop it in the first trimester, it's actually okay. And so the risk for Mason obdurate A orbs is later in pregnancy. But I still will counsel people, and especially if they're trying to get pregnant and if they're not on birth control, I'm really, really cautious about it and really belabor that point of the risk of it. But I'll still use it in anybody with microalbuminuria or any kidney issue. But the rest of patients who don't. Now that we're going to know, because we're going to check a microalbumin, I would have them on amlodipine. Because the great thing is a lot of obs will just keep people on their chronic amlodipine if they're on it once they get pregnant. We don't have any data supporting it for pregnancy, but we also don't have any data really suggesting that it's dangerous in pregnancy. And so it's one that I've seen a lot of obs be comfortable just Leaving people on. Or it's an easy one to just switch over to nifedipine since, you know, they've already tolerated the calcium channel blocker.

[B]

That's really helpful. Thank you.

[C]

And also HTTC is our sort of third drug that we typically use in pregnancy. It's not perfect because there is some potential theoretical risk of intrauterine growth restriction and it's not great for breastfeeding either. But it's something where if you need two drugs, the amlodipine, HTT is sort of the one that causes the least night nightmares.

[A]

Okay. And then home blood pressure monitoring. They should be doing that. And you said at 20 weeks you're handing off to OB. Is that just because you're in preeclampsia, eclampsia territory?

[C]

Yeah. And patients with chronic hypertension have a huge increased risk of developing preeclampsia. It's around 30 to 50% risk of preeclampsia. And I just wanna make sure we have high risk OB or at least OB involved and watching them too. So I'm usually with them. I'll still often follow those patients because I'm more in a hypertension focused clinic. But I think at that point it's reasonable for us to say, I feel uncomfortable now.

[A]

And they're all being started on aspirin these days. Like a baby aspirin for preeclampsia prophylaxis, which is. That's something newer. I don't remember that happening when I was like many, many years ago when I was doing OB rotations.

[C]

Yeah. I think the guideline came out about five years ago.

[B]

I think that's right.

[C]

Ending it. And it was anyone 12 weeks onward who. Who is older or who has hypertension. Because it does reduce the risk of preeclampsia and other major adverse events related to. In pregnancy. It reduces risk of adverse maternal and baby outcomes.

[A]

Okay, we have one, I guess one last situation or one last opportunity for you to get on a soapbox, which I would greatly enjoy to hear this. So what's happening with. So let's say we had a patient coming in, into the hospital with blood pressure 198 over 136. No end organ damage. What are we calling that these days?

[C]

Yeah, so we're confident it's no end organ damage and that this person just has a high blood pressure. We're calling that chronic hypertension or chronic severe hypertension. If anyone is calling this hypertensive urgency in their outpatient node. In their inpatient node, please, please. Please shame them. This is no longer considered acceptable practice. This is something I see mostly in ER notes which I feel like, okay, okay, they can take a little time to catch up with our guidelines. It's not really their guidelines, but when I'm seeing it in a lot of general internal medicine notes, I start criticizing people to their faces. But no, it's not urgent. That's the key. I think the main goal of the messaging is don't treat it as something urgent, don't call it something urgent because that means you can potentially cause harm by trying to, to lower them too quickly. We now have several observational studies and hopefully some trials upcoming. I've been hearing rumors that there are some trials in the works in this because in the past Nobody could get IRBs to approve trials because everybody thought it was not safe to not treat high blood pressure. But now we have all this data showing that it's probably more unsafe to treat these patients quickly. And so now there's equipoise for a trial so we'll have better quality evidence. But at the moment the best evidence we have suggests that if you treat these patients quickly with short acting agents, either IV or short acting orals, IV obviously worse, that you can cause ischemia, you can cause aki, you can cause ischemic cardiac events, you can end up putting them into ICUs and keeping them in the hospital longer. And so I think that it's an area where it merits calling it something different. So hopefully that'll help change behavior.

[A]

It's kind of culture and institution dependent in my experience having moved around. But it's been in places where it's the culture to treat that acute severe hypertension or even just chronic uncontrolled hypertension. It's hard to get people to just like there's prn, hydralazine or labetalol order just as part of standard order set still too. And I think that easy, it makes it easy to order it. So I think it makes it harder to get rid of the behavior.

[C]

Except I'm gonna do a quick soapbox on that. I think a lot of that is treating the nurses because you don't wanna get that 2am phone call from, from a nurse worried about a blood pressure. And so I think that if we can, when we educate the nurses we see a lot of good effects from that. And we've done that in some areas where we're dealing with this, where you teach the nurses that this actually can cause harm to over treat. And then nurses start trying to dig in oh, is it because the patient is anxious? So instead I'm going to reach out to the doc asking for an anxiety med, not asking for a blood pressure med. Or is it because the patient's in pain? Let me get a pain scale from them before I start for that hydralazine or that clonidine. And so I think that it helps empower nurses. And this is an area where they shine. And it also is an area where if we can change that culture and start treating the underlying cause of that high blood pressure, especially inpatient, but also outpatient. I mean, we're getting those calls and it's scary. But if we can just escalate their med, get them a home blood pressure cuff. I know that's easier said than done in many cases. It can go such a long way. Way, though, that's where that blood pressure watch would be amazing if we had it.

[A]

Well, the nurses that listen to this show, they know what's up with blood pressure. They know we don't like to treat IV pushes for PRN hyper, you know, the PRN IV pushes. We don't like that on this show. And I'm excited that there's randomized trials that are going to be coming out. We'll have better data to support this or maybe we'll learn that we were wrong and maybe it was the right thing and then we'll really feel stupid.

[C]

Paul?

[A]

Well, sure we would, but, you know, that's science. I would have to change my mind on it, so I'm admitting that now. Audience.

[B]

The big outcome that differs is that patients are just more likely to get hospitalized. At least that was the study. But otherwise, I think the study that we talked about in the past, where there are no outcomes in terms of mortality or even blood pressure control, they're just more likely to have the hospital, which, as we know, is also toxic exposure. So, yeah, yeah. So I think it's in keeping with what I know. So I love that this was very explicit.

[A]

Well, Paul, we have covered a lot and I think I'm out of. My list is all checked off. I don't have other things on my wish list to talk about right now. Do you have other things on your list that you wanted to get in before we get take home points?

[B]

Just a quick one. Jordy, we talked a little bit. I would love to hear about the revascularization for renal artery stenosis, which is something that we've talked about on the show before. The evidence has always been sort of conflicting, it seems to me. So, yeah, I guess where are we at with that now? How have things changed and how is that addressed in the guideline, if that's not too big a topic for you to sort of clean up with?

[C]

Yeah, I'll do it very briefly. Basically, we still typically don't revascularize patients for renal artery stenosis. It's less commonly done than done. And so if you have suspicion for renal artery stenosis as the cause of cause of someone's hypertension, we're only even really testing for it. And if someone's really, truly resistant and they're even refractory hypertensive, or if they weren't somebody who fit the trial evidence that were all these negative trials. And so people who really didn't. Weren't in the trials were people who had much worsening kidney function because they were having ischemia to their kidneys and needed to have an intervention to prevent that, or albuminuria because they're hyperfiltering from ischemia to their kidneys. And so those are situations where we would still be referring and evaluating for potential revascularization with a stent. The other one is recurrent pulmonary edema, because those are patients where they're getting really severe volume overload as a result of the pathogenesis of what's occurring from the renal arterage stenosis. And they actually really can benefit a lot from a stent if they are severely stenosed. And so that's when we start. Start doing the workup. Usually is those situations so substantially acutely worsening kidney function, really, really refractory, can't control their blood pressure, or having recurrent pulmonary edema. Those are the situations.

[A]

We talked about this before. This was a Neph madness episode where we talked about renal artery stenosis. I have really moved this that even imaging anybody for that, like, way down my algorithm. Like, it's maybe one of the last things I would do after we talked about lifestyle stuff and aldosterone. I'd sort of do all that testing first. Is that okay, or are you imaging them up front more quickly?

[C]

No, because we even have learned the Dopplers often are just not able to catch it. And so you're gonna need to do a CT angio. So I'm typically only really doing that if I have a high level of suspicion. The other group that I'll do it in is if I'm worried about fibromuscular dysplasia, which is usually younger women. 90% of people with it are women. And so I do have a couple of men that have had that, but they're super rare. And so I tend to just stick with the most likely demographic for that one. And then the man would be caught if he has more severe hypertension.

[A]

I like it. Well, we can follow that. That's good. And we talked about also, you can also mine the chart. People might have already had a cat sc and if, like, you know, if there's asymmetry in the kidneys or one kidney is atrophic or something like that, you know, there's, there's, you can get some clues there as to what might be going on. So, Paul, now are we ready for

[B]

take home points or I guess, you know, we could do this for another two and a half hours.

[A]

Jordi, you have one more.

[C]

Yeah. Can I give a couple other things I wanted to briefly mention that were points that we didn't get to. One thing that I wanted to mention because I think it doesn't come up in most sort of overviews of the guidelines because it was something that was just quietly removed. But that means that there's no bullet point of we added this new thing or we highlighted this new thing. There's no more race based recommendations. So we were sort of prophetic about this. We talked about this in one of our prior episodes. But there's no more recommendation to use ACE inhibitors, arbs preferentially in non black people and then calcium channel blockers or to include ACE inhibitors arbs in non black people, but not include AA inhibitors arbs in black individuals and to preferentially use calcium channel blockers and thiazide diuretics. So that's been removed from the guideline that's no longer part of it because the studies have shown now they've panned out, that it didn't help to address poor blood pressure control in black patients to sort of go based off of that. It was more in the age of when like monotherapy and all had trial in the 90s and when you were just using one drug. But now that we know that almost everyone needs multiple drugs to reach control and that the control goals are getting lower, that the places that have really achieved really great blood pressure control in black patients are the ones that have done these race agnostic algorithms where you just get everybody to control fast regardless of whatever drug you use and that people benefit from that. And so there will be more literature coming out on that soon. But I just wanted to mention that that's, that's good.

[A]

Yeah, that just simplifies things. Like it's just, just like just get Them on the combination of meds that's going to control blood pressure, that's going to help everyone and there's no right. Anyway, we did talk about that on a previous episode with you and I think let's keep this going. I think we talk to you once a year and then you just keep predicting what's going to happen down the line with the guidelines. So that way we're way ahead. The audience, they like to feel ahead.

[C]

Well, this time they let me on the guidelines. So I might have had some reverse causality.

[A]

Well, I didn't want to point that out. That it's, you know, you're kind of like it's a self fulfilling prophecy or what would this category. How would we categorize this, Paul? She's sort of like edging things. She's using her will, she's bending them to her will. But that's okay. That's impressive.

[B]

She's lending her expertise and moving the needle appropriately.

[C]

I was arguing with a lot of senior people who knew more than me to convince them to change their opinions that they've had for a long time.

[A]

I love it. I am so proud of you. I mean that sincerely. It's very impressive and we're lucky to have access to you to come on the show and give all this great knowledge to our audience. So what would be a couple take home points that you want them to remember from this discussion?

[C]

Yeah, I think the key ones are please don't undermine the importance of the device you use to make measure blood pressure and ask people if they're using watches and just be a healthy skeptic of those for a while. I think they'll be really cool in the future, but definitely not there yet. And then the other big one is check everyone now for their Renin and Aldosterone. One thing that we didn't really touch on, but that's really an important part of that is there are less barriers. Just check it. You don't need to think about stopping medications. You don't need to think. Take a deep breath. Just check arena and Aldo and then go from there. And if you're not sure how to interpret it, that's one thing I do really trust open evidence for.

[A]

Okay, I like it. I like it. Plug for open evidence. A great product. At some point a Curbsider sponsor. So full disclosure there. All right, Paul, well, let's get to an outro.

[B]

This has been another episode of the Curbsiders bringing you a little knowledge food for your brain hole.

[A]

Yummy.

[B]

Still hungry for more Join our Patreon and get all of our episodes ad free twice monthly bonus [e-mail] curbsiders. You can find our show [e-mail] and sign up for our mailing list to get our weekly show notes in your inbox. This includes our Curbsider's Digest which recaps the latest practice changing articles, guidelines and news in internal medicine.

[A]

And we're committed to high value practice changing knowledge and we want your feedback. So you can email email us@escurbsiders gmail.com if you want CME credit. It's available for all health professionals through VCU healthcirbsiders.vcuhealth.org A special thanks to our writer and producer for this episode, Dr. Deb Gorth, and to our whole Curbsiders team. Our technical production is done by podpace. Elizabeth Proto does our social media. Jan Wotter runs our Patreon. Krista 2 Men 2 moderates our Discord. Stuart Brigham posed our theme music and with all until next time, I've been Dr. Matthew Frank, water and Matt.

[B]

I'm just going to leave this here. Just as a test, by the way, as a natural experiment. I know there are no scorpions in Bora Bora. I was talking about scorpions in Trinidad. So if anyone comes at me, we know they didn't listen all the way to the end. I as always Armenian Dr. Paul Nelson Williams. Thank you and goodbye.

[C]

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[B]

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[A]

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[B]

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