Time to make more noise about our biggest killer: heart disease

Jesse M. Ehrenfeld, MD, MPH , Immediate Past President

Improving heart health for patients begins by improving the quality of team-based care for high blood pressure, and by giving health care organizations the necessary tools and education to strike back at cardiovascular disease—the leading cause of death for adults in our nation.

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Developing a modern approach and framework to solve the chronic disease riddle has been a cornerstone of the AMA’s strategic priorities for more than a decade. It has resulted in tools and resources for health care organizations, education and training modules for physicians and health professionals, and national public awareness campaigns centered on early detection of hypertension and type 2 diabetes.

The urgency of this work has only intensified in recent years amid a surging number of cases. It is estimated that six in 10 adults in our nation suffer from at least one chronic disease.

Despite this alarming growth, far too many people remain in the dark about these silent killers. One recent survey from for the American Heart Association (AHA) found that more than half of respondents were unable to recognize cardiovascular disease (CVD) as the leading cause of death among U.S. adults—even though that has been the case for more than a century, and CVD kills, on average, one person in the U.S. every 33 seconds.

The threat is magnified when you consider that 48.6% of the U.S. population has some form of CVD and 46.7% have hypertension, as reported in the journal Circulation. Of those with hypertension, only about 25% have their condition under control. And that situation is worsening. After decades of progress, the proportion of adults with hypertension whose blood pressure is under control is declining.

Gaining control of hypertension is the single most important intervention for preventing death from a heart attack or stroke. To help in these efforts, the AMA has created multiple solutions to advance national blood pressure control efforts.

Foremost among the AMA’s hypertension solutions is the AMA MAP™ Hypertension quality improvement program. The MAP initialism stands for these three key elements physicians and health care organizations should focus on:

  • Measuring blood pressure accurately.
  • Acting rapidly to optimize treatment.
  • Partnering with patients to support self-management going forward.

This evidence-based quality improvement program incorporates practice facilitation, peer-to-peer education, and a targeted set of performance metrics and evidence-based strategies and action steps. All are aimed at helping physicians and other health care professionals achieve significant and sustainable hypertension control among their patients.

Correctly diagnosing hypertension and creating an effective plan to treat it depends on measuring blood pressure accurately on a consistent basis. Apart from patient-related factors like recent caffeine or nicotine use, inaccurate measurements can result from a host of positioning and procedure-related errors.

Chief among these is using the wrong cuff size, but flawed readings can also result from improper positioning of the patient or cuff, and the use of a blood pressure device that has not been clinically validated for accuracy or properly maintained, among numerous other factors.

The AMA convened measurement experts in hypertension control, resulting in the launch of the U.S. Blood Pressure Validated Device Listing (VDLTM), another free resource physicians and care teams can use to select accurate blood pressure measurement devices for use both inside and outside of clinical settings. While measuring blood pressure may seem routine, the skills required to do it are complex and can fade over time—which is why guidelines recommend retraining every six to 12 months.

In response to the high prevalence of uncontrolled blood pressure, the AMA and the AHA created Target: BP, an overarching initiative that features educational programs, self-guided tools and resources, and annual award categories that align with the AMA MAP framework. Target: BP supports health care organizations and communities to improve blood-pressure control for the patients they serve with the latest scientific evidence from the AHA, AMA and other experts.

Target BP also assists health care organizations in their quality improvement journeys, and recognizes them annually for committing to improvement, adopting evidence-based blood pressure activities, and achieving blood pressure control greater than 70% with the patients they serve.

Target BP’s positive impact is growing. Last year, organizations serving 8.6 million people with hypertension submitted data to the program, and more than 1,700 health care organizations were recognized for outstanding efforts to prioritize blood pressure control. Among those organizations, more than half—866—achieved gold or gold-plus award level recognition, which requires BP-control rates of greater than or equal to 70%.

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Patients can take these steps to lower their high blood pressure

With sound data in hand from accurate measurement, immediate action to control hypertension is required to avoid serious risk of CVD and associated comorbidities. Failing to begin or enhance treatment for hypertension, otherwise known as clinical inertia, contributes significantly to worsening rates of BP control.

Several factors drive clinical inertia from the health system standpoint, including time constraints and inefficient electronic health record workflows. However, the standardized treatment protocols outlined under the AMA MAP Hypertension quality improvement program are designed to overcome clinical inertia and help physicians and all members of the care team to get involved— and stay involved—in hypertension management. Since the average patient with hypertension requires two or more medications to achieve control, the protocols emphasize adding medication classes and monthly follow-up to rapidly reduce risk.

Effective treatment of hypertension includes engaging patients to become more fully involved in managing their health by understanding the long-term risks posed by uncontrolled BP. The AMA offers a wealth of information and resources to help physicians and care teams show patients how to accurately measure their blood at home or at other locations outside of a clinical setting. For example, the AMA 7-Step Self-Measured Blood Pressure Quick Guide allows patients to actively participate in managing their blood pressure and has also been shown to improve adherence to antihypertensive medications.

Overcoming medication nonadherence is a vital consideration in controlling hypertension. Research shows that patients do not take their prescribed medicines about half the time, and that most of them do not inform their physicians of that fact. The eight steps to improve medication adherence outlined in this AMA STEPS Forward® toolkit include creating a blame-free environment for medication discussions, and involving patients more directly in treatment-plan development.

Hypertension disproportionately affects populations that have been historically marginalized. Nearly 80% of Black adults in the U.S. with hypertension do not have it under control. In 2020, the AMA, AHA, AMA Foundation, American College of Black Cardiologists Inc., Minority Health Institute Inc., and the National Medical Association established the Release the Pressure campaign to raise awareness about heart health among Black women, and to encourage them to track their BP numbers and develop a wellness plan within their personal support network. To date, the campaign has provided self-measured blood pressure training to more than 144,000 Black women.

Additionally, the AMA, AHA and the Advertising Council have launched a series of public awareness efforts including the “Get Down with Your Blood Pressure,” which emphasizes the importance of BP management with Black, Hispanic/Latino, and Native American adults. Among other initiatives, the AMA continues to work with West Side United and Wellness West in our hometown of Chicago to improve heart health and reduce the 14-year gap in life expectancy between those who live there and those who live in the city’s most affluent neighborhoods.

The AMA and our partners are working tirelessly to raise awareness of the growing problem of uncontrolled hypertension, and to provide continued support and resources to physicians, care teams and the patients they serve to gain the upper hand on one of our nation’s most pressing health challenges.