Eugene Yang, MD, often confronts the complexities of weighing various medical interventions for high blood pressure. Among these is when to scale back antihypertensive drugs or stop them completely.
He considers a patient's comorbidities, severity of symptoms, and risk factors for heart attack and stroke, among other variables. Central to this calculus is the recognition of age as a pivotal determinant of quality of life, according to Yang, the chair of the Prevention of Cardiovascular Disease Council at the American College of Cardiology.
For older adults, for example, the variance in functional status can be striking. One octogenarian may be bedbound due to severe dementia, while another might be playing pickleball three times a week.
"This happens to me in my practice all the time. I have patients who are restricted in mobility and have severe memory loss: Their functionality is quite poor," Yang said. "In a patient where we have a limited life expectancy, where they have limited function or core memory, the goal is not to prolong life: It's to make them more comfortable."
Knowing when to deprescribe blood pressure medications is crucial. For some, lifestyle changes can do the trick. For others, particularly older patients, their comorbid conditions and medication regimens need to be considered.
"There's a recognition that we need to move to a new paradigm where we need to decide when to be aggressive and when to be less aggressive," Yang said.
The American Heart Association and the American College of Cardiology most recently released guidelines in 2017, changing the cutoff for diagnosis from 140/90 to 130/80 mm Hg. The groups have issued no updates since then, leaving primary care physicians and their colleagues to navigate this territory with caution, balancing the benefits of reduction with the potential harms of undertreatment.
One example of an area that needs updating is the consideration of the age, currently missing from current guidance on hypertension management from government and medical bodies in the United States. However, European Society of Hypertension guidelines, updated in June 2023, recommend adults over age 80 or those classified as frail should be treated when their systolic blood pressure exceeds 160.
"For the first time, we have a chapter in the guidelines on hypertension and management in older people," Reinhold Kreutz, MD, PhD, immediate past-president of the European Society of Hypertension, said. "If a patient has low blood pressure and symptoms such as dizziness or frailty, a reduction in medication should be considered."
High blood pressure does not always present with noticeable symptoms, and patients do not always show up for an office visit in time for early intervention. It can pave the way for severe health complications including heart failure, stroke, kidney disease, heart attack, and, ultimately, death.
Grim statistics reveal its toll: Hypertension was a primary or contributing cause of nearly 700,000 deaths in the United States in 2021, and nearly half of adults have the condition. Only about one in four adults have their high blood pressure under control.
New Research Provides Insight
A recent study may provide needed insights for primary care clinicians: Gradually reducing hypertensive medication may not induce the feared fluctuations in blood pressure, contrary to prior concerns.
Researchers in Seoul, South Korea, analyzed the blood pressure of 83 patients diagnosed with hypertension who reduced their use of medication. They found that the use of less medication was associated with an increase in blood pressure readings taken at home but not in the clinic nor did it appear to influence blood pressure variability. The mean age of participants was 66 years.
Research shows systolic blood pressure variability is an important predictor of cardiovascular outcomes, as well as the risk for dementia.
When crafting treatment plans, clinicians should recognize the diverse factors at play for a particular patient, particularly concerning other health conditions.
Obesity, diabetes, and hyperlipidemia are among the common comorbidities often intertwined with hypertension. Because additional conditions come with more symptoms to consider and various medications, these health profiles demand tailored approaches to hypertension treatment.
Clinicians can recommend lifestyle modifications like dietary changes and regular exercise as first steps for patients who are diagnosed with grade 1 hypertension but who do not have cardiovascular disease, chronic kidney disease, diabetes, or organ damage. However, in cases where comorbidities are present or hypertension escalates to grade 2, clinicians should turn to medications for management, according to the International Society of Hypertension.
Patients with heart failure and reduced ejection fraction have unique challenges, according to Keith C. Ferdinand, MD, the Gereld S. Berenson Endowed Chair in Preventative Cardiology at the Tulane School of Medicine in New Orleans, Louisiana.
"Patients who have heart disease, they get a pump so the blood pressure comes down — but medicine is often needed to prevent further heart failure," Ferdinand said.
Ferdinand stressed the importance of continuous medication to stave off further cardiac deterioration. He advocated for a cautious approach, emphasizing the continued use of medications like sacubitril/valsartan, beta-blockers, or sodium-glucose transport protein inhibitors to safeguard against heart failure progression.
Patients should also self-monitor blood pressure at home and be taught how to properly fit a cuff to enable accurate measurements. This approach empowers patients to actively engage in their health management and detect any deviations that warrant further attention, he said.
Medications for Hypertension
The use of any of the five major drug classes — angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, calcium blockers, and thiazide/thiazide-like diuretics — and their combinations are recommended as the basis of antihypertensive treatment strategies.
Yang said primary care clinicians must be careful to decrease doses slowly. Central-acting medications such as clonidine and beta-blockers ultimately reduce heart rate and dilate blood vessels.
Decreasing the dose too quickly can create a rebound effect, and medication should be means reduced and closely monitored over the course of several weeks, Yang said.
"You cannot just withdraw abruptly with certain medications — you have to wean off slowly," because patients may experience high blood pressure again, Yang said.
Lindsay Kalter is a freelance journalist living in Michigan.