Assessing our nation’s control of blood pressure: A Q&A

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Whenever you see a physician, an assistant probably takes your blood pressure. But does she tell you what the numbers mean?

The top number, called the systolic blood pressure (SBP), measures the maximum pressure your heart exerts while beating. The bottom number, called the diastolic blood pressure (DBP), measures the amount of pressure in your arteries between beats. Both are important. High systolic and diastolic blood pressure are associated with a higher risk of heart attacks, heart failure, stroke and kidney disease.

But what is considered high enough to treat? I was recently surprised to learn that physicians are still debating the national blood pressure clinical guidelines. To learn more, I spoke with Shreya Shah, MD, a clinical instructor of primary care and population health at Stanford.”

Why have clinical guidelines for blood pressure been controversial?

“Recommendations regarding optimal blood pressure control have shifted over the past decade. In 2003, the recommendations were to target a systolic blood pressure less than 140 for most patients and less than 130 for patients with certain risk factors. In 2014, new recommendations relaxed the blood pressure goals to a SBP less than 140 for most patients and less than 150 for those 60 and above. This was a big change in recommendations and thus sparked controversy.

Newer studies, especially the SPRINT trial, point towards the increased benefits of more intensive blood pressure control. This led to the recent set of guidelines in 2017.

At Stanford, we’re working to bring blood pressures down as close to normal as possible. We are targeting a SBP less than 140 and DBP less than 90 in all patients. But for those with certain risk factors, especially increased risk for heart disease, we may recommend lowering the goal to a SBP less than 130 and DBP less than 80.”

Are these goals being met? What did your latest study find?

“Using a national database, Randall Stafford, MD, and I analyzed patterns of blood pressure control for millions of patients who were treated for hypertension in 2016.

Our study, which appears in the Journal of General Internal Medicine, found that we’re not doing a great job with blood pressure control: 43 percent of hypertension patients had a SBP of 140 or higher and 24 percent of patients had a SBP of 150 or higher.

There were also higher rates of uncontrolled blood pressure among certain demographic groups — blacks, Hispanics and patients with Medicaid. These groups may have had less intensive attention to their high blood pressure for a number of reasons, including less access to high quality care and an inability to afford some medications.”

What can be done?

“Studies have demonstrated that team-based care leads to better improvements in blood pressure when compared to traditional models of primary care. Team-based care for hypertension involves the patient and their primary care physician, as well as other health professionals such as pharmacists, nurses, dieticians, case managers and social workers. Especially for treatment strategies involving health behavior change, physicians may not be as effective as other people whose training focused on these skills.

Stanford has already implemented this team-based care model in our primary-care clinics. And we are looking at other strategies, including helping our patients to be more involved in managing their high blood pressure. For instance, I encourage patients to regularly measure their blood pressure at home. The American Heart Association has resources available with information about choosing a home blood pressure monitor and using the correct home blood pressure technique.

I also encourage my patients to adopt a largely plant-based diet, lose weight and become more physically active. These non-medication strategies can be helpful for preventing high blood pressure, but are also as an integral part of treating high blood pressure.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

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