COVID-19 may have stirred a silent killer. Find out what to do.

Timothy M. Smith , Contributing News Writer

Your patients could have no signs, no symptoms. They might not feel different at all. Or they could get headaches or nosebleeds, but they might never connect the dots. In other words, hypertension is easy to miss. And if left unchecked, high blood pressure can increase your patients’ risk of life-threatening conditions, including heart disease and stroke.

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Which is why it has been so important during the COVID-19 pandemic for patients with high blood pressure to continue to work together with their primary care physicians—to keep it under control.

A webinar, “COVID-19's Collateral Damage: Uncontrolled Blood Pressure and Drug-Related Overdose and Death,” featured insights on how blood-pressure control—already in a downward trend in the U.S. since 2014—has almost certainly worsened since the pandemic began. It also outlined steps physicians can take to improve out-of-office blood pressure monitoring.

Early in the pandemic, in addition to the health risks directly related to COVID-19, serious concerns surfaced about what the indirect impact from the COVID-19 pandemic might be due to the disruption of health care-related services. “What would be the toll of deferring treatment for acute cardiovascular conditions like chest pain, heart attacks, heart failure exacerbations and strokes?” said Michael Rakotz, MD, vice president of improving health outcomes at the AMA. The effects were, in fact, dramatic.

“What followed after the initial phase of the pandemic was a decrease in hospitalizations for these things, which likely contributed to the increase in non-COVID-related deaths,” Dr. Rakotz said, adding that there’s potentially an even bigger wave of impact yet to come. The big unknown is, “What is the impact of the disruption in primary care for preventing exacerbations of cardiovascular disease in those who already have it, and new heart attacks and strokes in those who are at high risk?”

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How prepared were we to remotely manage conditions like high blood pressure without in-person visits? According to research published this year based on data from 2019 pre-pandemic, nearly 70% of health professionals recommended the use of self-measured  blood pressure (SMBP) monitoring to their patients with hypertension. And, more than 60% of patients with hypertension reported measuring their blood pressure outside of the office. The problem is that only about 7% reported sharing their readings with their health professionals via the internet or email, which is an important strategy to improve hypertension control.

“That is an extremely low number and concerning, and I think it points to the fact that we have to close the gap in access to technology and enable more people to share their blood pressure information with  healthcare professionals,” Dr. Rakotz said.

The pandemic exposed this gap even further. Comparing the number of ambulatory primary care visits in the second quarter of 2020 with the same months in 2018 and 2019, “there was a 50% reduction in office-based primary care visits according to a study published in JAMA Network Open last year.  “At the same time, we saw a 30-fold increase in telehealth visits—from 1% of all visits in primary care to about 35%.”

But more to the point, during those telehealth visits, “blood pressure was assessed less than 10% of the time.”

A very important factor to getting blood pressure under control, Dr. Rakotz said, is integrating SMBP into clinical practice, which is recommended in the current guideline for managing high blood pressure in adults from the American College of Cardiology and American Heart Association .

But there are numerous challenges—to patients, to health professionals and to health systems—in implementing SMBP programs. These include the perception of inconvenient protocols, out-of-pocket costs and lack of financial incentives.

One of the most immediate, however, is that most BP measurement devices are not validated for accuracy. In fact, one study showed that just 18% of nearly 300 upper-arm cuff devices sold in Australia were proven accurate according to international validation standards. Dr. Rakotz said the numbers are similar in the U.S.

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Here are the key steps physicians can take to overcome these challenges.

  • Consult a validated BP measurement device list. Go to validatebp.org for the first of its kind listing in the U.S.
  • Use guideline-driven patient education and user instructions. AMA MAP BP™ resources are available on the AMA website and feature an easy-to-use set of tools and resources for training patients in self-measured BP.
  • Know these CPT® codes. Two new codes for services related to SMBP were released last year: 99473 can be used once per device when a patient receives education and training facilitated by clinical staff on the set-up and use of an SMBP measurement device validated for clinical accuracy, including device calibration; 99474 can be used monthly for SMBP data collection and interpretation when patients use a BP measurement device validated for clinical accuracy to measure their BP twice daily, with a minimum of 12 readings required each billing period. Learn more about the new CPT codes for self-measured BP.

The webinar also included a presentation on the drug-overdose epidemic. The AMA believes that science, evidence, and compassion must continue to guide patient care and policy change as the nation’s opioid epidemic evolves into a more dangerous and complicated illicit drug-overdose epidemic. Learn more at the AMA’s End the Epidemic website.