Evaluation of hypertension control measures

There is no universally applicable optimal solution among the current mainstream hypertension control measures. According to the national multi-center research data led by the 2023 "China Hypertension Prevention and Treatment Guidelines", the long-term blood pressure compliance rate of comprehensive intervention adapted to individual conditions (lifestyle adjustment + standardized medication + matching monitoring frequency) can reach 61.7%, which is more than 2.6 times the compliance rate of single drug treatment or single lifestyle intervention. I have been doing chronic disease management in a community health service center for almost five years. This data is really obtained in clinical practice every day, and it is not watered down at all.

Uncle Zhang, who I met at a community free clinic last month, is a typical example. He is 56 years old. He has been diagnosed with high blood pressure for three years. He has never stopped taking medicine. However, every time the high blood pressure is measured, it is above 160. When I asked him, he found out that he pickled radishes every day and drank two taels of white wine for dinner every day. The doctor advised him several times to cut down on salt and wine. He always said, "I have been eating this for the rest of my life and I can't change it." No matter how good the medicine is, it can't stand up to this. Interestingly, the public health field and the clinical frontline have always had different views on the priorities of lifestyle intervention. The public health faction has made a calculation: If the daily salt intake of the entire population can be reduced from the current average of 10.5g to the 5g recommended by the guideline, the national prevalence of hypertension can be directly reduced by 9 percentage points, which is equivalent to eliminating nearly 100 million hypertensive patients. The input-output ratio is extremely high ； However, most grassroots clinicians feel that this account is too ideal. Take the North as an example. The soy sauce and pickles in a meal of many families add up to more than 6g of salt intake. It is unrealistic for an elderly person who has been eating a heavy diet for decades to suddenly switch to a lighter diet. Instead, it is better to first make individualized "reduction requirements" for patients who have been diagnosed. For example, first reduce it to 8g per day. It would be good if you can achieve it.

Of course, blood pressure can be stabilized just by adjusting your lifestyle. After all, less than 10% of patients with mild initial hypertension still have to take medication. I met a 62-year-old aunt in the emergency department before. After taking amlodipine for half a year, she felt her ankles were a little swollen. She heard from neighbors that antihypertensive drugs hurt her kidneys, so she secretly stopped taking the medicine. As a result, she was sent here because of a sudden cerebral infarction half a year later, and half of her body was still in trouble after being rescued. The controversy over medication regimen has actually been going on for almost ten years. Clinicians of the older generation prefer "stepped medication": prescribe one type of medicine first, take it in small doses, then add more if it doesn't work, and add the second type if it doesn't work. They think this is more secure and less likely to cause hypotension. ； However, evidence-based medical evidence in recent years more supports "initial low-dose combined medication". Taking half a tablet of two antihypertensive drugs with different mechanisms has half the side effects than increasing the dose of a single drug, and the speed of reaching the standard is 30% faster. The 2023 version of the guide also recommends this plan to most newly diagnosed patients. However, many grassroots hospitals are still accustomed to using the old method. After all, they are afraid that the elderly will not tolerate the new drugs and will be held responsible for problems.

Speaking of which, I have to mention the smart blood pressure monitoring equipment that is very popular now. I met a 28-year-old programmer a while ago. After he was diagnosed with high blood pressure, he bought a smart watch that can measure blood pressure in real time. He checked it once an hour. When he saw the value exceeded 130, he became nervous. The more nervous the higher the blood pressure was, the vicious cycle lasted for almost half a month. Later, the doctor asked him to adjust the monitoring frequency to once in the morning and evening. Don't bother to look at it at ordinary times. His blood pressure stabilized within two weeks. At present, the academic circles are not completely unified on the positioning of ambulatory blood pressure monitoring. One group believes that 24-hour ambulatory blood pressure is much more accurate than office blood pressure. It can also detect "white coat hypertension" and "covert hypertension" and should be used as the gold standard for diagnosis. ； But the other group thinks that ordinary patients don't know how to use it. If the cuff is tied looser or tighter, the data will be far different, which can easily mislead people. It is better to teach everyone how to use the home upper arm blood pressure monitor correctly, so that the measured numbers will be more reliable.

In fact, the most challenging control plan is for elderly patients with other underlying diseases. An 82-year-old man I followed up last month had a carotid artery stenosis of 70%. The previous doctor lowered his blood pressure to 120/70. He complained of dizziness every day and almost fell when he went out. Later, we reduced the antihypertensive medicine by half and controlled the blood pressure to around 140/80. The old man felt energetic and could go shopping and walk without any problem. Many patients think that the lower the blood pressure is, the better. In fact, this is not the case. For the elderly with severe carotid artery stenosis and old chronic coronary artery disease, lowering blood pressure too low will lead to insufficient blood supply to the brain, and in severe cases, it may induce cerebral infarction. In recent years, the Department of Geriatrics has been promoting "individualized blood pressure targets." Not everyone has to stick to the 130/80 line. In fact, many ordinary patients do not know this.

To put it bluntly, controlling high blood pressure is like adjusting the pressure of your old water pipes. Some people have clogged water pipes, so they need to clear them first and then adjust the pressure. Some people have water pumps that are too powerful, so they need to adjust the pumps first. There is no one method that can work for everyone. Your Aunt Li, who dances square dance every day downstairs, takes half a pill of valsartan every day plus salt control. Her blood pressure cannot be stabilized. Your father-in-law, who drinks every now and then, may have to take three medicines together. A plan that can stabilize blood pressure for a long time without side effects is a good plan.