Hospice Doctor Measuring Blood Pressure To Senior Woman

Originally published in the South Dakota Medicine Journal, February 2018

Stephan Schroeder, MD, CMD, CMQ
Medical Director, South Dakota Foundation for Medical Care

February is American Heart Month and offers an opportunity to focus on a significant factor in cardiac health: hypertension. The diagnosis and treatment of this condition should be an emphasis of patient care no matter the location or the specialty of the provider. Making the patient aware of hypertension and providing accurate diagnosis, treatment or referral, if needed, should be a priority for all clinicians. It has importance in maintaining population health and should not be ignored or taken for granted. The costly consequences in life years and dollars from untreated blood pressure (BP) are staggering. The value of appropriate management is enormous in helping decrease the potential bad outcomes of cerebrovascular disease.

In late 2017 a set of guidelines for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults was released by the American College of Cardiology and the American Heart Association Task Force on Clinical Practice Guidelines. It is 481 pages in length and contains 106 graded recommendations. These Guidelines represent a comprehensive resource that has been the subject of many journal editorials and viewpoints. There are some significant changes from previous recommendations and values previously considered normal will now be considered for treatment. The new guidelines for BP ranges are provided below.

Blood Pressure Range  Value
Normal  <120/80
Elevated  120-129/80
 Stage 1 130-139/80-89
  Stage 2  >140/90

Based on the new BP guidelines, estimated prevalence of hypertension in the US will raise to nearly 46% of the population. In addition, at least two to three BP measurements with proper technique are recommended to confirm the diagnosis. Values collected outside of the provider office, such as at home or with a wearable monitor, are recommended to confirm the diagnosis and for the titration of medication dosing if needed.

In the area of initiation of therapy, there is an emphasis on nonpharmacologic interventions for those with elevated pressures. Initiation of medication therapy depends on both the pressure level and cardiovascular disease risk. Long-term management includes recommendations on types of medication. In Stage 2 patients with an average BP of more than 20/10mm Hg above the target, treatment should begin with two first-line agents. Systolic BP has evolved as a more important measurable factor.

A few editorials have commented that translating the updated guidelines to clinical practice has a number of challenging elements. Patient education, practice organization and clinical endpoint performance measurement will all likely be affected. Electronic Health Record (EHR) interoperability and team based care, including community services and telemedicine, are also needed to help transform BP management. The need for more frequent clinical encounters may affect compliance and follow-up care as well as the affordability and cost of this care. Potential harms from polypharmacy treatment reinforce the need for a shared decision making process with patients and family concerning risks and benefits, especially in elderly patients.

Changing guidelines and recommendations are often a source for differing opinions and challenges, i.e., lipid targets, mammogram age categories, PSAs, yearly wellness exams etc. The true challenge should not be the adopting of newer more rigorous hypertension guidelines, but rather attempting to change cardiovascular risk factors. The focus should lie with healthy lifestyle changes. The benefits of weight loss, salt avoidance, limited alcohol use, exercise and diets, such as the DASH diet, have and will continue to be modifiable factors that are crucial to augment pharmacologic treatment. This may help to slow or alter the development of hypertension in the first place. Then, when needed, the medications can reduce the risk using evidence-based recommendations.

One of the Great Plains Quality Innovation Network (QIN) projects has the goal of improved cardiovascular care and reduced cardiac healthcare disparities, including BP control. The Great Plains QIN can provide technical assistance as well as learning events to assist clinics and home health agencies in quality reporting and improved outcomes. Please contact me (Stephan.Schroeder@area-a.hcqis.org) or Holly Arends, CHSP, CMQP (Holly.Arends@area-a.hcqis.org) at 605-660-5436 for more information.

1. Whelton PK, et al 2017 High Blood Pressure Clinical Practice Guidelines: Hypertension Nov 13,2017
2. JAMA December 5,2017 Volume 318 Number 21