New Guidelines, Increasing Hypertension Numbers, Resistance and Resistance to Change?

The authors found that as the overall population of those who met the criteria for HTN increased, so too did the population with treatment-resistant HTN, which rose from 12.0% to 15.95% of those with treated HTN, a relative increase of 33.0%.2 In comparison, other studies of the new guidelines have reported a relative increase of 42% for the overall diagnosis of HTN, increasing from 31.9% to 45.6% of the entire US population.3 At the same time, these studies found only a 5% relative increase in the number of people recommended for medical treatment, rising from 34.3% to 36.2% of the US population, or a 5% relative increase.3 Thus, placing the current study by Patel et al in context, they demonstrate that the increase in treatment-resistant HTN is not as large as the increase in HTN overall but greater than the increase of those for whom medical therapy is now recommended.2'3 These new, more aggressive goals will likely have salutary consequences, as a recent analysis found that achieving the 2017 systolic BP guidelines would reduce the incidence of CVD by 610,000 events annually and reduce death among US adults older than 40 years by 310,000 people every year.4 Given the linear relationship between BP and CVD, quantifying the impact on those with the most severe forms of HTN and treatment resistance is important, and the current study provides a useful start.5 Noteworthy in this study are several assumptions made about the population studied. For these patients, treatment approaches such as weight reduction and increased physical activity remain underutilized and can be remarkably effective anti-hypertensive strategies.9,10 For example, weight loss of more than 5% results in a sustained BP reduction in overweight individuals.11 Regular aerobic exercise has also been reported to decrease systolic and diastolic BP by as much as 15 and 9 mm Hg, respectively.12 As the number of patients diagnosed as having HTN grows, it will undoubtedly seem like a larger percentage of the current workload in cardiovascular and other internal medicine and family practices. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Hypertension. 2018;71(6):e140-e144].