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Treating hypertension in primary care: A comprehensive process
Uncontrolled hypertension can be a significant risk factor for heart disease, kidney disease and stroke, and primary care clinicians are often the first to detect signs of prehypertension and hypertension. However, a confirmed diagnosis of hypertension requires more than an in-office screening. As of October 2015, the U.S. Preventive Services Task Force recommends that patients with elevated in-office BP have out-of-office BP monitoring, either with 24-hour ambulatory BP monitoring or with home BP monitoring.
“The advice from the U.S. Preventive Services Taskforce is that you do not make the decision based on one blood pressure, even really high blood pressure, unless you have other secondary findings of hypertension,” Sarah L. Woolsey, MD, board-certified family physician and Medical Director of HealthInsight Utah. “You should get more than one number that’s higher than 140 mm Hg/90 mm Hg in-office, or you can choose to have the patients to do self-monitoring at home or a 24-hour ambulatory blood pressure. To diagnose hypertension, we’re now getting information outside the office setting.”
Identifying at-risk patients
Well before a diagnosis of hypertension is made, a clinician can identify patients who may be at risk for hypertension in the future.
“Probably the easiest and most efficient way is to ask for family history of hypertension,” George L. Bakris, MD, director of the ASH Comprehensive Hypertension Center at University of Chicago Medicine, told Healio Family Medicine. “If both parents, or either one of the parents, an aunt, or an uncle have hypertension, that should automatically raise suspicion for risk.”
Additionally, Bakris said he considers patients who habitually sleep fewer than 6 hours per night, those with high intake of stimulants like caffeine, and those who consume excessive amounts of alcohol to be at risk for hypertension. Older patients with arthritis also need to be monitored for hypertension, he said.
“Not only does the pain contribute to hypertension, but also a chronic ingestion of drugs like Aleve and Motrin, at prescription strength, will definitely raise blood pressure,” he said.
Additionally, patients with low potassium are potentially at risk for secondary hypertension, Bakris said.
“Probably the most common cause of low potassium is patients receiving diuretics who are either eating a lot of salt — well beyond the recommended 2,300 mg a day — and/or are taking in a low potassium diet,” he said. “If a patient has been told that their potassium is low, that should immediately raise a red flag for a secondary cause of hypertension, even if they’re not on a diuretic.”
Not all patients at increased risk have BP readings that are particularly high, according to Michael K. Rakotz, MD, clinical assistant professor of family and community medicine at Northwestern University’s Feinberg School of Medicine.
“Anybody who has confirmed elevated blood pressures above the normal range is considered at risk for hypertension,” Rakotz told Healio Family Medicine. “They may not have blood pressures greater than 140 mm Hg/90 mm Hg taken at multiple visits , which is the current cutoff for hypertension. If they are above 120 mm Hg/80 mm Hg, the person has prehypertension which places them at increased risk for developing hypertension.”
Screening and diagnosis
Woolsey said that due to the high prevalence of hypertension in the U.S., her office screens every patient aged older than 2 years at every office visit.
“You can screen somebody in the office, but you have to know that up to 30% of people with a high blood pressure might have white coat hypertension,” she said. “Screening in the office setting is fine, but you have to be aware that if they’re elevated, you’re going to want to get more information.”
Bakris agreed that white coat hypertension is an important factor to consider, adding that many offices approach BP screenings improperly.
“Traditionally, people come in, it’s a busy office with a high turnover rate. Patients are brought in, they’ve maybe just arrived 5 or 10 minutes earlier, then we’re checking their blood pressure,” he said. “That’s not the way it needs to be done, because when you do it that way, you will almost always get a reading that is higher than normal.”
Instead, Bakris said, the patient should be seated in a quiet area of the office, free of interactions with nurses or technicians, with the BP cuff already on his or her arm.
“After 4 to 5 minutes, you can measure the pressure, then repeat it a second time,” he said. “In a perfect world, you could repeat it a third time, and the average of those three readings would reflect the blood pressure. You really need a minimum of two.”
Rakotz said he also has patients with elevated in-office BP perform home BP monitoring. He said a week-long home BP average (2 readings measured twice a day for seven days) equal to or higher than 135 mm Hg/85 mm Hg is the equivalent of having multiple office visits with BPs equal to or higher than 140 mm Hg/90 mm Hg, and consistent with a diagnosis of hypertension.
In patients who use home BP monitors, Rakotz emphasized the importance of instruction by a healthcare professional on how to use the monitor to get an accurate measurement. Additionally, he said it is important that monitors are tested for accuracy in the office before being relied upon to make diagnostic and treatment decisions.
“You want to make sure the cuff fits the patient properly, and that when you test the home monitor in the office, it is tested against the office measurement standard, and is shown to be equivalent,” he said. “That way, you know the monitor is working accurately in that patient before you rely on it to make clinical decisions.”
Bakris said the premature or erroneous treatment of patients with white coat hypertension can lead to additional problems.
“It’s been estimated that a lot of the ‘side effects’ patients are complaining about have little to do with the drugs, and more to do with the fact that they have white coat hypertension,” he said. “They’re being given drugs, they go home, and their blood pressure normally drops. Now, it’s dropping even more, they’re lightheaded, they don’t feel well. These aren’t necessarily drug side effects; they’re a result of the patient being given the drug indiscriminately.”
Pre-pharmaceutical interventions
For certain patients, it may be reasonable to recommend lifestyle changes before deciding to treat with a BP medication. However, many factors need to be weighed when determining which patients might best benefit from prepharmaceutical approaches.
“When we look at a patient, we don’t just look at the number. We look at their cardiovascular risk, we look at whether they have diabetes or kidney disease, and we look at their age,” Bakris said. “So, if someone comes in and they’re 35 years old with blood pressure of 137 mm Hg/88 mm Hg, and they’ve got no risk, they are going to get a lecture on lifestyle, and we’ll re-evaluate them in 3 to 4 months.”
Woolsey also considers a patient’s comorbidities and family history when deciding whether to initially try a prepharmaceutical approach, and takes into account the severity of the high BP.
“If the patient has a dangerously high blood pressure, it’s appropriate to begin to treat them pharmaceutically,” she said. “If a patient has mildly elevated blood pressure and is motivated to make diet and exercise changes, such as the Dietary Approaches to Stop Hypertension (DASH) diet or losing 5 to 10 pounds, that can normalize a mildly elevated blood pressure.”
Rakotz said he begins to recommend lifestyle changes for any patient whose BP is above the normal range.
“It starts before the patient even has hypertension — anybody with confirmed BPs greater than 120 mm Hg/80 mm Hg in the office setting will be advised to make healthy lifestyle changes,” he said. “We recommend the low-sodium DASH diet and working your way up to 30 minutes of brisk walking on most days. But we acknowledge that any reduction in sodium and increase in physical activity is better than doing nothing. It's ok to start with small changes.”
Bakris said when he discusses lifestyle changes with patients, he frames it in terms of the “two S’s”— sleep and salt.
“I talk to them about foods like pickles, sausage, ham, processed meats and canned soups, which have disproportionately very high salt,” he said. “If they eat out, they should ask for the food to be prepared without salt. They can’t order soup, they can’t order lasagna, they can’t order pizza. Chinese food is extremely salty.”
He added that individuals with hypertension should order sauces on the side, because this is where a large proportion of salt is found.
Addressing the matter of sleep is another component of Bakris’ approach. He advised that patients minimize distractions at bedtime and go to bed when they are ready to sleep.
“That means no reading, or watching TV, or listening to the radio, and no exercising within a few hours of going to bed,” he said. “Don’t drink stimulants. Just go to bed when you’re tired and prepared to sleep.”
Bakris said patients also receive a fact sheet, embedded in EPIC electronic medical records software, which lists the sodium content of foods and instructs patients on how to read labels. Finally, he recommends restricting alcohol intake to two drinks per day for men and one drink per day for women, and he advises obese patients to lose weight.
Choosing a medication
Rakotz said he would consider adding a medication for a patient with hypertension whose initial lifestyle trial was ineffective, or in a patient who did not follow the lifestyle recommendations.
“If we opted for lifestyle change in a low risk patient, we’d recheck their blood pressure in 3 or 6 months, and see how they do,” he said. “If they improve, great; we might stick with lifestyle alone and continue to reevaluate them. But if they come back in 6 months and their BP is significantly higher or they haven’t made the lifestyle changes, we discuss starting medication.”
Bakris said he would start with a single pill combination medication (two medications in one pill) in any patient with a properly-measured BP above 160 mm Hg/100 mm Hg. In patients who have been on a lifestyle change regimen for 1 month but have not reached their target BP, Bakris said he will prescribe medication.
“Ideally, I want to have people around 130, 132,” he said. “So if, with lifestyle, you’re still at 138 or 140, you’ve bought yourself a medicine.”
In selecting a medication regimen for a patient with hypertension, Rakotz said he recommends using one of several available evidence-based treatment algorithms. One commonly used algorithm was released jointly by the American Heart Association (AHA), the American College of Cardiology (ACC), and the CDC. He said the Million Hearts Initiative website offers several evidence-based treatment algorithms, including a template to build your own, and added that many health systems are already using their own treatment algorithms.
“They’re like a playbook to tell you how to treat patients with hypertension,” he said. “They take much of the guesswork out of it for physicians, and that’s why we strongly recommend that they’re used. It really makes it easy to pick the right medication for most patients and know when to see them back for follow up. “An algorithm, though, should not replace a physician’s clinical judgement,” Rakotz notes.
Bakris said he usually starts with a single-tablet combination medication, consisting either of a renin-angiotensin system blocker and a calcium blocker, or a renin-angiotensin system blocker and a diuretic.
“I start with either one of those two single-pill combinations if the patient’s blood pressure is at 160 or higher,” he said. “If they’re between 140 and 159, I would recommend lifestyle and start them on one drug, unless I don’t expect the patient to comply with the lifestyle changes.”
Bakris said that in patients who are aged older than 65 years or are black, the one drug he would start with would be a calcium antagonist, or if the patient consumed excess salt, a diuretic.
“That’s because the blockers of the renin-angiotensin and the ACE inhibitors, the ARBs, are not very good as blood pressure-lowering agents in those two groups,” he said. “I reserve that for younger people or Caucasians.”
Drug-drug interactions
Woolsey said that because there are so many hypertension medications and because patients taking these drugs may be older or have comorbidities, avoiding drug-drug interactions is a complex undertaking. She cited the American Geriatrics Society’s 2015 update of the Beers Criteria, which lists drugs that pose a high risk to older adults.
“There are actually a number of hypertension medicines that are on the Beers list as being risky, because they can slow the heart rate and cause low blood pressure,” she said.
Additionally, Woolsey said she would avoid medications that affect kidney function.
Rakotz added that ACE inhibitors should not be used together with angiotensin receptor blockers.
“Most recent algorithms will also tell you that, although beta blockers were recommended as first-line therapy for hypertension in the past, they are no longer recommended in most situations as first-line therapy for hypertension absent other specific conditions,” he said.
Bakris emphasized the importance of providing a potassium-sparing agent or a potassium pill to any patient with normal kidney function taking a diuretic only. He also said patients who are on ACE inhibitors or angiotensin receptor blockers should be encouraged to drink plenty of fluid.
“If they’re not drinking at least a liter and a half, or a quart and a half, of fluid per day, then they’re likely to get dehydrated,” he said. “The drug classes, like ACEs and ARBs, actually dramatically increase in potency when the patient is dehydrated, and will likely cause orthostatic hypotension.”
When to refer
In some cases, it is reasonable for the primary care practitioner to refer the patient to a specialist.
“If a primary care physician has a patient who is on an optimal dose of three drugs, one of which is a diuretic, and still has uncontrolled blood pressure, that patient is considered to have resistant hypertension,” Rakotz said. “Most primary care physicians will refer patients with resistant hypertension to a specialist for 24-hour ambulatory monitoring, and additional workup if needed.”
Patients with difficult to control or labile BP on fewer than three drugs, may also benefit from being referred earlier, he said.
Woolsey concurred that hypertension refractory to three medications may be best referred to a specialist. She added that certain suspected comorbidities may warrant referral.
“Obviously, if you think there’s an underlying issue, such as sleep apnea or endocrine tumors, you may need to do other testing and referral,” she said. “It depends on the reason for the high blood pressure.”
Bakris also suggests a “three-drug rule,” but adds that the case for referral is also dependent on the primary care physician’s comfort level.
“I would say it depends on how comfortable they feel and how much experience they have with these patients,” he said. “Generally, board-certified hypertension specialists are not only experts in blood pressure; they’ve taken exams and have experience in seeing patients who are difficult to control.”
Rakotz said when considering referral or any other aspect of hypertension diagnosis or management, physicians will soon have access to an updated guideline for hypertension. The guideline, which is expected to be released in late summer or early fall, was drafted by the AHA, ACC and various other medical societies.
“This is the first comprehensive Hypertension guideline since 2003 in the United States,” he said. “We’ve had other partial recommendations from other organizations, but not a comprehensive guideline. This will be very exciting. I’d like to see all primary care physicians pay very close attention to the recommendations that are coming.” – by Jennifer Byrne
References:
Million Hearts. https://millionhearts.hhs.gov/. Accessed June 12, 2017.
Piper MA. Ann Intern Med. 2015;doi:10.7326/M14-1539.
Disclosure s : Bakris, Rakotz and Woolsey report no relevant financial disclosures.
For more information:
Michael K. Rakotz , MD, can be reached at 635 N Dearborn St, Chicago, IL 60654; email: mrakotz@nm.org
George L. Bakris , MD , can be reached at 5841 S. Maryland Ave, Chicago, IL 60637; email: gbakris@medicine.bsd.uchicago.edu.
Sarah L. Woolsey, MD , can be reached at 756 E. Winchester, Salt Lake City, UT 84107; email: SWoolsey@healthinsight.org.