Thursday, May 09, 2019

by DUSTYN WILLIAMS, MD

Hypertension, or high blood pressure, is a leading cause of heart disease and stroke that has escalated to alarming rates in recent years, affecting nearly 1 in 3 adults in the U.S. In an attempt to reduce its prevalence, the Eighth Joint National Committee (JNC-8) released a set of hypertension management guidelines. However, various concerns arose regarding the recommendations and as a result, the American College of Cardiology (ACC) and the American Heart Association (AHA), along with nine additional specialty organizations, published an updated hypertension guideline in November 2017.

The ACC/AHA updates were driven by the JNC-8 report’s narrow scope of recommended treatments, which specifically focused on hypertensive patients without comorbidities. Since hypertensive patients frequently suffer from comorbid conditions, the guidelines led many to receive inappropriate or inadequate medications. In addition to the lack of focus on comorbid conditions, JNC-8 also dismissed beta blockers, which are necessary for isolated hypertension and embraced a “go-slow” treatment approach.

The newly released recommendations account for:

• Adjusting hypertension ranges and the initiation of therapy
• Setting ambulatory blood pressure monitoring as the gold standard for diagnosis and management decisions
• Prioritizing the treatment of comorbidities, such as diabetes, in a timely manner
• Using calcium channel blockers, diuretics, and ace-inhibitors as first-line agents after comorbidities are treated, or if none exist
• Treating patients with multiple medications as necessary if comorbidities do not exist 

Major changes in guidelines

Lowering hypertension-related blood pressure ranges was a significant adjustment in the ACC/AHA release, which will subsequently increase the number of patients classified with hypertension. Stage one hypertension systolic rates originally ranged from 140-159 and diastolic rates from 90-99, and are now set at 130 systolic and 80 diastolic. Stage two hypertension was altered from 160-179 systolic and 100-109 diastolic to 140 systolic and 90 diastolic.

While these new guidelines will lead to an increase in the number of stage one and two diagnoses, the change makes logical sense from a patient safety perspective. As hypertension exacerbates, it becomes more challenging to control. Thus, lowering the threshold for hypertension compels physicians to intervene earlier, ultimately slowing progression and resulting in fewer adverse events.

By lowering ranges, lifestyle interventions such as weight loss and adoption of a healthier nutrient intake can begin earlier in treatment plans. Not only does this help to eliminate the progression of hypertension, once diagnosed, it also facilitates increased patient engagement much sooner.

The decision to establish more lenient blood pressure thresholds was made in response to adverse patient events following aggressive treatment protocols — patients passing out from too much medication, for example. The commission failed to account for patients who benefit from higher blood pressures at rest, such as those who become hypotensive on dialysis or those with autonomic dysfunction that causes orthostatic hypotension upon standing. Further, JNC-8 assumed that hypertension exists on its own, thereby failing to recognize comorbid conditions that often more accurately direct anti-hypertensive treatment.

The recommendations also assumed that blood pressure monitoring could only be completed in the clinic, which left patients unmonitored and without critical support between clinic visits. Conversely, the ACC/AHA now strongly recommends ambulatory blood pressure monitoring, which can occur outside of the clinic if patients are supported with the appropriate tools, and tailoring the anti-hypertensive regimen to a patient’s comorbid conditions. While this is more complicated than the JNC-8 recommendations, the ACC/AHA guidelines are more appropriate, more accurate, and easily achievable with implementation of new technologies.

Leveraging technology to monitor blood pressure

The ACC/AHA recommends that patients with severe hypertension receive timely evaluation and drug treatment supported by patient monitoring and dose adjustments. Although it’s possible to remotely monitor hypertension and hypertension-related disorders, this process would require a tool that enables self-monitoring of blood pressure multiple times throughout the day. By allowing patients to self-monitor, they can effectively associate their symptoms or lack thereof with their blood pressure.

Telemedicine solutions offer promise in helping hypertensive patients record their blood pressure appropriately. Easily-understandable reminders can ensure that patients take the appropriate dose of medications at the prescribed time. As patients record data, providers must have the ability to aggregate and analyze the data and make titrations as needed. Small frequent titrations in blood pressure medications will allow for patients to rapidly reach treatment goals and prevent the occurrence of adverse events.

By centralizing communications, hypertension specialists can choose an optimal anti-hypertensive regimen for each patient based on their existing comorbid conditions. For example, a provider may prescribe beta blockers and ace-inhibitors for a patient with systolic heart failure, while avoiding beta-blockers as front-line agents and ace-inhibitors altogether for a patient with chronic kidney disease stage IV.

These solutions will also allow for individualization to occur in treatment. For instance, a telemedicine application can remind dialysis patients of the altered medication treatment plan on the days they receive treatment for their condition. If platforms adopt predefined hypertension regimens based on comorbid conditions, then provider organizations can achieve facility-wide standardization in hypertension treatments. Further, titration capabilities along with ambulatory blood pressure monitoring can provide patients with a sophisticated reorganization of blood pressure medications throughout the day, optimizing blood pressure rates and reducing adverse events, while allowing patients to manage their condition from the comfort of their own home.

As the ACC/AHA hypertensive guidelines align with the shift towards quality, health care organizations participating in quality programs may require more stringent blood pressure goals. To achieve these goals and ensure patient safety, it is essential that technology is leveraged to allow for tight control, real-time feedback and medication adjustments between clinic visits.

DUSTYN WILLIAMS, MD

Dr. Williams is the Co-founder and lead educator at OnlineMedEd, Co-founder at DoseDr, Clerkship Director Tulane Internal Medicine, LEAD