Primary Viewpoints Episode 3: The Challenges of Hypertension Management

September 30, 2020

In episode 3 of Primary Viewpoints, Brigham and Women's hypertension expert Naomi Deirdre Fisher, MD, discusses the challenges of hypertension management in primary care.

The following transcript has been edited for clarity and length.

Sydney Jennings: Hello and welcome to Primary Viewpoints from Patient Care Online, a monthly podcast that features informative conversations with health care experts, opinion leaders, and practicing physicians, about what impacts primary care medicine today.

My name is Sydney Jennings and I am the Associate Editor at Patient Care Online and in our third episode Grace Halsey, senior editor of Patient Care Online, talks with Naomi Deirdre Fisher, MD, director of the Hypertension Service and Hypertension Specialty Clinic at Brigham and Women's Hospital and associate professor of medicine at Harvard Medical School, about the challenges of hypertension management at the level of primary care.

Grace Halsey: It's been about 3 years since the American Heart Association/American College of Cardiology published its revised guideline on blood pressure management in adults that included the change in the cutoff for stage 1 hypertension going from 140/90 to 130/80. There was a good deal of discussion around that topic and I'm wondering if there still is controversy over the actual target? Or if clinicians are much more focused on simply getting their patients under control?

Dr Fisher: I think discussion is putting it mildly. You're right, when the guidelines were published in late 2017, they were met with a firestorm of challenges. They had been a long time in coming. For decades, hypertension was simply >140/90 and that's the way we all learned it and we all practiced it. Many doctors, and primary care physicians in particular, were really reluctant to look at this new goal of 130/80 and to accept it; both for diagnosis of hypertension and for treatment goal. But in the time that has passed, I do sense a general acceptance. I think there's been a widening understanding that there is increased cardiovascular risk along a continuum and that nothing magically happens at that cutoff point of 140/90.

Grace Halsey: I've read over the years, too, that some of the thought behind lowering the cut point was that, as you said, the disease happens along the continuum, and there are already changes happening at lower levels of elevated blood pressure. There was also, I believe, concern that this might lead to hundreds of thousands of Americans being put on blood pressure medicine. Also, one of the authors of the guidelines said, No, we really hope it will be a yellow light, and that people - physicians, patients - will start to take lifestyle changes a little bit more seriously.

Dr Fisher: For the vast majority of patients who fall into the newly created category of stage 1 hypertension - that is a systolic pressure between 130-140 - we're going to be recommending lifestyle changes and not medications.

Grace Halsey: From your vantage point, how are primary care physicians doing overall in 2020 with managing hypertension? I know some things have gotten better over time, but where are the areas that specialists see sticking points or areas for improvement?

Dr Fisher: Improvement has come in the area of increased awareness. For a long time, hypertension kind of sat in the background as a chronic disease and we kind of skipped over it and we got to the reason that a patient was in your office that day, which could be fever, chest pain, or something much more exciting. There is definitely a widening understanding and a widening awareness that it has to be brought to the forefront. The areas that need improvement are really to go further. There is a long, long history of what we call "therapeutic inertia" on the part of us; we doctors not taking care of hypertension with enough of a focus. And there's also of course, great resistance on the part of patients. Patients don't take medications for all sorts of reasons. They can be expensive, there can be side effects that are real or perceived. They just don't understand why they need to take medication for high blood pressure, it doesn't cause any symptoms. I think our job would be so much easier if hypertension caused pain. Of course, the therapy really starts with lifestyle modifications and those are so very, very hard. We do know that now there's an ASCVD risk calculator built into the treatment and primary care doctors have been really good and quick to pick that up because they have experienced in the statin prescribing world to do that. But there's a lot of challenges. In fact, most times I would say we have to treat patients with more than one antihypertensive medication to get them under control. So there are just a lot of pieces, a lot of stumbling blocks to get over.

Grace Halsey: And I think if a patient is diagnosed with hypertension, it is highly likely that is not the only thing metabolically going on.

Dr Fisher: When we add our hypertension pills, we're adding it to a long list of pills they are already taking.

Grace Halsey: I was interested in the American Heart Association, American Medical Association, Target:BP program to help practices improve their blood pressure control rates. There is a lot of focus on the very basic core competency of accurate blood pressure measurement, whether that's in the office or having patients do it at home. Is there really a real problem with accurate blood pressure measurement?

Dr Fisher: Yes, without accurate, proper blood pressure measurement, we can't possibly provide good care for our patients. For better or worse, the blood pressure reading is the outcome that we're measuring and that we’re guiding all of our therapy by. So, I think the issue of measurement has a lot of facets. We understand pretty well “why”—why we have to measure. Let’s talk about where we have to measure it. And then I'd like to talk about "how" and then I'd like to talk about "when."

But the where—for decades patients come into the doctor's office, they get their blood pressure measured—160 over 105. The doctor says you have high blood pressure and starts a medicine. They come back in 3 months, their blood pressure still high. The doctor may say, why don't you take a few more months to try and lose weight; they come back again, may still be high. That's kind of the way it's been working. We understand well now that it's blood pressures out-of-office that are much more important to capture. These are the blood pressures that really predict target organ damage, risk of having a heart attack or a stroke, or going into heart failure, or developing blindness or kidney disease or cognitive decline. There are so many ill effects of high blood pressure. And many studies have shown us that it's the out-of-office blood pressures that really matter. So, we have to change our focus from in-office blood pressures to out-of-office and home blood pressures. And they can be done with home blood pressure monitoring or with ambulatory 24-hour blood pressure monitoring. There are some new techniques in the office that also help to eliminate the white coat effect. That's a really big deal, for example, too.

So before I leave the “when,” do you have any comments on that? And then we can go on to “how,” where we get measurement mistakes.

Grace Halsey: The approaches seems very simple to us lay people who just write about this for a living, you go in, you get the patient to sit still, put their feet on the ground, you don't talk to them. But I guess that in the space of a day, with 15 people in the waiting room, doing it [measuring BP] quickly and accurately at the same time, is a challenge.

Dr Fisher: Right, right. So we can talk about the technique now about measuring blood pressure. And you're right, it's a big challenge. And I think whether you're measuring a blood pressure at home, or whether you're measuring it in the office, often it's a medical assistant who does it, it really has to be done correctly.

I always cite Murphy's law when I talk about measuring blood pressure, because anything that can go wrong will. Patients can have just had a cigarette or a cup of coffee within a half hour before getting their blood pressure. Maybe they just ran up the stairs. They maybe have to go to the bathroom, it's really good to have an empty bladder before blood pressure is measured. And very often they're brought in from the waiting room into the MA’s little suite to have their blood pressure measured, and they're sent into the PCP office. But they ideally should be seated for several minutes and come to a full rest. There's generally not time for that in an office flow. But of course, it can happen at home. So patients should be seated resting feet flat on the floor. It's really important if the arm is at the level of the heart, and not too low, not too high. It's very important that the cuff is a reliable one. This is not a case where a generic is a good product necessarily. We need something that's been validated by biomedical engineers. The cuff has to fit well--it can't be too tight and it can't be too loose. And we can't talk during the blood pressure measurements because all of these things affect what the blood pressure is. So yes, you're right.

And then the last facet I want to talk about is “when” to measure blood pressures because when patients start measuring their blood pressures at home, sometimes we doctors receive pages and pages of what looked like random blood pressure's faxed in to us. We don't know what to make of them or how to make any decisions. So there is actually a proper algorithm that's been developed by the American Heart Association. After a patient has been titrated, a drug dose has been changed, we recommend that there, they wait to get into steady state for a week or two, and then measure their blood pressure according to a very specific algorithm, measuring it twice a day, in the morning, and in the evening, always before their pills. And that way we can calculate a weekly average.

Grace Halsey: How are patients doing with that on average?

Dr Fisher: I would say that almost all of my patients have a home blood pressure cuff and use a home blood pressure cuff because without that, I'm really hamstrung. And with good education, they do well, it's really the onus is on us as physicians to explain the importance to patients. But this is this is a team approach, we really have to get patients engaged and involved, understand why they have to measure their blood pressure and how to do it well.

Grace Halsey: I did a small slideshow, I think I might have gotten the information also from Target:BP a while back, and it suggested the number of millimeters off the measurement could be for various reasons—the patient has legs crossed, patient has his arms crossed, you're talking. It was pretty dramatic if I remember correctly.

Dr Fisher: Yes, there is the chart from American Heart, I know the one to which you are referring. It’s a little bit overdramatized because—it’s 10 points plus 10 points plus 10 points. It looks like your blood pressure could be overshot by 100. That's not always so additive, but it's referring to particular studies which have shown how dramatic each of these offenses in technique can be.

Grace Halsey: I can't leave out a question about the impact of COVID-19 on management of hypertension, because so many people, especially people with chronic conditions, are so concerned that they are not going in for maintenance for regular routine follow-up. Has hypertension suffered a similar fate to diabetes and COPD?

Dr Fisher: The COVID-19 pandemic has changed the way we practice medicine and probably permanently. In most cases, it's been a disaster. Patients aren’t coming in for cancer screenings, for stress tests, for vaccinations. But I think for this particular diagnosis of hypertension there may actually be a benefit.

We are transitioning more to home blood pressure monitoring because we have to, right? It's not reasonable for a patient to come into the office to have a blood pressure measured, not only because of the pandemic, but because as we've already explained, I care a lot more about what their blood pressure is at home anyway. So, it's the right thing to do. Home blood pressure monitoring is more appropriate. It's more cost effective. It's safer, and it's giving us better data. So, for us in hypertension, this is providing us a tremendous opportunity to have our remote monitoring programs grow.

Grace Halsey: That answered the next question which was whether this [the pandemic] is going to lead us into a lot more telemedicine in general. It certainly is a really huge bump in education for the patient with hypertension at home.

I was interested that the other day you said you were very busy in clinic and that sounded hopeful. Are you seeing patients on a regular basis?

Dr Fisher: I'm seeing patients in clinic but it's remote clinic. I direct hypertension clinic at the Brigham and Women's Hospital, so my patients all have high blood pressure. But unless there's a specific need for me to examine them, we're conducting business over the computer and spend a lot of time evaluating their blood pressures, their symptoms, their history, titrating the medications that way. But yes, I'm very gratified that business is busy. Patients are understanding that they can really get this part of their care without any pause during the pandemic.

Grace Halsey: Is there anything else you might want to say to primary care physicians about hypertension management and preventive cardiology?

Dr Fisher: Hypertension has now become the number one global risk factor for disease. I think it's finally capturing the interest that it deserves. It's a global problem, a global problem of really immense significance that's affecting 1 in 2 adults in America. So if you don't have hypertension, surely your friend does.

Treating hypertension is doable, but it's tough. It really takes a focus. It takes an understanding that this is an engagement of the patient and the doctor together. It's teamwork. We have to take into consideration very innovative ways to treat hypertension. We have to encourage lifestyle modifications because obesity needs to be named as a single outstanding, growing epidemic on its own that's really responsible for a large part of it. There are a lot of issues that make it challenging, but I would say the hope is that if we align our resources, we really can make a huge, huge dent in cardiovascular risk and help our patients significantly.

Grace Halsey: Great. Thank you so much, Dr. Fisher.

Dr Fisher: Thank you. It's been a pleasure.