High Blood Pressure (Hypertension)Prevention and Control

SASH – September 25, 2012

Suzanne Lapointe, RN, BA, CNN

Fletcher Allen Health Care, Nephrology

Robin Edelman, MS, RD, CDE

Vermont Department of Health

Topics for Today• How are we doing with blood pressure

control?• Measuring and monitoring blood pressure• Management of high blood pressure

– Medications– Lifestyle changes

• Self-management options for SASH enrollees

• Self-management support by SASH staff

Blood pressure during each cardiac cycle

Systole (larger number)

Diastole (smaller number)

YouTube video link for measuring blood pressure

http://www.youtube.com/watch?v=ixG8R6LY9qU

December 2003 in Hypertension. 2003;42:1206

High blood pressure is an independent risk factor for CVD*, Stroke and Kidney Disease = Vascular Disease

Hypertension can affect the heart, brain, and kidneys

Hypertension promotesatherosclerosis and arteriosclerosis

*CVD = cardiovascular disease

7

High Blood Pressure in US– “a neglected disease”

Institute of Medicine (IOM) February 2010

“High blood pressure is out of control for too many Americans”

Centers for Disease Control and Prevention (CDC) September 2012

1/3 adults have it; 1/2 > 60y, 3/4 >70y

More than half have uncontrolled high blood pressure

~ 40% aren’t aware that they have high blood pressure

1/6 die from uncontrolled blood pressure (~ 1000 per day)

easy to prevent, simple to diagnose, inexpensive to treat

The Lancet, 361:2149-2151

genetic predisposition

environmental factors

Causes of high blood pressure are multi-factorial

saltobesitysmoking

Management of Blood Pressure

Goal

Individual strategy

Group strategy

physicians, patients, systems

Blood Pressure Numbers

What’s more important

(the big number, or the smaller one)?

And why?

Lifestyle modification – patient specific achievable goals

Weight reduction (10 - 20 lbs helps) – SBP 5-20 mmHg

Physical activity (30 minutes/day as part of ADL) – SBP 4-9mmHg

Avoid excessive alcohol ingestion, stop tobacco – SBP 2-4 mmHg

Avoid high sodium intake – SBP 3-5 mmHg for 2 g reduction

DASH diet – SBP 8-14 mmHg

Avoid high sodium intake – shop around the edges of the supermarket except for the deli

12%

6%

5%

77%

CDC

Optimal medication regimen should…

Reduce volume thiazide diuretic (for all unless eGFR < 30 ml/min, hyponatremia, CHF) K sparing diuretic (K< 4 meq/l & eGFR >30 m/min) in addition to thiazide loop diuretics in CKD patients (edema, eGFR < 30 m/ml)

Reduce renin/angiotensin effect ACEi/ARB; renin inhibitors (DM, CKD, proteinuria/albuminuria, CAD, LVH)

Reduce myocardial activity Beta or Alpha/Beta blocker (titrate dose to keep HR in the 60’s) Vasodilate CCB (dihydropyridines best for BP) or vasodilator (hydralazine, minoxidil)

Add central or peripheral SNS agents as fifth line Clonidine, alpha methyldopa, alpha blockers

Use medications in multiple classes. Two to 4 are commonly needed. (e.g. Diuretics + ACEi/ARB + Beta and alpha blockers + CCB)

Inadequate Response to Therapy

Volume overload: medications (NSAIDs), excessive salt intake, kidney dysfunction

Non adherence to therapy: too frequent dosing,

expense, intolerable side effects. - Use several drugs in low doses to maximize

effectiveness and minimize side effects rather than maximum doses of one drug

Drug problems: wrong drug or dose; combinations of drugs that don’t work well together Other medical conditions: smoking, excess alcohol,

anxiety, pain, sleep apnea, obesity

Approaches to improving BP Control

patient participation and ownership having a goal

knowing when not at goal (measuring BP at home) having a way to modify treatment to get to goal

Self-management is what people do to take care of themselves.

Self-management support is what staff do to help people take care of themselves.

Steps in Self-Management Support

• Collaborative setting of goals and action plans

• Identification of barriers and challenges

• Personalized problem-solving

• Follow-up support

Action Plan (a short term plan for doing something measurable) that fits into a longer range goal

1. Something a person WANTS to do

2. Describes:

What (the doable behavior)

How Much How Often (# of days)

When (time of day)

3. Confidence rating (1-10)

1 = no confidence; 10 = total confidence

Examples: (Long range) Goals & (shorter term) Action Plans

• Improve fitness to lower blood pressure– Walk for 20 minutes in

the morning on 4 days this week

– Ride the stationary cycle after lunch on 5 days this week

• Eat better to lower blood pressure– Have 1 cup of

vegetables at lunch & supper on 3 days this week

– Have 1 cup of oatmeal in place of salty breakfast sandwich on 4 days this week

Benefits of self-monitoring blood pressure

• Avoid faulty high readings from “white coat hypertension”

• See quicker changes in response to improved behavior

• Easy and safe to measure

• Encourages behavior improvement

• Builds self-efficacy (self-confidence in one’s ability to self-manage)

Recommended Website

http://www.nhlbi.nih.gov/

U.S Department of Health and Human Services

National Institutes of Health

National Heart, Lung, and Blood Institute