Hypertension needs to be managed quickly and carefully for patients to avoid health problems
Heart disease and stroke rank first and fifth among the causes of death in the United States, respectively, and hypertension puts patients at increased risk for both.
Since 1999, there has been a strong, significant, inverse relationship between the proportion of deaths in the United States due to stroke and the proportion of people with BP < 140/90 mm Hg in NHANES data sets, suggesting that better control of blood pressure reduces stroke rates in the U.S. population as a whole.
Despite improved treatment options and better rates of blood pressure control, one in three American adults has high blood pressure, according to statistics released by the Centers for Disease Control and Prevention. This equates to more than 77 million patients with hypertension, or 29% of the adult population. The prevalence of hypertension is forecast to increase as the population ages, with people who are normotensive at age 55 having a >90% lifetime risk.
Hypertension is associated with annual national costs of $46.4 billion when direct and indirect costs of care are included. Hypertension was a primary or contributing cause of death for more than 360,000 patients in 2013, or nearly 1,000 deaths per day.
The American Heart Association reports that more than 80% of patients with hypertension are now aware that they have the condition. Only about half have their blood pressure under control.
Recognize patients who are at risk. Hypertension is often asymptomatic and may therefore remain unrecognized if at-risk patients are not screened. Patients with prehypertension and diabetes are more likely also to have high blood pressure, as are patients who are obese, smoke tobacco, drink excess alcohol, have a diet high in sodium and low in potassium, and live a sedentary lifestyle.
Stress levels can also be a factor. African-American patients are more likely to have high blood pressure than patients of other backgrounds.
Advanced age is a risk factor for both sexes, though that risk can vary: more men than women have high blood pressure until age 45. Between the ages of 45 and 54 and 55 to 64, men and women have equivalent risk.
After age 65, a much higher percentage of women have hypertension than men. Some believe this is due to the so-called survivor effect, because men who do not achieve blood pressure control die more often than women of the same age (who are less likely to have hypertension at younger ages).
Create a hypertension management protocol for your practice. Establishing a practice-wide management protocol for hypertension can create efficiencies while allowing for personalized care.
Consider the following points for inclusion when crafting a management protocol:
Latest guidelines. The eighth Joint National Committee broke new ground by recommending a blood pressure target of <150/90 mm Hg for patients over 60 years of age, and <140/90 mm Hg for all others.
The American Diabetes Association suggests <130/80 mm Hg in younger patients with diabetes if that target is easily achieved and well-tolerated.
Similarly, the National Kidney Foundation recommends blood pressure of <130/80 mm Hg for patients with chronic kidney disease and elevated ratios of albumin:creatinine in the urine.
Lab testing. Conduct routine laboratory tests, including electrocardiogram; urinalysis; blood glucose and hematocrit; serum potassium, creatinine and calcium; and a lipid profile before initiating pharmacologic therapy.
Liifestyle modifications. Include lifestyle modifications in the treatment plan for all patients, and institute oral antihypertensive therapy in those who are appropriate candidates.
Patient assessments. Assess patients for target organ damage and existing cardiovascular disease.
Encourage self-monitoring. Whether through readings done at home or in community settings, encouraging patient self-monitoring can help patients assume responsibility for, and maintain awareness of, blood pressure control. Currently, remote monitoring of home blood pressures is not reimbursed until and unless the patient makes an office visit, and ambulatory blood pressure monitoring is paid for only in cases where the final diagnosis is “white-coat hypertension.”
Nonetheless, emerging evidence indicates that home blood pressures can be a useful adjunct to office blood pressure readings, particularly if “masked hypertension” or “white-coat hypertension” are likely. In addition, they can reinforce the patient’s understanding of the important role of medication adherence in blood pressure control.
Reinforce the importance of a healthy lifestyle. Lifestyle changes are a critical part of disease management for patients with hypertension. Not only do they have the potential to reduce blood pressure, they can also enhance antihypertensive drug efficacy and decrease overall cardiovascular risk.
Key lifestyle shifts include:
Establish expectations for follow-up and monitoring. After treatment has been initiated, most patients should return to the office for monthly visits until blood pressure goals have been achieved. During these visits, lifestyle modifications should be reviewed and medications adjusted as necessary.
Certain patients may require more frequent visits, such as those with stage 2 hypertension, complicating comorbidities, or associated diseases such as diabetes or chronic kidney disease. Follow-up can typically be extended to three- to six-month intervals after blood pressure is at goal and is stable.
-Reviewed by William Elliott, MD
Department Chair, Biomedical Sciences;
Division Chief, Pharmacology
Professor of Preventative Medicine, Internal Medicine, and Pharmacology, Pacific Northwest University