Implementation of the New Hypertension Guidelines
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Implementation of the New Hypertension Guidelines

October 14, 2019


– Hello, I’m Karen Griffin, program chair of this year’s council
on hypertension meeting, and I’m here this morning
with Dr. Brent Egan from the Medical University
of South Carolina. Dr. Egan is this year’s recipient
of the Marvin Moser Award. Congratulations, well deserved, and you also gave a wonderful
lecture this morning in our plenary session talking about the implementation of the
new hypertension guidelines. So I was wondering if you
care to say a few words about the healthcare
burden of hypertension on the healthcare providers. – Yeah. I think that’s
a significant issue. Translating guidelines into
practices is a challenge, when that includes over
100 million individuals now that have hypertension, so
I think as many people know, we went from a definition of hypertension beginning at 140 over 90, to 130 over 80 for most adults. And that raise the number of hypertensives from about 72 million to 103 million. In addition to that, those with
blood pressure of 120 to 129 are also identified as being elevated, and suggestion that they
have home blood pressures and lifestyle interventions,
follow-up visits. So once we have those two groups together, it’s about 130 million individuals. And I think as I mentioned
in the presentation, particularly when it
comes to hypertension, most of those individuals have other chronic problems, chronic
health conditions. So in the context of a usual office visit, which may be 15, 20 minutes at most, taking care of these individuals and doing all that’s needed to
control blood pressure leads to more stringent targets, becomes quite challenging. – So that leads to my
next question, which is, what are some of the strategies you use to implement these new guidelines? – One of the things that we’ve used, we’ve been working with
American Medical Association, American Heart Association
for some time now, on implementing something called
target BP, or MAP, which is measure accurately, act
rapidly, partner with patients. So the guideline is a very good document, but I think what we
tried to do in terms of the implementation to
control blood pressure is distill that down to
three critical steps. So we know that the office
blood pressure measurement is often artificially high. There are things that we
can do in the office setting to get a more accurate reading,
and those were discussed. One thing we like to do is if that an initial office blood
pressure is elevated, to do something called
automated office blood pressure, where the patient is
put in their exam room, they have an automated device that takes three blood pressures with one-minute intervals between them. The staff need to be trained to be able to do something else with that time, so it requires a little practice redesign, come back, enter the mean of those three into the electronic record systems, which we then capture as
the automated pressure. The advantage of that
is that blood pressure correlates much better with
usual daytime blood pressures, than does our typical
office blood pressure. And so it’s something that can be done in the office setting, it’s something that we found that most
practices can do consistently, if they have a little training and house staff can reapportion,
reallocate the time, so that they’re not losing that interval while the pressures are being done. – Wonderful, wonderful. Can you say a few words about target BP? – Love to. So we’ve already talked a bit about trying to measure the
blood pressure accurately. We also try to work
with them on the intake, or the first blood pressure,
to try to make sure that the patient’s been seated properly, resting for a period of time, that we’re not talking to them, appropriate-sized cuff, arm support, back-supported, feet on the floor. So what we find there that if
you are an automated office, blood pressures are required if that first blood pressure is done well. So while the automated office,
blood pressure takes a time. if you’re in a clinic with
say a 65% control rate, it’s now only about a third of patients that need that automated office. And so it tends to be something
that’s fairly manageable. The next step is that if we confirm with the automated office the blood pressure is really high, we want the clinician
to take a critical look at the treatment regiment. What we find in about 85% of patients that are not controlled, is they’re not on three different
blood pressure medications at half-maximal doses. And so one of the first
thing we like to try to do is make sure we’re moving our
uncontrolled hypertensives toward three medications
at half-maximal doses. We particularly like an ACE or an ARB, a calcium channel blocker and a diuretic as part of those three, and again, working toward half-maximal doses. And using single-pill
combinations where possible, to decrease pill burden. So that’s the act rapidly part. Obviously, the lifestyle
components are important. We’ve used what we call a DASH for Good Health Southern style, where we take the DASH eating plan, and then tailor it to
meet more of the (mumbles) and the meal preparation habits of the people in that region. And so while ours have been
good for a Southern diet, you may want some for Westerner, Mid-Westerner, Northeastern. But I think adopting
DASH so that it fits into the kinds of foods that people
are more typically eating, but those have been
reformulated, if you will, to be consistent with
the DASH eating plan. So, number one. Number two, a lot of our
hypertensive patients are older, they may have some arthritis,
they tend to be heavy. There’s a number of things going on, and so we almost always have recommended moderate and high intensity
physical activity, which is very difficult for
a lot of our hypertensives. Now, if people enjoy that, and they’re capable of
doing that, I think, great, do the moderate and high intensity. But what studies have shown is we take completely sedentary people, and get them to do say an hour a day of low intensity physical activities, just move a little bit, do something, that has significant
benefits on blood pressure, and also reduces the risk
of developing diabetes. Those are a couple of practical things that we found very useful, and can engage the patient more actively and supporting the medical therapy with some lifestyle changes. – Great. Thank you very much. This is very informative,
and I look forward to hearing more about
your work in the future. – Terrific. This has all been fun. – Thank you.
– Thank you.

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