Hypertension: How About a New Year’s Resolution?

January 8, 2014

Where are we left after a flurry of hypertension publications as 2013 was ending and 2014 beginning? Let’s summarize our recent encounters with the available facts.

Where are we left after what may be characterized as a flurry of hypertension publications as 2013 was ending and 2014 beginning?

Let’s summarize our recent encounters with the available facts:

• JNC 8 simplified targets for blood pressure management but did not give us a lot of direction on how to reach those targets.

• It will be medical management for renal artery stenosis-not dilatation and stenting-for the foreseeable future.

• It may be that technology, in the form of renal denervation therapy, will come to the aid of antihypertensive medications to treat those with resistant hypertension who aren’t reaching targets.

• The American Society of Hypertension (ASH) sounded a discordant note through a publication that added some practical directions to the JNC document.

But isn’t the bottom line, all the aforementioned aside, that we need to do a better job of managing hypertension right now? And what is best way in 2014 to accomplish that goal?

I was holding back a final 2013 publication that gives us some “nuts and bolts” for the day-to-day struggle to decrease cardiovascular risk consequent to elevated blood pressures.1 The authors began with some sobering reminders of previous failures. About 65 million Americans are hypertensive. In 2001-2002, less than half of the hypertensive cohort was at target.

Kaiser-Permanente Northern California implemented a large-scale hypertension program in their hypertensive population-a group that increased in size from 349,937 in 2001 to 652,763 in 2009. The program distinguished itself not only in that imposing size but also through the iterative sharing of performance metrics, the application of evidence-based therapy, medical assistant visits for blood pressure measurements, and a reliance on single-pill combination therapy (ACEI/thiazide).

Steps 1-4 recommended antihypertensive regimens (each “next” step escalation was taken if patients were not at target on 2- to 4-week follow up with medical assistants who forwarded the information to the responsible primary care practitioner) were changed every 2 years based on the available evidence (much more frequently than JNC revisions, to be sure!). The index years were 2001, 2003, 2005, 2007, and 2009.

For example, Step 1 was a thiazide or a beta blocker in 2001 but was a thiazide or a thiazide/ACEI combination in 2009. Not only did beta blockers fall out of the evidence-based guideline over time for Step 1, but in 2009 they did not reappear until Step 4. Beta blockers were not mandated in Step 4 but served only as an option.

Looking at previous guidelines in our recent editorial series (see JNC 8, part 1; JNC 8, part 2; ASH summary), the only conspicuous absence was dihydropyridine calcium channel blockers (ASH summary) earlier in the steps. However, that addition to the guidelines has been more recent than 2009.

What did this multifaceted approach accomplish? Hypertension control increased from 43.6% of the cohort to an astounding 80.4%! This figure is even more impressive when we look at the national average. Those figures are a mediocre increase in control from 55.4% to 64.1%.

Yes, it is time for a New Year’s resolution. Because it appears that responsibility for better blood pressure management falls smack dab into the realm of primary care (not the JNC 8 committee), this large-scale hypertension control model looks like the real deal. It allows for blood pressure readings and evidence-based adjustments without multiple visits to an already overworked practitioner.

I am rededicating myself to quality in this arena and applying the Northern California model to my practice. Because one resolution should be enough for now, I will save my personal commitment to weight loss for consideration in 2015.

References:

1. Jaffe MG, Lee GA, Young JD, et al. Improved blood pressure control associated with a large-scale hypertension program. JAMA. 2013;310:699-705.