Hypertension Management: Measurement, Medication Impacts & Team-Based Care

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Geralyn Warfield (host): I'd like to welcome back our audience to our Heart to Heart Nurses podcast. And with us today is Cheryl Dennison Himmelfarb, and I'd like you to introduce our yourself to our audience, please. 

Cheryl Dennison Himmelfarb (guest): It's great to be here with you, Geralyn. I'm Cheryl Himmelfarb and I am a Professor and Vice Dean for Research at the Johns Hopkins School of Nursing. 

I'm very proud to say I am a Past President of PCNA. And my research is in the area of hypertension. And I focus a lot on team-based strategies to improve high blood pressure care.  

Geralyn Warfield (host): Well, hypertension is obviously a huge [00:01:00] issue that affects, I believe it's 1 in 2 individuals, perhaps, across the US or some very large number. 

And I'm wondering what it is about hypertension that makes it tougher sometimes for us to identify and manage. Is it, does it have a lot to do with maybe how we measure it? Or not measuring it properly? What are some factors that affect it?  

Cheryl Dennison Himmelfarb (guest): Wow, that's a great question. I would say one of the challenges with high blood pressure is most people don't know that they have high blood pressure. So, for most people, there aren't any symptoms or signs that their blood pressure is elevated. And so, if we're not screening, there's no way we'll know that an individual has elevated blood pressure.  

And then you brought up another really good point, which is proper blood pressure measurement technique. 

Unfortunately, often in clinic settings, we are rushed and don't take the time to ensure proper blood pressure [00:02:00] measurement technique. And so, our measurements may not be accurate, and that can lead to overestimation of high blood pressure or underestimation as well.  

Geralyn Warfield (host): And so, what are some indications that you might find in clinic for somebody who might have resistant hypertension? 

Cheryl Dennison Himmelfarb (guest): So, resistant hypertension is defined as someone who is on at least three different classes of blood pressure-lowering medications. And they've still not reached a gold blood pressure less than 130/80. Or, someone who's on four classes of meds. And that's considered ‘treatment resistant hypertension’, whether they're at goal or not. 

But there are a number of really important factors that weigh [00:03:00] in as we try to decide whether someone actually has treatment-resistant hypertension.  

One of the most important things, which you've brought up already, is blood pressure measurement. It's really critical that we ensure proper blood pressure measurement in the clinic so that we can have a high level of confidence in the data to drive decisions. 

Some studies have shown that up to 1/3 of individuals who have apparent treatment-resistant hypertension actually just had improperly measured blood pressure. So, they had achieved goal when the blood pressure was measured properly. So that blood pressure measurement technique is, really the kind of the basic foundation for all decisions to be made in [00:04:00] blood pressure management.  

Another really important issue is adherence to medication. So, while we may have prescribed three different classes of medications, it's not unusual that an individual may not be taking those medications as prescribed.  

There are myriad reasons for individuals not taking meds as prescribed. But some data suggests that as many as 50% of individuals actually don't take their meds as prescribed.  

And this can be related to factors such as cost of medications, side effects of medications, time management, just difficulty remembering the meds or fitting a complex medication regimen with multiple pills per day into daily activities, transportation to the [00:05:00] pharmacy to pick up medication refills. So, there are a number of factors that that influence that.  

Another important factor is working…well, it can be a barrier when patients don't expect to have to take multiple medications to get their blood pressure controlled. And so, that brings us back to the importance of shared decision-making and really partnering with patients as we set goals for blood pressure management. And then work with them to understand that actually over half of people with high blood pressure require two or more medications to get to blood pressure goal.  

And so, if people understand that as they're starting their blood pressure treatment, it helps them to understand this first prescribed [00:06:00] medicine, this first prescribed dose, probably won't be enough. In fact, most people need at least two or more meds. 

And so. we've got to work closely to help manage expectations, be clear about what the process is, how will we get there? Well, you'll manage your blood pressure at home, so you know the effect of your blood pressure medications and your lifestyle changes that you are taking to try to get to blood pressure goal. I'll have access to that data. 

We'll also have clinic measurements, and that's going to be driving our decision-making as we decide, do we need to increase the dose? Do we need to add an additional medication? As we're working toward the goal we've set together.  

Geralyn Warfield (host): I really appreciate the fact that you've described the importance of communicating effectively and frequently with patients and setting those expectations and those goals right up [00:07:00] front. 

Because many of these patients, hypertension is not necessarily the only issue that they're facing. So, the 1, 2, 4, whatever the number of prescriptions that we're asking them to take for this particular disease state is on top of everything else that's going on. And so, it's a balancing act where you might be focusing just on hypertension, but there are other issues that are affecting your patients that then get pulled into that shared decision-making conversation. 

Cheryl Dennison Himmelfarb (guest): Oh, Geralyn, you could not be more correct. And many individuals have really complex medication regimens, complex conditions that they're working to manage. And in fact, that can play an important role in managing treatment-resistant hypertension as well.  

I encourage providers to work with other members of the team. This is a team sport, hypertension management. And so, working closely with pharmacists, for example, to understand [00:08:00] what are some of the potential interactions, drug-to-drug interaction. So, some drugs can actually directly increase blood pressure. Some drugs can decrease the effectiveness of blood pressure medications. 

And so, and supplements as well. So many individuals take supplements like licorice root supplements, or St. John's Wort. Those are just two examples of supplements that actually can increase blood pressure.  

And so, it's important to look at that big picture of an individual's conditions as well as their medication regimen. Because there also may be some insights there to help us understand other factors that could be impacting our ability to get to blood pressure goal.  

Geralyn Warfield (host): We are going to take a quick break and we will be right back.  

Geralyn Warfield (host): We're going to continue our discussion about hypertension and hypertension management, and resistant [00:09:00] hypertension by focusing a little bit more on something that you described earlier in our conversation, and that is home blood pressure monitoring. 

How do we encourage our patients to do this effectively? What are some strategies that we might use to make sure that we're getting not only those patients in the clinic and doing those measurements effectively, how do we make sure that that's happening at home?  

Cheryl Dennison Himmelfarb (guest): It's very important. So, I'd say the most important way is bringing it up and having the discussion. “Do you check your blood pressure at home? What kind of device do you use? How do you fit that into your day? When do you do that? “ 

And a lot of patients ask, “Well, what kind of device should I buy? Where do I get it?” And, actually many insurers will cover the cost or provide home blood pressure monitors because of the benefits [00:10:00] to individuals in being able to self-manage their condition with that additional information. 

And so, there actually is a published list of validated home blood pressure monitor devices. [See show notes for link.] I refer to that regularly and recommend to patients who ask what type of device they should consider, and I share the list with them so that they can be sure to get a list from that validated list device. 

I also talk to them about proper blood pressure measurement technique. That when they check their blood pressure at home, they should be sitting, if possible, in a quiet place, sitting for at least five minutes before they measure their blood pressure, making sure they've emptied their bladder.  

Ideally, they have not smoked cigarettes or drank caffeine within 30 minutes before measuring their blood pressure. And they should sit [00:11:00] with their back rested as I am now against a chair, feet flat on the floor—both feet flat on the floor—and with their arm at heart level.  

And so that's the way that they can try to replicate the blood pressure measurement technique that we are using in the clinic, and they can get the most accurate blood pressure measurement at home.  

We also recommend that they check their blood pressure a couple of times a day. And many of the devices now will actually allow you to check two to three measures at a sitting, with one minute between the measurements so that we can actually track the average blood pressure.  

And we recommend checking in the morning before a shower because a hot shower can actually impact your blood pressure. But before the shower, before blood pressure medications.[00:12:00]  

And then, also in the evening. And again, in the evening after dinner, but before a bath or a shower. And that way we can see the trends in blood pressure at different times of the day. And then those multiple measures, two to three measures each time, allows us to have higher confidence that those are accurate measurements. 

Geralyn Warfield (host): We have been discussing quite a lot of information today. Is there anything else that you'd like to share with our audience that I've neglected to ask about?  

Cheryl Dennison Himmelfarb (guest): Well, I think we've covered most of it, I think. You know, there are a couple of important factors that, among individuals who are taking blood pressure lowering meds, about 1 in 5 have apparent treatment [resistant] hypertension. 

So, 1 in 5 individuals are taking at least three blood [00:13:00] pressure-lowering medication classes. And they're not getting to blood pressure goal. I think through, what we recommend is that through proper blood pressure measurement technique, through shared decision-making with patients including a focus on medication adherence, and encouraging self-measured blood pressure at home, many individuals can indeed achieve blood pressure goals that they've set.  

And, one other thing, as I mentioned just to wrap up is, you know, making sure that we're looking closely at conditions or other drugs in the regimen that can be impacting blood pressure. Through those strategies, many of those individuals can get to blood pressure goal. 

Geralyn Warfield (host):  Thank you so very much for spending time with us today. We are so grateful to you for sharing your expertise, and we look forward to putting this into practice immediately in [00:14:00] terms of making sure that we're taking those blood pressure readings accurately and helping our patients do the same when they're not in the clinic setting. 

Cheryl Dennison Himmelfarb (guest): Thanks to you, Geralyn, and thanks to PCNA. I really appreciate the opportunity to be here.  

Geralyn Warfield (host): Thank you so much. This is Geralyn Warfield, your host, and we will see you next time. 

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