When it comes to effective treatment of high blood pressure (BP), three challenges must be confronted: diagnostic uncertainty, therapeutic inertia—failing to start or intensify treatment when BP is high—and treatment nonadherence. To do this, physicians can follow the AMA’s MAP framework, which stands for Measure accurately, Act rapidly and Partner with patients. However, one area that needs further focus is on acting rapidly or intensifying drug therapy to manage elevated BP.
“It takes 22 hours a day to implement evidence-based guidelines. These are three concrete steps that we believe are efficient to help control blood pressure,” said Brent M. Egan, MD, vice president of Cardiovascular Health at the AMA. “We’ve seen a lot of progress with measure accurately, and we’ve seen the blood pressure response to therapeutic intensification improve.”
“Act rapidly is a vital key to improving control rates to 75% and higher,” said Dr. Egan, adding that data show that “it’s very hard to get those high control rates without having the act rapidly portion really practiced well.”
Here are some ways to reduce therapeutic inertia and act rapidly to improve BP control.
“The guideline recommendations are important in terms of what types of medications to begin with,” said Dr. Egan. But “another key principle is that medications at half maximum or standard doses actually have about 80% of the blood pressure lowering effect of the maximum dose.
“Many of the side effects are dose related, so as we go from half-maximum to maximum doses, we sometimes buy quite a few side effects with a relatively modest further reduction in blood pressure,” he added. “The notion of using several medications—two or more medications—at standard or half maximum dose, rather than taking a medication from standard dose to the twice standard of maximum dose is more effective.”
“Adding a second medication at standard or half maximal dose has about three times the blood pressure lowering effect of doubling the dose of a single medication,” said Dr. Egan.
“The advantage of single pill combinations is they add medications together that basically have additive lowering effects on blood pressure,” said Dr. Egan. “Sometimes when we, as clinicians, select different combinations, there are less than additive effects on blood pressure.”
“For those of us clinicians who are concerned that the response to a single pill combination may be too large, many single pill combinations are available with two medications in half standard or quarter maximal doses.
“Beginning with quarter doses of two medications is unlikely to dramatically lower blood pressure response in most patients,” added Dr. Egan. “Certainly, we always recommend the clinicians use their own judgment.”
More rapid control and better clinical outcomes are documented when treatment begins with single-pill combinations rather than a single antihypertensive medication. In fact, several studies have documented that BP is controlled sooner and to a higher level when antihypertensive treatment is initiated with single-pill combinations with two medications, compared to a single medication. Other research indicates that patients with hypertension have fewer cardiovascular events when begun on single-pill combinations compared to a single BP medication.
For BP control, read about the U.S. Surgeon General’s guide to overcoming clinical inertia.
Typically, physicians should be alerted through the EHR if the medication has not been filled by a patient. However, there are other ways to uncover if a patient has not been following their medication regimen.
“One easy thing to do is to ask the patient just to bring their medication bottles with them and we can see when it was prescribed and how many refills remain,” said Dr. Egan. “We can get an idea of whether the patient's taking the medication or not.”
Additionally, when a patient reports significant side effects, they are less likely to take their medication. Patients who find the medication is too costly, are often not taking it as prescribed and may be splitting tablets to have it to last longer,” he said.
Throughout the COVID-19 pandemic, people have delayed in-person medical visits for chronic conditions such as hypertension. Even with telehealth visits, managing a patient’s blood pressure can be difficult without proper measurement.
“One of the most common problems I see is that a lot of patients with hypertension still do not self-monitor,” said Dr. Egan. “Many of our patients with hypertension for their electronic visits simply don’t have a blood pressure number to share with us.
“That makes it very difficult to know if the blood pressure is controlled, but even if it’s uncontrolled on the previous two in-person visits, most of us are unlikely to intensify therapy when we don’t know what the current blood pressure is,” he added. With telehealth, the number of visits has not gone down for many patients, but the values needed to make a good treatment decision are often missing.
For patients with uncontrolled BP, monthly follow-up is part of acting rapidly. E-visits are an efficient means for providing monthly follow-ups, given the patient has been trained to self-monitor their BP and is using a validated device. In fact, some performance metrics for BP control have been revised to allow self-measured blood pressure in assessing hypertension control.
The AMA has developed online tools and resources created using the latest evidence-based information to support physicians to help manage their patients’ high BP. These resources are available to all physicians and health systems as part of AMA MAP BP™, a leading evidence-based quality improvement program that provides a clear path to significant, sustained improvements in BP control. The AMA also supported the development of the US Blood Pressure Validated Device Listing (VDL™), the first list of U.S. BP measurement devices validated for clinical accuracy.
For more information on acting rapidly, including the latest evidence-based strategies to reduce therapeutic inertia, register for this free CME/CE webinar, led by Dr. Egan.