PCNA’s Role in the New Hypertension Guidelines: An Interview with Cheryl Dennison Himmelfarb

Cheryl Dennison Himmelfarb, RN, ANP, PhD, FAAN who is Associate Dean for Research and Sarah E. Allison Endowed Professor at Johns Hopkins was a member of the American College of Cardiology (ACC)/American Heart Association (AHA) Hypertension Guidelines¹ writing committee. Early in the process, the ACC and AHA worked with a number of partner organizations that they felt would be key in the development and dissemination of the guidelines, to facilitate getting them out into the hands of the clinicians who provide the majority of care in hypertension. Cheryl was appointed as a representative of PCNA to inform the development and as well as the dissemination of the guidelines. Cheryl agreed to an interview with PCNA.

What in your background specifically helped you focus on the need for these new guidelines and the writing of these new guidelines?

“I previously worked as an Adult Nurse Practitioner – in primary care and preventive cardiology, and for the last twenty years have been involved in research to improve the quality of cardiovascular care. I have focused quite a lot on improving quality of care and outcomes for hypertension particularly among low income and other vulnerable populations.”

What was the nature of the writing team?

“It was a very complimentary team that consisted of a number of specialists in hypertension: individuals who had decades of experience in hypertension research as well as primary care expertise and a wide variety of specialties such as geriatrics, nephrology, and neurology for the stroke outcomes. Although the group consisted primarily of physicians, I was there as a nurse and Nurse Practitioner, with a Pharmacist and a Physician’s Assistant on the committee as well. The committee also included two individuals to represent the lay public perspective. So it really brought some very complementary expertise and experiences to the committee.”

What was the process?

“The goal of the guideline was ‘Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults.’ So there certainly was an important focus on prevention as well as it being an evidence-based document intended to guide hypertension detection and management. In addition to randomized controlled trials as a source of evidence, we also included epidemiological studies and other observational studies as well, to guide the recommendations. And as we looked at trials of strategies to reduce blood pressure we did look at, importantly, impact on outcomes, such as: reducing heart attack, stroke, and coronary artery disease–so the goal not being simply to control high blood pressure but to prevent the consequences. Concentrating on those strategies that are most effective in reducing those consequences of uncontrolled high blood pressure.”

Can you comment on the nurses’ role in prevention and management of hypertension based your work on the writing team?

“I think nurses play a critical role and I applaud the American College of Cardiology and the American Heart Association because recently they have been much more attentive to ensuring that nursing expertise is represented on guidelines and position statement writing panels. I think our role is critical, if you look across the nation nurses are providing care to a majority of those with or at risk for hypertension. Nurses are really at the forefront, especially if you also consider the broad roles of nurses which often include the roles such as office manager, coordinating office activities, and quality improvement activities within primary care settings as well hospital-based settings. But a lot of hypertension management occurs in the primary care setting. And then looking at nurse practitioners and the role of advanced practice nurses in managing populations with hypertension. Nurses are critical, and a very strong body of evidence exists supporting the effectiveness of nurses and nurse-managed care for hypertension and nurses as members of team-based care.”

What is the unique nursing perspective related to the new Hypertension Guidelines?

“Nurses understand the need to and how to involve patients in shared decision making, so that we are promoting adherence and lifestyle changes that are essential for achieving blood pressure control. Nurses play a critical role and bring expertise that many most physicians do not have.”

What unique contributions did you make to the discussion as a nurse and one focusing on prevention?

“I contributed to quite a lot to the guideline sections focused on strategies to improve hypertension control including team-based care, quality improvement strategies, health informatics-based approaches, as well strategies to promote adherence. I think those were areas where I brought valuable expertise that added to that of the committee.”

What impact will the guidelines have in your opinion?

“The guidelines have really provided a platform for a lot of discussion and debate about what the definition of hypertension should be. How low should we go? I think that there is great potential to improve the cardiovascular health of our nation by raising awareness of the risk associated with uncontrolled high blood pressure much sooner for most individuals. Importantly, there is a lot of discussion about how many people will be on blood pressure lowering meds now. But the reality is the majority of individuals who are newly diagnosed with hypertension based on the new definition of high blood pressure, the majority will be recommended for lifestyle modification only. A smaller proportion will be prescribed medication in addition to lifestyle modification. I think that is a very positive direction and again, has great potential to improve the cardiovascular health of our nation by raising awareness and changing behaviors much sooner–and hopefully avoiding many of the consequences of uncontrolled high blood pressure like heart attack, stroke, and renal failure.”

How easy is it for nurses to focus on prevention using the new guidelines?

“There is an important focus on accurate blood pressure measurement as well as the value of home blood pressure measurement. And so those are two areas that are highly relevant to nursing. The better we understand accurate blood pressure measurement the better for our patients. An important nursing role is how we support our patients in ensuring that they are measuring their blood pressures at home accurately and they know what to do with that information. Then another important new piece related to prevention is the new risk-based approach to management of hypertension, which is new in this guideline. It requires that we ensure that our patients are aware of their level of cardiovascular risk. So not just their blood pressure level, but what is their ASCVD risk score, which provides us with a nice data point on which to base our discussions, our patient education, and our counseling to help patients adhere to any recommendations or determine what changes are they willing to make. We try to help patients to understand the benefit of making positive changes in terms of reducing their risk.”

Any concluding remarks?

“It’s been a wonderful experience for me; a very valuable, positive professional experience to be able to participate as a member of this committee and to know that I did make very valuable contributions to a guideline that has potential to be implemented broadly to improve cardiovascular health. In including nurses, the ACC and AHA have set a tone communicating that nurses are critical to the work of hypertension prevention and management.”

1. Whelton, P.K. et al.(2018) 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Journal of the American College of Cardiology, 71 (19) e127-e248; doi: 10.1016/j.jacc.2017.11.006