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How Can We Improve the Management of Patients with Hypertension?

Joseph S. Alpert

Joseph S. Alpert, MD

Hypertension continues to be a major health problem in the United States, affecting more than 76 million US citizens. Despite marked improvement in detection and therapy of patients with hypertension over recent decades, substantial morbidity and mortality still occur, especially in the Southeastern United States. Hypertension detection programs are common throughout the country and can even be found these days at shopping malls and churches. The extensive array of effective medications available for the therapy of hypertension has markedly improved the percentage of patients with effective control of elevated blood pressure not only in the United States but throughout the world.1

However, adherence to recommended medical therapy remains a problem, particularly because lifelong therapy for hypertension is almost always required. In recent years a number of innovative venues have been developed in an attempt to improve patient adherence to evidence-based lifestyle and medical therapy. Bobrow et al2assessed the effect of automatic treatment adherence support messages delivered via cell phone. Short personalized messages were repeatedly sent to patients reminding them about their condition and prescribed therapy. Some patients were additionally enrolled in a substudy involving cell phone interaction with a member of the research team. These investigators noted small improvements in blood pressure control with and without active interaction from the research staff. Tsuyuki et al3 in Alberta, Canada and Hedegaard et al4 in Denmark tested the effectiveness of a pharmacist-led intervention on blood pressure control in adult patients with hypertension. The Canadian group observed a clinically important and statistically significant reduction in blood pressure with the pharmacist intervention. The Danish group noted considerable improvement in adherence to prescribed antihypertensive medication consumption, but unfortunately there was no significant impact on blood pressure control or clinical outcomes.

McManus and coworkers in Oxford, England performed a randomized trial testing self-monitoring and self-titration of antihypertensive therapy in 278 patients compared with usual care in 277 patients. Self-monitoring and self-titration resulted in significantly better control of blood pressure at 12 months.5 Finally, Uhlig and colleagues undertook a systematic review and meta-analysis of studies on self-measured blood pressure monitoring with and without additional support, such as cell phone reminders and pharmacist interventions, in the management of hypertension. Their analysis demonstrated that self-monitoring of blood pressure with or without the various supporting venues just mentioned significantly improved blood pressure control compared with usual care.5

In this issue of the American Journal of Medicine, Milani et al at the Ochsner Clinic in New Orleans contrasted blood pressure control in a group of patients using commercially available digital products specifically designed to improve medication adherence and hence control of hypertension.6 These patients were compared with a large number of usual-care individuals matched for age, gender, and body mass index. The digital hypertension control intervention significantly improved blood pressure control, thus confirming what was noted in the reports from the medical literature cited above. The digital intervention devices were well accepted by the patients.

The “take home” message for me from this study and the others just reviewed is that in the 21st century, physicians should be encouraging their patients to purchase self-monitoring blood pressure devices, and if adherence to medical therapy still seems less than adequate, then additional measures, such as the digital applications studied by Milani et al, or another support intervention, such as a pharmacist-run hypertension clinic, should be sought.

As always, I welcome communications about this editorial on our blog at www.amjmed.org.

 

To read this article in its entirety please visit our website.

-Joseph S. Alpert, MD (Editor in Chief, The American Journal of Medicine)

This article originally appeared in the January 2017 issue of The American Journal of Medicine.

One Response to “How Can We Improve the Management of Patients with Hypertension?”

  1. Dr Alpert makes a compelling case for self-monitoring of blood pressure that may be particularly helpful in those suffering from “dietary” hypertension (1, 2). Adherence to the Dietary Approaches to Stop Hypertension (DASH) diet has been shown to be effective for controlling hypertension, but multivariate linear regression does not identify the precise cause (3). IF, sustained hyperglycemia variably increases blood viscosity and blood pressure, then checking pre- and post-prandial (1-2 hours), blood glucose levels will enable a patient to titrate their diet and exercise against their blood sugar. A bowl of breakfast cereal may cause a sustained blood glucose of 12mM per litre and a BP of 150/100 mm that persists for 4 hours, whereas a dinner of vegetable curry may only cause a peak blood glucose of 6-7mM per litre and postprandial BP of 130/85 mm. Clearly, the precise effects of such dietary dosages of carbohydrates will vary within, and between, individuals, their glycogen stores, adrenaline levels, exercise etc. though they are displayed in real time by a simple, home glucose monitor enabling precise control.

    Self-monitoring technologies are simple, accurate and well-established; they provide the basis for “precision, lifestyle, medicine” particularly in preventing type 2 diabetes, hypertension and cardiovascular disease.

    References

    (1) Alpert JS.
    How Can We Improve the Management of Patients with Hypertension?
    Am J Med. 2017 Jan;130(1):1-2.

    (2) Rebholz CM, Crews DC, Grams ME, Steffen LM, Levey AS, Miller ER, et al.
    DASH (Dietary Approaches to Stop Hypertension) Diet and Risk of Subsequent Kidney Disease.
    Am J Kidney Dis. 2016 Dec;68(6):853-861.

    (3) Blumenthal J.A., Babyak M.A., Hinderliter A. Effects of the DASH diet alone and in combination with exercise and weight loss on blood pressure and cardiovascular biomarkers in men and women with high blood pressure: the ENCORE study. Arch. Intern. Med. 2010;170(2):126.

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