‘Drastic changes’ needed to combat rising hypertension rates, worsening control
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It is estimated that one in two U.S. adults has hypertension, considered the most prevalent CV condition and a potent risk factor for MI, HF, stroke and death. Yet, BP control continues to worsen, and the disease burden remains substantial.
Despite the well-established risks of hypertension and benefits of antihypertensive treatment, the age-adjusted percentage of people with hypertension whose systolic and diastolic BP was controlled to less than 140/90 mm Hg was 53.8% in 2013-2014 and 43.7% in 2017-2018, according to an analysis of National Health and Nutrition Examination Survey data published in Hypertension in 2021. Average systolic BP rose across all age groups during the study period. Since that time, COVID-19-related shutdowns abruptly cut off many patients’ access to routine care and treatment, leading to worsening BP control.
“Hypertension control had already started to diminish prior to the pandemic,” Cardiology Today Editorial Board Member Keith C. Ferdinand, MD, FACC, FAHA, FASPC, FNLA, professor of medicine in the John W. Deming department of medicine at Tulane University School of Medicine, said in an interview. “Since the NHANES analysis, newer analyses from a combination of commercial, Medicare and Medicaid registries have concluded and confirmed a diminished control of BP, which actually worsened with the pandemic. Using the BP cutoff of 130/80 mm Hg, we are probably down in the teens or the lower 20s for percentage of people with BP controlled.”
A pooled cohort study of patients followed at three large U.S. health care systems published in December found a substantial decrease in the monitoring of BP, coinciding with an increase in both systolic and diastolic BP, as well as a decrease in the proportion of BP control during the COVID-19 pandemic period. Findings persisted even after accounting for differences in patient sociodemographic and clinical characteristics.
“Hypertension control rates in the U.S. are depressing and headed in the wrong direction,” Naomi D.L. Fisher, MD, director of hypertension services and the hypertension specialty clinic at Brigham and Women’s Hospital, told Cardiology Today. “The prevalence of hypertension is rising while control rates are falling. At the same time, we know we must reach tighter targets to prevent heart attacks and strokes. Drastic changes are needed.”
To change course, experts have proposed that a fundamentally different way of caring for people with hypertension is needed — one that puts hypertension at the forefront. New models must embrace multidisciplinary, team-based care that includes patient self-management education and remote monitoring, with coaching and support designed for a chronic condition that is managed long term.
“BP is the most prevalent risk factor, not only for CVD but for a host of other diseases. Yet, we do not handle it well,” Carl J. Pepine, MD, MACC, Chief Medical Editor of Cardiology Today and Eminent Scholar Emeritus and professor in the division of cardiovascular medicine at University of Florida, Gainesville, said in an interview. “BP control is not as attractive as some interventional procedure for obstructive arteries in the coronaries or peripheral vasculature. It is not as attractive as an [electrophysiology] procedure, with ablations and pacing. But it turns out to be the most important risk factor we can modify.”
Complicated factors at play
Hypertension is complex, with genetic and environmental contributions playing a role in disease development, Fisher said.
“Without a doubt, environmental risk factors have played the biggest role,” Fisher said. “Those include an unhealthy diet and the obesity epidemic, which contributes directly to a large rise in BP. There are specific dietary factors that we know contribute to high BP, and they include excess dietary sodium and alcohol intake, as well as low dietary potassium. Our modern lifestyle, where we are eating out more and cooking less, where there are more constraints on our time, is a recipe for poor cardiovascular health.”
Certain populations are at greater risk for poorer outcomes and lower hypertension control, especially those with constrained resources, such as people with limited access to health care, racial and ethnic minority groups, and pregnant and postpartum women. Social determinants of health, defined as where people are born, live, work and play, have led to Black adults in the U.S. having the highest rates of hypertension in the world, according to Willie M. Abel, PhD, RN, FAHA, associate professor at the School of Nursing at the University of North Carolina at Charlotte.
In a cross-sectional study published in February in JAMA Network Open, Black adults with hypertension living in Baltimore who reported better perceived neighborhood health were more likely to practice hypertension self-care, particularly those with greater in-home food availability.
“A lot of things have contributed to the highway of hypertension,” Abel told Cardiology Today. “We have to look at our history. Discrimination and racism increase psychological distress and turns on the biological stress response. Studies have shown that prolonged chronic stress causes continued sympathetic nervous system activation, which can result in hypertension.”
‘Remote management is where we are headed’
Most hypertension is diagnosed and treated based on BP measurements taken in a doctor’s office, even though the U.S. Preventive Services Task Force and the American Heart Association recommend BP measurements be taken outside of the clinical setting to confirm the diagnosis before starting treatment.
The typical model of a patient getting a BP reading in clinic is broken, according to Pepine, who added that ambulatory and home BP monitoring should be used much more widely.
“In my own personal experience receiving noncardiac care, my BP is measured while standing on a scale in the hallway of a busy clinic, with a pulse [oximeter] on my finger and a BP cuff on the other arm,” Pepine said in an interview. “I suspect that it is not much different throughout our country. The Europeans are far ahead of us. They have, in the U.K. in particular, embraced ambulatory BP monitoring and include that as part of their care.”
One drawback is that many health insurance plans do not reimburse for out-of-office monitoring, Pepine said.
During the pandemic, BP visits and BP measurements dropped by about half and rates of hypertension rose, Fisher said. These data should provide another incentive to work toward remote BP management programs, Fisher said, including innovative programs that automatically transmit home BPs and offer algorithmic-driven care.
“Out-of-office BPs have become necessary,” Fisher said. “They are better at predicting CV outcomes than office BPs. If these aren’t possible, at least we could try offering no-cost visits for BP checks, or free parking for these visits. But remote management is where we are headed.”
Optimizing treatment adherence
U.S. pharmacy claims data suggest an antihypertensive medicine nonadherence rate of 31%, Robert M. Carey, MD, MACP, professor of medicine and dean emeritus at University of Virginia School of Medicine in Charlottesville, and colleagues wrote in a review in JAMA published in November. However, self-reporting alone has limited accuracy compared with more objective adherence measures.
“Even before the pandemic, we knew that about 50% of patients over 1 to 2 years no longer take their BP medications as prescribed,” Ferdinand said. “What we are starting to discover is that shared decision-making is the best pathway to control BP.”
Adherence support, consisting of interventions such as patient coaching support and automated reminders, can be delivered to patients who may have limited motivation to treat a chronic, asymptomatic condition, according to Carey and colleagues.
In an NIH-sponsored pilot study conducted at Tulane University, Ferdinand and colleagues enrolled 36 patients with hypertension (64% women; 89% Black; 74% with diabetes). Participants were given a wireless BP monitor that automatically tracked and recorded readings via Bluetooth to a cloud-based mobile app (Sphygmo) and received daily text messages about medication compliance from a software system (Mosio).
At 8 weeks, The Krousel-Wood Medication Adherence Scale score improved from 2.19 at baseline to 1.58 (P = .0001). Systolic BP declined by a mean of 10.5 mm Hg at 2 months (P = .0027); diastolic BP did not change (P = .1337).
There were no changes to pharmacotherapy and no doctor’s visits during the study, Ferdinand said.
“What this shows is if patients buy into the need to control their BP and use valid devices communicating even just electronically with their clinician, that will increase adherence and increase BP control,” Ferdinand said.
‘Simple things can work’
Data have shown that self-management interventions can significantly decrease BP and increase self-efficacy and medication adherence; however, structured support is often needed for such interventions to be successful. With funding from the NHLBI, Abel and colleagues conducted a pilot study to test the effectiveness of an established chronic disease self-management program and interactive technology-enhanced coaching for Black women with uncontrolled hypertension.
By the third month, participants’ BP decreased and stayed below 130/80 mm Hg for the duration of the 9-month study with improved medication adherence scores, Abel said. The findings were observed in both the treatment and the control group.
Abel credited the chronic disease self-management program as a likely driver behind the success in both groups.
“It helped those with hypertension to learn how to take care of themselves,” Abel said. “That is very important. During one of the sessions, one of the women asked us, ‘Why have our physicians not told us how to do these things?’ That is a problem. The main things are eating right, weight management, physical activity, strategies to deal with stress and depression. Doing simple things can work.”
New drugs, novel treatments
Despite discouraging news about poor and stagnant hypertension control rates, there are encouraging developments from industry, with some device-based treatments for hypertension reaching maturity. These are encouraging, Pepine said, because many trials document nonadherence to BP-lowering medications in 30% or more of cases.
“There is renewed interest in renal denervation, as summarized in the 2023 ESC Hypertension Council Consensus Statement,” Pepine said. “It is a sound approach to be able to denervate using the sympathetic nervous system that travels in the arteries of the kidney. There have been a number of high-quality studies documenting BP lowering over 24 hours. Some have shown effects are sustained for up to 3 years. There are approaches to do that now that do not require a catheter (eg, adapting lithotripsy techniques or focused ultrasound).”
There are also new treatments in the pipeline for resistant hypertension. In a phase 2 trial, baxdrostat (CinCor Pharma/AstraZeneca), an aldosterone synthase inhibitor, yielded substantial dose-related decreases in BP in patients with treatment-resistant hypertension, according to results from the phase 2 BrigHtn trial presented at AHA in November; another phase 2 trial of baxdrostat, HALO, missed its primary endpoint, but investigators believe that was due to nonadherence during the study, and AstraZeneca has announced plans to proceed with a phase 3 trial. In the phase 3 PRECISION randomized clinical trial, aprocitentan (Idorsia/Janssen), a novel, oral, dual endothelin-receptor antagonist, over 48 weeks lowered BP in people with treatment-resistant hypertension prescribed multiple antihypertensive drugs.
‘Make the patient an active partner’
Even with new classes of medications in the pipeline and the promise of new treatments like renal denervation, the most important tool for hypertension control remains shared decision-making, Ferdinand said. People with hypertension must be informed about the need to control their BP, and often, more than one therapy is needed, he said.
“BP medicines are not bad. They’re good,” Ferdinand said. “Placebo-controlled trials, mainly from the 1960s, showed that at 2 years, half of patients in the placebo groups either had an MI, stroke or had died. In the U.S., ambient sodium is so high and so difficult to control that most patients middle-aged or older need two or more therapies. Combination therapy and the appropriate use of medicines is the best way to control BP, along with lifestyle modifications.”
Providers should also provide people with hypertension with a home BP monitor to get a better sense of the ambulatory BP throughout the day, Abel said.
“Just like we provide people with diabetes with a blood glucose monitor, people with hypertension need to have home BP devices,” Abel said. “With the technology available today, patients can send their BP measurements to their physician in real time. The goal is to make the patient an active partner in their health care and more accountable for managing their BP with lifestyle changes.”
Engagement and education for both patients and providers are lacking and remain a large need, Fisher said. But the biggest takeaway for clinicians is that hypertension cannot be managed by a single provider.
“Hypertension is too big of a problem for clinicians to manage alone,” Fisher said. “We do not necessarily do the best job of it anyway. Programs that involve pharmacists, nurse practitioners and nurses have already proved successful. Now, we have demonstrated the success of programs that involve community health workers and patient navigators, to help with hypertension care.
“As the scope of the problem enlarges, the number of different levels of staff and professionals we use to tackle it has to grow as well,” Fisher said. “The traditional model of office care for hypertension is failing us. We must expand our ability to monitor BP and treat hypertension remotely.”
- References:
- Abel WM, et al. J Clin Hypertens. 2023; doi:10.1111/jch.14617.
- Carey RM, et al. JAMA. 2022;doi:10.1001/jama.2022.19590.
- Dinakis E, et al. Hypertension. 2022;doi:10. 1161/HYPERTENSIONAHA.122.19350.
- Egan BM, et al. Hypertension. 2021;doi:10.1161/HYPERTENSIONAHA.120.16418.
- Gotanda H, et al. Hypertension. 2022;doi:10. 1161/HYPERTENSIONAHA.122.19861.
- Lunyera J, et al. JAMA Netw Open. 2023; doi:10.1001/jamanetworkopen.2022.55626.
- Reddy TK, et al. Abstract 11679. Presented at: American Heart Association Scientific sessions; Nov. 5-7, 2022; Chicago (hybrid meeting).
- Schlaich MP, et al. Lancet. 2022;doi:10.1016/S0140-6736(22)02034-7.
- Yancy CW, et al. JAMA Cardiol. 2023; doi:10.1001/jamacardio.2023.0372.
- For more information:
- Willie M. Abel, PhD, RN, FAHA, can be reached at wmabel@uncc.edu.
- Keith C. Ferdinand, MD, FACC, FAHA, FASPC, FNLA, can be reached at kferdina@tulane.edu; Twitter: @kcferdmd.
- Naomi D.L. Fisher, MD, can be reached at nfisher@bwh.harvard.edu.
- Carl J. Pepine, MD, MACC, can be reached at pepinecj@medicine.ufl.edu.
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