Increased screening for elevated blood pressure, self-monitoring may reduce risk of CKD
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Stanford University nephrologist Vivek Bhalla, MD, FASN, FAHA, understands the value of more aggressive screening for primary aldosteronism, a condition that can lead to high blood pressure.
“I think awareness is a primary factor,” Bhalla, associate professor of medicine/nephrology and director of the Stanford Hypertension Center, told Healio/Nephrology News & Issues. “Our research, and that of others, has demonstrated that even the most common clinical symptoms, such as severe hypertension, hypokalemia or an adrenal nodule, are not triggering screening practices.”
Source: Monika Godara.
Bhalla co-authored a review of primary aldosteronism with Stanford colleague Mario Funes Hernandez, MD, in the American Journal of Kidney Diseases. The authors focused on ways to detect the syndrome earlier and lower the risk of hypertension.
“A clinical condition may be missed due to its higher-than-recognized prevalence or inadequate diagnostic screening,” the authors wrote. “Both factors apply to primary aldosteronism, which is woefully underdiagnosed as a cause of hypertension and end-organ damage. “Screening tests should be strongly considered for diseases that pose significant morbidity or mortality if left untreated, that have a high prevalence, and that have treatments that lead to improvement or cure,” they wrote.
National problem
In the general population, it is estimated that one of two adults has hypertension, considered the most prevalent cardiovascular condition and a potent risk factor for myocardial infarction, heart failure, 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 patients with hypertension whose systolic and diastolic BP was controlled to less than 140/90 mm Hg was 53.8% in 2013 to 2014 and 43.7% in 2017 to 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.
Impact of COVID-19
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,” 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 with Healio. “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 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 2022 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 Healio. “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.”
According to the latest annual report from the United States Renal Data System (USRDS), 130,522 patients were newly diagnosed in 2020 with end-stage kidney disease. Of that group, 37,168 patients had hypertension listed as the primary cause of kidney failure.
While that was lower in the patient count for hypertension as a primary cause of ESKD compared with diabetes – accounting for 59,474 patients diagnosed that year – the rate of cases of ESKD linked to hypertension has seen a steady increase since 2000, according to the USRDS, except for a small dip between 2019 and 2020.
BP monitoring
Some have questioned whether an annual review of BP is adequate to ward off the risk of CVD or progression toward chronic kidney disease. In an updated review on screening for hypertension published in JAMA in 2021, the U.S. Preventive Services Task Force (USPSTF) recommended screening for hypertension in adults aged 18 years or older with office blood pressure measurement.
“The benefits of treatment of hypertension in preventing important health outcomes, such as stroke, heart failure, and coronary heart disease events, are well documented,” the USPSTF wrote. “Treatment can include lifestyle changes, pharmacotherapy, or both.”
Sources interviewed for this article said ambulatory blood pressure monitoring and home monitoring are tools that help identify cases of hypertension sooner.
“Out-of-office BPs have become necessary,” Fisher said. “They are better at predicting [cardiovascular] outcomes than office BPs ... – remote management is where we are headed.”
Bhalla agreed. “Screening rates are atrocious. Less than 2% of eligible patients are being screened for a targetable, possible curative treatment,” he told Healio/Nephrology News & Issues. “Ambulatory blood pressure monitoring is now covered by insurance more than it was before.”
Ambulatory blood pressure monitoring offers “the most evidence-based risk information for future cardiovascular events,” the USPSTF wrote in its recommendations. Most hypertension is diagnosed and treated based on BP measurements taken in a doctor’s office, even though the USPSTF and the American Heart Association recommend BP measurements be taken outside of the clinical setting to confirm the diagnosis before starting treatment.
Tara I. Chang, MD, MS, chief of the division of nephrology and associate professor of medicine at Stanford University School of Medicine, said easier-to-use devices could help identify more patients with elevated BP.
“Detecting and diagnosing high BP is certainly one factor in the persistently low rates of BP control in the general population and in the CKD population,” Chang told Healio/Nephrology News & Issues. “Traditionally, high BP is detected and diagnosed in the doctor’s office, but many people don’t get to a doctor regularly. Trying to meet people where they are – such as in churches, schools, barber shops and salons – could be one way of improving detection of high BP.
“Another active area of research is finding ways to measure high BP without using a traditional BP cuff, such as with wearables or smartphone-centered devices,” Chang said. “So far, there aren’t any alternative devices that have proven to be accurate enough to replace the BP cuff, but I am optimistic that one of these new technologies will pan out.”
“The landscape will change once cuffless BP devices are available and more ubiquitous in the population,” Bhalla said. “Devices in other spheres (eg, continuous glucose monitors and rhythm monitors) have been adopted for several reasons, so this may happen in hypertension, but we aren’t there yet.”
Technique
Increasing the frequency of BP measurements through ambulatory monitoring and even home monitoring can help lead to an earlier diagnosis of hypertension, but technique must follow established guidelines to ensure accuracy.
“The annual measurement recommendations of the USPTF are a step in the right direction,” Rajiv Agarwal, MD, MS, with the division of nephrology, department of medicine, Indiana University School of Medicine, told Healio/Nephrology News & Issues. “But if we do it once a year, let us devote 10 minutes to getting the blood pressure reading right.
“When we do this, we have patients sit in a quiet room without e-devices or other people for 5 minutes and then get three readings at 1 minute apart,” Agarwal said. “Initially, we do this in both arms. This gives us excellent data.”
In his First Word, Alfred K. Cheung, MD, reviews recommendations from a consensus statement adopted by 13 international organizations on best practices for conducting a blood pressure reading. The recommendations include advising patients to avoid caffeine, alcohol, nicotine and exercise for at least 30 minutes before a BP measurement; require a health care provider administering the BP measurement to be fully trained, and retrained annually, in BP measurement; and obtain two or more measurements, 30 seconds apart, with the values averaged and recorded as the final value for that episode.
Home monitoring
In addition to ambulatory blood pressure monitoring, clinicians also encourage patients to perform measurements at home.
“I prefer home BP monitoring for obtaining out-of-office BPs,” Paul Drawz, MD, MHS, MS, associate chair of clinical research and associate professor of medicine in the division of nephrology and hypertension at the University of Minnesota Medical School, told Healio/Nephrology News & Issues. “Most patients are interested in measuring their BP at home, and I have found it to be a good way to get patients more engaged in the management of their hypertension.”
Drawz and colleagues are conducting a retrospective study with the Minnesota VA Health Care System to evaluate the effect of home-based BP monitoring (HBPM) on long-term BP control and cardiovascular outcomes.
The researchers are looking at veterans aged 18 to 90 years with uncontrolled clinic BP enrolled in HBPM programs and a cohort of veterans not enrolled in HBPM programs. “In Aim 1, we will evaluate the effect of HBPM on major adverse cardiovascular events, non-cancer mortality, and adverse events. In Aim 2, we will assess the impact of HBPM on clinic BP, BP medication intensification, and medication adherence. In Aim 3, we will determine facility-, provider-, and patient-level factors associated with use of HBPM in routine practice,’ Drawz and colleagues wrote.
“These findings will inform selection of patients for and the design of a much-needed randomized controlled trial evaluating the effect of HBPM on clinical outcomes compared to office-based hypertension management,” the authors wrote.
New direction
To improve assessment and treatment, experts have proposed that a fundamentally different way of caring for patients 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 cardiovascular disease, but for a host of other diseases. Yet, we do not handle it well,” Carl J. Pepine, MD, MACC, Eminent Scholar Emeritus and professor in the division of cardiovascular medicine at University of Florida, Gainesville, said in an interview with Healio.
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.”
Populations at risk
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, historically underrepresented 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 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 for Black people,” Abel said. “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.”
According to USRDS data, the number of newly diagnosed cases of ESKD among white people decreased from 67,994 in 2019 to 61,031 — a drop of almost 7,000 patients. Yet during the same period, the number of new cases among Black people increased from 33,795 to 34,922.
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. 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.
Multidisciplinary effort
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 a single provider cannot manage hypertension.
“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/Hypertension.122.19350.
- Egan BM, et al. Hypertension. 2021;doi:10.1161/hypertensionAHA.120.16418.
- Ferdinand DP, et al. Am Heart J Cardiol Res Pract. 2023;doi:10.1016/j.ahjo.2023.100253.
- Gotanda H, et al. Hypertension. 2022;doi:10.1161/hypertensionAHA.122.19861.
- Hernandez, MF et al. Am J Kidney Dis. 2023;doi:10.1053/j.ajkd.2023.01.447
- Home Blood Pressure Outcomes Evaluation Study (HOMESTEAD) Project #1R01HL157667-01A1. https://reporter.nih.gov/search/U3_34BVy5EGBcXhUNrBPbA/project-details/10364199.
- Lunyera J, et al. JAMA Netw Open. 2023;doi:10.1001/jamanetworkopen.2022.55626.
- 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.
- Rajiv Agarwal, MD, MS, can be reached at ragarwal@iu.edu.
- Vivek Bhalla, MD, FASN, FAHA, can be reached at vbhalla@stanford.edu.
- Tara I. Chang, MD, MS, can be reached at tichang@stanford.edu.
- Paul Drawz, MD, MHS, MS, can be reached at renaldiv@umn.edu.
- Keith C. Ferdinand, MD, FACC, FAHA, FASPC, FNLA, can be reached at kferdina@tulane.edu.
- 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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