CEimpact Podcast

Hypertension Updates Every Pharmacist Should Know

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Advancements in hypertension management are shifting the landscape of treatment, from new guideline recommendations to technological innovations. This course explores key highlights from the AHA's recent scientific statements, including single-pill combination therapy and the clinical limitations of some blood pressure devices, alongside updates to the 2025 hypertension guidelines. You will gain a clear understanding of how these changes affect patient care, medication strategies, and pharmacist-driven interventions.

Recent ACC/AHA Cholesterol Guidelines further emphasize comprehensive cardiovascular risk assessment and evidence-based management of dyslipidemia alongside other major risk factors such as hypertension. These updates complement the hypertension topics discussed in this episode by reinforcing the importance of coordinated, risk-based approaches to reducing cardiovascular disease.

This resource provides a concise, guideline-based overview of hypertension management, summarizing the 2025 ACC/AHA recommendations for blood pressure classification, treatment goals, and stepwise pharmacotherapy. It highlights first- and second-line antihypertensive options, emphasizes individualized, risk-based treatment decisions, and outlines practical considerations for therapy initiation, intensification, and monitoring to optimize cardiovascular outcomes.

HOST
Rachel Maynard, PharmD
GameChangers Podcast Host and Clinical Editor, CEimpact
Lead Editor, Pyrls

GUEST
Tomasz Jurga,  PharmD, BCPS, BCACP, BCCP, HF-Cert, CDCES, AACC
Clinical Pharmacist Practitioner
LTC Charles S. Kettles VA Medical Center

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PRACTICE RESOURCE
Receive the exclusive Practice Resource to use as a reference guide for this episode by purchasing the GameChangers Clinical Update Series.

 
CPE REDEMPTION
This course is accredited for continuing pharmacy education! Click the link below that applies to you to take the exam and evaluation to claim credit:


 CPE INFORMATION
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Identify recent guideline and practice updates that may influence the diagnosis, treatment, and monitoring of hypertension.
2. Discuss current and emerging tools

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Show Intro And CE Credit

SPEAKER_00

Here on Game Changers, we're all about helping you stay ahead of pharmacy practice. But why stop at listening? You can earn CE credit for this episode and hundreds more by visiting CEimpact.com and logging into your account or creating a new one. Get credit, get inspired, and make your learning count.

SPEAKER_01

Hey CE Impact subscribers, and welcome to the Game Changers Clinical Update Podcast. I'm your host, Rachel Maynard, and we've got a jam-packed lineup for our discussion today. We'll be covering a variety of updates related to hypertension. That's because a new guideline on the prevention, detection, evaluation, and management of high blood pressure in adults was published from the American College of Cardiology and American Heart Association and other organizations late last year. So we'll highlight what's new with those guidelines. Plus, there have been a few interesting scientific statements released from the American Heart Association also late last year, which are raising some new questions about issues such as single pill combination therapy for managing hypertension and copless devices for measuring blood pressure. So to navigate some of these changes and updates and how they'll fit into practice. I'm so excited to introduce our guest today, who is an expert in cardiology, Dr. Tom Jurga. So welcome, Tom.

SPEAKER_02

Hi, how are you?

SPEAKER_01

Great to have you. Very excited to have your expertise in this area. Maybe for our audience, you could share a little bit about your background, your current role, and why you're interested in this topic or passionate about it.

Screening Beyond Blood Pressure

SPEAKER_02

Absolutely. So first of all, thank you for having me on this podcast. I'm very excited to talk about all the updates and the statements from the 2025 hypertension guidelines. So, like I like introduced, my name is Tom Jurga. I am a cardiovascular pharmacist. I specialize mostly in chronic cardiovascular conditions, hypertension, of course, dyslipidemia, um, heart failure. I work at an Arbor VA, so I mostly work with veterans. And again, most of my practice focuses on chronic conditions. So I spend most of my time managing medications, performing comprehensive medication management for veterans with heart failure, hypertension, dyslipidemia, coronary diseases, and so on. I'm also the PGY2 cardiology pharmacy residency director for our facility. So I currently have my first resident, and we are trying to improve outcomes by uh by engaging in research on multidisciplinary care at the VA. So we're really trying to focus on not just patient outcomes, but also how pharmacists, nurses, cardiologists can come together and improve these outcomes through multidisciplinary approaches to uh medication management, screening initiatives, and things like that. So I'm really excited to talk about this topic because hypertension is kind of an important topic. Um as I'm sure most of our listeners know, uh almost half of America of adult Americans have hypertension. And uh we can talk more about this as we go on through the guidelines and the statistics, but quite a few of those patients either don't know they have hypertension, or if they do, it's very poorly controlled. So definitely excited to talk more about this topic.

SPEAKER_01

Yeah, well, thank you so much for that intro. This is definitely in your wheelhouse, I would say then, very close to your practice and what you're teaching. And I also love how you have the focus on interdisciplinary care and and working as clinicians together to improve care for patients. I think that's gonna really resonate with a lot of our listeners too, who are you know trying trying to model that approach as well. So great to see great to have you. And let's go ahead and start with the we I mentioned a few different resources. So the guidelines, but also a couple of scientific statements. And as you said, hypertension is a huge topic. So we're gonna try to tackle some of the highlights with these. But if we start out with the recent hypertension guidelines, these 2025 guidelines were updating and replacing the last set of guidelines from that same group, which were published in 2017. And it, you know, it's a large document, big set of guidelines. But what would you say are some of the main takeaways that our listeners should be aware of from these guidelines? And what's changed from the the 2017 guidelines?

SPEAKER_02

Yeah, that's an excellent question. So when the uh 2025 guidelines were published, there are a few new statements that are completely brand new to the 2025 guidelines that didn't exist in the 2017 version. Um, and then there's been quite a few updates. So I would say the most important takeaways for our listeners are some of the new recommendations. So I guess let's focus maybe let's go through these in a logical sequence. So, first and foremost, screening. The some of the new updates talk about screening for patients with hypertension and not just measuring blood pressure, of course, but also really thinking about comorbidities uh that exist with hypertension. So when you are dealing with patients with high blood pressure, you also want to screen for things like thyroid disease. Um, you want to screen for things like renal disease. So, not just checking a basic metabolic panel to look at the serum caratin, but also performing a urinary microalbumin test to see if there's any albuminuria in the urine, because that can really guide treatment. Another thing is you know, thinking about thyroid thyroid conditions, liver conditions, you know, evaluating uh lifestyles, diets. So all of those things like really go, all of those things really go hand in hand in trying to uh not just manage medication therapy, but also performing proper education on lifestyle changes. So beyond that, beyond those.

SPEAKER_01

Actually, before we move on, I don't want to interrupt your train of thought, but let me just ask you quickly. So the focus on screening for those other comorbidities and other conditions is is not only to identify potential secondary causes and what might be contributing to underlying hypertension outside of you know primary hypertension, is that is that fair to say like this is one of the benefits of screening and identifying some of those other issues, or is it mainly to help guide therapy recommendations if you are identifying some of those other issues?

SPEAKER_02

That's actually what I was segueing into. Oh, perfect.

Secondary Causes And Primary Aldosteronism

SPEAKER_01

Great, okay.

SPEAKER_02

Yeah, so yeah, I know that was my long-winded way of segueing into secondary hypertension. So the the 2017 guidelines definitely talked about secondary hypertension and resistant hypertension, but the 2025 guidelines make some new recommendations about those topics. So when we're doing this initial screening, basically what we're doing is we're not delaying screening of those secondary forms of hypertension. And then just to review, we've we're kind of stuck with these definitions of primary hypertension and essential hypertension. But what we're really ignoring with those definitions is that a lot of patients do have secondary causes for hypertension. And the most common causes of secondary hypertension are things like obstructive sleep apnea, things like primary aldosteronism, and things like renal disease. If we think back to our times in pharmacy school, we might remember things, buzzwords like fuel chromocytoma, aortic coarctation, Cushing's disease. But those don't contribute as much to secondary hypertension. For sure, they're uh very, very important because if somebody does have fuochromocytoma, you definitely want an endocrinologist to be involved. But again, most of the time patients have chronic conditions like OSA, primary aldo, and renal disease. And these can account for about a third of all causes of hypertension. And so a lot of patients don't just have OSA or don't just have uh renal disease. A lot of these patients may have you know multiples, multiple comorbidities. So when we're thinking about uh screening for these secondary forms of hypertension, the 2025 guidelines like really focus on early screening for primary aldosteronism. And these new recommendations in the 2025 hypertension guidelines actually go in line with different guidelines that was published by the Society for Endocrinology. Uh, because they tweaked, they tweaked, they did a little tweak in recommendations for screening for primary aldosteronism. And why does primary aldosteronism matter here? Because when you're secreting aldosterone, which is what primary aldosteronism is, that revs up your renaldosteron ongiotensin system and that causes, of course, you know, more vasoconstriction, and then of course, high blood pressure. So a lot of people with primary aldosteronism may have sudden spikes in blood pressure. They may have gone their whole lives with normal blood pressures, and then all of a sudden they have higher blood pressures like in their 30s and 40s. So that's a nice red flag to be aware of when you're discussing these sorts of things with your patients. And then the biggest update is performing the actual screen because previously there was really no recommendation in the hypertension guidelines about doing the screen for primary for primary aldosteronism, but now it's in line with the 2025 endocrinology recommendation for primary aldosteronism, which basically states that when you have somebody with high blood pressure, do the screen as soon as you can and don't wait until you're adding the fourth agent for your blood pressure regimen. Okay. And and pharmacists can really be involved in this because they can make these recommendations. If you work for centers where you have the ability to order labs, you can perform a serum aldosterone and a renon activity screen to get the aldosterone renin ratio in order to see if somebody has a primary aldosteronism. And just remember, whenever you're recommending uh this screening lab, it has to be done first thing in the morning. And uh previous recommendations mentioned that you have to wean people off of ARBs and ACE inhibitors and spironolactone and other aldosterinal antagonists. But now the recommendation is you can keep people on ACEs and ARBs, even though we know it might cause a little bit of a false negative, but definitely do it before you add on the aldosterinal antagonist because once you have the aldosterinal antagonist, that might really um um cause a false negative. So that that that I think that's one of the bigger takeaways from the 2025 guidelines, that early screening for primary aldosteronism.

SPEAKER_01

Okay, okay, so I I love how you called out the role of pharmacists there. One question I did have along those lines is are are these tests, these screening tests, because this is a new recommendation, are they typically covered by insurance or is that sort of uh maybe progressing, expected to be standard of care based on the new guidelines? Is there any issue with coverage?

SPEAKER_02

I love that question, and we'll definitely get into insurance when we're talking about the pill combinations. Um so for the for the most part, these uh sorts of screens are covered by insurance. Um, I know that at the VA we are able to perform these uh screenings without any issues. Um I'm not sure how expensive these uh tests are because it really depends on you know your state coverage, your your employer coverage coverage, and things like that. So it's it's it's definitely a question. It is it's definitely the answer to that question definitely um is based on your uh individual coverage.

SPEAKER_01

Sure, sure. Okay, but yeah, really good to know that there is this focus on being proactive screening before even initiating treatment and being aware of some of these potential comorbidities that could be contributing to hypertension, and again, how that might affect management too. So that's that does seem like a really important takeaway. And and as you said, new recommendations from the guidelines. So thank you for calling those out. What what other changes do we have to be aware of?

PREVENT Risk Score Replaces Pooled Cohorts

SPEAKER_02

So now when we're we're going past screening and the biggest change in the guidelines is actually the treatment pathway. So let's spend a little bit a little bit of time talking about this. So as we know previously in the 2017 guidelines, the goal blood pressure was less than 130 over 80, and treatment typically started for patients who have stage one hypertension. So, again, to review, normal blood pressure is less than 120 millimeters of mercury over 80 millimeters of mercury, systolic and diastolic. Elevated blood pressure is a systolic of one between 120 and 129, and then stage one hypertension is a systolic above 130 over 80 diastolic, and then stage two is a systolic above 140 over 90. So in the previous guidelines, the recommendation was to start therapy for people who have stage one hypertension and have comorbidities, or those patients who have a 10-year ASTVD risk score of greater than 10%. Right? So I remember back in 2017 there was though there was there was a lot of discussion about this because it seemed like it included a lot more patients that require medication therapy. Because remember, previously the GNC 8 guidelines had a lot more lax recommendations for blood pressure screening and uh blood pressure goals, less than 140 over 90 for the uh for the most part. And then the 2017 uh guidelines really big had a big uh shift in blood pressure goals and initiation of treatment. And that 10-year risk score really made a big difference because if you are somebody who doesn't have risk factors for cardiovascular disease, somebody who doesn't have cardiovascular disease, then if your blood pressure was in the 130s over over 70s or even 130s over 80s, then you didn't necessarily require medication therapy um uh uh right away. Uh the guidelines mostly focused on lifestyle modifications and then reassessment within a few months, uh within three to six months. And then the 2025 guidelines they tweak that a little bit because not only do we have a new calculator that's recommended by the 2025 guidelines, but we also have a new goal. So the previous guidelines use the pooled cohorts equations to calculate the 10-year ASCVD, etheroscrotic cardiovascular disease risk. These current guidelines actually are the first guidelines to endorse the new calculator called the PREVEN Calculator that was released by the American Heart Association. And the prevent calculator differs immensely from the pulled cohorts equations. And you can find the prevent calculator on the American Heart Association's website. Um, it utilizes a few different figures, so it uses some of the similar, some similar inputs as the pulled cohorts equations like age, like blood pressure, of course, but it goes away with race as a as a as as a as an input in the calculator. And we can talk about race-based uh recommendations for hypertension at length later on, but that's the biggest change in that in that calculation screen. And then the prevent calculator also looks at other things like BMI, like A1C, like the urinary albumin-cratinin ratio, uh, so a marker of kidney disease. So it really focuses on that cardio, renal, metabolic uh syndrome space. Um and then the prevent calculator, the prevent calculator is also based on a much larger uh sample, a large a much larger database of patients than the pulled cohorts equations. So it's thought to be more accurate. What also happened with the prevent calculator is that it eliminates some patients who may be statin candidates because it may produce a more lax number. So with the 2025 guidelines, the recommendation to start pharmacotherapy in stage one hypertension patients is not 10% anymore, but 7.5%.

SPEAKER_00

Okay.

SPEAKER_02

So if you have somebody who is at stage one hypertension and their 10-year AA C V D score based on the prevent CVD calculator is a 7.5 or greater, it's recommended to start first-line drug therapy.

SPEAKER_01

Okay. So to recap that, those are really important changes. We moved away from the pulled cohorts equation calculator. We now have the new prevent CVD calculator, which is available on the AHA website. So easy to find, easy to use. As is the pulled cohorts equation, do you think, sort of gone? Like no real role for that calculator anymore, or we're really fully moving over to prevent, or is there any controversy around that?

SPEAKER_02

I don't think there's any controversy about that. I think it's well, there's some discussion about whether the prevent calculator calculator should really replace the pulled cohorts equations. We I think what we have to do is wait for the 2026 uh cholesterol guidelines to be published because those will be coming out fairly soon in the first quarter of 2026. Yeah, yeah. So I am actually very excited to see whether whether they will also endorse the prevent calculator. And if they do, you know, what kind of tweaks will they make to the recommendations?

SPEAKER_00

Okay.

SPEAKER_02

So is the pooled courts equations uh sunset? Not yet.

SPEAKER_01

Okay, got it. But yes, we'll see with the the lipid guidelines and whether they move to this prevent calculator as well. So, okay, but at least for hypertension for now, the recommendation is to use this new prevent calculator to assess risk. And then the threshold has gone down. So for patients with stage one hypertension, instead of the threshold for treatment being 10%, it's gone down to 7.5%. Is that right?

SPEAKER_02

That is correct.

SPEAKER_01

Okay, perfect. So that's an important change because patients may be going on to that website themselves and assessing their well, they may not have all the data necessarily, but if they do, you know, they're able to enter the the information themselves and see where their personal cardiovascular risk is and be able to know, okay, go to the pharmacy and say, hey, or go to their pharmacist and say, I have a risk of 8.5%. Should I start treatment or not? And the pharmacist would need to be able to answer that question.

SPEAKER_02

You bring up such an excellent point because the pooled cohorts equations were always publicly available, and so is the prevent score. But in all my years of practice, I have never once heard anybody say, Hey, I checked my own uh, you know, yeah, yeah, yeah, yeah. 10-year score based on based on my labs and my values and everything.

SPEAKER_00

Yeah, yeah.

SPEAKER_02

I feel like we should this is this is a two this is definitely an interesting point to make because patients can check their scores themselves. And the American Heart Association website and the American College of Cardiology, which has the pulled pulled course equations, they all make recommendations and tell consumers and patients what to do with those numbers. So I think one of the things that we can do as uh as a profession is basically just you know talk about this score. If if you're concerned, you know, talk to your pharmacist, talk to your talk to your doctor about about what your score means for your health.

Lower Targets And Dementia Risk

SPEAKER_01

Right, right. And empowering patients, patients, patient education. I think healthcare is becoming so much more democratized, and patients have so much more access to information than they had in the past. So it's you know, certainly possible in terms of patients finding it themselves, but also for our role, helping to make patients aware of what the tool is, considerations with it, how to use it wisely. And you know, uh everything in medicine, right, is is gray. And so there needs to be individualization and and shared decision making there. But but yeah, that's a really important point to call out. And then I think you also were highlighting, were you highlighting the goal as well has shifted a little bit, or is that still pretty consistent in terms of what the you were you were contrasting JNC eight versus the 2017 guidelines now that I'm thinking about it. So the JNC eight was 140 over 90 as the target, 2017 was 130 over 80 as less than 130 over 80 as the target, and that is reiterated in these most recent guidelines. Is that is that correct? Do I have that right?

SPEAKER_02

There's actually a little tweak when you all right. Yeah, so the 2025 guidelines are are are a little funny, and the they're the first guideline I think that put a little gray spin on a recommendation because because when you actually read the recommendation from the 25 2025 guidelines, it says that patients should target a blood pressure of less than 130 over 80, and then ideally, if possible, less than 120 over 80. And it's and that's all in one sentence as a class one recommendation.

SPEAKER_01

Okay, so sort of getting at the idea that lower is better, again with caveats though, because of course there are all kinds of patient situations that may or may not warrant or be appropriate for that lower goal. And so that's probably where they were sneaking in some of that encouragement, but also needing to use clinical judgment along with that, right?

SPEAKER_02

Clinical judgment goes a long way. Yeah, some patients cannot achieve a lower uh lower goal for sure, yeah. But yeah, I think it's a really interesting recommendation that they made, and I can't disagree with it, of course. So, in general, we know that for every five millimeters of mercury that you lower your blood pressure, your systolic blood pressure, you get a 10% reduction in cardiovascular outcomes. And that is true for both primary and secondary prevention. So I see why they just want to go lower. If it's if it's if it's safe to do and if it's if it's feasible for the patients, then the mantra basically is why not?

SPEAKER_01

Mm-hmm. If it's tolerated, of course, again, I'm thinking in my mind, coming into my mind as the older adult, frail, maybe already on multiple blood pressure medications, at risk of falls. Obviously, the risk benefit there may change because you're thinking about risk of fall versus risk of cardiovascular outcomes, depends on their life experience. Expect to see all of those factors right have to come to that decision too. So but yeah, it is putting it into perspective for the patient reducing your risk of a heart attack is stroke and giving those numbers that you said, Tom, I think is really a compelling message can help make it make therapy justified if it's appropriate and safe to do so.

SPEAKER_02

Absolutely.

SPEAKER_01

Excellent. You know, the other thing I'll just tie on to that the discussion on goals is one thing I found interesting in the guidelines was that they added, I think it was a new recommendation, or maybe a strengthened recommendation around it. I believe it was a greater strengthened recommendation around that less than 130 over 80 target, specifically with the endpoint of reducing dementia, reducing the risk of dementia. And so sort of highlighting that. And again, I think that's something patients may hear about or be interested in from a personal perspective. And again, if you're trying to work with a patient and figure out what's important to them in terms of management and outcomes, that could be another important point. Was that of interest to you, or is am I recalling that correctly?

SPEAKER_02

No, that's that's an that's an absolutely great point because we're for I work, I'm a cardiovascular pharmacist. All I care about is cardiovascular disease. But yeah, hypertension is not just a risk factor for cardiovascular disease. Of course, it is the number one cause of cardiovascular disease and the number one cause of strokes, of course, but it's also uh of high concern for dementia. Um, high cholesterol is a is a risk factor for them for early onset dementia, high blood pressure is so absolutely there are other reasons that you want to lower your blood pressure besides just cardiovascular disease. It's just that cardiovascular disease is the number one killer of Americans. Actually, cardiovascular disease is the number one cause of death in the uh in the world. So we definitely want to you know wanna reduce your risk of cardiovascular disease.

SPEAKER_01

Right, right, right. Yeah, lots of compelling reasons. So again, in those discussions with patients, just having that information I think is super important. So what else from the guidelines? Any other key takeaways? I know we've we've already spent a good amount of time talking about them, but obviously it's a large document. Again, lots of updates and new recommendations to consider, but any other key takeaways that we should be aware of?

Starting Two Drugs With One Pill

SPEAKER_02

Yeah, I I think because we want to we definitely want to spend enough time talking about you know screening, treating, and things like that. So let's just uh focus on the treatment pathways. So the the guidelines reiterate previous recommendations that if you have stage two hypertension, you want to start with two drugs from different classes that have um uh the that that have um uh different mechanisms of action. So the new guideline sneaks in a recommendation about potentially starting a one-pill combination, which I know is a topic of interest for us today. Uh so I think we can spend some time talking about that. And I think what I I think this is not a I think this is not an outlandish idea because a lot of patients and providers have been very hesitant to start two medications at the same time. Um, very often you see patients with stage two hypertension in the real world starting just one medication. And I hear this a lot from my patients, and it is quite their inertia to overcome. I hear things like if I start two medications at the same time, and if there's a problem or if there's a side effect, we don't know which medication caused it. So I would so therefore I would prefer to start one medication. And that is a very legitimate, you know, logical thing to say from a patient. As clinicians, as pharmacists, I think it's important for us to reiterate some education about starting two pills instead of one when you have stage two hypertension. First and foremost, patients who start one pill therapies are less likely to progress to a second pill down the road because, again, there might be inertia, there might be lots of follow-up, or there might be hesitancy. Um and the patients might feel like because the first pill didn't work, they might feel discouraged from they might they might feel discouraged to add another one, which totally makes sense and that resonates. So starting two medications off the bat makes more sense. And as pharmacists, we kind of know side effects of medications, right? Like if you start an ACE inhibitor and a thiazide at the same time and you have low potassium, you kind of know which one's causing low potassium. Or if you start an R and a calcium material blocker at the same time and you develop edema, you kind of know which one's causing edema, right? So these are things that you can definitely reiterate with your patients. You know, we're we're trying to do this, not because we want to cause side effects, but because we know that if we start one medication, you're less likely to achieve blood pressure control in the future. And I think an interesting point to make about single pull combinations is that surprisingly, when you do in studies in observational trials, there's no randomized control data to compare this, but observational studies show that when you compare single pill combinations to two separate medications of the same class and strength, you actually achieve better blood pressure reduction with the single pill combination. Which again, this comes from observational data. So take that with a grain of salt, and there can be a lot of reasons why this happened. Maybe patients are less adherent to the two medications, so maybe that's why the single pill combination works. Um, but what we see in the real world is that in fact, taking you know the two medications from different classes does cause problems with adherence. Um in the world of pharmacy, you're very aware of the concept of polypharmacy, right? If you take five or more medications, that's typically the definition of polypharmacy, then patients are less likely to uh take medications and they're less likely to be adherent. Um, so being able to uh combine some of these medications into a single pill can really be of great benefit. The the other thing to consider is we live in 2026 and you know prices change. I remember a time when any pill combination was out of reach because it was too expensive, wasn't covered by insurance. But nowadays, most combination pills are covered by insurance and they're actually tier one medications. So, yes, financial considerations are important, but at the same time, we know that they're covered by insurance, even out-of-pocket costs are sort of comparable to single pill medications. So starting with two medications is actually a great idea, is actually a great idea. And even when you consider costs, when you do start those two-pill combinations, because you achieve uh better blood pressure control faster and you're able to potentially reduce cardiovascular outcomes over time, uh, that actually does translate to to cost savings for the patient. Because if you think about it, because if you think about it, cardiovascular disease does cause a loss of quality of life, does constitute, does constitute a huge cost to healthcare and to the patient. So starting two medications at the same time can actually save you money in the long term.

SPEAKER_01

And also the fact of needing to go back for repeat visits to check your blood pressure, see how it's going, if it takes time, as you said, that therapeutic inertia is a real issue. And so if you start it and sort of set it and forget it, then you may need repeat visits, refills, all of those costs add up too. And even just taking two separate pills, two copies for two separate products, that's in and of itself. And then also taking two physical tablets or capsules, whatever by mouth, that's the literal pill burden for the patient, too. So simplifying that regimen for them, making it easier for them. Yeah, I think it's really interesting you brought up the concerns around, I think the concerns that maybe many of us were taught as pharmacists, even that you you sort of start one at a time so you know what might be causing an issue, a side effect, or how the patient's tolerating one product over another. But I really love that you called out we are very familiar with the common side effects for these classes of medications used for hypertension. And so it's often quite not difficult necessarily to determine what might be causing an issue. And then, you know, even the fact that most people are not at not going to get to goal with money medication alone. And so it's not that adding two at the same time is going to drop them to blood pressure that's going to be very symptomatic for them necessarily, depending on where they're starting. But that's maybe less of a clinically important consideration than we might have thought, you know, in the past. Do you agree with that sort of thought? Or what would you say about people who might be concerned about starting off a patient, say they are stage two hypertension, eligible for starting combo therapy? How would you help the patient feel reassured about starting and not being at risk for substantial blood pressure lowering or substantial side effects? How would you educate that patient?

SPEAKER_02

That is an excellent point to make. Yeah. So I think, again, I'm just kind of reiterating the fact that pharmacists are drug experts. So the rate of side effects is obviously not something to ignore. We know that side effects from medications do happen. But when we're treating high blood pressure, especially stage two hypertension, we got to think about the risk benefit, right? So we what I like to tell my patients is I would never start a medication that I think would be dangerous for you. I always want to weigh the risk of benefit. And when we're talking about the benefit, it's you know, reducing the risk of myocardial infarctions, heart attacks, strokes, things that don't just cause, you know, quote unquote death, but things that can cause a lot of debility. So there's substantial benefit. And the side effects that we're talking about are comparatively very, very mild. So we're talking about things like you know, some electrode imbalances, some edema. The the biggest fear that a lot of patients have surrounds things like orthostasis, syncope, you know, just this dizziness, lightheadedness, lightheadedness, and false. A lot of my patients are older than the typical population. You know, and on average, a veteran is in the cardiovascular clinic is about 10 years older than somebody in the general population. So I hear this a lot from my patients. And you can really use your power as a pharmacist to re-educate about these very, very real concerns. You know, if I take two medications at once, I might fall down. Um, I might you know hit my head. A lot of my patients are on blood thinners. Um, so you can use your power as a pharmacist to choose the right therapy for that patient. So let's talk about some clinical aspects of choosing the right therapy for the right patient. So let's think back. Let's put our pharmacy student hats on or our residency hats on and think back to the accomplished trial that looked at patients at high cardiovascular risk. And that study found that combination ACE inhibitor and um uh and calcium general blocker was superior to an ACE inhibitor thiacy combination. So, my favorite go-to is the combination, for example, of anasopro amlodapine, because that's a single-point combo. It's fairly cheap, it's covered by most insurance companies. And when we think about the side effect of lightheadedness or dizziness, it's a it's a very, very, it's it's it's a very broad term, right? That can be overcome by simple things like proper hydration. A lot of you know, elderly patients don't drink enough water, which is a very, very, a very real thing. Um, and then the uh the syncope or the presyncopy or the lightheadedness or the dizziness that occurs when you take certain medications doesn't really have much to do with the magnitude of blood pressure difference. It has more so to do with that orthostatic hypotension, with that drop in blood pressure when you stand up. So when you think about medications that are more prone to orthostatic hypotension, ACE inhibitors and calcium general blockers and anti-tensin receptor blockers are the least likely to cause the side effect. Diuretics are more likely to cause the side effect. Beta blockers are much more likely to cause orthostatic hypotension than ACE inhibitors, ARBs, and even thiazides, which might be very surprising to a lot of people because hold on, beta blockers don't cause a big drop in blood pressure. That's why they're not first-line medications for blood pressure. So, why do they cause so much uh dizziness? Because again, a lot of patients and a lot of providers think about these side effects in terms of magnitude of blood pressure difference over time, which is not true. Um, it has more so to do with that sympathetic inactivation or the vasodilation or the volume depletion, about the change in blood pressure when you stand up, as opposed to chronic changes in blood pressure over someone's over someone's therapy. So these are some really important things that you can point out as a pharmacist when you're starting two pool combinations. You know, we know that the rates of side effects are low, we know how to uh predict them, we know which medication can cause which nuanced side effect. And then you can talk about the other benefits besides just reducing blood pressure and besides just reducing the risk of cardiovascular events, right? If you have somebody with renal disease, we know aces and arms are of huge benefit, especially, especially if you have diabetic kidney disease. Or if you have somebody who has cardiovascular disease and they present with angina, we know that calcium tuna blockers help reduce the symptoms of angina. So that's another benefit, right? So there's uh there's other reasons why you might want to start certain medications with certain patients.

SPEAKER_01

Sort of this two for one benefit in some cases, and also thinking two for one in terms of just starting right out of the gate, two for two combo meds for a patient with stage two hypertension. And again, I I love the reassurance you provided there, the way you put it in the perspective of how you would talk to a patient, that's really helpful. And as you said, clinical benefits, but also adherence benefits, cost benefits, daily impact on life benefits. So a lot, lots of great considerations there. And I think that that was an important change in the guidelines is sort of highlighting the role of single pill combination therapies, but also there was that supplemental scientific statement to support that as well. So for our listeners who want a little more detail about that, that's another great resource to refer to. Any other sort of considerations with combo therapy in general and anything to sort of wrap up that that side of the discussion before we move on?

SPEAKER_02

Yeah, I think let's move on to the race-based recommendations because the combination really comes into play here as well. Um, so much like the prevent calculator has gone away with race-based calculations and they actually implore something called the social deprivation index, the new guidelines, the new 2025 guidelines, also go away with race-based anti-hypertensive medication recommendations. And I love that. I love that we're finally moving away from this ancient misunderstanding that black patients, because they have low renin activity, therefore they will not respond to ACE inhibitors and ARBs. Um, this was based on old data from the 80s, which was unfortunately confirmed by studies like the Allhat trial, where we saw that thiazide calcium blocker combinations and subanalyses were better for black patients as compared to ACE inhibitors and ARBs. And you know, this kind of reinforces the idea of, you know, take secondary outcomes, subanalysis with a grain of salt, because studies are not powered for those. So all of that kind of reinforced this idea that because of these uh studies, because of the low renin activity, black patients are less likely to benefit from ACE inhibitor and ARB therapy, which new data shows that that's absolutely not true. So, first of all, when we look at the stratification of hypertension in the United States, we see that black patients are at the highest risk of having uncontrolled hypertension. So delaying potentially beneficial therapy like ACE inhibitors and ARBs in patients who may have things like a kidney disease or diab or diabetic kidney disease is is really problematic. Um, and then because we know that, for example, thiazides uh may cause a few more side effects, because we know that calcium internal blockers may cause uh some potential side effects, delaying therapy with ACES and ARBs is problematic. So combining medications in these populations is crucial because first and foremost, there is no calcium internal blocker thiazide combination bill out there right now, as as of the recording of this of this episode. Uh so you have you you have you you have dozens of combinations, and it's funny how single calcium genocker thiazide pill does not exist. There's triple combinations now that have an ARB, the thiazide, and a calcium channel blocker, but no single pill uh calcium channel blocker thiazide combination, which I think is really funny.

SPEAKER_01

All right. Well, yeah, I mean that's the other consideration too with the combo therapies, is knowing what options are available and whether you can or can't combine the preferred therapeutic options. And you talked about ACEs or ARBs, ACEs or ARBs plus calcium channel blocker or thiazide as good options, not going to an ACE plus an ARB that is not a good option. I don't think there's any combo pills available that, but just wanted to reiterate that too, because that's sort of a misconception, I think, from maybe eight years ago. And uh yeah, but we do have plenty of combo pill options available, and it does make it easier to not have to maybe worry, quote unquote, about the race-based considerations that were previously in the guidelines. It's a bit more straightforward now. We have more options available for all of our patients.

SPEAKER_02

Exactly. Yeah, just just just follow the guidelines, follow, follow, follow the comorbidities, follow the conditions, don't follow um um antiquated race-based recommendations.

Cuffless Devices Need More Validation

SPEAKER_01

Excellent. Excellent point to summarize that with. So I I know we're running out of time, but I do want to quickly touch on this other scientific statement from the AHA that was released at the end of last year, also, which is highlighting the coughless blood pressure measuring devices. So things like smartwatches or fingertip monitors, there's rings, all of these different devices. And I think this is sort of a hot topic that, again, pharmacists might be asked about because people are always looking for ways to more and more interest in sort of monitoring your own data, but also we know the importance of monitoring and assessment of blood pressure in diagnosis, but also ongoing monitoring. And so helping patients find an appropriate device to monitor if they're interested in doing so, or for those people who are just sort of those interested in knowing what their numbers are, where where does that scientific statement sort of end up in terms of the role of these coughless devices for measuring blood pressure?

SPEAKER_02

Yeah, this is kind of this is kind of an easy one. Um, so the 2020 the 2025 hypertension guidelines sp specifically say there's no benefit of using coughless devices. Which, you know, if a patient comes to me and they and they say, you know, there's this cuffless device, it's either um um like a ring or or like a pulse exometer uh type of a device or a smartwatch that can you know measure someone's blood pressure. It's very convenient for a patient, right? Because they don't have to sit down, put the cough on, follow all the procedures. Um it's very convenient for patients, and they would, you know, if they have the technology, then I I understand why people would love it, but unfortunately, they're just not validated. They they have to be um uh they they have to be validated, validated before we can make any recommendations for using coughless devices. The other thing is which people don't realize, you know, which kind of goes hand in hand with convenience, they have to be calibrated correctly. So it does take time to calibrate them. You have to do it once in a while. And a lot of our patients unfortunately use typical cough devices inappropriately. This is another topic we can talk about for hours. Um but if they're but if they're if they're using if they're calibrating their devices with with inappropriate techniques, then you know we're just uh we're we're we're we're left with inaccurate numbers. Um so I think the biggest takeaway is couple of devices exist, they might be very convenient, uh, but unfortunately we have to uh wait for more validation studies to confirm whether they are useful for our patients. As of right now, we unfortunately have to keep reiterating using a typical blood pressure cuff with you know the proper procedures, you know, sit down, relax, keep your feet flat on the floor, relax your back on the on the on the on the on the on the backrest, uh wait for five minutes, and then check your blood pressure, and then do it again after a minute and take the average of those two readings. So while inconvenient, it is the best thing that we have for making sure that we check our blood pressure the right way.

SPEAKER_01

In terms of making therapy decisions, because of course, like you say, patients may be interested in their devices and what they're showing, interested in those numbers, but in terms of us as clinicians being able to make a therapeutic recommendation or change, having the sort of that accurate validated approach that you just described is what we need to go with, and just basically being aware it's a bit too soon for a prime time in terms of using those cospless devices for evaluating and engaging the effects of therapy then.

SPEAKER_02

I will say this if it starts the conversation about screening for hypertension, and if somebody comes to you and says, Hey, I have this cospless device, and it shows a blood pressure of 150 over whatever, over 90, hey, that started that at least started the conversation, right?

SPEAKER_01

Yeah. Excellent point. Excellent point. Awareness is always a good thing, right? Because you mentioned right at the beginning of this conversation, many people with high blood pressure in the US don't realize they haven't. And so any cue or clue that starts that conversation is a good thing.

SPEAKER_02

Exactly.

Pharmacist Takeaways And Wrap-Up

SPEAKER_01

Okay, perfect. So we've talked about a lot today, and in terms of some key takeaways or high-level summaries, you know, this is this is the game changers podcast. So, what are some of the key game changers based on everything we talked about today and everything that you know about the hypertension guidelines and these statements? What are I I normally try to nail it down to one, but I feel like we have a few key game changers here. So, what would you want to summarize our discussion with today?

SPEAKER_02

Yeah, absolutely. I mean, we talked about these guidelines for a long time because there's Just a lot to talk about. So the key game, the key game changers, the key things, if you're a pharmacist, really, really remember. Start screening early. And when I say start screening early, don't just think about blood pressure numbers, think about the all all the other things: thyroid conditions, renal disease, BMI, so obesity, um obstructive sleep apnea, primary aldoctrinism. Like really think about early screening for secondary causes of hypertension and for comorbidities that might contribute to cardiovascular risk. And then once you do that screening, you know, in the very beginning I talked about how multidisciplinary approaches to medication therapy management and to patient outcomes are of high importance to me. So if you're someone who practices in the community, if you're somebody who practices in the hospital, it doesn't matter. You're a pharmacist that can connect patients with other providers, with specialists. Pharmacists are the number one trusted profession in the United States. I hope that still holds true. We're the most accessible profession in the United States. So you are the first person the person the patient will typically talk to about their conditions. So definitely have that discussion with patients about referring to a specialist if you believe more has to happen for screening purposes. And then the other game changer that I think is a really important takeaway is the actual blood pressure cutoffs, screening for blood pressure. Remember that if you're at stage one hypertension, you know, now the recommendations are to use the prevent CVD calculator on the American Heart Association website. And then if you have stage two hypertension, really consider starting two medications at once. And if possible, use a single pull combo to help with that. Again, going away from race-based recommendations, just kind of focusing on the comorbidities and what patients want. Talk to the patients, see what medications make the most sense to them, you know, based on side effects, benefits, and things like that. Um and then follow-up is really important. We talked about inertia, we talked about problems with titrating therapy, adding combination therapy, adding medications on is of greater benefit than titrating medications themselves. So when you have somebody with high blood pressure and you think that they need more reduction, add on a medication instead of titrating that first medication. If the blood pressure is still uncontrolled on two medications, you can consider adding a third one and then titrating to target doses. Because when you have more medications on board with complementary mechanisms, that benefit in blood pressure reduction will be greater. That is a lot.

SPEAKER_01

Yes, but all such important points. I we could honestly spend an hour, I think, on each of those individual topics, but I love your recap. Prevention. Your recap was screening. So in terms of screening, thinking about those comorbidities and other screening that needs to happen and referral, multidisciplinary care, initiation of treatment when appropriate with a combo pill, if it makes sense to do so, and thinking about the broadening of the menu of options that we have for patients potentially as those race-based considerations were removed, and the the importance of avoiding therapeutic inertia either when starting or when adjusting therapy. And the I I I really love the the idea of having more comfort with starting a combo pill. That that is something that I think may take some getting used to, but is an important change in the guidelines to highlight. And then the importance of appropriate monitoring and follow-up and continuing to support patients in their care because obviously they want to make sure therapy is working for them and helping to improve those outcomes and doing so with an appropriate blood pressure monitoring device, which is not a cutless device per se. Uh so does that summarize it all in all? Any other questions?

SPEAKER_02

We can talk for hours about this. Yeah, that is an excellent summary. We haven't even covered all of the new recommendations. Oh, I know. I know. But I think we covered the most important things for pharmacists.

SPEAKER_01

Yeah, yes. We're gonna have to have you back for another discussion later on.

SPEAKER_02

Right too.

SPEAKER_01

Thank you so much, Tom. Your expertise is amazing on this topic and just love your passion for optimizing care for patients and interdisciplinary multidisciplinary care. I just think it's fantastic, and you're really supporting pharmacists and all that we can do. So really appreciate your expertise here. Thank you.

SPEAKER_02

Thank you for having me. This was a pleasure.

SPEAKER_01

Excellent. Well, we did talk about a lot today. Uh, so all of these will be summarized in the practice resource that will go along with this podcast on the CE Impact website. So be sure to check that out because again, lots of great tips here from Tom, and we want to make sure we have those takeaways for you to work with in your practice. And listeners, be sure to claim your CE credit for this episode of Game Changers by logging in at CEimpact.com. And as always, have a great week and keep learning. I can't wait to dig into another game changing topic with you all next week.