In honor of High Blood Pressure Education Month, I’ve invited Susan Steigerwalt, MD, FACP, of St. Claire Specialty Physicians, P.C., to write a guest blog post on the topic of hypertension. If you’d like to get involved in the education process, you can join DaVita and the kidney care Twitter community as they host a Tweet Chat in honor of World Hypertension Day, which is May 17th. This online event takes place on Thursday, May 16, at 6 p.m. MT. For more information, follow the #kidneyaware hashtag.
May is National High Blood Pressure Education Month. This is a time to reflect and reenergize in the struggle to improve blood-pressure control—yours and your patients’—and review tools and resources for patients and providers. While we are still awaiting the eighth version of Managing Blood Pressure in Adults: Report from the Joint National Committee (JNC 8)—due out any month—there are important initiatives, updates and technologies that will help with improved control of blood pressure. Inadequately addressed lifestyle issues continue to get in the way of achieving control—and some of this low-hanging fruit needs to be picked!
Let’s talk about resources and initiatives first. The Centers for Disease Control and Prevention (CDC) website this month features hypertension. It has a simple explanation of hypertension and control tips, with links for patients and providers. The Million Hearts initiative from the US Department of Health and Human Services (HHS) attempts to prevent one million heart attacks and strokes over five years and includes a Facebook page and resources for healthcare providers, including pharmacists.
The HHS and CDC program “Team Up. Pressure Down.” presents simple tips for providers to improve patient adherence to therapy. This includes ways to engage patients in exposing barriers to taking medication regularly, and reminds providers about simplifying regimens (once daily) as well as assisting patients to enable them to measure blood pressure outside of the doctor’s office. Multiple studies have shown that home blood-pressure measurement with feedback improves control. Every office needs a home blood-pressure-measurement program, and every patient in whom you are tracking blood pressure needs to measure at home. Check out the aforementioned websites for valuable tools, whether you are a provider or a patient!
Our sedentary lifestyles combined with our sugar-laden eating habits spells disaster for our waistlines and our blood-pressure numbers. Researchers are in the process of identifying “weight sensitivity” genes that will determine those who benefit most from weight reduction, but in the meantime abundant data shows that even 30 minutes of brisk walking five times per week will improve control of blood pressure—even in resistant hypertensives—and that obesity is responsible for about 60 percent of the increase in high-blood-pressure rates in this country over the last 15 years.
Sleep—that is, not getting enough of it—sabotages both weight loss and blood-pressure control. Sleeping fewer than six hours per night is associated with weight gain, stroke and other cardiovascular events, even in the absence of known hypertension. Thirty percent of working adults get fewer than six hours of sleep per night. Sleep-disordered breathing also contributes to uncontrolled high blood pressure, stroke and atrial fibrillation. Screening for sleep disorders and insufficiency using tools such as the Epworth Sleepiness Scale takes about one minute.
The Dietary Approaches to Stop Hypertension (DASH) diet is more than a flash in the pan! Adherence to DASH (eating four or five servings of fruits and vegetables daily, whole grains, low-fat dairy, limited sweets and moderate meat and sodium) is associated with improved blood-pressure control and decreased risk of recurrent kidney stones. DASH is being studied in patients with CKD for improvement of acidosis, blood-pressure control and CKD progression.
What about updates on evaluation and treatment of hypertension?
Control levels have been simplified: Most patients, including diabetics, need a blood pressure of less than 140/90 when taken in a doctor’s office. Exceptions include the elderly (people >80 years of age, whose goal is 150 mmHg systolic in-office) and individuals with more than 1 gram of protein in the urine over 24 hours, or a history of stroke (for these groups, lower blood pressure is indicated—less than 130/80 mmHg in-clinic).
Medication administration: Taking at least one BP med at night improves outcomes in middle-aged hypertensives, including diabetics MAPEC study1; and a combination of ACE inhibitors and calcium-channel blockers (ACEI/CCB) is superior to ACE inhibitors and hydrochlorothiazide (ACEI/HCTZ) ACCOMPLISH2. Control rates improve with the initial use of combination medications, even in Stage 1 hypertension.
Resistant hypertension: Use of 24-hour ambulatory blood-pressure monitoring (ABPM) shows that up to one-third of those who exhibit resistant hypertension in-office have controlled blood pressure out-of-office. This available technology is woefully underused, in part due to resistance from insurers. ABPM also identifies patients with “white coat” hypertension (higher in-office than out-of-office measurements, associated with moderate increased cardiovascular risk) and masked hypertension (BP higher out-of-office than in-office, which means increased risk for the patient and is an area of intensive current study). For individuals with true treatment-resistant hypertension, a thorough search for secondary causes is indicated; if none are found, renal denervation offers promise as an additional tool to improve control.
I hope you will join me in celebrating National High Blood Pressure Education Month by improving your blood pressure and that of those around you!
By Susan Steigerwalt
Susan Steigerwalt, MD, FACP, is director of the Resistant Hypertension Clinic at St. Claire Specialty Physicians, P.C., and at the Providence Hospital Heart Institute. She’s a practicing nephrologist and is also a site principal investigator for the Symplicity trial of renal catheter denervation in resistant hypertension.
- Hermida, et al. Chronobiology International 2010. September 27(8): 1629-1651
- Jamerson K et al : NEJM 2008 (359): 2417-2428
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