2017 Guidelines for Prevention, Detection, Evaluation, & Management of High Blood Pressure in Adults

2017 Guidelines for Prevention, Detection, Evaluation, & Management of High Blood Pressure in Adults

– 2017 Guidelines for the
prevention, detection, evaluation and management
of high blood pressure in adults. This fireside chat featured Dr. Brent Egan from the Care Coordination
Institute in South Carolina who discussed the four new categories for classifying blood pressure, changes to the prevalence
of high blood pressure as a result of the new guidelines, treatment of high blood pressure with non-pharmacological and
pharmacological interventions, revisions in blood pressure goals and the use of
self-monitored blood pressure to manage patients with
high blood pressure. – Guideline of 2013
the group is restricted to a fairly narrow set of questions really didn’t address a
lot of the broader issues in hypertension so I think given the fact
that it’s been about 14 years since we’ve had a major guideline, the 2017 guideline has
generated tremendous interest. The other thing as you know
is we’ve had a lot of data come out since 2003 and
we’ve known for many years that we have a lot of people who were called pre-hypertensive that were at significant risk for increased cardiovascular events and we’ve now redefined that a little bit. We’ll get into more of
the details in a moment. So in terms of summarizing
some of the key changes if we look at the number of people that would be diagnosed
as hypertensive today versus the application 2003 guidelines, we’ve gone from roughly 72
million hypertensives in the U.S. to about 103 million. So under the new guideline with hypertension being
defined at 130 systolic rather than 140, we’ve now have added
about 31 million people in the U.S. with hypertension, going from about 32 percent
of the adult population to 46 percent of the adult population. So I just summarize quickly
under the 2003 guidelines, essentially everybody with hypertension had a recommendation for
pharmacologic or drug therapy to lower their blood pressure. Today of those additional hypertensives, the majority have a recommendation
for lifestyle change. So the greatest impact on the
prevalence of hypertension has been on younger people
under the age of 65. Most of whom will have a
recommendation between 130-139 for lifestyle change. Most of the change in
actually patients treated will be amongst those 65 and older. So again, just to simplify,
a lot of that increase in 31 million is because of
what’s happening to people below 65 now being
diagnosed with hypertension. But for many of them
because of the requirement for risk settle, which we’ll
talk about in a moment. For the majority of them, it’s going to be a
lifestyle recommendation with a continued recommendation for drug therapy at 140
plus which is again similar to the 2013 guideline. So to summarize quickly, while the new guideline
identifies 31 million more people as hypertensive, it identifies
about 4 million more for treatment with medications. Being that there’s 27 million that have a recommendation predominantly for lifestyle change to
lower that blood pressure. – There are a lot of big
numbers as well for millions of individuals that will fall
into these new guidelines so what was the major contributing factor to the increase in the
number of individuals that now fall into those guidelines? Is it more threshold related? – Yeah so I think in terms
of threshold related, we take an individual with a
blood pressure of 130 to 139 versus less than 120, there’s probably at least a 50 percent or more increase in the actual likelihood
of cardiovascular events. But for many years, we argued whether it was that pre-hypertensive range of blood pressure itself
that conveyed risk or whether it was because of the fact that they were more likely to develop hypertension in the future. I think as time has gone on, we’ve become more and more convinced that a blood pressure of 130 to 139 itself increases risk for cardiovascular events. But the other part that’s
associated with the risk is when you take
individuals with a pressure of less than 120 versus 130 to 139. The group with the 130 to
139, they’re a bit heavier, they have higher cholesterol values, particularly triglyceride values, reduced HDL cholesterol, their blood clots more readily, they have more inflammation, so perhaps about half
of the risk associated with that blood pressure is due
to the blood pressure itself and about half of the risk is due to these associated
factors that seem to track with the blood pressure. Which again if you’re looking to deal with the issues that occur, lifestyle will deal not
only with the blood pressure but with many of the others. While the blood pressure medications, by in large, will deal with the blood
pressure component. So with that, we’d
probably get better results if we could lower the blood pressure with lifestyle because we’ll be reducing the
excess weight in many cases, we’ll have a better nutritional pattern, we’ll decrease inflammation
and a number of other things. We’ll decrease oxidized LDL and some other things that
track with blood pressure by doing it with lifestyle change, we probably don’t do as efficiently when we just use medications. – You mentioned as well, pre-hypertension, so that was something in the
previous guidelines as well, a certain segment of the population that was identified as pre-hypertensive. Within the new guidelines, that new terminology is not there. So where do those individuals fall within the new hypertension guidelines? – There’s an interesting
history so I’ll go through the history fairly quickly here. The first time I’m aware that
pre-hypertension was used was in a 1939 paper and in that 1939 paper by Robinson, they looked at insurance data and outcomes, they also
had some clinic based data. But they showed that individuals in the blood pressure range of 120 to 139 did not live as long and had
more cardiovascular events and that they were more
likely to develop hypertension than individuals with
pressure of less than 120. So even in 1939, the blood pressure range of 120 to 139 systolic was identified as pre-hypertension. At that time, 60 percent of the population had a blood pressure of less than 120. About 20 percent had a
blood pressure of 120 to 139 and about 20 percent had a blood
pressure of 140 and higher. Now we know over the
years it looks as though the blood pressure
distribution in the U.S. has been moving to the
right to higher levels. And we do know that those,
we’ve known since 1939 that pre-hypertension
range was increased risk. What we’ve done with the new guidelines is we’ve said, again,
I’ve focused on systolic to try and keep this simple, and for most of the people the systolic is probably the stronger
predictor of outcomes. For young people, the diastolic pressure is also important. But once we get to the age
of 50 and so or higher, systolic is at least the
stronger, so for simplicity, keep it there. So again, in the JNC 7, 120 to 139 systolic was pre-hypertension. We’ve taken half of that group half of the range, 130 to 139, and it turns out that
probably five eighths of the individuals are 120 to 129 and three eighths are 130 to 139. So it’s not exactly,
well it’s half the range, it’s about three eighths of the patients and now we’ve said the 130 to 139 group has stage one hypertension. Before we said stage one hypertension was 140 to 159 systolic. Now we’ve defined it as 130-139. We defined stage two hypertension as anything 140 and higher. So for the group 120 to 129, we’ve termed that high or
elevated but not hypertension. We’re still defining
normal as less than 120. So that’s where we are today
in terms of those definitions. – And within those different cut points you have normal blood pressure, elevated blood pressure, stage one and stage two hypertension for the different cut points. Now our categories with the
new hypertension guidelines. You mentioned as well
lifestyle interventions or as they term it in the guidelines, non-pharmacologic interventions. That’s undulates back and forth as to lifestyle or
behavioral interventions which we heard before as well of course. That’s a substantial
portion of the population it looks like that falls
within these new guidelines. Can you discuss a little
bit about what those are, what the recommendations are for lifestyle or behavioral interventions or non-pharmacologic interventions according to the new
hypertension guidelines? – Yeah I think over the years we’ve had several evidence-based lifestyle or non-pharmacologic changes
to lower blood pressure. Those that have gotten the most attention have been for example, eating a DASH or dietary approach to systolic hypertension type eating plan and for those that aren’t familiar, basically we’re trying to
increase fruits and vegetables oftentimes in South Carolina,
we see about two per day and I’m not being critical,
this is the way it is. And sometimes that’s
only if we give credit for ketchup and french fries. But we’d like to get under DASH, dietary approaches to
systolic hypertension, eight or nine. What we seem to have good data for is even going from two
to three to five or six has a significant effect
on lowering blood pressure. So it’s basically going
from processed foods to more natural foods. More foods the way nature produces them than the way we process and change them. And if we can do that and get more fiber, we typically will get less sodium, we’ll get more potassium, more calcium. We get more of the minerals
that we believe are good for blood pressure and
more balance out the sodium which for many peoples is not
so good for blood pressure. Of course, sodium restriction, but the issue is if we just restrict salt, without improving the quality of food we don’t seem to lower
blood pressure as much as if we also improve the quality of food as we’re also reducing the sodium. So those other things that I mentioned the healthy foods have the antioxidants, we talked about oxidative stress, potassium, the calcium,
magnesium that are beneficial. And so we think, preferably,
eat a healthier diet. Move to more natural foods,
less processed foods. The DASH program also included
low fat dairy products. It’s hard to get dairy
products into most adults, but those have an additional benefit beyond the fruits and vegetables alone. Getting more fiber from
grains and so forth also again just increasing
those natural foods seems to make a significant difference. In many people with
elevated blood pressure, it can lower the blood pressure eight to ten millimeters of mercury. What we’ve shown in some of our studies, even half way adherence,
say five to six a day in folks with what was called
previously pre-hypertension, now stage one hypertension, can lower the systolic six to
eight millimeters on average. So we can get a good response
to the DASH eating plan. It can be done in ways
that I think most people can probably adhere to it and will find it quite palatable as well. – When I was looking through and reading through the guidelines, that’s one of the things that I saw that was really interesting, potential pull out for
translation as well. Where looking at from the
non-pharmacologic interventions and the effect on blood
pressure that they have. Especially as you look
at physical activity, reduction in alcohol or
limiting alcohol consumption, weight loss among those who need it, and then improvement in
healthy diet as well. You mentioned ASCD risk
or risk scores as well. So we’re familiar with ASCD risk or atherosclerotic
cardiovascular disease risk score calculations, as we’ve
heard Framingham Risk Scores in the past and the new 2013 guidelines that came out looking at
risk scores in particular and its application for
cholesterol management. Which many people I know are very familiar with looking at cholesterol management with ASCD risk scoring. This is the first time
that I’ve recognized it being included within hypertension
management in particular. Which may add some complexities of course to the treatment of hypertension at large but also just a new
term, a new incorporation of a new concept within
hypertension management. So can you talk a little
bit about ASCD risk scores? – I would be happy to do that and that actually falls in line with what a lot of the rest of the world does particularly the Europeans like to risk stratify and then base that therapy on the absolute risk of subsequent events. So I think the ASCVD risk score was part of the 2013
cholesterol guidelines, also part of the U.S.
Preventative Services Task Force were updated 2016 cholesterol guidelines. I think more and more hopefully clinicians will be
using electronic records to automatically calculate, certainly there are apps they
can use on their cell phones because we talked earlier today physicians, clinicians are so busy. It takes 22 hours to
implement the guidelines they already have so we’ve
got electronic records that automatically does that calculation for them so much the better. But I think it is an
important consideration so the way the guideline was set up is if you have a blood
pressure of 130 to 139, and a 10 year risk of a major cardiovascular
event of one percent per year or higher, 10 percent or higher over 10 years. The recommendation is to
get not only lifestyle but pharmacologic or drug therapy to lower the blood pressure. And that’s part of why we’re
not recommending drug treatment for all of them because
many of these individuals have an absolute risk of less
than one percent per year for a cardiovascular event. So we wouldn’t want to
put them necessarily at the risk of medication
without a good opportunity to see some of the benefits
of taking that medication. That’s part of why that recommendation is. And so I just want to take a moment to go back to what you said
about physical activity. Because of the one
thing that people can do that probably has the greatest impact on their overall cardiovascular risk it is to be physically active. Good nutrition is extremely important I would never underestimate
or undersell it. But getting physical
activity is extremely useful. It substantially reduces risk for diabetes and cardiovascular disease. It’s extraordinarily important. And for many of our
individuals with hypertension specifically over the age of 50 many of them have been a bit heavy. They’ve got arthritic joints, walking three to four miles per hour can be very challenging. But there’s pretty good data now that low intensity physical activity in previously sedentary individuals by this I’m aware of some
recent studies for example where they looked at walking
about two miles per hour. Or looked at doing one
quarter deep knee bends, not even half deep knee
bends, but quarter. If we do that ten percent
of our sedentary time, substantially affects on
lowering blood pressure and reducing risk for diabetes. So for those individuals out there that have difficulty with moderate to vigorous physical activity
at least 30 minutes a day most days of the week who
are predominantly sedentary, I would really encourage them on low intensity physical activity. There’s actually pretty good data from a lot of analyses that have been done that low intensity physical activity is almost as effective as moderate and high intensity physical activity for reducing the development of diabetes. And when you think about it, the research that has been done, I’ll try to go through this quickly so we don’t bore our listeners, but with low intensity physical activity, we activate the muscle fibers that are most sensitive to insulin, its the slow twitch oxidative fibers. So those are almost one hundred percent activated by low intensity
physical activity. So moderate and high intensity activity does not drive the activities most important slow twitch
oxidative fibers anymore. We get some effect on the
fast twitch oxidative fibers that don’t nearly have
the metabolic capacity of these slow twitch oxidative fibers. So when we look at this physiologically, low intensity physical activity pretty much maximizes the activity of the slow twitch oxidative fibers which are very important for metabolism. And so I really encourage
folks that may have difficulty, we know for many people,
moderate to high intensity physical activity can be very challenging. I would encourage them to take ten percent of
their sedentary time and turn that into a low
intensity physical activity that doesn’t wear them out. Gardening, cleaning the
house, just walking around, you don’t have to walk fast, just get out there and walk, can have tremendous benefits in people that are otherwise sedentary. – Absolutely. And we know
that even small bouts having physical activity
is for functional health, physical health, health outcomes as well. There’s an activity called leveling up where they’re trying to move people from lower levels of physical activity to higher levels of physical activity as part of one of the
CDC programs as well. A great benefit of those
who have no activity moving up a little bit. Of course walking being
the most common form of physical activity. Having people walking to and from work, to and from different areas as well, where they’re going throughout their day is very important. – And the point that you raise, this is things that a lot of folks can do. We need to try to work on safety in some areas for people to walk more. That’s one of the things
we discussed earlier today. I think looking to make
that more practical for a larger segment of our population. Yeah it doesn’t require a lot of expense and walking even one and a
half to two miles per hour. If you walk one mile, it’s far better than sedentary as you’re saying. So I think the key is to get folks moving. And even six minutes an
hour seems to be sufficient to have major health benefits. – I think we translate that many times when we’re doing our surveillance work. Rather, some activity is better than none. And basically any movement
is beneficial for health. I don’t know I think the guidelines are gonna have it in bouts
of ten minutes or more. So as people try to continue
to work towards that if they’re doing no activity, trying to do ten minutes at a time can help with functional
health and health outcomes. – Well I just want to take a moment to emphasize what you just said. While we’d like to have 30
minutes, maybe in one session, the people do ten
minutes three times a day pretty much get, as I understand, very similar health benefits, so it doesn’t need to be all at once. It can be during a break in the morning, during a break in the afternoon and maybe a few minutes in the evening. – So it sounds a lot like the lifestyle behavioral interventions that we’ve been discussing are related to really the previous guidelines as well. It sounds like a lot of
them really haven’t changed quite a bit actually and that having a healthy diet, participating in physical activity, weight loss, reducing alcohol consumption as those are somewhat the same. Are there any differences
in recommendations for pharmacologic therapy? – I think that’s an important question. I think we’ve long recognized the benefits of making sure for most people that we’re giving the
medications one time a day rather than two or three times a day. I think the other thing is
we’ve learned over the years that getting two or more medications into the same pill seems to make a very significant difference. We actually looked in our database found 110,000 patients that
had not been previously treated for their hypertension, looked
at their initial therapy. Those that were started on
single pill combinations were fifty percent more likely to get their hypertension controlled in the first year despite the fact that they started with
higher blood pressures. So people are more likely
to take medications in a single pill than
they are separate pills. They seem to be more
likely to stick with it. It seems to be easier to
increase the dose of medications in a single pill than it is to increase the doses
of separate medication. We call that sort of therapeutic inertia. So the therapeutic inertia goes down. When the blood pressure is not controlled it seems to be easier
to increase the doses of the single pill than to increase the doses
of the separate pills. Just all of these things fit together. We now have data suggesting perhaps that even starting two medication only get better blood pressure control but perhaps even better clinical outcomes. So I think whatever we can do to make it more convenient
for the individual. A lot of times, two
medications in one pill may actually cost less than
buying the separate medications. So particularly for people’s difficulty
affording medication, remembering medication once a day, reduce the pill number. There’s another thing I think is important for clinicians to recognize. Many of our patients have
more than high blood pressure. In fact the majority of patients who have high blood pressure have several other chronic
medical conditions. And so they’re taking medications
for several conditions. If their medications are
running out at different times, they have to make more visits to the pharmacy to get those medications, they’re less likely to get and take them. If we can consolidate the refills into fewer visits to the pharmacy that actually can
improve outcomes as well. So I think there’s a lot we can do listening to patients carefully, individuals that are
taking these medications. What concerns do they have in trying to find acceptable solutions? We’ve done that a little bit with what’s called a Map Program and we’ve seen that by
working with practices, and partnering with patients, engaging sort of team based care, we can significantly increase
the blood pressure response to the medications they’re prescribed by addressing some of these simple issues. – I think that was another component of the new guidelines as well that I was really encouraged by looking through the strategies to improve hypertension control that were listed in the guidelines as well that included many of the components that I know that you’re implementing within the South Carolina environment that we see nationally as well. There have been official things like team based care focusing
on medication adherence. And so are there any specifics, I know medication
adherence is so challenging within that there’s primary
medication adherence where somebody gets the prescription at the doctor’s office and then ends up never actually getting it filled. The secondary where they’re going into the provider’s office, they’re getting it filled,
they’re getting maybe one refill and then it trails off after time as well. We see this decline
really across the board with medication adherence and trying to keep people
on it over the long run. Is there anything you can share, any wisdom that you have from the South Carolina experience or nationally or even globally where you’ve seen that
there’s been benefit within the medication adherence arena? – Well one thing that I’d point out that we rarely talk about is that roughly 70 percent of people taking medication are actually controlled at less than 140. And three quarters of them are
controlled at less than 130. Those rates have been going up. So to me, if people weren’t
taking the medication it would be unlikely that we
would get those percentages the goals we just discussed. So I think in some ways,
adherence may be improving more than we think it is. It’s still needs to be better. There’s still problems with persistence on medication. But when we look at the data a good 70 percent of
people taking medication for the blood pressure when they go in for the NHANES exam have a blood pressure of less than 140 and three quarters of them have a blood pressure less than 130. I don’t think that would occur if they weren’t taking
a substantial proportion of their medications. So I think we need to focus more on those who may not be getting enough and we believe that probably
taking 75 to 80 percent of the pills is really important to get the benefit that
is potentially there. And so I think again as we said, trying to make sure that we engage and this is sometimes not discussed, but patients that are
involved in the decision about taking medication, what kind of medication it is, are actually, the studies
show, more likely to adhere. So I think in the old days a physician would you know prescribe a medication they believe it’s best for the patient. But if they haven’t engaged the patient in that decision, the adherence doesn’t seem to be as good. So for example if we look at
some of our minority patients, they seem to be less
engaged by their clinicians in the decision about
what medication they take. And so maybe part of
that adherence difference is in fact a difference
in patient engagement in the decision about the
medication in the first place. I think we need to look at some of that. So again I think it takes team based care because the primary
clinician may not have time to do all of the things
we’re taking about. We have to figure out
how to partial it out. But again patients that
are involved in decisions about their medications seem to be more likely to take them. Once a day, decreasing
the number of pills, consolidating refills, and then also if we can get patients to monitor their blood pressure at home. So if your blood pressure
is not controlled at home and you’ve been prescribed medication, turns out you’re more likely to take it. If you not only take your
blood pressure at home but get those blood pressures back to your clinician’s
office between visits, you’re more likely to
take your medication. If you not only take
your home blood pressure but get your via email or something, get the blood pressure to your clinician, and the clinician’s
office gets back with you with some encouragement or
advice, you do even better. So we have a really strong evidence base about how we can get a greater
adherence with medication. Some of these things, they take time. I think we have to figure out
how to make these efficient, involve other team members. But I think we have a strong evidence base of what some of the things can be done. Out of pocket costs. There’s some studies that suggest out of pocket costs may account for a third of variance in adherence. So again, the more we can
decrease out of pocket costs we’ll probably likely see
improvements in adherence. So I think these four dollar formularies, some of these medications
being at no cost. But I think we have to look at whether a four dollar
or ten dollar co-pay makes a lot of sense when we look at hypertension’s consequences, its complications, its long-term impact. I think we really need to do
careful economic assessments of these because we may be short sighted because and it may not matter
all that much on income. I think co-pays affect
people with higher incomes and lower incomes, so I think we need to look at how we have individuals pay for their medications as well. – You mention the before,
some of the conversations about the intensification of therapy or how it will likely be needed, the intensification of therapy or inferred that some of that
related to lower thresholds. And so as we look at
the different stage one that have clinical ASCVD or ASCVD risk scores
greater than ten percent. Stage two hypertension
that are recommended for pharmacologic therapy. We have some questions
as well that came in through state partners
that we’re considering how that would impact those, especially the elderly, as
well, as you mentioned before that there were other thresholds that were previously published that were higher targets for those. And so Janice Gray from Alaska
had a particular question and she’s worried about the increase in falls and syncope
episodes, or syncopal episodes that may be related to the lower targets, especially for the elderly population. Can you speak to that a little bit? – Yeah. I think, you know, Sprint gave us a lot of data on that and again it was systolic
blood pressure trial where they looked at
target of less than 120 versus less than 140. In the older group, in this
case, it was quite a bit older. The group 75 and older that was assigned to the target of less than 120 actually achieved an average
systolic of 123 to 124. They had very significant reduction in number of cardiovascular events. But we also saw more
hypotension and syncope as it related to that. So there is, I think, as
this individual has raised, there is some cost if you will to aiming for these lower targets. But it looks like also
a significant benefit. In particularly in Sprint, they saw a very significant
benefit on heart failure which is one of the more
serious complications of hypertension. So I think many of the elderly with heart failure can certainly recognize what a major issue that is and not having, certainly prognostically,
heart failure is not good. The mortality is still
around 20 to 22 percent in the Medicare population
with heart failure. So I think we need to balance that and I think sometimes that’s where an individualized decision may be useful. But on balance we know
that we will prevent more strokes and heart attacks when we control the blood
pressure a bit better. So again, as you mentioned or suggested with the 2013 guideline, the individuals over the age of 60 without diabetes or chronic kidney disease, it was acceptable to treat
them to less than 150. I think Sprint effectively
dispels that notion and suggests that’s not stringent enough. And so we do I think need to be cautious. What’s often said with
our older hypertensives is to start low in terms
of the drug therapy and go a little bit slower. I think we need to be
a little bit cautious because we have another study with somewhat older
high risk hypertensives. If we take more than six months
to get the pressure down, then during that time
there may be an increase in events that would have not been there if we’d got the blood pressure controlled in a shorter period of time. So I don’t think we have to control it in the first month
or the first two months, but I think looking to
get the blood pressure under better control
in less than six months I think seems to be a
very reasonable target. I think having the elderly monitor their blood pressure at home. Then I think sometimes we can
see a significant discrepancy between the office and at home pressure. One of my older patients actually had a 100 millimeter difference between her office and her home pressure. And before I got her home pressures, I was making her a little dizzy. And so we really need to be aware of those kinds of things. The blood pressure fall on standing and making sure that we’re not dropping that so low that we begin to cause confusion and syncope. And so I think we need to be aware, we need to engage them in helping us to monitor and appropriately
gauge that therapy. But I think what Sprint did show us is for individuals over the age of 75, even those that were considered frail, even those that were considered frail, may have had difficulty getting around, it seemed to be beneficial
to control the blood pressure to less than 140, with an
average of about 123, 124. So I would say again, I think we need to involve patients in this. What I often say to some of my older hypertensive patients is we have very good evidence that treating the blood pressure is significantly reducing stroke, probably very good for heart failure. We may not have quite as much data on the coronary heart disease, but I think Sprint gave us some. But what my elderly patients
almost uniformly tell me is that they would really prefer to avoid strokes and heart failure. They don’t want to have
a heart attack, an MI. But they’re more concerned
about the stroke in particular. They don’t want to end
up in a nursing home with a stroke. And so I think if we understand, we go in with our eyes wide open, we talk about the advantages, the disadvantages, it doesn’t take long, it doesn’t
take a long conversation. But engaging that
individual in that decision so that they know what the bargain is, what the trade-offs are, and that then really engages them in the treatment process as well which is one thing we just talked about. – I think you have a
case study to write up for white coat hypertension as well with 100 millimeter difference there You’re intimidating I
guess in that clinic. – You know that was the interesting thing. She always looked happy to see me and she was always wanting
to show up for appointments, never missed an appointment,
but yeah 100 millimeters. Pretty striking, yeah. – You’re a scary individual. – I sure am. – You do mention that as it relates to self-measured blood pressure though which is I think another
important component within the guidelines that was really not within the previous
guidelines as well. You know a lot of movement towards that with out of office blood
pressure measurement or the inclusion within that, a lot of international guidelines
include that of course. Even within the diagnosis and
management of hypertension. And this guideline actually
looks at the inclusion of that within the confirmation and
the management of hypertension. Can you speak to some of that as well? How you’ve seen the beneficial effects of self-measured blood pressure being included with some
of the programmatic work that you’ve done? – Yeah I think it’s very useful for individuals to know
their blood pressure, and to be confident in
their ability to manage it. I think most people would be, a lot of the monitors that exist today, many of which are really quite accurate that learn how to use those appropriately, position themselves, understand
the arm placement, so forth. It can do these well and
I think most individuals including most older individuals can very appropriately monitor
their own blood pressures. And I think having this, it’s
part of the engagement process but for the 20 to 25 percent, particularly as we get
into the older individuals that probably do have a
significant office effect, I think it’s really
important to identify that. While we said for many
years that their prognosis was based really on the office and not on these
self-measured blood pressures, enough studies have been done, enough time has gone by that these self-measured blood pressures appear to be at least as
important prognostically as the office blood pressure. So I think if an individual
has the proper equipment, receives proper instruction, that there’s very important
prognostic information as well. And so while there’s arguments about how benign “office or
white coat hypertension” is, we know that it’s significantly less risky than having the high
blood pressure at home. In fact, individuals with non-hypertensive office blood pressure that have a hypertension
home blood pressure basically have the same prognosis as individuals with high
blood pressure in the office and high blood pressures at home. It’s called masked hypertension. So again, getting people to
self-monitor blood pressure even if they have a
non-hypertensive reading if that reading is elevated at home it identifies a higher risk individual. And so one that we the
clinicians may think about, increasing the risk factor management. You mentioned already the ASCVD risk atherosclerotic
cardiovascular disease risk being part of the cholesterol guideline. And so I think it’s so
important to mention with the new guideline, saying that if they’re 130 to 139 they have to have at
least a 10 percent risk of cardiovascular disease all of those patients should be candidates for statin therapy, under both the 2013 and the 2016 cholesterol guideline. And what we know is for many patients the benefit of treating
both the blood pressure and cholesterol on reducing cardiovascular
disease is additive. So if we get a 25 percent or so reduction by treating blood pressure and 25 percent reduction with statins we get roughly a 50 percent
reduction by using both. And so I think that’s
also an important part so we’re not wasting
time calculating the risk if it’s greater than 10 percent, they’d qualify under the 2016 guideline if it’s greater than 7.5 percent with cholesterol’s in that 70 to 189 or 70 or higher range, they’d qualify. So the vast majority of
individuals that qualifies having hypertension
under the new guideline qualify for treatment
would also be qualified to receive a statin. And we know that there are
25 million plus Americans who qualify for a statin today that are not receiving that. If they were receiving those statins we could prevent nearly 200,000 cardiovascular events per year. So while we’re talking
about blood pressure, recognizing that virtually
all of these individuals would also qualify for a statin with enormous projected benefits. – It’s great to see the crossover as well between the lifestyle interventions that are beneficial for blood pressure management or prevention, preservation of cardiovascular health really and cholesterol lowering or
cholesterol management as well. There’s a couple of other questions we have coming in from
state partners as well. So Sarah E., Julie can you go
down a little there please? Thank you so much. Sarah E. Tharlacker from Washington state. I think this is a great question as well because it’s one we struggle with. When will providers be expected to adhere to or implement new guidelines? They were just released
November 13th I believe and we’re less than a
month away from that. – Yeah that’s gonna be interesting. A number of the physicians we work with have been convinced for many years that lower targets are better so have already been doing that. There are some that
have been more skeptical I think that are more concerned about the adverse effects in truly. Whenever we make a more
intensively treated group we see more adverse effects. You see more significant
electrolyte abnormalities, you see more emergency department visits. So there is a trade off. But I think the decision
of a very thoughtful group that got together and
considered these issues for many, many months was that the balance would suggest that
treating to a lower target in getting the blood
pressure for hypertensives as a group in that range of 120 to 125 between 120 and 125 on average
is the optimal range to be. I think we have a lot
of data to suggest that. That does not mean that every individual be 120 to 125. But probably at least half
of individuals will be maybe in that range or a little higher about half the individuals
would be a little lower. But on average, that 120
to 125 range seems good. As I mentioned earlier today, since 1999 if we look at
treated hypertensives in the US we’ve actually achieved the
blood pressure less than 140. The average since 1999 has
been in the 120 to 124 range and so that has been achieved in fact, when we’re able to get the
blood pressure under 140. So I think that brings a
little more attention to that. But I think it also you know particularly as we get
into the older years, we need to be a little bit on guard because we will have some individuals below 115 and below 110. So as we aim to get the population into that 120 to 124 range we’re gonna have individuals that are clearly lower than that and some that are higher than that. Particularly in older individuals with partial clogs to the arteries. There may be some issues there. But again I think the self-monitoring, the followup can make
this a safe proposition. – And the, many will relate that as well to performance measures within the 2013 cholesterol guidelines for so long we’re looking at thresholds, LDL levels, specific components within that LDL profile, switched over to eligible populations. And so we really had to look at how we’re doing surveillance. I think it changed a lot
about how we even looked at performance measures as well as it relates to how well
you’re managing cholesterol within a population. Because it’s not you’re
trying to push an individual down to a certain threshold, but you’re trying to put that individual that’s eligible on that medication for the beneficial effects of it. And so as we look at hypertension now, lower thresholds, we have
subgroup that is now eligible for non-pharmacologic interventions. And so the incorporation of that into a new performance measure will take a little time as well for it to be developed,
for it to be endorsed and put out and then captured by insurance world for
reimbursement as well within health systems. So how long would you
anticipate that happening? Or how long would it
be until you’re really seeing the effects of these guidelines as it relates to impacting
the performance measures? – You know it will be
interesting to see but certainly if it does change into
NCQA type guidelines and what happens now is health systems and individual clinicians get graded on those guidelines, the more and more transparency so that the consumer can see what those performance levels are. And right now I mean American Heart under their target BP program had targeted control rate of
80 percent to less than 140. That now becomes 80
percent to less than 130. The one concern I have is we aim for those very high control rates, we then have to push the mean lower and lower to get higher control rates. So basically blood pressure
is a variable quantity and so people that are familiar with means and standard deviations and blood pressure doesn’t
follow that exactly because there’s always
skewings in the upper end. But if we say the mean
that we’re achieving for the optimal range is
120 to 124, we just said. If we get 80 percent control rates to less than 130, well
the standard deviation of even eight millimeters, which is probably on the low side, is probably gonna be closer to ten. So 80 percent or so means that we have to get one and a half standard deviations below the target. So if it’s 10 millimeters for example and the goal is 130, we’ll need to get the mean down to 115. If that makes any sense at all to those that are listening because the issue is blood
pressure is not a fixed quantity. We cannot regulate the blood pressure of an entire group of
patients to 120 to 125. It’s even very difficult to
regulate the blood pressure of individual between 120 and 125. And so again clinicians
currently are judged only on the last blood pressure
measurement of the year. So if you need to be
sure that your patient has at least an 80 percent chance of being controlled in the last visit of the year, then you also need to
get the blood pressure of that individual on average probably at least one and
half standard deviations below the target. And I think sometimes
that’s not appreciated in the writing of the guidelines. I think the guidelines
are based in the evidence. The problem is when we translate that into a metric, it becomes something that we grade and pay health
systems and clinicians on. So my only concern and this
is my only real concern with the guideline is
how that’s translated. What I would suggest is it would probably be safer if we could judge control other than just the
last visit of the year. I think we need to look as
we update the guidelines and aim for these lower targets to maybe think about broadening that out. Now the guideline was developed in 1999 when a lot of practices didn’t
have electronic records. So you had to do chart review. Today with electronic
records, it’s very easy to quickly find all the blood pressures that have been entered into that record. And so we can look at other criteria to judge the control and maybe not have to push the mean so low to achieve these high control rates the systems are going to be graded on. – Really appreciate your perspectives and opinions on that area. We have another question that
would be relevant as well. I found this as a relevant component within the guidelines as well as I was looking for a lot things I think that you were speaking to as it relates to translation
of these guidelines as well. And so you mention before
masked hypertension, white coat hypertension, there’s sustained hypertension, there’s a couple of great figures within the guidelines that
look at how to compare those in the clinic, out of the clinic and there’s even thresholds as well that are included within the guidelines for different cut points as it relate to how mask hypertension or white coat hypertension would be diagnosed within
those different settings using out of office blood
pressure measurements as well. But another component that I saw was the incorporation of accurate
blood pressure measurement. I know you’re passionate
about that as well and we’ve looked at different
ways to do this as well. I mean validated instrument, having those regularly
updated as well and managed and E. Spalding as well,
I don’t know what state that individual is from, it’s a bit of a long paragraph but I’ll try to read through it. Would the change in the numbers or percentage of people
who are now considered to be hypertensive, is there a prediction you’d like to share about how these
numbers may be affected as clinicians pay better attention to accurate blood pressure measurement? And so as a clinician himself, they have to admit that they don’t follow accurate
blood pressure measurement protocols which really impacts accurate diagnosis and measurements. We see that within
surveillance, within NHANES and having that very
standardized approach. Having worked in clinics myself for a number of years as well, having seen extreme variation across those when they get taken in at the triage area to when they get back at the back office as well. So can you speak a little bit about accurate blood pressure measurement and how you’ve incorporated that or looked at that within South Carolina? – Yeah we’ve worked with
many of the clinics. It takes a little bit
of practice re-design for many of them. It changes the workflow processes a bit because I think folks are accustomed to getting quite a bit
of medical information, there’s time pressures,
not only on the clinicians but some of the office staff. And so to work through
with them some efficiencies they can gain, I think as a nation we should probably invest more to getting really good health system engineers into our practices to help them to find those times and to be able to do things in the right way. I think we ask practices
to do and clinicians to do a lot of fairly low value services and I think we need to figure out how to focus on those services that drive the outcomes
of interest the most. I think too often we’ve driven things by p values that may have little impact on the variance of outcomes. You’ve got a large population you have significant finding that drives a half of one percent of the variance in the outcome. But the clinics can do
that almost perfectly and almost not move a needle. We need to find those things that count for five, 10, 15, 20 percent of the variance in outcome and make sure those
things receive priority. And I don’t think we’ve done
a very good job of that. And in helping individuals, because here’s what we’ve observed working with a lot of practices. There are some that have people with excellent organizational skills, excellent efficiency, those practices often operate efficiently. There’s not necessarily
a part of the training of healthcare professionals to have this organizational efficiency. And so the variation between
practices can be tremendous even if they’re part of
the same healthcare system. So I think finding ways to share those best and most efficient practices across clinics. We’ve encouraged a lot of practices to do the automated office blood pressure which is written out with
the five minutes of rest then just getting patients into the clinical room by themselves. Putting on an accurate automated monitor, leaving the office or room for three to five minutes while three pressures
are taken and averaged. We know for most people that’s
a much better reflection of their usual daytime pressure than the way we typically
take an office blood pressure. What it requires is that
person knows exactly what they’re going to do
with that five minutes out of the office so
they’re not losing time. That requires a little bit of
thinking and reconsideration. And we go into practices, we often saw this as we bought them lunch and asked if the critical staff had a
chance to talk about it and think about how they could re-do it. We saw the arms come unfolded, much more engagement. I would say 19 out of 20 times, the staff would think about how to do that and still get all of their work done. And now a little bit of reinforcement because the tendency is to return to previous patterns that requires a little reinforcement from time to time until it becomes more of a habit. But what I’m saying is
I think it’s difficult to implement on a dime. But if we allow the staff to think about how a better process could be implemented, you allow them to think about how they’re going to be able
to get their other work done. What we’ve seen is the
majority of practices can figure out how to do it. And they need some periodic reinforcement because the tendency is to return to the previous condition. But it can be done. We’ve seen a lot of practices successfully make that transition. And it’s a big part as you
see of measuring accurately because if we’re including an office or white coat artifact, we’re obviously gonna have
a lot more people to manage. And so we want to try as we can so here’s what I say and this is off note I’ll say this clearly. We want to do two things with
an office blood pressure. First of all, we want it to reflect the pressure that’s in the artery. I refer that to as accuracy. We’d also like that pressure in the office to reflect the average pressure outside the office. I call that representative. So we want both an accurate and a representative blood pressure. Now interestingly, not
only does this automated office blood pressure appear to reduce the white coat effect, strangely enough it also appears to reduce the masked hypertension effect. So in both directions, not always, but it’s significantly better than the usual office blood pressure. That’s why we’ve been encouraging more and more practices to figure out how to implement this automated office blood pressure technique. Now I think it was wise
of the guideline writers not to mandate that. They basically assumed it will continue to measure blood pressure in
more of the usual office way. But I think as time goes on, we need to work with practices, help them redesign, help them to focus on the things that really drive variance in outcomes. And maybe ask them to
do less, for example, if most of us go into the physician, do you get your temperature taken? I mean I often get my temperature taken. Well, it takes probably longer to measure temperature than to take my waist circumference. How many of you get your
waist circumference measured? Waist circumference turns
out to be about as important as systolic blood pressure
in cardiovascular risk. Now if I don’t go in with
a cold or flu or something do I need temperature? I’m just saying. And that’s just one example. But again I think if we,
and there’s some very good, health system engineers that do healthcare right here in Atlanta. At Georgia Tech, you’ve got some of the best people in the world doing this and I think we need to get them into the practices and
convey their insight because they can really help our practices redesign for efficiency to make sure we get the important
things done and done well. – I think that is another,
I keep bridging back to hypertension guidelines looking for these translation points. These little lighthouses along the way where I’m trying to pull out I guess relevant things that
came out to me for that. And so the strategies to
improve hypertension control include several of those as well. The incorporation of
electronic health records, the performance measure incorporation, accurate blood pressure measurement, and then a lot of the quality
improvement initiatives you’ve been discussing as well as it relates to
self-measured blood pressure, team based care, pharmacy
incorporation and others. There was actually a recent publication by the Division for Heart
Disease and Stroke Prevention as well of best practices for cardiovascular disease
prevention programs. That was released that
includes a lot of conversations or relates to what are really the evidence based interventions that can be done and programs to move the needle for
some of these interventions and so it relates definitely
to this conversation. One of the other individuals from our state partners as well made reference to this idea
of hiding in plain sight and said that individuals
with undiagnosed hypertension may be lurking in the
health care environment may be regularly seen by
their healthcare providers or have a touch points with that. I believe it was Tarik Ego from Colorado. Again as this relates to
that hiding in plain sight or identifying those
undiagnosed individuals we would anticipate
that this would increase as there’s more individuals then as the threshold moves lower that would fall within these categories of elevated blood pressure
and stage 1 hypertension that would need intervention as that would relate to
significant burden potentially within the healthcare
system and the environment. What are some of your
ideas or recommendations as it relates to really capturing this in a large population, as it relates to the healthcare environment
but potentially even to our clinical, community
partners as well? – Well I think you
raise an important point and I think a lot of folks
that have high blood pressure or interested in your blood pressure find ways to get blood pressure
measured in the community. I think certainly that
we know there are several pharmacies that include automated devices. Some of these actually been
a lot of work put into them, some of them actually do quite a good job of measuring the blood pressure accurately and getting relatively
representative blood pressure. I think we need to standardize
those best practices as we said the self-monitoring. But the hiding in plain sight I think is an interesting issue. As we’ve looked at the NHANES data, more often these are the individuals that don’t get necessarily two visits to primary care a year. They have insurance, many of them, they actually get some care, but what we’ve found is if they have less than two visits a year,
the likelihood that they’ll be aware is down, the likelihood that they’ll be treated is significantly lower, the likelihood that they’re
going to be controlled. Now as time has gone on, we’ve made the healthcare system
more and more responseful, getting those patients in
an adequate number of times. But I said we’re already burning out our primary care workforce so I think we also need
to educate the individual about the importance
of if you are concerned about the pressure, if you’ve
had an elevated reading, know your numbers, it’s important to get into the healthcare system. Now as time goes on, time is precious I think we can do more of this
out of the office context. I mean I don’t think
it necessarily requires an office visit, which I
think would really help the situation. If we can get accurate,
representative pressures outside the office and
we’ve done an evaluation at one point to know what
additional risk factors or other health problems exist, a lot of this can be done with smartphones or email or other secure
messaging processes. I think typically for
individuals under the age of 65 that are still employed
and there’s an issue with taking a half day or day off of work for a medical visit. But a lot of the problems are related to the frequency of visits. And when a patient is uncontrolled, we know that if we can get individuals in on a more regular basis, preferably monthly, but at
least every other month, the likelihood of attaining
control is better. Now if that can be done, as I say, text messaging or other means, I don’t think it necessarily
requires an office visit. I think that’s something
else we looked at. The need is to more systematically re-engineering our healthcare system to create those contact or touch points that allow a successful move from an elevated to control
blood pressure value. I think they’re going to
be a lot of opportunities. I think the technology to
support that is improving. I think the understanding
of our population use the technology to achieve good results without necessarily
making a physical visit to a fixed location will really help us in controlling some of these
things like hypertension. – Yeah I think that the idea that community clinical linkages which has been a catch
phrase for many years now I think is going to continue to be an important component
of hypertension management and prevention as we move forward as well. That’s excellent as it relates to that. Well any other items
today that we didn’t cover that you captured from your read of the hypertension guidelines that maybe I didn’t touch on may be interesting for you to point out. I’ve been asking the
questions the last hour, pulling it in from our state partners, but is there anything
you saw from your read of the hypertension guidelines that you really felt was
just an interesting component or a new component that would be relevant for clinical practices? – I think one thing that was interesting was this actually quite a long guideline if you look at it, it’s
several hundred pages but I think one thing they did was bringing in the guidelines for things like stroke and
ischemic heart disease, and heart failure and so many of the hypertensive patients not only have these conditions but they may have depression,
COPD, and other things. Beginning to recognize that hypertension rarely occurs in isolation. And we need to think about
the integrated management of chronic diseases in our
hypertensive population. I mentioned earlier
today the average patient with heart failure has about
ten chronic conditions. And again when we focus
on what are physicians supposed to do with the hypertension, we sometimes lose sight of the fact that this clinician is also being asked to manage nine or ten
other chronic conditions. So beginning to bring
that into the guidelines and hopefully over time, making that integrated so it’s
a little bit more efficient. We maybe need to think about fewer visits but longer visits. I mean and more of these using other ways of taking care of this so that we actually allow efficient and effective care to occur. The other thing I think
is worth mentioning it’s I don’t mean to be political on this, because I don’t think it really is, but what we know that uninsured patients in this country with hypertension, when we looked at the data, you know we look at the NHANES
data fairly frequently, did not have an improvement in blood pressure control
since 1988 to 1994. While the insured
population had a 22 percent absolute improvement in
blood pressure control. And so it didn’t seem to matter whether they had public insurance or private insurance, it’s either. So whether you like public
insurance or private insurance, doesn’t seem to really matter. Having health insurance
was the key variable. And so people who don’t
have health insurance they made fewer visits, they were less aware
of their hypertension, less likely to get it treated and less likely when treated,
to have it controlled. And each of those
contributed roughly equally to the poor hypertension control. So whether you’re for private insurance or public insurance, I think the key is to
provide enough insurance to people with risk have access to the healthcare they need to have their condition
diagnosed and treated to goal. And so it’s extremely important, so if we have no improvement over 25 years in uninsured individuals,
we need to look at that. – Excellent. Well there’s
many relevant resources as well that I just
want to briefly mention that the Guide to Community
Preventative Services or the Community Guide has a lot of evidence-based interventions that relate to a lot of the components that we talked about today. The out of office blood pressure, reduced out of pocket costs, in particular, self-measured
blood pressure, the Million Hearts Initiative has a lot of resources as well
that would be relevant for this conversation hiding in plain sight. A lot of resources related to that. Change package is another. So just really a lot of rich resources that are available for state
and local partners as well. A lot of time and energy and it had been well-informed by a lot of its partners as well, including yourself, so Dr. Egan we just really appreciate your time today with at Fireside Chat. Thank you so much for coming to CDC today and we’re just really pleased that you’re able to have
conversation with us today. And we’ll get you back over to Julia to wrap up the webinar. – [Julia] Great thank you so much. We really appreciate
everyone joining us today. As you can see on your screen, this event will be recorded and housed on NACDD’s
cardiovascular health website and we’ll be promoting that link to our off the cuff newsletter. On Monday, you’ll also be receiving a link to an evaluation and we really appreciate your feedback. Thank you again for joining us today and with that we will
close the Fireside Chat. [Applause]

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