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Although the cardiovascular death ratehas declined in the United States, thenumber of hospitalizations for cardiacdisease has not. The improvement incare has been offset by an increase inthe number of older Americans. By2050, more than 100 million Americanswill be 60 years of age or older,and about 30 million will be older than80 years.

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The following transcript has been edited for clarity and length.

Hello and welcome to Primary Viewpoints from 

, a monthly podcast that features informative conversations with health care experts, opinion leaders, and practicing physicians, about what impacts primary care medicine today.

My name is Sydney Jennings and I am the Associate Editor at 

 and in our third episode Grace Halsey, senior editor of 

, talks with Naomi Deirdre Fisher, MD, director of the Hypertension Service and Hypertension Specialty Clinic at Brigham and Women's Hospital and associate professor of medicine at Harvard Medical School, about the challenges of hypertension management at the level of primary care.

It's been about 3 years since the American Heart Association/American College of Cardiology published its revised guideline on blood pressure management in adults that included the change in the cutoff for stage 1 hypertension going from 140/90 to 130/80. There was a good deal of discussion around that topic and I'm wondering if there still is controversy over the actual target? Or if clinicians are much more focused on simply getting their patients under control?

 I think discussion is putting it mildly. You're right, when the guidelines were published in late 2017, they were met with a firestorm of challenges. They had been a long time in coming. For decades, hypertension was simply >140/90 and that's the way we all learned it and we all practiced it. Many doctors, and primary care physicians in particular, were really reluctant to look at this new goal of 130/80 and to accept it; both for diagnosis of hypertension and for treatment goal. But in the time that has passed, I do sense a general acceptance. I think there's been a widening understanding that there is increased cardiovascular risk along a continuum and that nothing magically happens at that cutoff point of 140/90.

I've read over the years, too, that some of the thought behind lowering the cut point was that, as you said, the disease happens along the continuum, and there are already changes happening at lower levels of elevated blood pressure. There was also, I believe, concern that this might lead to hundreds of thousands of Americans being put on blood pressure medicine. Also, one of the authors of the guidelines said, 

No, we really hope it will be a yellow light, and that people - physicians, patients - will start to take lifestyle changes a little bit more seriously.

 For the vast majority of patients who fall into the newly created category of stage 1 hypertension - that is a systolic pressure between 130-140 - we're going to be recommending lifestyle changes and not medications.

From your vantage point, how are primary care physicians doing overall in 2020 with managing hypertension? I know some things have gotten better over time, but where are the areas that specialists see sticking points or areas for improvement?

: Improvement has come in the area of increased awareness. For a long time, hypertension kind of sat in the background as a chronic disease and we kind of skipped over it and we got to the reason that a patient was in your office that day, which could be fever, chest pain, or something much more exciting. There is definitely a widening understanding and a widening awareness that it has to be brought to the forefront. The areas that need improvement are really to go further. There is a long, long history of what we call "therapeutic inertia" on the part of us; we doctors not taking care of hypertension with enough of a focus. And there's also of course, great resistance on the part of patients. Patients don't take medications for all sorts of reasons. They can be expensive, there can be side effects that are real or perceived. They just don't understand why they need to take medication for high blood pressure, it doesn't cause any symptoms. I think our job would be so much easier if hypertension caused pain. Of course, the therapy really starts with lifestyle modifications and those are so very, very hard. We do know that now there's an ASCVD risk calculator built into the treatment and primary care doctors have been really good and quick to pick that up because they have experienced in the statin prescribing world to do that. But there's a lot of challenges. In fact, most times I would say we have to treat patients with more than one antihypertensive medication to get them under control. So there are just a lot of pieces, a lot of stumbling blocks to get over.

And I think if a patient is diagnosed with hypertension, it is highly likely that is not the only thing metabolically going on.

: When we add our hypertension pills, we're adding it to a long list of pills they are already taking.

 I was interested in the American Heart Association, American Medical Association, 

 program to help practices improve their blood pressure control rates. There is a lot of focus on the very basic core competency of accurate blood pressure measurement, whether that's in the office or having patients do it at home. Is there really a real problem with accurate blood pressure measurement?

 Yes, without accurate, proper blood pressure measurement, we can't possibly provide good care for our patients. For better or worse, the blood pressure reading is the outcome that we're measuring and that we’re guiding all of our therapy by. So, I think the issue of measurement has a lot of facets. We understand pretty well “why”—why we have to measure. Let’s talk about where we have to measure it. And then I'd like to talk about "how" and then I'd like to talk about "when."

But the where—for decades patients come into the doctor's office, they get their blood pressure measured—160 over 105. The doctor says you have high blood pressure and starts a medicine. They come back in 3 months, their blood pressure still high. The doctor may say, why don't you take a few more months to try and lose weight; they come back again, may still be high. That's kind of the way it's been working. We understand well now that it's blood pressures out-of-office that are much more important to capture. These are the blood pressures that really predict target organ damage, risk of having a heart attack or a stroke, or going into heart failure, or developing blindness or kidney disease or cognitive decline. There are so many ill effects of high blood pressure. And many studies have shown us that it's the out-of-office blood pressures that really matter. So, we have to change our focus from in-office blood pressures to out-of-office and home blood pressures. And they can be done with home blood pressure monitoring or with ambulatory 24-hour blood pressure monitoring. There are some new techniques in the office that also help to eliminate the white coat effect. That's a really big deal, for example, too.

So before I leave the “when,” do you have any comments on that? And then we can go on to “how,” where we get measurement mistakes.

 The approaches seems very simple to us lay people who just write about this for a living, you go in, you get the patient to sit still, put their feet on the ground, you don't talk to them. But I guess that in the space of a day, with 15 people in the waiting room, doing it [measuring BP] quickly and accurately at the same time, is a challenge.

 Right, right. So we can talk about the technique now about measuring blood pressure. And you're right, it's a big challenge. And I think whether you're measuring a blood pressure at home, or whether you're measuring it in the office, often it's a medical assistant who does it, it really has to be done correctly.

I always cite Murphy's law when I talk about measuring blood pressure, because anything that can go wrong will. Patients can have just had a cigarette or a cup of coffee within a half hour before getting their blood pressure. Maybe they just ran up the stairs. They maybe have to go to the bathroom, it's really good to have an empty bladder before blood pressure is measured. And very often they're brought in from the waiting room into the MA’s little suite to have their blood pressure measured, and they're sent into the PCP office. But they ideally should be seated for several minutes and come to a full rest. There's generally not time for that in an office flow. But of course, it can happen at home. So patients should be seated resting feet flat on the floor. It's really important if the arm is at the level of the heart, and not too low, not too high. It's very important that the cuff is a reliable one. This is not a case where a generic is a good product necessarily. We need something that's been validated by biomedical engineers. The cuff has to fit well--it can't be too tight and it can't be too loose. And we can't talk during the blood pressure measurements because all of these things affect what the blood pressure is. So yes, you're right.

And then the last facet I want to talk about is “when” to measure blood pressures because when patients start measuring their blood pressures at home, sometimes we doctors receive pages and pages of what looked like random blood pressure's faxed in to us. We don't know what to make of them or how to make any decisions. So there is actually a proper algorithm that's been developed by the American Heart Association. After a patient has been titrated, a drug dose has been changed, we recommend that there, they wait to get into steady state for a week or two, and then measure their blood pressure according to a very specific algorithm, measuring it twice a day, in the morning, and in the evening, always before their pills. And that way we can calculate a weekly average.

 How are patients doing with that on average?

In episode 3 of Primary Viewpoints, Brigham and Women's hypertension expert Naomi Deirdre Fisher, MD, discusses the challenges of hypertension management in primary care. 

Primary Viewpoints Episode 3: The Challenges of Hypertension Management

Hypertension

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