Many US adults fail to achieve sustainable control over high BP

Matthew Solomon, MD, PhD

Hypertension is a silent killer. Most patients have no symptoms, and even a modest rise in BP increases the long-term risk for heart attacks and strokes. Controlling BP is the cornerstone of primary prevention, and we have many evidence-based, effective medications available.

Yet, as Paul and colleagues found, achieving BP control remains elusive. The gap between hypertension prevalence, treatment and control is long-standing, and Paul’s study illuminates the little progress we have made.

It is not for lack of trying. The patients in Paul’s study were on BP medications for 18 months. So, what happened? Most likely, patients stopped medications due to cost and side effects, adherence was poor, repeat BP measurements weren’t frequent enough, and medications weren’t up-titrated as needed.

But these problems can be overcome.

At Kaiser Permanente Northern California, the large, integrated health system where I work, we have successfully demonstrated that systematic programs involving doctors, nurses, pharmacists and medical assistants that track BP and medication usage, identify poor adherence and intervene to adjust medications using evidence-based algorithms, often at a quick, BP-focused visit, can be effective.

Our BP control rates surpass national averages, and our program is used as a model for other systems. The key is a multi-faceted approach that focuses on population management and interventions outside the typical doctor visit.

Controlling BP is one of the most important preventive treatments in our arsenal. It behooves us to take the time to address it at each patient interaction, titrate medications frequently and often, and work within our systems and teams to create comprehensive systems to control BP. Modeling programs on what successful organizations have done to improve population BP control rates would save lives.

Eugene Yang, MD, FACC

The main message of this paper is that despite national efforts to improve BP control in the U.S., in this survey of more than 1 million patients between 2006 and 2018, no significant improvement in BP control was observed, with only 30% to 50% of patients achieving sustainable control after 18 months of monitoring.

The downstream effects of high BP are not insignificant — even small BP fluctuations of 2 to 3 points have a profound effect on cardiovascular morbidity and mortality.

Therapeutic inertia is one possible explanation for Paul and colleagues’ findings. The American College of Cardiology and American Heart Association guidelines recommend that intensification of — or increasing of — treatment for high BP occur until the BP is under control. The intensification should continue monthly until the patient reaches the threshold for BP control. This observational study indicates this follow-up occurs far too infrequently.

Patient inertia — the patient not interested or willing to adjust treatment — is another possible explanation. Or the findings may be due to a combination of these as well as other factors that cannot be identified by this study. Interestingly, a high percentage of patients were treated with beta-blockers for BP, almost 50% overall, even though it is generally not considered a first- or second-line treatment.

If I have a patient whose BP is not controlled, I always encourage lifestyle modifications such as weight reduction, diet and exercise, but if the BP is very elevated, more than 10 points higher than their treatment threshold, I make a change immediately. I also tell the patient to be accountable for themselves: I recommend they purchase a home BP monitor with an arm cuff, train them on the correct way to properly measure their BP and then ask them to send me their BP readings after 2 to 4 weeks to review. If resources are available, a team-based approach enlisting the help of a pharmacist, advanced practice provider or other member of your clinical support team can significantly improve patients’ control over their BP.

Seth Shay Martin, MD, MHS

This large scale, nationally representative study by Paul and colleagues shows clear room for improvement in BP control in individuals who initiate antihypertensive medication.

The study was not specifically equipped to dissect the reasons for lack of BP control, but these disappointing results likely stem from a combination of factors. These may include patient nonadherence to prescribed therapy, inadequate patient follow-up and adjustment of the BP-lowering drug regimen and lack of sufficient concurrent lifestyle modifications like sodium reduction in the diet and increased physical activity. The deeper explanation may be our medical system and its inability to engage all patients in BP management and support their long-term success.

What is particularly troubling is that only 30% to 50% of the population achieved sustained BP control over 18 months. This is a small window in the context of hypertension treatment, where effective treatment is typically needed over a span of decades, and the results in terms of BP control would likely look even more concerning over a longer duration of follow up. Signals that are also concerning are the observations that the BP control did not appear to improve over the last decade and patients with cardiovascular disease had even lower probability of achieving BP control.

The big picture here is that our current medical system is not effectively translating evidence and clinical guidelines to practice. We have an implementation problem. We have a health equity problem. Despite effective therapies, many generic, we are not getting them to the masses. Humbling results such as these can be found in other areas of cardiovascular medicine, from lipid management to heart failure management.

In my opinion, what is needed is truly disruptive approaches to the delivery of care embracing our digital future and the shift of care from the hospital to the home and community. We are heading towards a future wherein technology plays an increasing role to increase access to care, to help us educate and inspire our patients as they take on a more active role in their health care and as we collaborate in their care to achieve better outcomes.