Things You Need To Know About Hypertension

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Reduce Your Risk

Just as we think we have known it all about hypertension, COVID-19 came along and ripped that thin sheer of confidence away from us. We can never be too safe but we can do as much as possible to reduce our risk and manage hypertension. It is time to know more about our health status and not just brush it aside.

Different Hypertension Reading Targets

According to MOH (2017), one in four Singapore residents have hypertension. A person is diagnosed with hypertension when the blood pressure is equal to or above 140/90 mmHg.

These hypertension readings get adjusted every few years as researchers and doctors discover more, and when population changes and shifts. The most recent debate is on the new American Heart Association (AHA) which has a lower cut-off guidelines (130/80 mmHg) for high blood pressure.

Singapore, however, will continue to use the current 140/90 mmHg to indicate hypertension. This is the same value used in Europe and Australia.

Minor Differences Between The 2 Major Professional Bodies

Although there are minor difference between the categorisation of different grades of hypertension between the 2 major professional bodies, the unifying principle lies in the presence of cardiovascular risk factors, treatment should be initiated earlier to bring control to the condition.

AHA/ACC (American Heart Association, American College of Cardiology) Guideline Recommendations by Blood Pressure Category

Blood Pressure (BP) Category	Pressure Ranges	Recommendations
Normal BP	<120 / <80 mmHg	Promote healthy lifestyle; reassess BP annually
Elevated BP	120-129 / <80 mmHg	Start with nonpharmacologic therapy; reassess BP in 3 - 6 months
Stage 1 Hypertension	130-139 / 80-89 mmHg	ASCVD (Atherosclerotic Cardiovascular Disease) or 10-year CVD (Cardiovascular Disease) risk ≥ 10%:Start with both nonpharmacologic and pharmacologic therapy. Reassess BP in 1 month. If at goal, reassess every 3-6 months. If not at goal, assess for adherence and consider intensification of therapy.
		No ASCVD and 10-year CVD risk <10%:Start with nonpharmacologic therapy, reassess BP in 3-6 months. If not at goal, consider initiation of pharmacologic therapy.
Stage 2 Hypertension	≥140 / ≥90 mmHg	Start with both nonpharmacologic and pharmacologic therapy. Reassess BP in 1 month. If at goal, reassess every 3-6 months. If not at goal, assess for adherence and consider intensification of therapy.

ESC (The European Society of Cardiology) 2018 Hypertension Guidelines for treatment

Blood Pressure (BP) Category	Pressure Ranges	Recommendations
High Normal BP	130-139 / 85-89 mmHg	Consider drug treatment in very high-risk patients with CVD, especially CAD
Grade 1 Hypertension	140-159 / 90-99 mmHg	Immediate drug treatment in high or very high-risk patients with CVD, renal disease or HMOD. Drug treatment in low moderate risk patients without CVD, renal disease or HMOD after 3-6 months of lifestyle intervention if BP is not controlled
Grade 2 Hypertension	160-179 / 100-109 mmHg	Immediate drug treatment in all patients. Aim for BP control within 3 months
Grade 3 Hypertension	≥180 / 110 mmHg	Immediate drug treatment in all patients. Aim for BP control within 3 months

Post-Diagnosis of Hypertension

Once a formal diagnosis of hypertension has been made and the severity of hypertension established by your physician, he or she will have to make the clinical decision on the appropriate therapy for you.

In general, there are a few guidelines which physicians adhere to. Bear in mind these are guidelines, and we recognise patients are unique individuals with different medical conditions and it is pertinent for us to tailor each therapy to each individual patient.

Actions Needed Based On Blood Pressure Cateogry

Blood Pressure (BP) Category	Pressure Ranges	Actions Needed
Normal BP	<120 / <80 mmHg	Your blood pressure is normal if it's below 120/80 mm Hg.
Elevated BP	120-129 / <80 mmHg	Elevated blood pressure is a systolic pressure ranging from 120 to 129 mm Hg and a diastolic pressure below (not above) 80 mm Hg. Elevated blood pressure tends to get worse over time unless steps are taken to control blood pressure. Elevated blood pressure may also be called prehypertension.
Stage 1 Hypertension	130-139 / 80-89 mmHg	Stage 1 hypertension is a systolic pressure ranging from 130 to 139 mm Hg or a diastolic pressure ranging from 80 to 89 mm Hg.
Stage 2 Hypertension	≥140 / ≥90 mmHg	More-severe hypertension, stage 2 hypertension is a systolic pressure of 140 mm Hg or higher or a diastolic pressure of 90 mm Hg or higher.
Hypertensive Urgency	≥180 / ≥120 mmHg	A blood pressure measurement higher than 180/120 mm Hg requires urgent medical care. If you get this result when you take your blood pressure at home, wait five minutes and retest. If your blood pressure is still this high, see your doctor immediately.
Hypertensive Emergency		This is an acute, persistent, marked elevation in blood pressure that is associated with signs of target-organ damage. These can include pulmonary edema, cardiac ischemia, neurologic deficits, acute renal failure, aortic dissection, and eclampsia. If you have chest pain, vision problems, numbness or weakness, breathing difficulty, or any other signs and symptoms of a stroke or heart attack, call 995 for ambulance.

Different Modality You Can Use

There was another debate in recent years on what would be the best modality to measure blood pressure.

The three major types of blood pressure measurements are: Office (Clinic), home and ambulatory.

Office (Clinic) blood pressure is the environment where BP measurements are taken by the doctor for the patient. In not so olden days, BP was taken by a manual pump mercury meter where the doctor pumps the bulb of the meter to raise the level of mercury to provide a pressure equalling or above the pressure and then letting it drop as the doctor hears your pulse with the stethoscope until the mercury level equals to your blood pressure. Even now, it is taken as the gold standard for non-invasive BP monitoring. Some caveats of Office BP include the phenomenon of white coat hypertension where patients by the mere presence of being in clinic and seeing healthcare workers trigger an increase in BP.

Home blood pressure monitoring became more prevalent with availability of affordable automatic BP meters that does not require medical training to take a manual BP pressure. Most patients are also more relaxed in their own homes, thereby reducing chances of white coat hypertension mentioned above. However, some BP meters are not well maintained at home with frequent knocks on BP meters and infrequent change in battery leading to some inaccuracies in home BP readings.

Ambulatory blood pressure monitoring uses meters that can automatically monitor BP on the go. It also includes 24Hr BP monitoring that allows the physician to monitor the fluctuations of BP throughout a 24-hour period. Ambulatory BP meters need to be of much higher accuracy and reliability as BP readings can be difficult to monitor while moving around.

Other blood pressure meters, such as hand/wrist BP meters are commercially available but are not certified or calibrated regularly, and may not provide adequate accuracy. Professionally used 24hr BP meters are certified for ambulatory BP taking and are regularly calibrated to provide the accuracy level required for a formal diagnosis of hypertension. Check with cardiac clinics for professional 24hr BP monitoring.

Reduce Your Risk In The Covid Era

In this COVID era, we may even see the need for earlier intervention to bring hypertension under control to reduce the risk to the patient.

Don’t brush hypertension away like a fly anymore. Contact us for an appointment to bring control to your hypertension.

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Footnote: Content provided in the tables shown above are taken from American Heart Association, American College of Cardiology, and The European Society of Cardiology.