Feeling the Pressure of New Guidelines for the Treatment of Hypertension
By Neal Roberts, PharmD
On November 13th The American Heart Association, the American College of Cardiology and nine other groups redefined high blood pressure as a reading of 130 over 80, down from 140 over 90. The change, the first in 14 years, means that 46 percent of U.S. adults, many of them under the age of 45, now will be considered hypertensive. Under the previous guideline, 32 percent of U.S. adults had high blood pressure.
High blood pressure is the leading cause of death worldwide and the second-leading cause of preventable death in the United States, after cigarette smoking. Hypertension leads to cardiovascular disease, strokes, severe kidney disease and other maladies that kill millions every year. The CDC estimates that High blood pressure costs the nation $46 billion each year. This includes the cost of health care services, medications to treat high blood pressure, and missed days of work.
The authors of this report expect that many adults younger than 45 will find themselves included under the new threshold. The lower score is expected to triple the number of younger men considered hypertensive and double the number of younger women with high blood pressure.
But the report's authors predict that relatively few of those who fall into the new hypertensive category will need medication. Rather, they hope that many found with the early stages of the condition will be able to address it through lifestyle changes such as losing weight, improving their diet, getting more exercise, consuming less alcohol and sodium and lowering stress.
While these more stringent guidelines may save additional lives, I expect many primary care providers and their younger patients may feel overwhelmed at the realization that many are joining the ranks of those with chronic disease. Despite the reputation and influence of the American Heart Association and American College of Cardiology some will be slow to adopt these new thresholds for intervention.
Convincing patients who feel well that their previous numbers are no longer considered “good” and that they must either alter their lifestyle and diet or take medication daily for the rest of their lives may be understandably, a tough sell. After all, there is a reason that hypertension is referred to as “the silent killer” since many patients suffer no symptoms until the acute onset of a heart attack or stroke.
Even prior to the release of this report, the United States had a huge problem with under treatment of high blood pressure. According to the CDC, only about half (54%) of people with high blood pressure have their condition under control. If one factors in these new lower thresholds for diagnosis, that percentage is likely to drop even further.
The good news for both patients and health plan sponsors is that medical management of cardiovascular disease by lowering blood pressure and cholesterol is now, quite inexpensive, and arguably a reasonable alternative to much higher cost interventions like coronary bypass grafting and stenting. Yesterday’s heavily advertised blockbuster drugs like Prinivil®, Norvasc®, and Lipitor® that built the fortunes of US drug manufacturers are now available on many drugstores “$4 lists” like classic albums in the bargain bin.
Lifestyle interventions like quitting smoking, reducing alcohol consumption, daily walks, and avoiding salt and fad laden fast food in favor of shopping and preparing home cooked meals with lots of fruits, whole grains, vegetables, and healthy protein sources may actually have a positive effect on household finances, especially when one factors in the money saved by needing to take fewer trips to the doctor.
Clearly, there is a mandate for those of us in the healthcare professions to work in earnest on this problem. With these new hypertension guidelines, the bar has now been officially raised for primary care providers who already find themselves with less time to discuss lifestyle and treatment options with their patients because of the increasing need to attend to administrative tasks involved in running a busy practice.
Creating lasting positive health behavior change is the key to solving our nation’s chronic disease epidemic but is given less time and attention by providers because of the lack of supports and reimbursement available for effective lifestyle management programs. We at Emtiro Health believe we can provide those supports and help patients and providers bridge the gap between knowledge and outcomes by removing roadblocks to effective treatment.
Imagine the scenario of a patient with hypertension, diabetes, dyslipidemia and a high 10-year risk of heart disease or stroke with difficulty affording medications and adhering to a healthy diet. The primary care physician introduces the patient to a nurse care manager assigned to the practice who happens to be at the office that day meeting another patient at their hospital follow up visit. The care manager does an assessment and creates patient centered goals with input from the physician. Referrals are made to a community based organization to provide food, a dietician to advise on menu planning, and a community pharmacist that will help the doctor choose affordable medication options and offers free delivery to the patient’s home. The nurse care manager teaches the patient to monitor his own blood pressure and blood sugar at home and reinforces the doctor’s instructions on what to do if those numbers are out of range.
During the first few months, regular check-ins with the patient by the care manager and pharmacist ensure that the patient is taking his medication and monitoring both blood pressure and blood glucose. Dieticians and other care team members are utilizing motivational interviewing techniques to encourage incremental improvements in diet and movement goals. The primary care physician is made aware of any side effects or other concerns that may need urgent attention, but continues to work “at the top of her license” by delegating patient education and responsibility for troubleshooting the frequent problems encountered when trying to coordinate chronic care.
Imagine if this program could be offered to every patient unable to meet blood pressure and other chronic disease treatment goals. In light of these support services, the new blood pressure treatment guidelines might appear to be less of a burden on an already overtaxed primary care network and more of an opportunity to reduce unnecessary death and disability associated with this common disease.