SARAH: And welcome back to the Southeast Ohio QI Hub video series. Today, I am joined by one of my favorite humans, Dr. Uma Mahesh Yalamaraju. UMAMAMHESH: Sarah, I'm sorry, you have to pronounce my name. It is Uma Mahesh Yalamaraju. AKA Raju, AKA Ragu. SARAH: It is so good to have you here, just so you know that. We may have to do another one of these already. UMAMAMHESH: Thank you. SARAH: So, we have invited Dr. Raju here to talk with us today about the updated hypertension guidelines. So, he actually did all his research and everything, so I don't even know where to begin. All right. We will begin with this. So, Dr. Raju, tell us about hypertension. We can talk generally first about hypertension if you'd like, and then we can talk about the guidelines. UMAMAMHESH: Hypertension is elevated blood pressure, and it is the most modifiable risk factor for mortality and morbidity. Especially, we don't have any symptoms. Maybe a good reason to see a doctor or have the blood pressure checked. That can really help to be healthy. SARAH: Awesome. Tell me more about hypertension. When we looked at the awesome resources that you brought, one of them was about diet. UMAMAMHESH: In fact, diet has a big role. We're going to talk about medications, but there are certain things one can do. One is a DASH diet- Okay ... which is basically more of fruits, vegetables, whole grains, low-fat dairy, lean protein, decreased sugar, and red meat. Okay. Those are things which can help. The key factor is sodium. Okay. For every 1 gram of reduction per day, the blood pressure can reduce by 3 millimeters. SARAH: Wow. UMAMAMHESH: And the goal is to have sodium less than 1,500 milligrams a day. 1,500 per day. So the DASH diet is telling us that if we reduce our sodium intake by 1 gram, that can reduce our hypertension by 3 millimeters of mercury. Correct. SARAH: Wow. And less than, you had said, 1,500 milligrams a day? UMAMAMHESH: Correct. SARAH: Wow, okay. UMAMAMHESH: If you can just substitute Na to K, sodium to potassium. Sodium, potassium. Okay. Potassium-enriched diet can actually further reduce the blood pressure by another 5 to 6 millimeters. So salt substitute can be used. Might not taste good, but maybe you can mix half regular salt with a salt substitute. We have fruits and vegetables which have high in potassium, or a simple baked potato with skin. You have to have the skin. You get roughly around 600 to 700 of potassium. Avocados and spinach, whatever anybody would like. Fish also has a good amount of potassium in it. Alcohol. 50% reduction of alcohol intake will reduce another 4 to 5 millimeters of blood pressure. SARAH: Wow. UMAMAMHESH: All right, so 50% of alcohol reduction to lower another 4 to 5. So if we lower our sodium by 1 gram, that's 3 millimeters of mercury. If we lower our alcohol intake by 50%, that's another 4 to 5 millimeters of mercury. SARAH: Anything else? What else can we do? UMAMAMHESH: Exercise. Aerobic and resistance. Okay. That can another reduction of 3 to 5 millimeters. SARAH: Wow. Reduction of 3 to 5. Awesome. UMAMAMHESH: Lastly, weight loss. For every 1 kg weight loss, the blood pressure can go down up to 1 millimeter. The bottom line is just lifestyle changes and diet can make a difference, 15 to 20 millimeters-mercury of blood pressure. That's huge. Pills are pills. SARAH: Pills are pills. I think this is simple, too. I feel like if maybe I explained that to a patient, that might be helpful for them, right? I think the biggest challenge nowadays, being a physician, is time with the patient. UMAMAMHESH: But there are two options. One, give more patient time for doctor, and in that way, they can educate. Once you educate, the outcomes will be better. Or the best other possibility is a team approach where you see the patient for high blood pressure, you see a dietician, maybe you see a pharmacist. Some places you will have exercise physiologists just telling them about exercise. It could be a group class. It is worth doing it. SARAH: Worth doing it. So we're going to lower our blood pressure just by changing things from the DASH diet. We could lower it 10 or more millimeters of mercury. So tell me, the outcomes, like the stroke outcomes and things like that, what are the reductions I can see? So how much do I have to lower my blood pressure to see those reductions? UMAMAMHESH: Before that, I just want to mention about what is the definition of high blood pressure. SARAH: Oh, okay. That's good. UMAMAMHESH: Normal is less than 120 over 80. Elevated is between 120 over 129 and less than 80. Stage one is between 130 to 139 and 80 to 89. And stage two is more than 140 over 90. SARAH: Did these change recently? UMAMAMHESH: They have made it more simplified as to approach how to treat each of the stages. The new updated guidelines from August 15th, 2025. SARAH: Okay. August 15th of 2025 are our updated hypertension guidelines. UMAMAMHESH: Correct. SARAH: And they provide a little bit more information what to do with each stage of those hypertension. UMAMAMHESH: Correct. And to answer your question, for every 10 millimeters reduction in systolic blood pressure-stroke reduction by 27%, heart failure reduction by 28%-major CV events by 20%, coronary artery disease 17%, and all cause mortality reduction of 13%. And on top of that, we can decrease the risk of dementia. It's win-win. Wow. This should be one of the most achievable targets and make a huge change in patients' health. In their health. SARAH: Is there any other resources or anything else you would like to share? Is there something that particularly you find easy to use that would be helpful for other clinicians? UMAMAMHESH: My go-to, and I've read this, and we can listen on your drive, is the "Curbsiders" podcast of hypertension guidelines which was, I think, from December of 2025. SARAH: December '25. Okay. I love it. UMAMAMHESH: It's simple. There are graphics. You can download the graphics and just hang it up on your wall, and it's easy to do. SARAH: That's amazing. Is there anything from it that you'd like to share? UMAMAMHESH: Couple of things. Okay. One is, when do we check aldosterone renin ratio? Because primary hyperaldosterone is actually a common thing more than what we ever knew about. 5 to 10% of all hypertension patients have primary aldosteronism. 20 to 30% patients with resistant hypertension. A simple test, aldosterone and renin activity. Okay. A blood test. You send it off. You don't have to stop any blood pressure medications unless they are on mineralocorticoid receptor blockers, like spironolactone. You have to hold it for about four weeks. And it's a simple test. Anybody with resistant hypertension should have it screened. SARAH: Okay. UMAMAMHESH: Number two is anybody with stage two high blood pressure should have a screening test for that. SARAH: So stage one or stage two resistant hypertension, be checking for primary aldosteronism. UMAMAMHESH: Resistant hypertension and stage two hypertension. SARAH: Okay. Resistant hypertension and stage two hypertension. UMAMAMHESH: I try to make it more simple. I don't know how much it costs. Maybe screen for every hypertensive patient- Test and we'll rule it out ... forget the guidelines. And also, the most important thing is we have to measure the blood pressure correctly. That is the starting point. If you get a wrong reading, we get the whole thing wrong. SARAH: Yeah. UMAMAMHESH: So that would be the most important. There are guidelines how to check that. And the second thing is, where do we buy this device? There's a website where you can go to validatebp.org which gives a list of blood pressure apparatus which are validated and can be used. They have low cost, high cost, it doesn't matter. As long as it's on the list, you can buy that. SARAH: That's great. UMAMAMHESH: Or we are fortunate in Athens, Ohio Health has a project where we've been giving free blood pressure machines for the last six months or so. SARAH: That's amazing. That's fantastic. So I think we've covered some really amazing pearls today, and I know that the "Curbsiders" resource that you had mentioned also provides some really very cool hypertension guideline pearls. So we talked about lowering the millimeters of mercury with diet changes that can be significant, weight loss, exercise, also getting the correct blood pressure monitor, and the correct machine, and making sure they're validated. I think the things that we covered today are really important and really excellent clinical pearls. And I know, so the guidelines were updated in August 2025 for the hypertension guidelines. You can find those updates in, there's a couple JAMA articles that provide those updates. Is there anything else that you wanted to share before we are finished with our hypertension discussion? UMAMAMHESH: The website, American Heart Association, it's a free access for the new guidelines if anybody wants to go and check. A couple of other things. There is no longer race-based medication selection recommendations. That has been eliminated. SARAH: That's been a while coming. I'm glad that's coming. So no longer race-based medication recommendations. UMAMAMHESH: And the second thing is, for stage two hypertension, it's better do a combination medication because compliance is such a major issue. People struggle. I have high blood pressure, and sometimes I'm upstairs and I'm too lazy to go down to take a pop a pill. I say, "Okay, I'm going to take it tomorrow." SARAH: Yeah. It's so easy to miss. So easy to miss. So medication adherence and using combo pills if possible, if that's an easier way to help with adherence. Yeah. UMAMAMHESH: Yes. SARAH: Okay. Fantastic. This was lovely. UMAMAMHESH: Thank you. SARAH: I would like to thank Dr. Raju for coming to spend time with us today. This was an update for your hypertension guidelines from the Southeast Ohio QI Hub, and maybe Mahesh will come back and join us again someday. UMAMAMHESH: Will do. SARAH: Thank you and have a good day. Thank you.