Hypertension Management: The Key to Reducing CVD Risk

Welcome to Heart to Heart Nurses, brought to you by the Preventive Cardiovascular Nurses Association. PCNA's mission is to promote nurses as leaders in cardiovascular disease prevention and management.  

Geralyn Warfield (host): Welcome today to our audience, and we are so excited to have Dr. Eileen Handberg with us this morning, and I'm going to let her introduce herself to you.  

Eileen Handberg (guest): Welcome everybody. My name's Dr. Eileen Handberg. I am a Professor of Medicine at the University of Florida in the Division of Cardiovascular Medicine. I am a Nurse Practitioner by licensure. 

I have been in cardiology for a very, very, very, very long time, probably 35 years, and I'm so excited to be here this morning. Thank you. 

Geralyn Warfield (host): Well, thank you so very much for being willing to share your expertise with us. We were talking right before we came on air about hypertension and how [00:01:00] it is literally the biggest opportunity for cardiovascular medicine to make a difference, and I'm hoping you could expound on that for our audience. 

Eileen Handberg (guest): Thanks, Geralyn. It's interesting. Hypertension is the single most prevalent risk factor that leads to all of the diseases that we take care of—coronary artery disease, heart failure—and it's the disease that's the most prevalent. And we seem to pay the least amount of attention to it. It's silent. We know that, you know, patients don't realize they have hypertension, so there's a patient acceptance issue, there's an identification issue, and then there's the management issue, all of which are complex. And we don't do a good job. 

If you look at the [00:02:00] hypertension control rates over the last 20 years, since the big public education campaigns went on in the 70s and 80s, our blood pressure control rates are still abysmal. You would think as much as we know about hypertension, as many drugs as we have on formulary to treat hypertension, that we would have hypertension control rates in the 70 to 80%, and we're still at the 30 to 50% rate. 

And so, why can't we get that right? And so, it's an opportunity, you know. You can take it as a negative or you can take it as a positive. And what I think is the most interesting thing, is this is one area of medicine that a lot of practitioners don't really care about. They're on to the fanciest equipment or treatment or device. [00:03:00]  

And yet this is so foundational. We talk about primary prevention, and we can't even get secondary prevention right, when we have a known disease and a known way to take care of it. And I think that what's sad is there's inertia on part of the patients, but there's inertia on the part of the providers. And we have to get over that. 

And I think this is an opportunity for nurses, nurse practitioners, PAs, pharmacists, to own this space. Because if we as providers could make a difference in blood pressure control rates, we would change the trajectory of cardiovascular disease.  

It doesn't, it's not about a stent. That's, you know, the end of hypertension. We need to get to patients—we need to identify that they are hypertensive, and we need to have them understand the benefit of treatment. [00:04:00] And then we need to deploy that rapidly, and we need to monitor it and make sure that we maintain good blood pressure control.  

And I think that there's a lot of circumstances where the patient doesn't understand hypertension. And they don't understand the long-term effects. And so, there's a lot of educational opportunity here for nurses, and the whole healthcare team, to educate patients.  

And it doesn't even, this is really a team-based disease, right? And it doesn't have to be, doesn't have to be the physician, doesn't have to be the nurse practitioner. It can be the medical assistant checking the patient into clinic. That's the first point where you say you have somebody take a blood pressure the right way, and then you say, “Wow, your blood pressure's elevated. Did you know you have hypertension?” That doesn't take a medical degree. [00:05:00] That can be a community health worker at a health fair.  

And so, we have all the opportunity in the world to make a difference in hypertension, and yet we sort of sit by passively and let these hypertension control rates be abysmal. 

We have to make patients understand that it's important to treat, it's important to keep in control, and that we're reducing their long-term risk. You know, we don't want them to have to come in for advanced heart failure therapy. We want them never to get there. But if we're not willing to invest the time in hypertension management, we've lost a huge opportunity.  

And it's not complicated.  

There are algorithms out there for treating blood pressure that are well established. And we did a large trial, now, oh my gosh, it's 20 years ago called INVEST, where we looked at two treatment [00:06:00] strategies for hypertension. One was a calcium antagonist-based strategy, and one was a beta blocker-based strategy, and each arm had three drugs. 

And the reason we did that trial was, back in the day, there was some controversy about calcium antagonists, but the important thing is we enrolled 22,000 patients from 860 sites around the world. We used an algorithm that started with an ACE or a calcium antagonist—I’m sorry, a beta blocker and a calcium antagonist—went to an ACE inhibitor, and then added a third line therapy. 

And what we ended up with was blood pressure control rates in the 70 to 80% range. So that was 20 years ago. It can be—my daughter's 25, she was born when we started that trial—that it can be done. If you look at some of the other groups that really [00:07:00] invest time and effort in blood pressure, it can be done. 

And so, to be at 30, if 50% in some places, is still not acceptable. And so, we have an opportunity, and this is a space that I think advanced practice providers, pharmacists, nurse practitioners, PAs, clinical nurse specialists, can own this space and really make a difference in outcomes. There are huge opportunities with community health workers, with medical assistants. 

I did a review of a project that somebody was doing using their medical assistants. And they basically took the blood pressures when the patients came into clinic and if their blood pressure was controlled, they put a green card on the front of the chart. If it is not under control, they put a red card. And it told the [00:08:00] provider, we have an issue, you have to address it at this visit.  

That's not complicated, and it makes the whole team become involved in the process of care. And everybody wants to own something. And so, making the whole team a part of that is an opportunity and it's an opportunity for patients and making patients aware of it. And having them understand, you know, I have patients come in all the time to clinic who say, “Well, my blood pressure at home is okay,” or, “You know, my blood pressure today in clinic because you're wearing a white coat is, you know, 160.” 

And I say to them, “I understand, but tell me what you think your blood pressure is when you get cut off in traffic.” 

“Hmm. It's probably 170.”  

“So, your blood pressure isn't smoothed out. You're having all of these ups and downs, and what we want to do is get better blood pressure control. And so, there's an [00:09:00] opportunity here to reduce your risk.” 

And there are lots of things, and this is PCNA, it's the Preventive Cardiovascular Nurses Association. And so, a lot of the things that we're all interested in, like diet, exercise, healthy lifestyle, all affect blood pressure in a very positive way. And I tell patients, “You know, if you can lose five or 10 pounds, we might be able to take a blood pressure medicine off.” So, you don't have to give up your prevention hat. You actually incorporate it in a more meaningful way, and you get a healthier lifestyle.  

And so, there's a lot more opportunity for patients. So, I think this is an opportunity for us. And I would hope that as a profession and as a team-based care thing, that we could pick it up and really own it. Nobody wants this space because, clearly, they're not managing it well.  

And so, if we had huge hypertension clinics [00:10:00] managed in the barbershop, in the hair salon, you know, the ones that have been documented in the literature that have been very successful at getting blood pressure control. There's lots of ways that we could do this creatively, and engage patients in a meaningful way and change outcomes. 

Geralyn Warfield (host): Eileen, you have given us so many great nuggets of information in just a few minutes, and I think that that inertia to treat on behalf of clinicians, as well as on the part of patients, really is a, a two-part disharmony, I guess I would say, rather than a harmony, because I think sometimes, for example, patients, have heard their blood pressure is okay, they may or may not remember what those numbers are, the fact that there's two numbers can be rather confusing. They don't understand, necessarily, what each of those means. 

And maybe it's because they haven't been to a provider in years, you know. That they haven't seen anyone for any reason for five years. And [00:11:00] so they're going on that five-year-ago number, which we know is just a pinpoint of time. 

And as you said, enough of us sit in traffic long enough that our blood pressure does go up and down. And so, it's important that we work together with our patients and our colleagues to make a difference in the very, most basic things like hypertension, that can then have far-reaching effects well into the future. 

And sometimes there's a disharmony between colleagues or between providers, and I'm wondering if you could speak to that just a little bit more.  

Eileen Handberg (guest): I think that you've hit the nail on the head for a large number of patients. Almost all of [00:12:00] us who do cardiovascular care have patients who have multiple providers. 

They have a general provider, they see someone for rheumatology, they see somebody for pulmonology, they see cardiology. And so, the information that they get from providers is not always consistent and in lockstep. And hypertension is one of those big areas because if you, if your primary care provider, let's say that they're not being aggressive about your blood pressure, and you have a blood pressure of 150 and they say, “That's okay.” And you come to me, and I'm like, my head's on fire. It's like that's 30 millimeters above the current recommended goal for blood pressure. We've got to take care of that, and we've got to take care of that right now. 

And so, it [00:13:00] creates this tension in a patient. “Well, Dr. Smith says my blood pressure's okay, and I'm going to see Eileen and she's like up in arms about this.” You know there’s this mismatch for patients…and it's hard to overcome that in some patients because there's inertia on patient's part. “I don't want to take another pill.” “You're going to add another pill because it takes three or four blood pressure medicines to get my… and I'm already on three or four other pills,”  

So you're fighting, kind of, upstream. But it's important to take those moments with patients and try and give them meaningful information. I think we don't do that a lot. 

I think showing patients a graphic about what the guidelines say. “These are the current 22, 2022 guidelines for blood pressure. Your blood pressure should be [00:14:00] for sure below 130, we'd like it to be 120.” There's a great epidemiologic graph that shows you from blood pressures of 110 up to 180, by decile of age; the incremental, exponential increase in risk for stroke, heart attack, death, when you look at populations of patients for blood pressure. 

And so, when I talk to patients, I say, “For every 10 millimeters you're above 110, you're increasing your risk. And the older you get, the steeper the curve, and so we want to get you at the low end.” But you have to think of a way to provide that information in this asynchronous kind of environment where there's this mismatch of information. 

And that can be a little bit challenging and something that we have to think about, because nobody likes to pit provider against [00:15:00] provider, right? Because there are a lot of ways to do things, but we have to go to guideline-directed medical therapy.  

And, and not everybody's up to date. And you know, sometimes you just have to say, ”The guideline that you've been told isn't the current guideline. This one's come out and this is what we're going to shoot for.” Yet, you know, do it in a positive spin. But it's important. The patient's health trumps our own egos. We have to make a difference in terms of long-term outcomes. 

And if we can't get blood pressures controlled, we're not going to get reductions in heart attack, stroke, and death. We're just not. You know, putting in the fifth stent isn't going to make the difference. Taking care of somebody's blood pressure when they're 40 will make a difference in terms of progression to heart failure, or progression of coronary disease. So, there's a lot of opportunity there.  

Geralyn Warfield (host): We will resume our [00:16:00] conversation in just a moment.  

Geralyn Warfield (host): We are back with Eileen Handberg. And we're going to switch gears just slightly to yet another way that we can all make a difference, and that has to do with leadership and involvement in professional associations and with our colleagues. So, Eileen, could you address that for us please?  

Eileen Handberg (guest): Yeah, thanks Geralyn. This is something I'm very passionate about. There are 27 million nurses in the. Think about that. There are 27 million nurses. We are the largest boots on the ground providers of healthcare. And our voice is not commensurate with the number of providers that we have, and I take issue with that. That's a problem in my book.  

It's an opportunity, and I understand that across the world, [00:17:00] how nursing has evolved is complex. It's seeped in a lot of cultural norms, roles that are long established and that what I'm going to say isn't an easy thing to do. It, it's not, necessarily, an easy thing to do in, in anybody's setting, but it's the most important thing to do for the profession. 

We're the most trusted profession. We have the patient's lives in our hands more than any other provider because we are educators. We're communicators. We're the force of healthcare that represents the patient and the family. Lots of providers do great things, but the group that advocates for patients, generally, is nursing. 

It's important [00:18:00] to lead. It's important to lead at the bedside, and nurses don't have any problem doing that. They do it every day, whether you're a clinic nurse, whether you're in the CCU, whether you're in the emergency room, you see it every day where a nurse has talked to the patient and the family. They have a desire, a need, some firmly held belief, and it's the nurse that helps articulate that to the healthcare team so that the care that's delivered matches that to the best possible way. It doesn't, it's not always a great match, but the voice is heard. That's leadership, and I applaud every nurse that's ever sat at the bedside and advocated—sometimes up against pretty strong forces—to make sure that the patient's voice is heard. 

But there's a lot more opportunity for nurses to lead, whether it's as a [00:19:00] charge nurse, whether it's as the strongest clinician that you can be by practicing evidence-based nursing medicine. You show the strength of your profession. You lead by example. You show the care that you provide is based in evidence. 

It's not just a one-off. It's not an anecdotal response to the previous person you took care of. It's based on evidence that says, based on what we know, this is the best way to take care of patients. And advocating for that. And we do, and hopefully most nurses will do that, but that requires lifelong learning. 

What you learned in nursing school, PA school, pharmacy school, medical school is one moment in time and if you don't keep up with the literature, if you don't keep up with your profession, you'll fall behind and you'll be [00:20:00] doing the same thing you learned when you are in nursing school or medical school. 

And I see that all the time. Patients are receiving medications that aren't the best meds. They're the meds that that provider grew up with. And so, they may not be getting the best bang for their buck.  

And then there's leadership at a higher level, whether it's at your institution, you take a leadership role in management, and again, leading by example. That’s important.  

But one thing that I think is truly important, and that a lot of providers miss, is the opportunity to participate in a professional society like PCNA, like the American Heart Association, like the Heart Failure Nurses Association—any of the societies in any of the areas of cardiovascular care or prevention or lipid, any area [00:21:00] —is the ability to make an impact on your profession at a national, international level.  

To advocate for the profession, it's a bigger way to advocate for patients. Because those organizations generally are immersed in trying to help move science forward, move education of providers forward. And so, participation in that is extremely important. 

And what I see out there, with the mass migration of retirements, we see this whole movement of this new group of providers coming into the space, because it's a, it's a pretty good career, right? It makes decent money. There's lots of nursing schools popping up. There's lots of PA schools, pharmacies, pharmacist schools [00:22:00] popping up, and so there's more opportunity to get into school.  

But what I don't see is these young folks joining professional societies, or even being aware of what they are and what they do. And I'm afraid for the professions that, especially nursing, that we have the potential to not continue to grow our voice. 

And in order to do that, we need the 27 million nurses to step up to the plate and say, “We are a force to be reckoned with. We have things to accomplish. We are the biggest provider. We can make a difference.” 

And to exert our influence on health policy, on governmental rules and regulations, on individual practice site locations, to really promote health and wellness and to [00:23:00] advocate for patients. 

And so, I always tell people that some of the richest experiences in my nursing career have been by joining professional societies like PCNA, or the American College of Cardiology, or the AHA. And you can belong to two, you can belong to five, and each will provide you something that the other doesn't. 

So, you don't have to just belong to one organization, you can belong to several. And you can belong to organizations of any type. You can belong to, you know, I Love the Manatee organization and enhance your life in other ways outside of your profession. And we all need that balance. I don't want people to think that you just have to live your profession, but giving of yourself to those organizations enriches your life.  

And what you learn in the Manatee Association might be something that you apply to your nursing organization, because there's a different skill set, [00:24:00] and you meet different people, and you network. And that's some of the richest experience I think you can have as a professional. Because people at home don't appreciate you as much as people outside.  

And so, you get a lot of pats on the back from belonging outside, and it helps when things at work aren't so hot, right? It gives you a different perspective. And so, this gives you an opportunity to see the world through different eyes. And I have friends all over the world in my profession now because of belonging to an organization, and I think that it's amazingly valuable.  

And so, I just encourage nurses to think about where do we want the profession to go? We're here as a profession to advocate for ourselves, and to advocate for patients, most importantly. I really do believe that. And if we don't stand up as a common voice, we may not do as good a job as we have the potential to do.  

Geralyn Warfield (host): We have been having an inspiring conversation with Eileen Handberg, who's given us two calls to action, both related to leadership: one in hypertension [00:26:00] management, and one to ourselves and our colleagues, in terms of leadership. This is Geralyn Warfield, your host, and we will see you next time. 

Thank you for listening to Heart to Heart Nurses. We invite you to visit pcna.net for clinical resources, continuing education, and much more.