Getting Hypertension Under Control

This past week an article in The New England Journal Medicine highlighted a frustrating paradox in cardiovascular health — despite remarkable advancements in our ability to lower blood pressure there are more people today with uncontrolled hypertension than ever before. (1) The question for us here is why and how the answer relates to your health.

Doctors today, including myself, often take for granted that today we have the technology to achieve blood pressure control in almost anybody. But just 50 years ago, this wasn’t the case. Back then, the therapies for controlling blood pressure (which included surgery interestingly enough) were limited, and often despite best efforts, blood pressure remained difficult to control. Today, cases of uncontrolled hypertension are rarely due to the limits of therapeutics. Instead they relate to limitations in healthcare delivery.

Before delving into specifics, let’s make sure everyone is on the same page about the importance of blood pressure control. Hypertension is one of the major controllable risk factors for cardiovascular health. As we age, hypertension becomes more the rule than the exception. In fact, 90 percent of people who have normal blood pressure at age 55 or 65 can expect to develop hypertension at some point in their lifetimes. Risk of cardiovascular disease is intimately tied to blood pressure. For every 20/10 mmHg increase in blood pressure a person’s risk of cardiovascular disease doubles. Conversely, reducing blood pressure through antihypertensive medications lowers rates of cardiovascular disease. Placebo-controlled studies show that treating hypertension reduces the risk of stroke by 35 to 40 percent, the risk of heart attacks by 20 to 25 percent, and the risk of heart failure by over 50 percent. Few interventions in medicine can claim to be as effective at preventing chronic disease.

That brings us to the paradox, which is best described with three dismal statistics:

• 28% of Americans are unaware that they have high blood pressure.
• 39% of Americans with high blood pressure are not receiving any therapy.
• 65% of Americans do not have their blood control under control.*

Figure 1. Percent of Americans aware of their hypertension, being treated for their condition, and at control. (2)

What we need now are not new medications to treat blood pressure but new approaches to detecting and treating blood pressure. Here are some of the problems, as well as some of the solutions, as I see it:

1. Some people just are not getting their blood pressure checked. Despite the ubiquity of blood pressure measurement (e.g., clinic visits, home blood pressure cuffs, automated machines in public areas), some people have not had their blood pressure checked in years. In a recent blog post, I presented an older woman who despite working in a medical office had not had her blood pressure checked for over two decades (see: http://beyondapples.org/2009/05/28/putting-prevention-into-practice-part-2/). Some of these people do not have access to healthcare. But many simply choose not to go to the doctor. Part of the problem is that many people do not see a compelling reason to go to the doctor unless they are ”sick.” This practice flies in the face of preventive health, which seeks to prevent and detect diseases before they become clinically evident, yet is prevalent in our culture. Do not make this same mistake. The United States Preventive Services Task Force recommends routine blood pressure measurement in all adults ages 18 and older every 1 to 2 years. Blood pressure measurement should occur in the context of a physician office visit (where you can also benefit from other preventive services). Hypertension seldomly causes symptoms so even if you feel fine you could be walking around with elevated blood pressures that are putting you at risk for long-term health problems.

2. Some people are not being made aware of their elevated blood pressures. The ubiquity of blood pressure measurement in a way contributes to our lack of attention to it. Often people get their blood pressure checked in a specialty clinic or ER without being told what their blood pressure is and, as importantly, what this means to their health. Over the past few years, I’ve seen multiple patients with poorly controlled blood pressure in various health care settings, who were sent home without being told that their blood pressure was abnormal. Because many people’s primary access point to the healthcare system may be through a specialty clinic, it is imperative that providers and patients take every opportunity to increase awareness about high blood pressure. Blood pressure measurement is a medical test. As I discussed in a recent blog post we as providers have to make every effort to inform patients of their test results and we as patients must make every effort to obtain the results of our tests (see: http://beyondapples.org/2009/07/30/forgetting-to-break-bad-news/), and blood pressure measurement should be no different.

3. Some people are not taking appropriate action to address elevated blood pressures. Both health care providers and patients often downplay the seriousness of an elevated blood pressure reading. Many patients are told “your blood pressure is a little high” without a plan for followup or a more thorough explanation. While it is true that a single abnormal blood pressure reading is not sufficient to diagnose hypertension, and may be elevated in the setting of pain or acute medical illness, abnormal blood pressure measurements should always be followed up. Simply attributing an elevated blood pressure reading to back pain or a cold is not acceptable because it could just as easily result from undiagnosed chronic hypertension. In a system in which patients only seek medical attention during acute illnesses following up abnormal readings takes on even greater importance. Patients who have elevated blood pressure readings on multiple occasions present another opportunity. Simply telling patients “their blood pressure runs high” is not acceptable. A diagnosis of hypertension (systolic greater than 140 mmHg or diastolic greater than 120 mmHg) or prehypertension (blood pressure greater than 120/80mmHg) should be made and a treatment plan initiated. While it is acceptable to treat Stage I hypertension with lifestyle modifications — weight loss, sodium restriction, physical activity, moderation of alcohol consumption, dietary changes – patients with Stage I hypertension should undergo a time-limited trial to get their blood pressure under control, and if unsuccessful, be immediately started on oral antihypertensives. Finally, those being treated for hypertension with oral agents, who continue to have uncontrolled blood pressures, should have their medication regimen aggressively titrated until their blood pressure is controlled. The vast majority of patients with hypertension will require two or more medications to achieve target blood pressures; failure to start additional antihypertensive medications is a common reason for uncontrolled hypertension.

In brief, get your blood pressure checked regularly. Whenever someone measures your blood pressure, ask them what the reading is and what it means. If your blood pressure is abnormal (over 120 mmHg systolic or over 80 mmHg diastolic), talk to your doctor about it. If you have hypertension, find out what your target blood pressure is and partner with your doctor to make sure you are at goal.

Blood pressure control is a paradox to be sure, but with these simple steps, it need not apply to you.

- Shantanu Nundy, M.D.

*”Under control” is defined as below 140/90 mmHg. However, this statistic underestimates control because for those with comorbid diseases (e.g., diabetes, coronary heart disease, chronic kidney disease) goal blood pressure targets are even lower.

References:

(1) Chobanian, AV. The Hypertension Paradox — More Uncontrolled Disease Despite Improved Therapy. http://content.nejm.org/cgi/content/short/361/9/878

(2) From Reference 1, Figure 2.