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Commentary

Current Status of Hypertension Identification, Treatment, and Outcomes


January 07, 2020

mungerHigh blood pressure is one of the most important risk factors for stroke, heart disease, and kidney disease.1-2 With approximately one in three of all US adults having hypertension the disorder remains one of the leading causes of cardiovascular morbidity.1  Clinical trials have shown benefit of pharmacological treatment in low to moderate hypertension for decades.   Several new studies have shed light on the current status of hypertension-related outcomes, identification, and treatment which are important for pharmacists to understand and apply to practice. 

Hypertension-Related Outcomes

Hypertension-related diseases have contributed to a reduction in US life expectancy from 2014.3-4 Life expectancy data from 1959-2016 obtained from the US Mortality Database and CDC WONDER focused on midlife deaths (ages 25-64) stratified by age, race/ethnicity, socioeconomic status, and geography across the 50 states.  Between 1999-2016 hypertensive diseases (e.g., coronary artery disease, stroke, peripheral vascular disease and renal disease) increased by 78.9% (from 6.1 deaths/100,000 to 11.0 deaths/100,000).3 The mortality increase is consistent with other 2019 reports.4

The second important study was published in the European Heart Journal in October, 2019.5 The study enrolled 19,084 patients with hypertension who were assigned to bedtime dosing of their entire daily antihypertensive regimen (ie, ≥ 1 medication) or upon awakening.  The primary outcome was cardiovascular disease risk reduction.  The study population was 60.5±13.7 years of age, 55.6% male, with a BMI of 29.7±4.8. The average number of medications were 1.80±0.89.  Participants were followed for a median of 6.3 years.  The hazard ratio was 0.55 (95% CI: 0.50-0.61) for the primary outcome; CVD death.  In each of the single components the hazard ratios were myocardial infarction [0.66 (0.52-0.84)]; coronary revascularization [0.60 (0.47-0.75)]; heart failure [0.58 (0.49-0.70)]; and stroke [0.51 (0.41-0.63)].  The results from this study show that patients may take their medications either upon awakening or at bedtime—if at bedtime there is a significant decrease in risk of death or long-term risk of cardiovascular disease.  Caution should be exercised if patients are taking more than 2 medications, if the patient has secondary hypertension, heart failure, unstable angina, life-threatening arrhythmias, atrial fibrillation, and kidney failure) and if their baseline mean arterial blood pressure (MAP) is not ≤ 60 mmHg.   

Hypertension Identification

A survey of 2000+ health care professionals queried about re-training to conduct blood pressure measurement after their initial training in professional school.6 A third of nurse practitioners and a quarter of medical assistants responded that they had not received additional re-training.  There is no reason to believe that pharmacists and physicians if surveyed would respond similarly.  Interestingly, more than half of respondents thought that a re-training in blood pressure measurement should be required. Obviously, inaccurate blood pressure readings lead to diagnosis errors, including labeled as hypertensive (a lifetime diagnosis) with subsequent treatment errors. 

The AMA has developed an e-learning module to provide health care professionals guideline-recommended training on proper blood pressure measurement.  It is called Achieving Accuracy: BP Measurement. 7 I strongly encourage all pharmacists and pharmacy technicians to take (or be required) to be trained on this module as soon as possible.

Hypertension remains a major medical problem worldwide.  Pharmacists can make an impact on this problem through proactive acts to improve this problem.  Staying current with new information about hypertension will help pharmacists make proper rational decisions about identification, treatment, and referrals.

Mark A. Munger, PharmD, FCCP, FACC, is a professor of pharmacotherapy and adjunct professor of internal medicine, at the University of Utah, where he also serves as the associate dean of Academic Affairs for the College of Pharmacy.   

References:

  1. High Blood Pressure Fact Sheet: https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_bloodpressure.htm  Accessed 11/2019
  2. Cardiovascular Risks of Hypertension: https://www.e .com/contents/cardiovascular-risks-of-hypertension Accessed 11/2019th
  3. Woolf SH, Schoomaker H. Life expectancy and mortality rates in the United States, 1959-2017. JAMA 2019; 322(20):1996-2016.
  4. Shah  NS, Lloyd-Jones  DM, O’Flaherty  M,  et al.  Trends in cardiometabolic mortality in the United States, 1999-2017JAMA. 2019;322(8):780-782
  5. Her, Crespo JJ, Dominguez-Sardiña M, et al. Bedtime hypertension treatment improves cardiovascular risk reduction: the Hygia Chronotherapy Trial.  Eur Heart J 2019;0:1-12.
  6. New Research Shows Need for re-Training on Blood Pressure Measurement. https://www.ama-assn.org/press-center/press-releases/new-research-shows-need-re-training-blood-pressure-measurement  Accessed 11/2019
  7. American Medical Associations Target: BP™ Initiative. https://www.ama-assn.org/press-center/press-releases/new-research-shows-need-re-training-blood-pressure-measurement  Accessed 11/2019
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