Hypertension control technology

The current mature hypertension control technology is essentially a set of "full-scenario intervention combinations that are layered to match individual characteristics." There is no universal solution, nor is there a once-and-for-all cure. The core goal is to stabilize blood pressure within the target range for a long time and minimize the risk of target organ damage.

Last week I met 58-year-old Uncle Zhang at a community free clinic. He had been taking nifedipine for three years, but his blood pressure still fluctuated up and down, reaching as high as 160/95. He was so frightened that he thought he had bought fake medicine. I chatted with him for half an hour and found out that he had to run a half-marathon in the park at around 4 a.m. every morning. He had pickles and porridge for breakfast. Sometimes he forgot to take his medicine and had to wait until the next day to take it. When these three things were put together, no matter how good the antihypertensive medicine was, it couldn't suppress him. In fact, this is also a misunderstanding that many people have about hypertension control: they always think that technology means taking medicine and buying high-end equipment, ignoring that technology itself must adapt to personal living habits.

What’s interesting is that the industry’s priorities for hypertension control have always been different. One school is the evidence-based clinical school, which advocates reaching the target first and then adjusting the cause. Especially for patients whose blood pressure has exceeded 160/100 or has suffered target organ damage, they should first rely on first-line antihypertensive drugs to lower the value below the safety line to avoid acute events such as cerebral hemorrhage and myocardial infarction. Lifestyle adjustments can slowly follow. After all, for many patients with poor compliance, solving the fatal problem first is the first priority. The other school is the chronic disease management school, which prefers to trace the source and classify the disease first. Especially for the initial onset of grade 1 hypertension in young and middle-aged people, if clear triggers can be found, such as being 20 pounds overweight, staying up late all year round, and eating pickled products, they can rely on 3-6 months of lifestyle intervention and adjustment. Maybe they can bring the blood pressure back to the normal range without taking medicine, and use less medicine if possible. There is actually no right or wrong between these two ideas. It just depends on the group of people who are suitable for it. I have seen middle-aged people who refused to take medicine and ended up with cerebral hemorrhage. I have also seen young people who just took three or four kinds of medicine randomly after being diagnosed with high blood pressure. It is not advisable to go to extremes on either side.

When it comes to specific technology implementation, the first thing to talk about is monitoring technology, which is the basis of all management and control. Don’t underestimate blood pressure measurement. In the past, many people only took it when they went to the hospital clinic. It was easy to develop “white coat hypertension” and become nervous when seeing the doctor. The measured value could be 20mmHg higher than usual. Nowadays, the commonly used 24-hour ambulatory blood pressure monitoring is very mature. If you carry a small box home, eat and sleep normally, you can completely measure the blood pressure fluctuations throughout the day, and accurately capture the hidden peak periods in the early morning and after meals. Wearable devices with blood pressure monitoring functions have also become popular in the past two years. I have recommended wrist monitors certified by the Food and Drug Administration to many patients who work in the office. A young man who works in Internet operations wore them for a week and found that whenever he had a weekly meeting to report on work, his blood pressure would rush to 145/90, which was normal at ordinary times. Later, he learned to take 5 minutes of deep breathing before meetings without taking any medicine, and his blood pressure stabilized. Of course, I have to mention that the values ​​measured by off-brand wristbands that cost tens of yuan can only be used as a reference. If they are used to adjust the dosage of medicine, they will definitely not work, and may cause problems. I also met a very serious patient who measured his blood pressure 8 times a day. The more he took the test, the more nervous he became, and the value became higher and higher. Finally, he was asked to change the test to once every morning when he woke up. His anxiety was relieved and his blood pressure stabilized.

Then there is the drug technology that everyone is most concerned about. The five commonly used first-line antihypertensive drugs (calcium channel blockers, angiotensin-converting enzyme inhibitors, angiotensin II receptor antagonists, diuretics, and beta-blockers) have been used for decades. Their safety and effectiveness have been verified. There is no "better", only whether it is suitable or not. For example, young patients with fast heartbeats are more suitable for β-blockers, while diuretics are more effective for elderly patients with salt-sensitive hypertension. In recent years, compound preparations have become more and more popular. Two antihypertensive drugs are made into one tablet and can be taken once a day. It has fewer side effects than taking the two drugs separately and has higher compliance. It is especially suitable for elderly patients with poor memory. To be honest, many elderly people cannot remember when to take medicine. If you prescribe three medicines for them to take three times, the probability of missing a dose can reach 60%. If you switch to a compound medicine that takes one tablet a day, and put a note on the refrigerator door to remind them to take it when getting milk, the compliance rate will increase to more than 90%. This is actually part of the control technology. Not only high-end medicines are considered technology.

Non-drug intervention techniques are now receiving more and more attention. Don’t think that they are all “health gimmicks”. Many of them are evidence-based. For example, for patients with salt-sensitive hypertension, if they reduce their salt intake to less than 5g per day, their systolic blood pressure can be reduced by 5-8mmHg, which is more effective than taking half a tablet of antihypertensive drugs. Many people say that the food is bland and tasteless. I often teach them to use lemon juice, mushroom powder, and dried shrimps to make it fresh. It is delicious without adding extra salt. Many patients have tried it and reported that it works. There is also exercise intervention. Not everyone is suitable for marathon running. Like Uncle Zhang mentioned at the beginning, the sympathetic nerves are already in a state of excitement in the early morning, and strenuous exercise will cause the blood pressure to spike. If you switch to a brisk walk for 40 minutes in the afternoon, or practice Baduanjin for 20 minutes every day, the effect will be better. I used to take care of a 62-year-old aunt. She practiced Baduanjin for three months, and her systolic blood pressure dropped by 12mmHg. Later, she also reduced the dosage of half a pill.

Of course, there are also many technologies that are in the controversial stage. Don’t be fooled by marketing accounts. For example, the high blood pressure vaccine that has been rumored for several years is still in the third phase of clinical trials, and it only targets angiotensin-type hypertension. It is not effective for all types of hypertension. It is still several years away from being launched. It is completely false to say that "one injection eliminates the need to take medicine." There is also the renal artery sympathetic nerve ablation that has been popular in the past two years. It uses surgery to burn off part of the renal artery sympathetic nerves to lower blood pressure. Now the indications are very strict. Only patients with refractory hypertension who cannot be controlled by taking more than three antihypertensive drugs can be considered for it if other triggers have been eliminated. Moreover, there are still some people who have no obvious effect after the operation. It is not a "radical surgery" at all.

After nearly six years of community chronic disease management, my biggest feeling is that the more expensive and high-end the technology for hypertension control, the better. If you recommend a wearable blood pressure monitor worth thousands of dollars to an elderly man living alone who cannot use a smartphone, you might as well buy him an upper-arm blood pressure monitor with big characters and let a community nurse come to his home to help measure it twice a week. To put it bluntly, the best control technology is the one that can persist and adapt to one's own pace of life.