World Hypertension Day: What Cardiologists Need to Know

In this discussion, Payal Kohli, MD, emphasizes the ongoing importance and evolving understanding of hypertension, often called the “silent killer” due to its lack of symptoms until severe complications occur. Dr. Kohli highlights common misconceptions, such as that hypertension is inevitable due to genetics or is only a consequence of aging. She also stresses the crucial role of lifestyle factors, including diet, exercise, sleep, and weight. Dr. Kohli underscores the importance of early detection, preventive care, and public awareness, particularly around events like Hypertension Awareness Day, which carries a 2025 theme of “Measure Your Blood Pressure Accurately, Control It, Live Longer”. She also discusses exciting new developments in hypertension treatment, including small interfering RNA therapies and endothelin receptor antagonists, as well as the need to identify secondary causes like hypercortisolism to better personalize care and outcomes.

Transcript:

Dr. Payal Kohli: Hello. I’m Dr. Payal Kohli. I’m a general cardiologist from Denver, Colorado. I’m also an associate adjunct professor in cardiology at Johns Hopkins University and Duke University. Today I’m so excited to talk about hypertension, which is an old trend, but certainly, there’s so many emerging things in the world of hypertension that I can’t wait to dive in.

Cardio Care Today: In your clinical experience, what are the most common misconceptions patients have about hypertension, and how can awareness initiatives help address them?

It’s funny that you mentioned that, Rob, because hypertension has been considered the silent killer for quite some time, because one of the most common misconceptions that I see my patients come in with is that they would be symptomatic. They would have symptoms because of their hypertension, and I think that that’s something we really need to raise awareness of, which is that hypertension can really be quite silent until you have that stroke, that heart attack, that aortic dissection, or that complication, so that’s a really common one that I see. The other thing that I don’t see patients often understanding is just how much our diet and lifestyle influences our blood pressure.

A lot of people feel like, “Well, my mom had hypertension, or my dad had hypertension, so I’m just inevitably going to get it.” What they don’t realize is that the amount of sodium we take in, the amount of exercise we do, whether or not we’re active, whether we’re sleeping enough, all of these factor into whether or not we develop hypertension. Then, finally, I would say that weight is a big misconception. People don’t realize that having extra weight is one of the biggest drivers of hypertension, and hypertension is not necessarily something you have to accept as you age. It’s not just the blood vessels getting stiffer, even though, of course, they do, but it is very reversible in the early stages, which people again don’t quite appreciate as patients. So, I try to educate my patients as best as I can, and I think raising awareness about just how it can creep up on you and be silent. You’re not going to know unless you check your blood pressure. That’s really critically important.

How do you integrate global awareness campaigns like Hypertension Awareness Day into your patient education strategies?

I am so glad that we have days, like Hypertension Awareness Day, which is on May 17th this year in 2025, because it’s really a chance for us to do a few things. The first is we can actually, as physicians or healthcare providers, use it as a way to start to screen people more aggressively, look at our hypertension screening protocols and think about, “Are we being aggressive enough in early detection and screening? Are we encouraging patients to be preventive in their approach to hypertension, to actually check it at home and what have you?” But I think, even on a more global level, initiatives like Hypertension Awareness Day can really help us to think from a global health perspective, “What is the impact of hypertension, and globally, not just for a single patient, but for the entire population of the country or the world, are we treating hypertension aggressively enough?”

Many recent studies, of course, have come out, including one from China that has linked poor control of hypertension to early onset dementia, and dementia is one of those conditions that each of us worry about as we get older. And so, to know that something like that is preventable by more aggressive blood pressure control is really empowering. I also think days like hypertension awareness days are a chance for healthcare providers to sit down and review the guidelines. There’s been a recent update to the European Society of Cardiology guidelines, looking at how we define hypertension and how we define controlled hypertension, and really, sort of shifting that focus to that less than 120 being a normal blood pressure, and that 120 to 129, which people often think is normal, actually raising a flag for what’s called elevated blood pressure or pre-hypertension.

What is the newest science in hypertension management?

It’s so interesting, because hypertension is probably my oldest friend in cardiology. I’ve been treating it ever since medical school, of course, because it’s something we’ve been dealing with for decades, but it’s also my newest friend, because there’s all these new developments coming in the world of hypertension that I’m finding fascinating. So, I’m just going to highlight a couple today. There’s lots of stuff cooking on the horizon, but novel therapeutics and new ways to think about causes of hypertension are where I’m really wanting to focus. One of the medicines that I want to talk about is a medicine called [inaudible 00:04:04], which is a small interfering RNA, and this is a really cool concept, because it’s the idea of treating hypertension with a twice yearly injection. As you know, siRNAs or small interfering RNAs are these interfering RNAs that turn off your messenger RNA. So when you give somebody this injection, it actually goes into the liver and it degrades the messenger RNA, which would then have turned into the protein for an enzyme called angiotensinogen.

Now, angiotensinogen is a precursor in the renin angiotensin aldosterone system. In fact, it’s one of the earliest precursors, so this is really targeting the RAS pathway, but it’s targeting it way upstream, and it’s targeting it in a way so that enzyme, that protein, is never actually made because you’re turning off the messenger RNA, which gives it that long tail of effect, that long-lasting effect. To me, a really interesting way to think about paradigm shifting in hypertension, where you’re now thinking about a twice yearly injection, because we know that some of those interfering effects can last for six months even after the compound is cleared from the body, and you’re talking about targeting the RAS system upstream, where we know that a lot of the current medicines that we use for treating hypertension actually target the RAS system downstream, where it’s actually exerting its effects, like RAS blockers.

Another class of medicines that’s really cool, that’s been cooking on the horizon, is ERAs or endothelin receptor antagonists. The class of medicines here is the apricotentin, which is an oral medication. We’ve often used ERAs in pulmonary hypertension. In fact, we’ve used them for many years, but now for the first time, they’re making their kind of foray into systemic hypertension, especially resistant systemic hypertension. The idea here is a different target, right? Because it’s a first in class type of a medication for systemic hypertension, and we’re already hitting with ACEs and ARBs, we’re hitting those receptors. We’re hitting calcium channel blockers, so now this is looking at ERA endothelium receptor antagonists as a way to target. Then, finally, I would say what I’m kind of excited about in my practice is really thinking about secondary causes of hypertension and not missing conditions like hypercortisolism, which I think is a lot more common than we realize.

Because often we see a patient in our office who’s diabetic, who’s obese, who’s got metabolic syndrome, they’ve got sleep apnea, they’ve got hypertension, and we just kind of say, “Oh, yeah. It’s essential hypertension,” but it’s not so essential. It’s not primary hypertension. Often it’s secondary being driven by an elevated level of cortisol, which is also potentially driving their metabolic syndrome, their diabetes, their obesity, and their weight gain, in addition to their hypertension. This becomes important, because when you think about targeting therapies and personalizing therapies, you want to think about causes, as well as treatments.