Lower BP Targets: It's Not All Up to Physicians


  • by Senior Associate Editor, MedPage Today
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    Medpage Today

The reduction of hypertension thresholds and treatment targets to 130/80 mm Hg in the newly-released American College of Cardiology/American Heart Association guidelines set a challenge for blood pressure control, raising the prevalence of hypertension to roughly 46% of adults and increasing the need for lifestyle counseling and medication management.

The guidelines mention the role of team care and have the endorsement of a range of other professional societies, including the American Academy of Physician Assistants, American Pharmacists Association, and the Preventive Cardiovascular Nurses Association.

This broad spectrum of providers will be part of the solution, as Lynne Braun, NP, PhD, told MedPage Today in this exclusive interview. Braun is a nurse practitioner in cardiology and professor in the College of Nursing and the College of Medicine at Rush University in Chicago.

A lightly-edited transcript of that conversation follows.

For patients in your clinic, what do you think is going to be the biggest challenge to applying the guidelines?

The biggest challenge to applying the guideline, although I fully agree with the new blood pressure target, is that we can't continue to have only about a 54% control rate of high blood pressure. Our challenge as practitioners will be to discuss with our patient what the new target level is, ensure that they are adherent to both lifestyle changes as well as medication management, and to help them to understand the importance of that.

Some patients are going to need more medication to get there, or they're going to need to really implement more lifestyle changes in terms of diet and physical activity, and perhaps reducing alcohol consumption, if that's an issue, and weight loss. We're really going to have to work all the harder with our patients to get them to that target level and to educate them why that's important.

Some patients still have kind of an old belief of, "Well, that's just my blood pressure. That's good for me," they tell me. I have to talk to them about the relationship between really any elevated blood pressure and the potential for having more heart attack, strokes, and deaths. So really talking to them about high blood pressure as a risk factor and what we know about lowering blood pressure to target.

Based on the previous targets, there was a certain amount of stroke reduction, heart attack reduction, and heart failure reduction. If you just take heart failure, we could say to our patients that people who have their blood pressure under good control have 50% less heart failure. I mean, that's huge. That's huge. It's not quite as dramatic in terms of heart attacks and strokes, but it's close. It's anywhere from 20% to some 30%.

The Preventive Cardiovascular Nurses Association and eight other groups that are part of the care team have signed off on the guidelines, and there are some mentions in the guidelines with regard to team care. So how important is getting all of these groups in the practice on the same page?

It's going to be critically important. It will start with the medical assistant who puts the patient in a room and takes blood pressures. There's an emphasis in the guideline about proper blood pressure measurement, both in the office and outside of the office -- in the home setting or anywhere outside of the office. Those individuals have to be educated in the first place about proper blood pressure measurement and then competencies have to be evaluated periodically. In my office, in particular, a lot of what the nurses do is communicate remotely with patients, and they do a lot of telephone problem solving with patients.

They are going to have to be well aware of what the new guidelines are as well. I certainly plan to have a series of in-services for the medical assistant and the nursing staff in the office so that they are very clear in what the new guidelines say and can articulate this to their patients as they discuss it with them or help to evaluate their blood pressure in the office setting. Team-based care is incredibly important. We're all going to have to be on the same page to get our patients to target levels, to end organ damage and events.

The performance standards that are set by many organizations are very important in driving the control rates. How will that work for your organization? Do you have to wait for things to happen at a federal or payer level?

Blood pressure control is evaluated right now with the previous targets, and we have a dashboard that we can look at that's part of our electronic medical record system to see what our blood pressure control rates are. That will all have to be reset, and that is part of our own performance measures that we are, to some degree, evaluated on.

That being said, though, I'd like to circle back to medication adherence because my performance measure, my control rate for my hypertensive patients, depends on them engaging in the lifestyle changes that I counsel them on and taking the medications that I may prescribe. It really requires the partnership between the provider and the patient and a lot of education, a lot of back and forth. The patient [has to be] feeling comfortable that if they're having an issue with a medication or need to talk to me, that they can get a hold of me, and we can handle that right away as opposed to waiting until the next clinic visit and me, at that point, finding out that they're having issues with their medication, and maybe they don't take it everyday or whatever it might be.

Their ability to self-care, if you will, which means taking their medication, monitoring their blood pressure at home, I know that's a significant component of the guideline, and it's something I've always done. I've always asked my patients, if they can, to purchase a blood pressure machine, bring it in [during] their next visit so that I know that they're taking their blood pressure properly and that I can evaluate how well it's working against mine, against my measurement of blood pressure. I've always done that, but I know that that's part in parcel with this guideline.

That's all part of self-care. It's taking good care of themselves, taking their medication everyday, if it's prescribed, engaging in the appropriate lifestyle changes, measuring their blood pressure, and then follow-up visits.