New Hypertension Guidelines: Practical Updates with Dr. Jordy Cohen

On the job learningBilling and CodingNP Students
Written By Liz Rohr

The newest hypertension guidelines include several important updates for primary care clinicians, including clearer recommendations for when to start medication, greater emphasis on home blood pressure monitoring, increased screening for primary aldosteronism, and the use of the PREVENT risk calculator to guide treatment decisions.

In this episode of the Real World NP Podcast, I sit down with hypertension specialist Dr. Jordy Cohen, a nephrologist, researcher, and member of the hypertension guideline-writing committee, to discuss what these changes mean for everyday clinical practice. Rather than reviewing every recommendation, we focus on the updates that are most likely to change how nurse practitioners diagnose, evaluate, and manage hypertension in primary care.

Below, you'll find key clinical takeaways, the full interview, additional learning resources, and the complete transcript.

Key Takeaways from the new hypertension guidelines

  • The PREVENT calculator replaces the Pooled Cohort Equations and can impact when to start hypertension medication.

  • Lower-risk patients with BP ≥130/80 have clearer treatment recommendations.

  • Single-pill combination therapy is now strongly encouraged.

  • Home BP monitoring is recommended before diagnosing hypertension.

  • Primary aldosteronism screening should be considered more often than previously recommended.

 

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Watch

 
 

What You'll Learn

00:00 – Meet Dr. Jordy Cohen and the biggest updates in the new hypertension guidelines

02:27 – What's changed in the updated guidelines and why it matters for primary care

04:00 – How to use the PREVENT cardiovascular risk calculator

07:30 – Managing hypertension in younger adults and when to evaluate for secondary causes

11:40 – Secondary hypertension workup, including screening for primary aldosteronism

15:20 – Resistant hypertension: common pitfalls and what specialists wish primary care clinicians would do first

19:20 – When to start one medication vs. combination therapy

22:10 – Choosing first-line antihypertensive medications and practical prescribing tips

25:40 – Hydrochlorothiazide vs. chlorthalidone vs. indapamide

29:45 – Who should be screened for primary aldosteronism and how to interpret the workup

36:00 – Why PRN clonidine should be avoided for severe asymptomatic hypertension

41:10 – Home blood pressure monitoring, validated cuffs, white coat hypertension, and masked hypertension

49:40 – Microalbuminuria, kidney protection, and additional clinical pearls for primary care

FAQs

  • The new guidelines recommend starting two first-line blood pressure medications for most patients with stage 2 hypertension instead of adding medications one at a time. They also use the PREVENT calculator to help determine when to start treatment in some patients with stage 1 hypertension.

  • Start two first-line antihypertensive medications for most adults with stage 2 hypertension, particularly if the blood pressure is ≥20/10 mmHg above the treatment goal (for example, 160/100 mmHg when the goal is <140/90 mmHg).

  • The PREVENT calculator is the ACC/AHA cardiovascular risk calculator that estimates a person's 10- and 30-year risk of cardiovascular disease. The new hypertension guidelines use it to help decide whether adults with stage 1 hypertension should start medication in addition to lifestyle changes.

  • Screen patients with resistant hypertension, hypertension with hypokalemia (even if it's only diuretic-induced), an adrenal adenoma, obstructive sleep apnea with hypertension, or hypertension diagnosed at a young age. Don't rely on hypokalemia alone—most patients with primary aldosteronism have normal potassium levels. Fun fact— AACE recommends screening all patients with stage 2 HTN for primary aldosteronism!

Resources mentioned in this episode:

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Continue Your Learning

The Hypertension Management in Primary Care Course is part of the Real World NP Chronic Care Series, a comprehensive continuing education program designed specifically for nurse practitioners. Through case-based learning and practical clinical frameworks, you'll learn how to confidently diagnose, evaluate, and manage hypertension using current evidence and guideline-based recommendations.

The course has been peer-reviewed by hypertension specialists to help ensure the content reflects current best practices while remaining practical for everyday primary care.

Explore the Hypertension Course →

  • Liz Rohr (they/them) | RWNP (00:00.981)

    Thank you so much for being here. I'm really, really excited for this. I've been waiting for so long. I'm bated breath. So go ahead if you want to share a little bit about yourself for the people.


    Jordy Cohen (00:10.86)

    Yeah, thank you so much for having me. I'm so excited to be on. So I prefer to go by Jordy. I have hypertension in my blood. My dad was a family practice physician and my mom was the person who just ran his office and was his only employee. And so it was just a huge part of my childhood was like just constantly talking about people mismeasuring blood pressure, how to manage hypertension. And so it became something that just ended up being embraced as a huge part of my career.


    And so now, even though I'm a nephrologist, actually the vast majority of what I do is all hypertension focused since so much of blood pressure comes from the kidneys. And so my clinical time is spent almost entirely with patients with hypertension, managing them in clinic. And my research is very heavily focused on ways that we can better be managing hypertension.


    Liz Rohr (they/them) | RWNP (00:39.699)

    of that.


    Liz Rohr (they/them) | RWNP (01:00.305)

    I love that. So is that what had you choose nephrology over cardiology when it came to like your fellowship decision time?


    Jordy Cohen (01:06.904)

    Yeah, I really loved the physiology of nephrology and really loved the underpinnings of how much of the kidney really leads to everything that we think about with hypertension and with other issues. And to me, the cardiology aspect of it is that's the target organ that's often affected the most by hypertension. But I think that the prevention part was not nearly as much about the practice of it when, at least when I was...


    doing rotations. There are some preventive cardiologists who really focus on it, but really so much of what they do is more on the target organ effects of the things that occur. Whereas I wanted to take things much more from the prevention standpoint.


    Liz Rohr (they/them) | RWNP (01:43.126)

    Definitely, I love that. my gosh, if I picked a specialty, nephrology is one of the top contenders. It's so interesting, so that's wonderful. So what are you most excited about for the updated guidelines? And by the way, I'm gonna, they will have already listened to your intro at this point, but you were part of making the guidelines. Like, incredible, yeah.


    Jordy Cohen (01:50.176)

    I agree.


    Jordy Cohen (02:02.594)

    Yeah, it was really, cool to be part of that. Yeah, I really loved getting that opportunity. I had sort of always idolized these people who got to sit on these guidelines and sort of seen them as being such a different tier or whatever be. So was so cool to get to be invited to be part of that. And also it really was fascinating because in the past, I think these guidelines had often been sort of an older generation of people who had sort of been the ones seen as like the longstanding experts in the field.


    Liz Rohr (they/them) | RWNP (02:23.317)

    Yep. Absolutely. Awesome. I love that. I love that.


    Jordy Cohen (02:27.822)

    And they've shifted more and more to making it integrated where it's a combination of very experienced people, but some more junior and mid-career folks to bring in some fresh perspective. And I really, really love that. They have really great nursing PhD and APP representation. There were PAs, were everybody a part of this committee so that there were really like a nice diverse range of very important voices in this space.


    Liz Rohr (they/them) | RWNP (02:52.021)

    So what are you most excited about in terms of the changes of these guidelines compared to the last ones?


    Jordy Cohen (02:56.878)

    Yeah, there was a lot in terms of the changes. I have a few things that really were the most interesting and I think most like clinically applicable to me. The first one being that I really love that they clarified what to do with lower risk people. So I think just in general, we didn't really know what the last set of guidelines of like, okay, so your blood pressure is greater than or equal to 130 over 80, but not greater than or equal to 140 over 90 and your lower risk. And we tried lifestyle modifications. Now what?


    Liz Rohr (they/them) | RWNP (03:04.447)

    Totally.


    Liz Rohr (they/them) | RWNP (03:09.454)

    Yes.


    Liz Rohr (they/them) | RWNP (03:18.805)

    Totally.


    Jordy Cohen (03:25.738)

    And I think it was sort of like a choose your own adventure of like, what do you think is most important? And a lot of that is because we don't have great data in younger people because in younger people, takes decades to end up seeing the bad effects of high blood pressure. And you can't really follow people on a trial for 30, 40 years. But I think that it doesn't mean that it isn't important. And so increasingly, we're really paying more attention to that and really putting more weight in, no, even if you're lower risk.


    Liz Rohr (they/them) | RWNP (03:28.754)

    Right.


    Liz Rohr (they/them) | RWNP (03:42.397)

    Yeah.


    Jordy Cohen (03:55.326)

    Yes, try lifestyle modifications first because they can often do a great deal, but if that's not enough and you're not getting to goal, then start treatment.


    Liz Rohr (they/them) | RWNP (03:58.568)

    Yeah. Totally. Yeah, that's super helpful. And also the prevent risk calculator is new compared to the pooled cohort equations. Do you want to touch at all on the prevent calculator or thoughts you have about it or what you like about it that's different or what you don't like that's different?


    Jordy Cohen (04:21.26)

    Yeah, I I really love the prevent calculator compared to the old pooled cohort equation. A big difference with the prevent calculator is that it's removed race. The reason being that race was doing a really heavy lift in the pooled cohort equations. Race was there to represent factors that aren't so much biological, but more factors that are more social determinants of health. Whereas it's hard to really just prescribe race as that because there's so much to unpack that's contributing to those factors that cause cardiac risk.


    Liz Rohr (they/them) | RWNP (04:46.149)

    Yeah. Yeah.


    Jordy Cohen (04:50.338)

    We've learned so much about how much your zip code matters in terms of your risk of cardiac disease, how changing zip codes can actually, if you go somewhere from a worse zip code to a better one, that your risk lowers. All of that is a lot to unpack and is very, very important in terms of your risk, less so than sort of just attaching a biological construct to race that is not a biology that's causing this. It's more of a social thing that's causing this risk, or multi-factorial.


    Liz Rohr (they/them) | RWNP (05:16.58)

    Totally.


    Jordy Cohen (05:18.232)

    But so the prevent equation is actually really incorporating that. It includes zip code instead of race, includes other social factors, whereas that previously wasn't part of the equation. And as a result, we're seeing a lot better calibration across broader groups of patients, and it's being validated externally much more carefully than the older equations were. And in real world, patients that look a lot more like the ones that we see in clinic, not just in like perfect study patients.


    Liz Rohr (they/them) | RWNP (05:36.981)

    Mm-hmm.


    Right.


    Jordy Cohen (05:45.302)

    So I love that. think that that's really a huge improvement. And it doesn't change the total number of people who are being diagnosed with higher risk hypertension. You end up with a very similar number in the end. So it's not like this big shift that's causing us to now label a whole lot more people inappropriately for more intensive blood pressure that you often hear sort of as the sensationalism in the news. It's really balanced. It's giving a very similar count.


    Liz Rohr (they/them) | RWNP (06:05.83)

    Right. That's great. this was, me if I'm wrong, but as I understand it, it was developed after chart review. Is that right? Like they looked at patient data in terms of like just


    over years and years and that was the basis of the formation of the Prevent Calculator. So it's based on like, yeah.


    Jordy Cohen (06:23.18)

    more real world data. Yeah, electronic health record data was a lot of what they incorporated. And they then have validated it on more generalizable electronic health record data from places that have more Asian patients, places that have more patients that are in underrepresented groups that aren't necessarily typically represented well in a lot of the sources of our data.


    Liz Rohr (they/them) | RWNP (06:33.619)

    Yes. Awesome. And so with the prevent calculator in the guidelines, so we're kind of looking to assess their 10-year and 30-year risk, right? And then we're looking at the, so lower risk is less than 7.5 % risk over the 10 years, is that correct? Do I have that right? So it's similar to the pooled cohort equations, it's just different.


    Jordy Cohen (06:58.796)

    Right, yeah.


    Liz Rohr (they/them) | RWNP (07:02.965)

    different calculator basically. And so you're saying, so for those lower risk people who are like 130 over 80 blood pressure and they have those low risk scores, those are the people who are gonna try a lifestyle modifications for three to six months and then start on a single agent, is that correct? Yeah, and that's different from before because it was kind of like you can if you want to sort of thing.


    Jordy Cohen (07:04.771)

    Yeah.


    Jordy Cohen (07:17.102)

    That's correct,


    Jordy Cohen (07:22.508)

    Exactly, before it was sort of like it left it was like period it was like three to six months of lifestyle modifications and then like that.


    Liz Rohr (they/them) | RWNP (07:26.132)

    Yes. And then what? Totally. That's super helpful. Yeah, do you have any thoughts about younger patients? And I say younger patients like in quotations, right? But like in terms of the people who are like in their 20s and 30s versus on the 40s, 50s, 60s, do you have any thoughts about just like whether it's related to the guidelines or just hypertension management in general? Do you feel like you have some guidance for people who are kind of feeling a little bit frustrated?


    Jordy Cohen (07:52.942)

    Yeah, it's a very difficult area because it's such an area of lacking in research that we are usually used to in the preventive cardiology blood pressure space. Like we're used to trials. Pediatrics is very used to not having trials. And we're going to up in the middle of that because we're being cared for by adult clinicians who aren't used to the pediatric lack of data space because of the fact that there are so few people who have these issues in the pediatric world.


    Liz Rohr (they/them) | RWNP (07:55.061)

    Yes.


    Yes. Yeah. .


    Jordy Cohen (08:22.924)

    They are suffering from lack of sample sizes. So I can't give you definitive responses, but what I can tell you is my practice. When I get a young patient that comes to see me, I think about what I would want to hear. And if it was me coming in the high blood pressure, whether or not I have a big family history or it came out of nowhere, I'd want to know why. And so I always look more aggressively in younger patients for secondary causes of hypertension so that we can feel comfortable saying we didn't find anything or ideally targeting a source.


    Liz Rohr (they/them) | RWNP (08:34.997)

    Yeah. Yeah.


    Jordy Cohen (08:53.374)

    And I also think about lifelong risk. And there's often this concern of I don't want to be on drugs for my whole life. And I try to understand why and where that's coming from, if that's something that I hear from a patient, and if it's like concern for side effects or like we don't know what these drugs do when they're in us for this long. I can often offset that because we do have really good data. These drugs have now been around, many of them, for 30, 40 years. And I can say we know that a lifetime of being on them is safe. So.


    The side effect risk is a little bit different in men versus women. For example, I'll often have men saying, well, I don't want let erectile dysfunction from a blood pressure drug. And I point out to them that actually erectile dysfunction is often occurring because you don't treat the hypertension more so than from the drugs themselves. And if you have a problem with one agent, we can try switching to a different one and see if that one's a better fit. For example, especially if there's stage one hypertension and they just need one drug.


    And so I really offer to work with them and I bring it up upfront to make sure that they feel comfortable having that conversation about that, especially being a female physician. I also, I tell them that if it were me and I knew that I could do something now to prevent me from having a stroke 30 years from now, having seen family members that have had them and how devastating that is, I'd like to do that. Especially knowing that there are some people where it happens much earlier and I won't know which person I am.


    Liz Rohr (they/them) | RWNP (09:53.388)

    Totally.


    Liz Rohr (they/them) | RWNP (10:11.685)

    Yeah. Yeah.


    Jordy Cohen (10:14.354)

    And I don't want to have to have a stroke with a kid in elementary school and things like that where it's hard to put yourself in that shoes as a 20 year old or somebody like in your late 20s, early 30s even. Like it's so hard to sort of have that grasp of mortality, but you can usually try to get at like, you seen bad results of things like this? And so I try to do it from patient centered approach though and appreciate that they may have different values than I do and understand where they're


    Liz Rohr (they/them) | RWNP (10:27.701)

    Totally. Yeah.


    Jordy Cohen (10:43.56)

    from and not force them to but strongly urge them to. And I go a lot heavier on lifestyle recommendations of course in that group but so many of them come in like with perfect lifestyles and like I'm running like two miles five times a week or five miles three times a week and I'm doing cardio and resistance exercise and I like have an app that's telling me how much salt I'm taking in and I'm pretty good and they're already doing so much now because they have access to so much more to help them with it.


    Liz Rohr (they/them) | RWNP (11:07.241)

    Wow. Right. Right. Wow.


    Jordy Cohen (11:12.29)

    and to already know what information to do to help themselves. And so I found that lifestyle modifications can be more effective in that age group, but also often they're already doing it and they aren't seeing enough of a result. I try to get at that wellness angle to get them encouraged to think about treating their blood pressure more.


    Liz Rohr (they/them) | RWNP (11:31.493)

    Totally. And so are these people coming in with secondary hypertension? Like, are you uncovering like other causes or or is it just they're just resistant?


    Jordy Cohen (11:39.926)

    It depends. Often, no. Often it ends up being that I call it idiopathic and can't find a source. But I try to more aggressively look for it in this group. And so I always screen a renin and aldo in this group of patients. I always get some sort of kidney imaging, ideally a CT angiogram, because a lot of them may have fibromuscular dysplasia that's not diagnosed and that you can treat with an angioplasty. And that would be something that would be reversible potentially quite early.


    Liz Rohr (they/them) | RWNP (11:44.98)

    Yeah.


    Jordy Cohen (12:04.75)

    and would save them from needing drugs. And so that's a group that I tend to do that more often, making sure they're not, in a woman that they're not pregnant. And I tend to also look for, like if there are symptoms or anything else that might lead me towards another etiology, I'll look for it more. I don't tend to get like a CT scan looking for an incidentaloma or anything like that, but really just thinking about


    their general risk if they have a strong family history, if there's anything else that I'm worried about could be contributing I'll look for. But those are the two main ones I look for. I screen a lot for substances that could be potentially intervening and contributing to hypertension as well. And other, including especially over-the-counter substances at that age because they're often not really prescribed too much otherwise.


    Liz Rohr (they/them) | RWNP (12:54.681)

    Totally. Or like workout supplements or what kinds of things are you finding for people?


    Jordy Cohen (12:58.218)

    Yeah, no more just if they're taking anything over the counter that we don't know a lot about because there are a bunch of drugs that have contaminants in them that could be contributing to hypertension. Glycorizic acid is back. So glycorizic acid is in black licorice and it's all I've also seen it in a few supplements recently and it is something that can cause a state that's very similar to primary aldosterinism in the way that it behaves and so


    Liz Rohr (they/them) | RWNP (13:03.091)

    Yeah. Right. interesting. .


    Jordy Cohen (13:25.806)

    it's something where if I see that someone is taking something regularly with that in it, they may be genetically predisposed to having severe hypertension from it. It's not that uncommon in the US for that to occur. And especially if they're getting in high doses of that, it could most likely be the entire culprit of their hypertension. So that's something I always ask about. otherwise, there are some other...


    Liz Rohr (they/them) | RWNP (13:32.621)

    Yeah. So interesting. I was going to say that. Yeah, yeah, yeah. Go ahead.


    Jordy Cohen (13:50.24)

    exposures that can contribute. I always will check a urine microalbum in these patients too, I forgot to mention because, and anybody now with hypertension that's part of the guidelines, which I love. But in these patients, like it could be an underlying kidney disease that isn't obvious because their creatinine might've been 0.4 in the past and now it's 0.8, so it still looks normal. And there could be some really significant underlying kidney disease that's being missed. And so really important to check, check urine.


    Liz Rohr (they/them) | RWNP (14:17.245)

    Totally. my gosh, so many things I want to ask you. I guess one of the things I'm thinking that occurred to me is that you're doing research and you're also seeing patients, correct? And so the patients that you're getting are typically resistant hypertension patients, is that right?


    Jordy Cohen (14:27.214)

    Correct, yeah.


    Jordy Cohen (14:32.788)

    No, so my clinic is a complex hypertension clinic. And I get a range. So I get a good number of resistant and refractory hypertension patients. I get patients with multidrug intolerance who may only be on one or zero drugs but have been having trouble tolerating drugs. So I help to try to figure out if there's something we can do from a drug standpoint or if this is somebody who may be that rare patient that will benefit from renal denervation. not rare patient, I shouldn't say that, but somebody who specifically could benefit from it.


    Liz Rohr (they/them) | RWNP (14:36.111)

    Okay. Mm-hmm. Mm-hmm.


    Jordy Cohen (15:02.912)

    skeptic but I think there is the right time and the right place for sure for renal denervation. And also patients with labile hypertension and I get plenty of consults requesting for help with secondary workup where people are either struggling with interpreting their secondary workup or just want help with like hey this is someone really young with hypertension and I'd like to make sure I don't miss something. So I get a lot of patients who are younger with


    Liz Rohr (they/them) | RWNP (15:20.747)

    Totally. Yeah, so I guess one of the things that I like I see a lot and I hear from people a lot is their frustration with


    people who have either multi-drug, like they have resistant hypertension or hypertension that's just on multiple drugs at that point. And they're kind of like deciding what they're gonna do. Do you have thoughts about like when you see patients who come from a primary care provider, for example, like what are some things that you're like, I'm so glad they did this or I really wish they did this. Like what are some thoughts you have in terms of that patient between the time they're in primary care and by the time they're seen by you or another specialist?


    Jordy Cohen (16:04.302)

    So I think it depends is the first thing, because I think it's very difficult with patients who have drug intolerances. That's a whole other situation of I don't ever judge what a clinician has done when they're trying to deal with like, the first lines don't work. What I think is unfortunate is when I get patients who never tried the appropriate first line therapy, and I do get that sometimes, something with the new guideline in particular that's really, I think,


    Liz Rohr (they/them) | RWNP (16:14.869)

    Right.


    Jordy Cohen (16:28.75)

    helpful that it's now in the guideline as a pretty strong recommendation is single pill combinations and making sure people are just using first-line agents. So I always get a bit concerned when I see somebody referred to me who's on like amlodipine and a atenolol or like lisinopril and pearl and a atenolol and it's like there's no reason we should be using a atenolol as a first-line therapy any longer. That's first and foremost or any beta block.


    Liz Rohr (they/them) | RWNP (16:34.291)

    Yep.


    Yeah. Right. Right.


    Jordy Cohen (16:54.894)

    unless someone has a really, really good indication for a beta blocker, like they've had an MI or they have persistent atrial fibrillation. Like these are the patients who should be treated with beta blockers because it's not for their hypertension, it's for another very specific indication. Beta blockers are not good antihypertensives and definitely not first line antihypertensives. And there is very large scale data showing that if you are using beta blockers as your first line therapy, that patients have a higher rate of


    Liz Rohr (they/them) | RWNP (17:06.579)

    It's for something else, exactly.


    Jordy Cohen (17:22.476)

    adverse cardiac events rather than when you're using the appropriate first line therapies. And so there's a lot of reason not to be using them and yet I still see them used so much. So that's like the first and foremost frustration. And then the other one is I think like make it easier on patients, especially as you're escalating to second and third drug. Psychologically, that's a lot for most patients, especially if they're juggling other health issues in many drugs or also younger people who have never been on drugs before and like they don't want to be on any and suddenly you're telling them they're on three.


    Liz Rohr (they/them) | RWNP (17:30.495)

    I see them all the time. Yeah. Yeah.


    Jordy Cohen (17:50.304)

    And so I just, single pill combinations are so patient friendly and we really have a lot of data now supporting that single pill combinations get people to goal blood pressures faster, more effectively, and that people adhere more to them. And so a big issue with hypertension is that patients just don't really take their medications because they don't really feel the hypertension. You sort of forget about it and it sort of floods into the background. And there's a lot of non-adherence and it's not like necessarily malicious non-adherence.


    Liz Rohr (they/them) | RWNP (18:09.909)

    Yeah.


    Liz Rohr (they/them) | RWNP (18:19.696)

    Right. Yeah.


    Jordy Cohen (18:20.142)

    people forget because it's like not in your face all the time. And so I think that the single pill combos really just help a lot with like simplifying it, making it easier to remember that one pill instead of those three pills or five or six. And they can really go a long way in terms of control. People sort of argue, oh, it takes away autonomy. It doesn't let me titrate each pill separately really well exactly the way I want to. And we have a lot of data showing that we think too hard about that. And it really doesn't matter that much.


    Liz Rohr (they/them) | RWNP (18:40.234)

    You


    Liz Rohr (they/them) | RWNP (18:45.012)

    Yeah.


    Jordy Cohen (18:46.986)

    and that really the key is that we're just not going up enough in most people and those that we are, then, and you really need to make that really specific titration for some reason, like, yes, separate them if you really need to. But in the vast majority of situations, that's like been a key. Like I have people refer to me with resistant hypertension, and the first thing I do is get them from like eight pills to like two.


    Liz Rohr (they/them) | RWNP (19:10.758)

    Yes. I love that.


    Jordy Cohen (19:11.066)

    and suddenly they're under great control and I haven't changed very much. anything, I'm sometimes reducing how much drug they're on when I'm doing that and it can be a huge game changer.


    Liz Rohr (they/them) | RWNP (19:22.037)

    Absolutely. And actually let's pause there for a second talk about, so in the guidelines, and please jump in if I'm incorrect, because I spend some time reviewing them, but it sounds like you have your first, you have your like less than 130 over 80 tier, which is single dose, single medication, single, like if you decide to do medication treatment, that level is just one med. And then once you get to over 140 over 90, that's when we start dual medication therapy, correct?


    Jordy Cohen (19:50.158)

    correct.


    Liz Rohr (they/them) | RWNP (19:50.557)

    Okay, and so that's where they kind of target the single pill combination was kind of in the guidelines of like, hey, these people really should start on two meds and it should be a combination med. Is it my on track here? Okay.


    Jordy Cohen (20:02.092)

    You're perfect. So most people who are higher risk, right, or starting antihypertensive therapy when their blood pressure is greater than or equal to 130 over 80, or those lower risk people who have failed their three to six months of lifestyle modifications. And those people start with one drug. But once you're going over 140 over 90, you're going to need two drugs to get to goal because the average blood pressure lowering from any single agent is less than 10 millimeters of mercury.


    Liz Rohr (they/them) | RWNP (20:14.542)

    Yep.


    Liz Rohr (they/them) | RWNP (20:20.277)

    Right. Yeah. Love that.


    Jordy Cohen (20:26.08)

    Also, you're starting at lower doses of these two drugs. You're not starting at like maximum doses. You're starting at a low dose of two, which minimizes the side effects from these drugs because you get more side effects the higher dose you get to within like the same drug. And so once you go above that median dose, you get much higher risk of side effects relative to the antihypertensive efficacy. And so when you start with a more moderate dose of two drugs, you tend to see fewer side effects and you tend to get people to go faster.


    And so that's amazing how powerful that can be. And that's why they're even coming out with drugs that are really low dose, multi-pill combinations to even help in the future, potentially with lower blood pressures. And they've seen this in trials. They're better tolerated that way. So we're all sort of afraid of not being able to tease out which side effect is caused by which drug when you do single pill combos. But really when you're starting at lower doses, you see fewer side effects. It's really the higher doses that you tend to see more. The big side effect that I see that I think is not


    Liz Rohr (they/them) | RWNP (20:56.543)

    Totally. I love that. Yeah.


    Jordy Cohen (21:21.336)

    tackles there is dizziness. You never know which drug caused the dizziness and that's where you then sometimes have to divide and unpack. But I think sometimes it ends up being more of a, that's people who have that specific response to just antihypertensive treatment in general.


    Liz Rohr (they/them) | RWNP (21:23.131)

    Yeah. Totally, totally. And I've heard you share on other podcasts some favorites that you have, excuse me, do you have any thoughts about like guidance for especially newer clinicians who are thinking about the dual?


    dual therapy. in the guidelines, we still have those top four, the ACEs, ARBs, thiazide type diuretics and the long acting. I always get the dihydropyridine and non-dihydropyridine. I always get them mixed up, but it's the amlodipine, felodipine that category. So the dihydropyridine ones. Okay, so those are the top four.


    Jordy Cohen (21:57.397)

    Thank you.


    Jordy Cohen (22:04.11)

    That's dihydropyridine, yep. No one has been to quiz anyone on this on whether you remember dihydropyridine.


    Liz Rohr (they/them) | RWNP (22:10.419)

    That's true, that's true, but it's just like, I just try to keep, like, I just remember the names. But anyway, so those are the top four categories. So if I'm a new grad, and I'm like, okay, so I need dual combination therapy, and I'm gonna choose from these categories, what are some of the dual combinations that you are thinking about, or that have worked well for you, or your patients, or are we looking at comorbidities, are we looking at, yeah, what are your thoughts on that, in terms of choices?


    Jordy Cohen (22:31.798)

    Yeah, great question. So my favorites, I don't get paid by any of these, you know, generic drug company people. My favorites are, I really like the Olmosartan containing single pill combos because they come in like every combo. You can get Olmosartan and Amlodipine, you can get Olmosartan and HCTZ, and then you can get Olmosartan and Amlodipine and HCTZ all three together. Yeah. And so, and it's often fully covered, like with no copay by most insurances, depending on where you are in the country and which insurance firm.


    Liz Rohr (they/them) | RWNP (22:38.225)

    Totally.


    Liz Rohr (they/them) | RWNP (22:51.735)

    wow, I haven't seen the three one, that's awesome.


    Liz Rohr (they/them) | RWNP (22:57.717)

    I love that.


    Jordy Cohen (23:01.568)

    Some do and some really can't stand these single pill combinations, but the majority of them actually do cover them and we don't always realize that. And like Medicare and Medicaid very consistently cover them. And so those are those that particular group I like because it gives you that flexibility of, if it's somebody with gout and I'm not sure if and when I'm ready to start HCTZ, let me start on the olmesartan and lutepine, then I can start with those two and then I can add the HCTZ later after I've gotten the on some allopurinol or something to make me more comfortable with their gout.


    Liz Rohr (they/them) | RWNP (23:30.459)

    Totally. that's great. Love that.


    Jordy Cohen (23:31.422)

    Or if it's somebody who has struggles with lymphedema. And I'm like, okay, let me start amlodipine after the ARB. Because if you start an ARB first, that can actually prevent edema from amlodipine. It doesn't prevent it entirely, but it definitely reduces it. And so then I'll start the amlodipine HCTZ first, and then I'll start at the amlodipine later. And so that nuance doesn't matter that much. I tend to think a lot about the side effects, because that's sort of my world.


    Liz Rohr (they/them) | RWNP (23:57.073)

    I love that. Okay.


    Jordy Cohen (24:00.936)

    Both of those are just really patient friendly and easy to tolerate. And then you can do that three pill combo without making any other changes. So I like that in particular. Valsartan does have similar flexibility but isn't as potent as Olmosartan. Olmosartan does have a theoretical risk of a celiac-like disease that happens in a very, very small number of patients. It's case reportable right now. Some people are not prescribing it. And I've seen gastroenterologists actually suggest stopping it for that reason.


    But I haven't seen compelling evidence yet that it's like something that's really worth changing our practice about and that it's like definitely causal. I think the jury's still out a little bit on that. But if that's something that worries you and like you have seen cases of it, then of course, by all means, choose another combination. But that's really the only caveat I've heard. And again, I can't find good evidence that it's definitely like a thing. And we haven't seen any cases here at Penn and we see.


    Liz Rohr (they/them) | RWNP (24:50.705)

    Yeah.


    Jordy Cohen (24:54.894)

    many, many, many, many thousands of patients who read this and thought it would have our favorite drug in our group, in our hypertension.


    Liz Rohr (they/them) | RWNP (24:56.405)

    Totally. This is just a little bit of a side note. So like when it comes to the thiazide type category, we have the hydrochlorothiazide, chlorothaladone, and indapamide. And I feel like I did like a whole bunch of deep dive research a couple of years ago putting together hypertension materials.


    And I just, I'm a little bit of a hater on hydrochlorothiazide because chlorothaladone has such good data. Am I just like way off here or like what is your thought about the, because chlorothaladone I feel like has been so wonderful for patients, but like it's never in any combinations. It's like, am I just, I, yeah, what are your thoughts on that? comparing the two.


    Jordy Cohen (25:42.732)

    Yeah, great question. So there's a bit to unpack there, so I'll take a minute on it. So, chlorthalidone is much more potent than hydrochlorothiazide, and that's really where you get your bang for your buck is the higher potency of the chlorthalidone You will get just as much potency from chlorthalidone-25 as you will from hydrochlorothiazide-50, but it is longer acting, so it'll cover you more over the course of full 24 hours. So, the downside is chlorthalidone has been associated with higher risk of hypokalemia and


    at the same relative dose and higher risk of hyponatremia at the same relative dose. So it seems to be a higher risk of adverse effects relative to hydrochlorothiazide, but it is more potent and longer acting. And so you have to sort of balance those and choose the right patient for the right drug, but it's definitely not available in most single pill combos. I think it's only available in one with like Azelsartan and it is very expensive and I've not seen that one covered by insurance. And the reason being is that it's very hard to compound.


    Liz Rohr (they/them) | RWNP (26:20.789)

    it's like tiny. Mm-hmm. Yeah. Right.


    Jordy Cohen (26:39.214)

    I don't know if you've ever seen a chlorthalidone pill. The pill itself is tiny and crumbly. So if you try to split it, even though they don't make a 12 and 1 half pill and that's what you would need to be the equivalent of HCTZ 25 it breaks in thirds and then there's dust everywhere. And I guess that has to do with the way that it just is compounded and it makes it very hard to combine it with other drugs. I've been told by people who know more about me in that area or know more than me in that area.


    Liz Rohr (they/them) | RWNP (26:51.352)

    Yeah. I see.


    Jordy Cohen (27:10.166)

    I, so I like chlorothaladone. tend to reserve it for somebody who's really resistant and I'm struggling and I think they're really adherent and maybe I'll break up their fixed pill combo and do that instead. The alternative one that I really like instead, if I really am worried about like longer acting effect, like I've done a 24 hour ambulatory blood pressure, which I can do in our ivory tower and I see that they are non-dipping and I really want to make sure I'm getting better 24 hour coverage.


    Liz Rohr (they/them) | RWNP (27:19.596)

    Yeah. Yes.


    Jordy Cohen (27:37.428)

    I like indapamide. Indapamide is also a great option for older and frailer patients because it just tends to have fewer side effects actually. It's a really long acting thiazide I like diuretic. Comes in 1.25 and 2.5 milligram tabs. And it just tends to be gentler and friendlier. So it's like my favorite for people who come in with multidrug intolerance. It's one that I'll often try early because I've just seen very few patients who've ever had an adverse effect to it.


    Liz Rohr (they/them) | RWNP (28:01.181)

    Nice.


    Jordy Cohen (28:02.754)

    It's slightly less potent, like I said, than Chlorthalidone but I think it's pretty close to the potency of HCTZ, but again, gives you a longer acting coverage. So yes, I think about those. There's finally going to be a single pill combination of Telmasartan-amlodipine and Indapamide that's going to come out, but it's only those three together. So you can't like build up your triple pill combo to get to them, and it'll be in lower doses though with an idea of starting early.


    Liz Rohr (they/them) | RWNP (28:05.461)

    cool, nice.


    Jordy Cohen (28:27.374)

    And this is based off of some international trials that I've looked in low resource settings that this has been a really good option. And so the drug company is working to make it very, very low cost to people who don't have insurance.


    Liz Rohr (they/them) | RWNP (28:27.423)

    Yeah. That's so great. And it's also helpful to hear that reframe, because I feel like, at least in the dropping into the real world of primary care and inheriting somebody with blood pressure that's out of range, not at goal, has a bunch of meds that are not on that like


    recommended tiers of what they should be on kind of thing. It's been a little bit overwhelming trying to get them back to the places that they need to go. So it sounds like the real place to go is that we just start them on the combinations and then go from there. And then chlorothalidone and indapamide can always adjust if it's getting tricky. in terms of the, yeah, so in terms of the, so we talked about the single pill combo. We talked about a little bit about the resistant hypertension.


    A lot of it is adherence, checking in on that and making sure they're on the right drugs. Secondary workup, you kind of touched on that, but any sort of pearls of practice that you have for clinicians, especially newer clinicians who are undergoing that resistant hypertension workup to begin with, like aside from looking at things like sleep apnea, it sounds like in the guidelines, there's like recommended that everybody get screening for the, my God, sorry, pause for a second.


    Jordy Cohen (29:49.038)

    For primary hyperaldosteronism Yeah. Yeah, so, yeah, and it's sort of a gentle recommendation. So the wording is to consider screening anybody whose blood pressure is greater than or equal to 140 over 90 for primary aldosteronism And it's because primary aldosteronism is actually present in around five to 10 % of people with hypertension. And then as you get to worse controlled hypertension and resistant hypertension, then it's present in up to about 20 % of people.


    Liz Rohr (they/them) | RWNP (29:49.203)

    What is that word? Yes. That's the word I'm looking for.


    Okay. .


    Jordy Cohen (30:16.0)

    So if you think about it, like one in 10 or one in 20 of the people that we see in our clinic who just have run-of-the-mill hypertension actually probably have primary aldosteronism. And so if we look for it earlier, we'll catch more, but that creates this burden on the system of like, what do we do next? And so I am looking for it more in my clinic. think it is good to definitely be thinking about it more, especially in people with resistant hypertension, people with hypertension and obstructive sleep apnea. That combination is a risk for primary aldosteronism.


    Liz Rohr (they/them) | RWNP (30:30.365)

    Mm-hmm. Mm-hmm. I don't have to tell you I feel. I feel good. I I feel I feel good. good. I feel good. good. good. feel good. I good. good. I I


    Jordy Cohen (30:45.718)

    People who have hypertension and have ever had a low potassium level, even borderline low, whether or not it's provoked by a diuretic. And people who are younger with hypertension. We should definitely be screening all of them 100 % with a plasma renin and aldo. The people who are just general run-of-the-mill hypertension, we should be thinking about it more. It's something where...


    Liz Rohr (they/them) | RWNP (31:05.589)

    I see.


    Jordy Cohen (31:09.098)

    it's not exactly clear what the next steps are gonna be because there aren't enough resources to necessarily do all the next steps in the workup. But at least think about screening forward and if you do see a really florally positive screening test, either start a mineralocorticoid receptor antagonist like spironolactone or a eplerenone much earlier than you otherwise would have.


    Or think about the next steps in evaluation if in the right people. I think especially younger people with earlier onset hypertension, I would send Wright to get an adrenal vein sampling test done to see if they are producing aldosterone more from one adrenal gland than the other. Because that test, if it shows that they do produce a lot more, four to one ratio is what they look for from one adrenal gland to the other, then the next steps would be surgery. And you will.


    Liz Rohr (they/them) | RWNP (31:53.785)

    Yeah.


    Jordy Cohen (31:55.402)

    easily find an endocrine surgeon who will very readily agree to remove that adrenal gland and more than half of people are cured by that and the rest are at least on fewer drugs during their life and do a lot better. And so I think that that's something that we can have a big impact on and if you don't feel comfortable doing the additional workup and sending people for surgery, at least it would get you starting people on spironolactone or eplerenone earlier.


    And it's important because aldosterone is super toxic to the heart and the kidneys. And so these people that aren't getting diagnosed are the ones who are developing hypertensive kidney disease, are the ones who are developing a lot of heart failure and a lot of other cardiac events like atrial fibrillation that are likely, at least somewhat, if not largely, driven by that unopposed aldosterone that's toxic to their heart and their kidneys and that we aren't actually capturing early enough to do anything to prevent these outcomes.


    Liz Rohr (they/them) | RWNP (32:38.581)

    Totally.


    Jordy Cohen (32:48.494)

    So I think it's a good idea to be thinking about it a lot more. I'm screening a lot more people. I'm finding so much primary doctortism by screening more. But I'm also running into other challenges, which I like people to be aware of, of like, what do I do with people being on drugs that affect the renin and aldo? And so most drugs are fine to keep on when we screen. If somebody's on, already on sprinolactone or eplerenone it's a little harder to interpret because technically those are going to make your renin higher. And what you're looking for is a really low renin.


    and a high aldosterone and the high ratio of aldosterone to renin to really diagnose somebody. And if you're already on the drugs that are treating it, that actually makes the renin no longer be low. And so that makes it really hard to tell whether or not they have it, but they're already on the treatment. So it won't really change their management. So I think if they're already on spironolactone and eclarinone, that's great. Like they should be covered, though they need to be on a high enough dose to cover it. And then people who are on all other drugs, can usually interpret the results on them.


    Liz Rohr (they/them) | RWNP (33:33.033)

    Right.


    Jordy Cohen (33:45.416)

    So in the general population, for example, our first line agents like calcium channel blockers, ACE inhibitors, ARBs, thiazide diuretics, they can raise renin a bit in just normal people, but they don't do it in people with primary aldosteronism really. And so the key is like screen while they're on them. And as long as you still get a positive test, you can interpret it. If their test is negative, most likely they still don't have primary aldosteronism because those drugs shouldn't be able to like change the results enough if they do have primary aldosteronism.


    Liz Rohr (they/them) | RWNP (33:56.893)

    Mm.


    Jordy Cohen (34:15.214)

    One challenge I've run into recently, for example, I have a patient that reached out recently that was like frustrated because I told them their lab results for normal and they're like, no, it says my renin is way above range. And I'm like, no, it's 11 and like the upper limit of normal is four. And what that really means is that your other first line drugs that you're on are appropriately raising your renin. That's not a scary high renin. That's not a sign of anything wrong. If I see a renin of a hundred, I start thinking about do renal artery stenosis, cause that can raise renin.


    Liz Rohr (they/them) | RWNP (34:17.013)

    .


    Jordy Cohen (34:45.07)

    Or do you have a tumor causing a high renin? Because that can cause renins in the hundreds or two hundreds. But a renin of like 10 or 11, I realize, oh gosh, most people don't know how to interpret that. That's just normal. That's like what we expect because you're on drugs that cause it to go up. And so if the patient, I think, Googled it and was terrified that she had a cancer, and I'm like, I was trying to talk her off a cliff. And this is not uncommon. So I think it's really important to just be aware of.


    Liz Rohr (they/them) | RWNP (34:55.694)

    Right. Cool.


    Mm-hmm.


    Jordy Cohen (35:11.01)

    These can impact, the drugs can impact renin and aldo, but the only drug that will really cause a false positive result, so most of them cause a false negative result that it's really unlikely to, false positive results can come from beta blockers, because beta blockers can lower your renin level. It's unusual that it would be enough to then see a true false positive with like the higher aldo.


    Liz Rohr (they/them) | RWNP (35:17.781)

    Okay.


    Jordy Cohen (35:32.658)

    but it can. And so that's the one drug that I would think about. If you get a positive result initially, then they recommend like holding it for a little bit if you can safely and then rechecking. If you can't safely hold it, then just if you're thinking about escalating their antihypertensive drugs anyway, because they're uncontrolled, then add the mineralocorticoid receptor antagonist early and there's very little downside to that.


    Liz Rohr (they/them) | RWNP (35:35.413)

    I see.


    Liz Rohr (they/them) | RWNP (35:54.73)

    Totally, totally. I guess what it's kind of reminding me of is thinking about, just thinking about all the different combinations of meds that I see on some people sometimes. And so there's a practice that people have done where if somebody has a high blood pressure in the office, when it comes to hypertensive urgency, like as I understand it, if it's a high blood pressure over 160, over 90, or higher than that, we're looking for.


    signs of end organ damage, but if there's not, then we're managing them outpatient. Those patients don't need to go to the ER. But the practice that I see a lot is people are like, oh, maybe we should just give them some clonidine and watch the blood pressure go down. I don't see it as much anymore. at your face. And they're like, let's just make sure their blood pressure. So those are patients like it's like 180 over 90, but they're like chilling. And they're just like, OK, yeah, can I go home now? So I don't see that as much anymore, but I do see it sometimes. Do you have thoughts about that?


    Jordy Cohen (36:47.118)

    Yeah, sorry to make faces on a podcast. realize other people can't see my faces. If those of you who can't infer, I am horrified. But this is also something that actually is done a lot in dialysis units. They actually have standing orders of clonidine because it's so common in our dialysis units for people to present with blood pressures of like 200s over 100s. Like you don't want to be sending every patient to the emergency room. And that also horrifies me.


    Liz Rohr (they/them) | RWNP (36:52.181)

    You


    Liz Rohr (they/them) | RWNP (37:05.567)

    Yep, great.


    Jordy Cohen (37:08.906)

    So yeah, you should never be using PRN clonidine for anything other than people who have autonomic dysfunction who, when they lie down, their blood pressure shoot up 60 millimeters of mercury and you know they're gonna be lying down for a whole night. That's the entire scenario where I use PRN clonidine and no other scenario. Clonidine has a lot of rebound hypertension. And so you're gonna give it to this patient who's already got a high blood pressure who already probably has stiff blood vessels from uncontrolled hypertension.


    and who already probably has some sympathetic light going on from this high blood pressure, and you're going to suppress it temporarily and then let it rebound back up even worse, that's horrific. That can cause harm. And also the sudden decline you can get from clonidine is quite unpredictable, hydrolyzine too. And so you can cause an ischemic event by lowering it too quickly also. And so really what these patients benefit most from is low and slow decline of blood pressure, unless there is a possibility that you are missing some target organ damage. Like if this person


    Liz Rohr (they/them) | RWNP (37:49.442)

    Yeah.


    Liz Rohr (they/them) | RWNP (37:54.239)

    Right.


    Liz Rohr (they/them) | RWNP (38:03.21)

    Great.


    Jordy Cohen (38:04.514)

    has some vague symptom that's new and like you're worried and this is not something you've heard from them before, like go with your judgment and go with your gut, of course, and send them in for additional help to make sure, mainly for screening, things we can't do in the office, like get a troponin in if you're really worried that there's something cardiac happening, for example, or CT of the head, if you're worried there could be something intracranial. We can do urine tests in the office if we're worried there's something kidney related. I do have patients who presented with hypertensive.


    Liz Rohr (they/them) | RWNP (38:15.227)

    Yeah.


    Great.


    Liz Rohr (they/them) | RWNP (38:27.028)

    Yep.


    Jordy Cohen (38:29.74)

    What was unclear was emergency or urgency. someone wisely asked them, what colors are you hearing? And they're like, it looks like T. And yes, that is a hypertensive emergency, actually, because it is slowly killing their kidneys. Not slowly, sorry, quickly killing their kidneys. But most of them are urgency, which is no longer even a term we're using. We're using the term severe hypertension, severe chronic hypertension. If there is no evidence of acute target organ damage happening, no signs of it, no obvious reason that we should be concerned of it, especially in a chronic


    most likely what's happening is one of two things. One, they're not taking their medication or two, they need stronger medication and their medication isn't enough for them anymore because they've had uncontrolled hypertension for a really long time. And lowering it quickly can cause ischemic events. Unless they're actively having a hemorrhagic event, for example, or something that really needs to result in very fast blood pressure lowering, anything you do quickly is gonna cause more harm than good and will cause more ischemia. We need to lower it slowly.


    Most of our best antihypertensive medications do start lowering blood pressure once you give it within a few hours, but it takes about two weeks to reach full effect, often in three or four weeks, and that's perfect in these patients because what you're doing is you're getting them to goal, but you're not doing it so quickly that you're gonna cause an ischemic event. You're doing it in a sort of like piecewise manner that their body can get used to this incremental decline in blood pressure.


    And so if they're not yet on multiple drugs, I stack on a second mid-level dose of a second antihypertensive medication. I have one patient, she came in on one drug, she was on amloidopine and she had blood pressures like the 180s over 110s kept getting sent to the emergency room with them. And we started her on a triple pill combination. She was just on amloidopine, we switched it to a three pill combo and she did beautifully and her blood pressure's got to goal So that was maybe a little bit cowboy for me, often I'll just do one drug.


    Liz Rohr (they/them) | RWNP (40:01.077)

    gosh.


    Liz Rohr (they/them) | RWNP (40:15.647)

    That's awesome. That's Yeah.


    Jordy Cohen (40:21.128)

    But I think if you're seeing blood pressure is that high in a younger patient, that she tolerated the decline, whereas it's sometimes an older patient with like more sort of stiff blood vessels, if you lower it too quickly, they're going to do much worse. So I go a little bit slower and they get more symptomatic. often, they're more likely to tell you they get dizzy with blood pressure lowering and that may be why they're not adherent. So I talk them through that. And I also set their expectations. It's really important to tell patients what I just mentioned, that if you look at your blood pressure tomorrow,


    Liz Rohr (they/them) | RWNP (40:25.033)

    Yeah.


    Liz Rohr (they/them) | RWNP (40:36.728)

    Totally.


    Jordy Cohen (40:49.846)

    It's not gonna be a goal, but you're gonna slowly get closer to goal in the next two weeks and be in close touch about what your blood pressures are. Obviously not every patient can or not every patient even has access to home blood pressures. It's a reason to really push for that. But there are ways to manage it safely in a stepwise manner that can save patients from a hospitalization that could cause more harm than good.


    Liz Rohr (they/them) | RWNP (40:51.155)

    Mm-hmm.


    Liz Rohr (they/them) | RWNP (41:09.09)

    Absolutely. And that reminds me of the, so in the previous guidelines, let me know if there's things that I'm missing that have changed, but in terms of the assessment of somebody's blood pressure. So if they have a blood pressure of 140 over 90 today, they talked about white coat hypertension assessment as well as masked hypertension. Well, that's more like if it's on the lower side and it's technically higher at home.


    and recommending that either the 24 hour home blood pressure monitoring, which we don't really have in FQHCs, but home blood pressure monitoring by the patient. And so I guess, are there any changes when it comes to that in terms of the new guidelines? From what I understand, it's a little bit more embraced that we can do home blood pressure monitoring instead of that 24 hour thing, which again, I've never ordered clearly based on how I'm even talking about it.


    Jordy Cohen (41:55.053)

    Yeah.


    Liz Rohr (they/them) | RWNP (41:57.301)

    like do you have that like so if somebody's first blood pressure is 140 over 90 are we starting to pill combo that day or are sending them home with blood pressure monitoring and then you told you you've mentioned in the past about validate BP so I don't know if you want to touch on that but what are your thoughts about that first initial diagnosis in that stage two and like what is the role of home blood pressure monitoring in terms of the diagnosis and then the ongoing management?


    Jordy Cohen (42:19.234)

    Yeah, really important points and there's a lot there, so I'll talk a lot more. So yeah, there's now a very clear level 1A recommendation that upon the time that you get that high blood pressure, before you diagnose somebody with hypertension and start them on treatment, you need to confirm it with some sort of out of office blood pressure. Realizing that very few people have access to ambulatory blood pressure monitoring and that there is...


    Liz Rohr (they/them) | RWNP (42:21.971)

    Yes.


    Jordy Cohen (42:44.846)

    Data suggesting that ambulatory and home blood pressure monitoring are relatively equivocal, except that we just can't get that nighttime blood pressure from the home monitoring reliably. And so we know that at nighttime, we're not going to capture non-dipping, but that's more of a prognostic indicator. That's not something we treat. So really, you're going to get the most useful information from either of those. The key is, as you mentioned, capturing white-coat hypertension.


    because we should not be treating white coat hypertension based off of the office readings. We should be treating it based on their home readings. And if their home readings are lower and you start them on an antihypertensive medication, you're gonna cause side effects. You're gonna lose that trust from patients. You're gonna make them not want to ever be treated the one when they do develop an indication for it.


    Liz Rohr (they/them) | RWNP (43:21.525)

    Mm.


    Jordy Cohen (43:26.914)

    The key also being that if they do have white coat hypertension, they have about a three-fold higher risk of developing sustained hypertension in next five years, and they need to be monitoring their blood pressure at home regularly anyway. So it's a really great opportunity for talking about that risk. And it's like, yes, you don't have hypertension yet. You don't want to miss that transition to sustained hypertension, because that's where the risk from white coat hypertension really comes from. It's not that we should be treating it as it is. It's that we miss it when they develop real hypertension, because they just keep saying, remember I have white coat hypertension


    But if they're not actually monitoring at home, then that can create issues. But treating it isn't doing them any favors until they develop it because you're really just going to lose trust from your patient and make them have adverse effects that they didn't need to have. Whereas also, whereas the home blood pressure monitoring is really the best option, it needs to be done right. And that's where I think a lot of clinicians struggle because if it's not done right, how do I trust it? And how do know it's being done right? And so what I tend to do is really push patients to get a valid monitor, as you mentioned.


    Liz Rohr (they/them) | RWNP (43:57.388)

    Right.


    Jordy Cohen (44:24.824)

    the American Medical Association's website, www.validateBP.org is an outstanding source of blood pressure monitors that are valid and available in the US. And it includes a lot of generic monitors that are truly valid. I'm the co-chair of it for full disclosure. I don't get paid anything. It's purely volunteer. And we are just a whole bunch of nerds that the AMA found who are willing to go through all like thousand checklist items that you have to make sure that you're adequately validated.


    Liz Rohr (they/them) | RWNP (44:43.893)

    I love it.


    Jordy Cohen (44:51.916)

    And just because something's FDA clear doesn't mean it's necessarily been adequately validated because the FDA tends to sort of take their word for it in their summary statement of like, we swear that we met all the criteria and like, we're really anal. We're like, no, you missed this one line of the guidelines, like that this doesn't count. If you don't give us that data, then we can't count you as being on here. So like, we're very, very tough on them. And so therefore I really do trust like the devices that are listed. It includes things like certain drug, like pharmacy brands, like devices that are not that expensive.


    Liz Rohr (they/them) | RWNP (45:20.053)

    Thanks.


    Jordy Cohen (45:21.602)

    that are really just a fancier device that they like slapped on their generic label. They do like really sort of interesting thing that they do that and to make it less expensive. And I think that's great that some companies do that. So really important to that the device is correct that it's a cuffed device and that you ask patients that because I have patients now that are delivering me blood pressures and then I asked them what device did you use and they're like, my watch can check my blood pressures. No, it cannot.


    Liz Rohr (they/them) | RWNP (45:31.033)

    Yeah, so important.


    Jordy Cohen (45:48.01)

    It tells you it can and they're quite aggressive in marketing that it can, but those cuffless devices are not ready for prime time yet. Even if they're FDA cleared, the rigor of what they're requiring is much less than what they require for clearing a cuffed device. And I just described some very minor concerns in that regard. But gosh, these cuffless devices, many of them are almost providing you with fiction. And most of them do require some sort of calibration against a cuffed device.


    Liz Rohr (they/them) | RWNP (46:05.939)

    Yeah.


    Jordy Cohen (46:12.974)

    But for example, the new Apple Watch doesn't, and it just gives them an indicator of yes, no, do you have hypertension. And it only signals people that they have hypertension 41 % of the time if they do have it. So if you have hypertension, there is a 41 out of 100 chance that it will let you know you have it, and a 59 out of 100 chance that it will not let you know you have it, even though you do have it. And so I just, I like to caution patients that it's just not ready for like,


    Liz Rohr (they/them) | RWNP (46:35.829)

    It's so crushing, yes.


    Jordy Cohen (46:42.798)

    actual clinical use and definitely don't get false reassurance from those readings telling you that you're fine, because they're just not ready to do that yet. And not boohooing their existence, I think that in the future they'll be fabulous and that there will be opportunities for these to really increase our ability to diagnose hypertension. And even though 41 out of 100 would be 41 out of 100 people that might not know they have hypertension. So there's a lot of good to be done, but just also a lot of caution of like not over thinking or not over utilizing.


    Liz Rohr (they/them) | RWNP (47:02.472)

    Exactly. Yeah.


    Jordy Cohen (47:10.722)

    the evidence either and making sure to always corroborate with really high quality cuffed readings. And then I use a lot of the infographics from targetbp.org. It's the American Heart Association and American Medical Association sort of combined brainchild that they had created. Now it's all run by the American Heart Association and it has awesome tools on the far right hand side that you can click the tools tab and like they have a million things but if you just search home blood pressure monitoring there's some great infographics that you can print out.


    Liz Rohr (they/them) | RWNP (47:15.454)

    Absolutely.


    Jordy Cohen (47:40.578)

    that are in multiple languages, but also are fabulous for patients who are illiterate because just by looking at the picture, it gives you everything you need to know to do it right, other than the five minute rest that you have to tell the patient. But otherwise, the picture tells you everything. The other caveat is patients who are severely obese or who can't do upper arm readings because of, for instance, prior surgeries or AV fistulas. Those are the one group of patients I do recommend wrist cuffed devices.


    Liz Rohr (they/them) | RWNP (47:42.281)

    Awesome.


    Liz Rohr (they/them) | RWNP (47:49.191)

    Awesome.


    Jordy Cohen (48:10.042)

    And severe obese patients, it's not all of them, but the ones who have very conically shaped arms, where the center of the blood pressure cuff itself is sort of sensing air because it can't go get like nicely affixed over their arm the way it should, those can get wildly inaccurate readings in patients with that arm shape. Also, if like, for instance, the larger cuff is too long for the length of their arm, especially in some shorter patients who are more obese.


    Liz Rohr (they/them) | RWNP (48:17.237)

    The full seal.


    Liz Rohr (they/them) | RWNP (48:26.773)

    Mm.


    Liz Rohr (they/them) | RWNP (48:33.747)

    Mm-hmm.


    Jordy Cohen (48:37.282)

    Those are all patients that I use wrist cuffs, but I make sure they're doing it correctly, because wrist cuffs are more susceptible to user error from movement especially. And so there is also a great infographic on targetbp.org, walking patients through how to do it in the most reliable way. So I love using that website for those sorts of resources.


    Liz Rohr (they/them) | RWNP (48:44.981)

    Mm.


    Liz Rohr (they/them) | RWNP (48:54.623)

    that's super helpful. I love that. Yeah, because I feel like even with like the watch, the Apple watch data, it's nice to know that they're developing it. But it's just so helpful to have that data to share with our patients, because a lot of these are just about conversations and their awareness about it. I guess I'm wondering if there are things that are coming to you in terms of what are some things that you would love primary care providers to know as it relates to like your work? It sounds like, you know, we're trying to


    Make sure that they are on the top line medications that we're starting that resistant hypertension workup before they come to see you We're utilizing this single pill combo as best we can or triple triple combo What other things can you think of that you're like? I really wish primary care would do this before they got here or I'm really glad that they did


    Jordy Cohen (49:43.372)

    Yeah, I think I'd mentioned microalbuminuria. That's a huge one. If you think to a microalbumin in your hypertensive patients the same way you do in a diabetic patient, that goes a long way. Because that can clue me into whether we're missing a secondary cause of hypertension, even if they don't truly have like fluorid kidney disease yet. And it can really affect their management. We now are seeing a lot less patients starting dialysis in our country ever since some of these newer agents came out. We have new, better agents to prevent patients from


    Liz Rohr (they/them) | RWNP (49:46.365)

    Right. Yes.


    Jordy Cohen (50:13.462)

    developing or worsening kidney disease in ways that we've never had in decades prior. So having that microalbumin can really go miles. It also helps you select that first agent so that you know that you should be using ACE inhibitor ARB first in these patients because it'll help to reduce that albuminuria. And then after that, thinking about SGLT2 inhibitors because they've been shown again to reduce major cardiac events, to prevent the risk of kidney disease progression, particularly in people who have a bit of albuminuria.


    Liz Rohr (they/them) | RWNP (50:38.549)

    Right.


    Jordy Cohen (50:43.244)

    So I think that that's a huge one. Sometimes cystatin C's can also be helpful, especially in patients where it's not clear exactly if there is like some extra muscle mass or low muscle mass that could be influencing their creatinine. Cystatin C is our new better metric of kidney function that we use in combination with creatinine to calculate EGFR more accurately than we had in the past. And then the other things that I tend to think about are that I wish that clinicians knew about is that they took away the race-based recommendations.


    Liz Rohr (they/them) | RWNP (51:10.761)

    Yeah.


    Jordy Cohen (51:12.198)

    It's not something that really made headlines because no one really highlights an omission, like that you just delete something where all those lists are, here's what's new. And really, I think it's critical, though, for people to be aware that we're no longer recommending that black patients only start ACE inhibitors and high, sorry, that black patients preferentially start calcium channel blockers and HCTZ or other thiazide-like diuretics.


    Liz Rohr (they/them) | RWNP (51:17.173)

    Yeah. Yeah.


    Jordy Cohen (51:37.922)

    and that they de-prioritize ACE inhibitors and ARBs in black patients. And so that used to be the case because of post-hoc analyses from the All Hat trial, which was the trial in the 1990s that determined which were our first line blood pressure agents. And when people had looked back at that data, they found that in black patients who were started on calcium channel blockers and thiazide diuretics that they got to goal better and that they had lower risk of stroke than those who had been started on ACE inhibitors and ARBs. But the problem is,


    that hasn't panned out in subsequent work and no genetic source of that has been identified. And when you look in groups like Kaiser Permanente and other groups like the Sprint Trial, where algorithms were used to just get everybody to goal as quickly as possible and really paying close attention to what the goal was, not what the drug was, that as long as people were getting first line therapy, they did great across the board and that you saw narrowing of health disparities in terms of blood pressure control.


    Liz Rohr (they/them) | RWNP (52:20.632)

    Yeah. Awesome.


    Jordy Cohen (52:32.33)

    even among the Kaiser group where they always use an ACE inhibitor first. And so really using an ACE inhibitor ARB first didn't prevent black patients from getting to goal, them to goal better and they ended up having better outcomes with that. Really probably what was happening was something that's very specific to that trial. It was an era where we were only using one drug to treat hypertension in patients who now would be on two drugs. And so I think there was just a lot of very major differences there. The way we collected respec, not we, I shouldn't say I was in like.


    elementary school, but the way that race was collected back then, the way that the people who conducted the trial collected a race back then was a mix of like, could be self-reported, it was often clinician-selected race, and it's like not, there are no social factors that were collected, like no other information that we have to really unpack what that could have meant. And again, there have been groups that have looked intensively at possible genetic causes of that and haven't been able to find it.


    Liz Rohr (they/them) | RWNP (53:01.177)

    Yeah. Medicine collected, yes. Yeah.


    Liz Rohr (they/them) | RWNP (53:15.821)

    Mm-hmm Yeah Mm-hmm


    Jordy Cohen (53:30.046)

    So the one thing that people argue is that black patients have more low renin hypertension. My counterpoint to that is, you know how you find a low renin? You test a renin in aldosterone and then that can help dictate appropriate treatment if somebody does have primary aldosteronism or if they're on like that spectrum of primary aldo where they have low renin hypertension, then that does guide me towards more like, you know, diuretic use and more eplerenone and spironolactone use. But that's,


    Liz Rohr (they/them) | RWNP (53:42.389)

    Totally. Yeah. Absolutely.


    Jordy Cohen (53:59.277)

    not what they're recommending. They were just recommending this blanket-like treatment based on the color of skin, which doesn't apply. really caused probably a lot more harm than good. An example of the harm was in the UK, they did this trial where they were looking at people right before they start dialysis. There was this old debate in the kidney community whether or not you continue or stop people's ace inhibitors and ARBs as their kidney function is nearing dialysis. Because the whole, the old adage was, well, if you stop the ace inhibitor and ARB, you give them a little bit of eGFR.


    Liz Rohr (they/them) | RWNP (54:12.085)

    Right. yes. Yes.


    Jordy Cohen (54:29.23)

    because we know ACE inhibitors in ARBs sort of reduce EGFR a little bit, and that that added EGFR will keep them longer from having to start dialysis and that there's no harm to doing it. That was always the thought, just do a different blood pressure. And then what was happening was that people weren't getting restarted on them once they started dialysis. And so they decided to do a trial there, which was really cool to randomize people to either continue or stopping their ACE inhibitor in ARB as they were having more kidney function.


    And they found that it didn't prolong the time until you ended up on dialysis. People didn't have any benefit from a kidney standpoint to stopping it sooner. But if you follow people longer, it looks like that there were more cardiac events in the people who stopped it. And then there was a target trial emulation that reinforced actually probably a lot more cardiac events in the people who stopped their asymmeters and therapies. So the reason I bring up that trial is what was really shocking to me is if you look, they couldn't recruit black patients for the trial.


    Liz Rohr (they/them) | RWNP (54:57.904)

    Mm.


    Liz Rohr (they/them) | RWNP (55:06.805)

    Yep, yep.


    Jordy Cohen (55:23.18)

    because in the UK they have that specific race-based prescribing and they have to adhere to it really closely because lot of the primary care doctors have to stick to their guidelines, like to a T, like they're held to that for their like metrics. And a bunch of people just really stick to it and never get people who are black onto an ACE inhibitor and ARB because like you're told not to, you don't start with those. You start with the calcium channel blocker and the thiazide diuretics. So have these advanced kidney patients.


    Liz Rohr (they/them) | RWNP (55:43.736)

    Yeah.


    Yeah. That's so great to know. Yes. Totally, totally. I love that. That's wonderful. And I think, guess maybe just one other thought. And I remember.


    Jordy Cohen (55:48.952)

    who could get so much cardiac and kidney benefit from being on this drug class that just never got there. And so just calling that out, like it probably caused a lot more harm than good. So I love when I see that there are black patients on ACE inhibitors and ARBs now knowing that it's probably causing a lot more benefit than harm.


    Liz Rohr (they/them) | RWNP (56:12.853)

    I think I heard you say this before, and I think I saw it the guidelines, but it was a much more emphasis on dementia, that managing blood pressure is preventative effectively. I don't know if there's any other thoughts you want to add, it seems like it's, like my takeaway from that is sort of both our understanding as clinicians, but also their counseling with our patients. Do you have, yeah, go ahead. Yes.


    Jordy Cohen (56:33.518)

    Yeah, I think it's a much more patient-centered approach to convincing people that we should try to go for lower blood pressure goals. And this is a new part of the guideline. One of the recommendations is to lower blood pressure to prevent dementia. And this is a high-level recommendation from trial data now. It's really the only thing we have at the moment to prevent dementia. And so if you lower people's blood pressure to less than 130, it is associated with about about or it reduces the risk of dementia, excuse me, by about 15 to 20%, which


    Liz Rohr (they/them) | RWNP (56:59.77)

    That's amazing. Yes, yeah. Totally. I love that. Well, thank you so much for being here. Any other last thoughts or pearls of practice you want to share?

    Jordy Cohen (57:01.048)

    When you have nothing else, that's huge. And I want to keep my brain. I don't want dementia. So yeah, I think it's something that is a really helpful tool to talk to patients about. Thank you for bringing that up. And the data is really, really strong.

    Jordy Cohen (57:18.092)

    No, nothing else. I think we covered some great stuff.


    Liz Rohr (they/them) | RWNP (57:19.797)

    It's so wonderful. Thank you so much again. I really appreciate it.

    Jordy Cohen (57:23.01)

    Thanks for having me.

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