Don’t let the pressure get to you—or your patients

Excerpted from page 14 of the January/February 2022 edition of AOA Focus.

Hypertension is one of the most common medical conditions in the U.S., affecting nearly 1 in 3 American adults. Moreover, while as many as 1 in 5 adults aren’t even aware of their condition, only about half of those who are aware can keep it under control. Often, it’s miniscule changes in the ophthalmic vasculature that signal changes in blood pressure, which is why regular, dilated eye examinations can prove so crucial to the management of patients with hypertension.

Here are three questions you should be asking about hypertension.

1. Are you taking your patients’ blood pressure?

You should, argues James Deom, O.D.

Hypertension is a condition that not only affects many patients but also could adversely affect patients’ vision—and, certainly, can be a matter of life and death.

But what is hypertension?

Per the Eighth Joint National Committee (JNC 8) hypertension guidelines, the following categories should influence doctors’ care guidance for the general population:

1. Normal – <120 mm Hg SBP and <80 mm Hg DBP (recheck in 2 years)
2. Pre-hypertension – 120-139 mm Hg SBP and 80-89 mm Hg DBP (recheck in 1 year)
3. Stage 1 – 140-159 mm Hg SBP or 90-99 mm Hg DBP (confirm within 2 months)
4. Stage 2 – ≥160 mm Hg SBP or ≥120 mm Hg DBP (refer to primary care provider within 1 month)

Keep in mind that numerous factors may influence blood pressure readings, such as arm positioning, white-coat syndrome, recent smoking or bladder urgency. Additionally, cuff size is equally important and Dr. Deom recommends having multiple sizes available (e.g., small adult, 22-26 cm; adult, 27-34 cm; large adult, 35-44 cm; adult thigh, 45-52 cm) to ensure accuracy.

2. What changes are you looking for in the eye?

There are numerous ocular manifestations of hypertension, many affecting the retina and choroid. Anywhere from 50-80% of hypertensive patients will develop hypertensive retinopathy, by far the most commonly associated ocular manifestation, often presenting as retinal microvasculature changes.

Hypertensive retinopathy can be classified into the four stages of the Keith-Wagener-Baker system.

Elizabeth Steele, O.D., suggests doctors look for hypertensive choroidopathy as a sign of previous acute hypertensive events. Hypertensive choroidopathy is represented by infarction of the choriocapillaris and subsequent change to overlying retinal pigment epithelium (visible in dilated fundus exam once well-established; earlier/more subtle changes visible with angiography studies, such as OCT-angiography). These physical changes, known as “Siegrist streaks” and “Elschnig spots,” should alert doctors that the

patient has had significant spikes in the past, Dr. Steele says.

3. How do you talk to patients about high blood pressure?

It’s critical to talk to patients about early vascular changes (e.g., crossing changes, increased ALR), even if “mild” or “common,” Dr. Steele says. Help patients understand the next stages of these changes, the damage they represent in the rest of the body, and connect the dots to lifestyle changes, including exercise, diet and smoking. Lifestyle modification should be a starting point in these conversations, Dr. Deom adds, and while not an easy talk, the constant refrain among a patient’s care team could be enough to spur action.

Dr. Deom suggests several nonpharmacological interventions for preventing or treating hypertension, including:

1. Weight loss. Expect about 1 mm Hg for every 1 kg reduction in body weight among hypertensive individuals.
2. Healthy diet. Eating healthy can lower SBP by as much as 11 mm Hg in hypertensive individuals.
3. Reduced sodium intake. Reducing by 1,000 mg/day can lower SBP by 5-6 mm Hg in hypertensive individuals.
4. Enhance dietary potassium intake. 3,500-5,000 mg/day can lower SBP by 4-5 mm Hg in hypertensive individuals.
5. Physical activity. Increased daily exercise can lower SBP anywhere from 4-8 mm Hg in hypertensive individuals.
6. Limit alcohol intake. Reducing alcohol to less than 2 drinks daily can lower SBP by 4 mm Hg in hypertensive individuals.