Continue BP control, maintain benefits
Helping patients maintain normal blood pressure over the long haul pays off in cardiovascular and other health benefits, yet studies show that U.S. adults continue to backslide.
Helping patients maintain normal blood pressure over the long haul pays off in cardiovascular and other health benefits, yet studies show that U.S. adults continue to backslide.
Nearly half of adults, 120 million, have hypertension, based on a 2017 guideline developed by the American College of Cardiology (ACC)/American Heart Association (AHA) and endorsed by a large multidisciplinary group of professional specialty societies. The guideline states that hypertension is diagnosed in patients with blood pressure readings consistently at or above 130/80 mm Hg without treatment and/or in those prescribed antihypertensive medications (irrespective of blood pressure level). But only 27 million of those adults, fewer than one-fourth, have their blood pressure under control, according to federal data.
Other findings based on less rigorous prior guidelines, setting a benchmark of 140/90 mm Hg and above to diagnose hypertension, have identified a steady erosion in control since 2009. From 2017 to 2020, 48.2% of U.S. adults with hypertension had controlled blood pressure, down from 52.8% in 2009 to 2012, according to data published in September 2022 in Hypertension.
Meanwhile, a recent secondary analysis of the Systolic Blood Pressure Intervention Trial (SPRINT), published in November 2022 in JAMA Cardiology, found that blood pressure improvements and related mortality reductions were difficult to sustain once the study ended.
The analysis, which followed the 9,361 participants for up to 10 years after randomization, found that any cardiovascular and overall mortality reductions in the intensive treatment group (target blood pressure <120 mm Hg) compared with the standard treatment group (target blood pressure <140 mm Hg) had largely vanished 4.5 years after the study ended. In addition, a look at blood pressure in a subset of 2,944 participants identified a gradual narrowing of systolic readings between the two groups, with no detectable difference roughly nine years after randomization.
"The lesson is clear that the benefit of blood pressure control is only continued if blood pressure control is continued. It's not a one-time intervention for long-term benefit," said Daniel Jones, MD, a past president of the American Heart Association. Dr. Jones, one of the authors of an accompanying editorial in JAMA Cardiology, pointed out that patients in the intensive group interacted with the study researchers at least six times each year, even after their blood pressure fell below 120 mm Hg. That study and others have demonstrated, Dr. Jones said, "that frequent interaction with the patient is crucial to blood pressure control."
But improving control shouldn't rest solely upon the internal medicine physician's shoulders, said Dr. Jones and other hypertension specialists. Potential strategies include recommending that patients check their measurements at home, using telehealth and other technology to touch base periodically, and training others in the practice to monitor and support patient efforts outside of the physician appointment itself.
Physicians also must guard against therapeutic inertia, delaying the start or addition of medication in the face of patient lobbying otherwise, said John M. Flack, MD, MPH, MACP, a hypertension specialist and chair of the department of internal medicine at Southern Illinois University School of Medicine in Springfield.
"I think there is a lot of resistance that patients have to taking antihypertension drugs," he said. "So there's a lot of bargaining that goes on between the doctor and the patient."
Maintaining control
The secondary analysis of the SPRINT study wasn't designed to look at what factors might have influenced the erosion of blood pressure control and related benefits after the study ended, said Nicholas Pajewski, PhD, corresponding author on the JAMA Cardiology study and an associate professor of biostatistics and data science at Wake Forest University School of Medicine in Winston-Salem, N.C.
Some potential contributors might include reduced patient adherence to the medications due to affordability, as they were free during the study, Dr. Pajewski said. As the participants aged, they also might have struggled to keep up with multiple pills not just for hypertension but other medical conditions as well.
Plus, therapeutic inertia might have been involved, Dr. Pajewski said. "It manifests as a wait-and-see approach," he said. For instance, a patient seeking help for painful gout might have a slightly elevated reading, and the physician decides to revisit measurements at the next visit. "So often this can manifest as you kick the can down the road, and then somehow nothing happens," he said.
Therapeutic inertia has been well documented, particularly involving older adults. One study, published in March 2023 in Hypertension, looked at whether hypertension medication was appropriately started or increased in the outpatient setting and found that only 11.1% of visits involving adults ages 60 years and older followed the ACC/AHA guideline.
Dr. Pajewski was involved with another secondary SPRINT analysis indicating that age bias might play a role. The analysis, which was published in July 2023 in Hypertension, looked at SPRINT participants by age who had blood pressure readings above goal and found that clinicians were 25% to 32% less likely to adjust medication to achieve better control in adults ages 80 years and older versus those less than 60 years of age. Those differences didn't seem to be explained by differences in the participants' frailty, cognitive function, or gait speed, researchers found.
Orthostatic hypotension, which is more common in older adults, is another factor that should not deter more aggressive control, according to the findings of a meta-analysis of nine studies published Oct. 17, 2003, in JAMA. The analysis involved 29,235 participants and found that intensive therapy lowered cardiovascular and all-cause mortality in the 9% with orthostatic hypotension as well as those without.
When patients exhibit orthostatic hypotension, physicians shouldn't assume that the blood pressure medications are at fault and cut back, said Stephen P. Juraschek, MD, PhD, lead author on the JAMA meta-analysis, an associate professor of medicine at Harvard Medical School, and an internal medicine physician and hypertension specialist at Beth Israel Deaconess Medical Center in Boston.
Citing other research that he was involved with, the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), which was published in Hypertension in 2019, Dr. Juraschek said, "What we found is that most first-line hypertensive medications don't cause [orthostatic hypotension]. They affect blood pressure in the standing and seated positions, and as a result there's no net exacerbation of that difference. So what we've been hoping is that people just be a little bit more cautious about assuming it's the hypertensive [medication]."
Dr. Flack, who with Dr. Juraschek was a coauthor on a recent AHA scientific statement on orthostatic hypotension published in January by Hypertension, said that most patients with orthostatic hypotension do not have symptoms of orthostatic dizziness and most patients with orthostatic dizziness do not have orthostatic hypotension. Also, he said, data from SPRINT showed less orthostatic hypotension when blood pressure was lower (i.e., better controlled).
Capturing accurate pressures
To guide better management, physician practices need to be designed to facilitate accurate readings, along with teaching patients to take home measurements, said Don Casey, MD, MPH, MBA, MACP, lead coauthor of the 2017 ACC/AHA guideline and an associate professor of internal medicine at Rush Medical College in Chicago. "If we're not measuring accurately, then we are not having good information to decide what to do next," he said.
Numerous factors can sabotage an accurate result, including whether patients have a full bladder, have crossed their legs, or talk during the measurement, according to a graphic developed by the American Medical Association and Johns Hopkins Medicine. Those variables each can boost readings between 2 mm Hg and 15 mm Hg.
In addition, the time required for blood pressure measurement can be difficult to incorporate into a busy internal medicine practice, Dr. Casey and other hypertension specialists noted. For instance, the readings in SPRINT relied not just on a correctly sized arm cuff and proper positioning of the patient but stipulated that patients rest for five minutes before a series of three automated blood pressure readings were taken.
One approach could be to carve out extra time, including the resting period, for a medical assistant or another trained staffer to take the patient's reading before the internal medicine physician walks in, Dr. Casey said. But increasingly, Dr. Casey and others said, physicians should encourage patients to regularly take their blood pressure at home to compile nuanced information about broader patterns.
"The in-clinic readings are so variable that they're almost useless to react to," said Dr. Pajewski, pointing to the findings of a study published in April 2023 in Circulation: Cardiovascular Quality and Outcomes.
In that study, researchers evaluated outpatient readings in 537,218 adults treated at the Yale-New Haven Health System in Connecticut and found that systolic measurements varied an average of 12 mm Hg between two consecutive visits across the population, which included patients with and without hypertension. That variability makes it difficult to monitor patients' blood pressure based only on office readings, as well as to assess the impact of any medication changes, the researchers wrote.
Dr. Juraschek added that all clinical trials of hypertension used clinic measurements to titrate treatment and that there have been no trials where treatment has been titrated to home blood pressure measurement or ambulatory blood pressure monitoring.
"I'm a huge advocate of home [blood pressure] monitoring, but I don't think we should discard clinic measures without further evidence," he said.
Ideally, most patients, including those with hypertension and those who are at risk for it, should check their blood pressure between office visits, Dr. Casey said. "To me, it's just like getting on the scale at home."
Home readings also provide an effective way to determine if patients are experiencing white coat hypertension or if their out-of-office readings also warrant starting medication, said ACP Member Jennifer Cluett, MD, a general internal medicine physician and medical director of the Comprehensive Hypertension Center at Beth Israel Deaconess Medical Center and a coauthor with Dr. Juraschek on the JAMA meta-analysis. Even if patients don't have hypertension at that point, developing a habit of home measurements can enable them to monitor their cardiovascular health moving forward, she said.
"The natural progression of blood pressure is to rise as we age," she said. "The one thing you want to avoid is to tell somebody at age 42 that they have white coat hypertension, and not educate them that at some point their out-of-office blood pressure may be at a range that needs treatment."
Standardizing approaches
Taking home measurements, though, might not be sufficient to achieve ongoing control, hypertension specialists said. Patients should be offered frequent opportunities for real-time feedback and related medication adjustments if necessary.
Telehealth provides one avenue, with the patient checking in via video visits or messaging to share readings, Dr. Jones said. Depending on the state laws involved, a nonphysician such as a nurse or a pharmacist could be trained and authorized to follow the physician's protocol and make any medication adjustments, he said.
The patient also could meet in person with the designated clinician, Dr. Jones said. This more interactive approach likely relies on investment by a larger health system that will pay for the staffer's related time, he said. "It can be done in a freestanding practice, but it would be hard," he added, given the staff-related investment required.
Physicians can offer the opportunity to make lifestyle changes when non-high-risk patients are motivated to avoid starting medication or are resistant to adding drugs, Dr. Flack said. In that scenario, he suggests that patients monitor their blood pressure at home for a six- to 12-week stretch, getting six distinct measurements each week based on duplicate readings. Dr. Juraschek added that guidelines recommend twice in the morning and twice in the evening for seven to eight days, with a minimum of 12 measurements over three consecutive days.
Monitoring for up to three months provides physicians with a better window into whether the patient can sustain changes over the longer haul, such as cutting sodium or boosting exercise, Dr. Flack said. Physicians can then review the data to determine if they should start or adjust medication, he said.
In some cases, patients might have achieved notable success in shedding pounds and adopting other healthier habits, but the readings haven't budged much, Dr. Flack said. While physicians should move forward with prescribing, they also should educate patients about the ongoing benefits of their healthier lifestyle. For example, he said, physicians can tell patients, "The drugs will not have to work as hard to control your pressure, because the more success you have making healthy diet/lifestyle changes, less medication will be needed to achieve blood pressure control."
Above all, physicians should adhere to the recommended guidelines despite any patient lobbying otherwise, Dr. Flack advised. "If you're not careful, what you will get pulled into are endless negotiations that go on perpetually."
When Dr. Cluett starts her patients on hypertension medication, she sets the expectation that they likely will need to add medications over the course of their lifetime to effectively control their blood pressure. The patients in SPRINT's intensive treatment group, she noted, required an average of 2.8 medications to achieve target readings.
"Patients often feel like needing the medication is a failure on their side for something that they should be doing better in terms of lifestyle," she said. "But that just simply isn't true. Lifestyle is so important. But it's only a piece of the overall puzzle."
She educates patients about potential side effects, such as the lower-extremity swelling that can develop with calcium-channel blockers. If patients know what side effects are related to the medication, they won't seek medical help elsewhere thinking it's another condition, Dr. Cluett said. She also alerts patients that side effects are often reversible or dose-related, meaning that they are present at higher doses and less problematic or absent at lower doses, and if they let her know, she can reduce the dose or switch them to another medication.
Dr. Juraschek acknowledged that some physicians may remain reluctant to treat hypertension aggressively given various concerns, including polypharmacy and patient frailty. But he urged his colleagues to consider prescribing to the targeted goal, along with close patient monitoring, given the larger health picture involved.
"Hypertension treatment is one of the most studied interventions out there. The results are so consistent," he said, in terms of benefits like reduced mortality. Plus, Dr. Juraschek added, physicians have an additional way to motivate patients by discussing the link between hypertension and cognitive decline and dementia. "In some sense if we step away from treatment," he said, "we could be contributing to cognitive issues in older adults when there are really few proven interventions."
