American Heart Month, which annually aims to increase awareness of cardiovascular health, has an extra degree of urgency in 2021, owing to the impact of coronavirus disease 2019 (COVID-19).

According to the Centers for Disease Control and Prevention (CDC), hypertension is a primary or contributing cause of death for nearly 500,000 people annually in the United States. Approximately 45% of US adults have hypertension — defined as systolic blood pressure (BP) ≥130 mm Hg or diastolic BP ≥80 mm Hg — or are taking medication for hypertension.1

​“It is important that patients understand what having hypertension means and what the implications are of having uncontrolled BP,” Nancy T. Artinian, PhD, RN, FAHA, FPCNA, FAAN, told Cardiology Advisor. Dr Artinian is a visiting professor at the Michigan State University College of Nursing in East Lansing, Michigan.

Hypertension is more prevalent in men vs women (47% vs 43%, respectively), and more common in non-Hispanic black adults (54%) than in non-Hispanic white adults (46%), non-Hispanic Asian adults (39%), or Hispanic adults (36%), according to the CDC.1 Among individuals for whom BP medication is recommended, BP control is higher among non-Hispanic white adults (32%) than in non-Hispanic black adults (25%), non-Hispanic Asian adults (19%), or Hispanic adults (25%).1


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“Developing a culturally sensitive relationship with the patient, so that patients are comfortable asking questions, and stating concerns or barriers that they may be facing is critical,” remarked Dr Artinian. “Working with the patient to set a BP goal, suggesting activities for them to try to achieve that goal, following-up on a regular basis to discuss progress, and working to overcome any barriers are also essential.”

A number of clinical resources are available to help clinicians provide care and support for their patients with hypertension and encourage them to adopt healthy lifestyles.

Hypertension Resources for Clinicians From the CDC

The CDC has made resources, graphics, and social media messaging on hypertension available to healthcare professionals. The CDC’s Clinical Resources for Hypertension Control toolkit provides information on medication adherence, standardization of patient care, self-measured blood pressure (SMBP) monitoring, patient lifestyle changes, and identification of patients with hypertension.2 The toolkit was designed to help clinicians implement protocols, leverage patient data to improve health outcomes, and learn from success stories of their peers.

These tools can be used together with hypertension control strategies described in the Surgeon General’s Call to Action to Control Hypertension, in which evidence-based interventions for controlling the adverse effects of hypertension are formulated.3 The Call to Action summarizes the current state of hypertension control, including related economic costs and disparities across population groups, and presents goals to support improved hypertension control at the population level.

The CDC’s Million Hearts 2022 national initiative also has clinical tools available for hypertension control and focuses on implementing a set of evidence-based priorities and targets that can improve patients’ cardiovascular health. The initiative’s Hypertension Control Change Package (HCCP) provides process improvements that outpatient clinical settings can implement when striving to achieve optimal hypertension control for their patients, as well as evidence- and practice-based tools and resources.4

Other Hypertension Resources

The National Heart, Lung, and Blood Institute provides an American Heart Month outreach toolkit of educational materials that promote healthy lifestyles to prevent heart disease, including fact sheets, social media resources, PowerPoint slides, and flyers.5

Hypertension guideline resources for healthcare professionals are also available from the American Heart Association (AHA) and include information on topics that include accurate BP measurement, a BP treatment algorithm and a hypertension guideline toolkit for pharmacists.6

SMBP Monitoring at Home

Increasing research indicates that SMBP monitoring and clinical support can help patients with hypertension lower their BP.

“SMBP monitoring is very effective, often reflecting a patient’s true BP status, since office BPs may be associated with ‘white coat hypertension,’ which increases the risk for false-positive diagnosis of hypertension and needless prescription of medications,” noted Dr Artinian. “SMBP is associated with BP reduction and improved BP control.”

Telemedicine use has increased during the COVID-19 pandemic. Patients with hypertension are at increased risk for COVID-19 infection and severe complications, and many patients with symptoms of heart attacks and stroke have delayed or avoided going to hospitals during the pandemic.

COVID-19 may increase the use of SBPM since it is not as easy for patients to get to their physician’s office these days, and they are relying on telehealth appointments,” said Dr Artinian. “SBPM allows patients to provide critical information about their BP to allow physicians to manage BP while they remain at home.”

The Million Hearts initiative has 4 unique guides for SMBP: action steps for public health, action steps for clinicians, engaging patients in self-measurement, and an interactive infographic for clinicians.

The Action Steps for Clinicians guide was designed to facilitate the implementation of SMBP with clinical support in 4 key areas: preparing care teams to support SMBP, selecting and incorporating clinical support systems, empowering patients, and encouraging health insurance coverage for SMBP with additional clinical support.7

The guide also includes appendices with information on appropriate SMBP preparation, clinical support interventions for SMBP, the proper way to check a home BP monitor for accuracy, and the burden and cost of hypertension.

“Clinicians are key to the widespread implementation of SMBP with additional clinical support,” note the guide authors. “Although public education campaigns can encourage patients to monitor their BP at home, clinician support is critical for empowering patients, training them on proper measurement techniques, monitoring home readings, and providing timely advice on needed medication titrations and lifestyle changes.”

AHA/AMA Joint Policy Statement on SMBP Monitoring

In 2020, the AHA and American Medical Association (AMA) published a joint policy statement on SMBP monitoring at home, as evidence indicates that this practice may be associated with health and economic benefits.8 The effectiveness of SMBP was reviewed, existing barriers to the widespread implementation of its use were identified, and recommendations to address those barriers provided.

One barrier to SMBP monitoring lies in the small number of private and commercial payers and Medicaid plans that provide coverage for this practice.

“The barrier of lack of reimbursement is slowly being addressed,” said Dr Artinian, who is a co-author of the 2020 AHA/AMA policy statement. “There are new current procedural terminology codes for SMBP monitoring, as of January 1, 2020. Educating providers about the effectiveness of SBPM and having reimbursement policies that are familiar and clear to providers may help.”

Lifestyle Changes and Ongoing Support

Lifestyle changes, including exercise, maintaining a healthy diet, quitting smoking, reducing sodium intake, limiting alcohol consumption, and reducing stress, are all important components that can help patients reduce their BP.9 Family support and regular visits with a healthcare provider are also key to controlling BP.

“Consistent follow-up over time is important,” said Dr Artinian. “Behavior change that is necessary to maintain a controlled BP takes time.”

References

1. Centers for Disease Control and Prevention. Facts about hypertension. https://www.cdc.gov/bloodpressure/facts.htm. Updated September 8, 2020. Accessed February 5, 2021.

2. Centers for Disease Control and Prevention. Clinical resources for hypertension control. https://www.cdc.gov/heartdisease/american_heart_month_clinical.htm. Updated January 19, 2021. Accessed February 2, 2021.

3. Centers for Disease Control and Prevention. The Surgeon General’s call to action to control hypertension. https://www.cdc.gov/bloodpressure/docs/SG-CTA-HTN-Control-Report-508.pdf. Updated October 2020. Accessed February 2, 2021.

4. Million Hearts 2022. Hypertension control change package, second edition. https://millionhearts.hhs.gov/tools-protocols/action-guides/htn-change-package/index.html. Updated June 22, 2020. Accessed February 2, 2021.

5. National Heart, Lung, and Blood Institute. Outreach toolkit. https://www.nhlbi.nih.gov/health-topics/education-and-awareness/heart-month. Updated January 27, 2021. Accessed February 2, 2021

6. American Heart Association. Hypertension guideline resources. https://www.heart.org/en/health-topics/high-blood-pressure/high-blood-pressure-toolkit-resources. Updated October 26, 2018. Accessed February 2, 2021.

7. Centers for Disease Control and Prevention. Self-measured blood pressure monitoring: action steps for clinicians. https://millionhearts.hhs.gov/files/MH_SMBP_Clinicians.pdf. Updated December 2014. Accessed February 2, 2021.

8. Shimbo D, Artinian NT, Basile JN, et al. Self-measured blood pressure monitoring at home: A joint policy statement from the American Heart Association and American Medical AssociationCirculation. 2020;142:e42-e63.

9. Mayo Clinic. 10 Ways to control high blood pressure without medication. https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/high-blood-pressure/art-20046974. Updated January 9, 2019. Accessed February 5, 2021.

This article originally appeared on The Cardiology Advisor