As if navigating the COVID-19 pandemic has not been challenging enough on its own, 2020 also shed light on a disappointing drop in BP control among American adults. The decline in blood pressure control has important consequences because hypertension is the leading modifiable risk factor for heart attack and stroke, placing those with hypertension, prior heart attack, stroke and heart failure are at increased risk for more severe outcomes if they acquire the SARS-CoV-2 infections.
And while there has been a call to make hypertension control a national priority, AMA member Clyde Yancy, MD, MSc, Northwestern Medicine’s chief of cardiology and vice dean for diversity and inclusion at Northwestern University’s Feinberg School of Medicine, has a different outlook and focus for 2021: let’s not just control, but prevent hypertension. Dr. Yancy is also past president of the American Heart Association, deputy editor of JAMA Cardiology and a Master of the American College of Cardiology.
During a recent interview, Dr. Yancy discussed his outlook for 2021 and beyond, outlining how physicians and health systems can shift to hypertension prevention.
AMA: Since the pandemic began, what are some lessons learned around hypertension?
Dr. Yancy: Lesson 1: The recognition that hypertension is a very important preexisting condition. In fact, it is sufficient to create a unique vulnerability to the novel coronavirus infection. Consequently, it is associated with more challenging outcomes.
Lesson 2: The most compelling vulnerability is advanced age, but what goes with advanced age is hypertension.
Lesson 3: If we're to begin to think about lessons learned during the pandemic, almost assuredly, it would be understanding not just how best to treat hypertension—because it’s not at all clear that being well-treated reduces the vulnerability to COVID-19—it would be more important to understand how we prevent the onset of hypertension. In other words, don’t just manage the risk, remove the risk.
This concept of primordial prevention—the prevention of risk itself—has been with us for quite some time but in the gloom of COVID-19, it is now a much more pressing question of how do we execute primordial prevention? Is such an idea actionable? If we can avoid the presence of hypertension, then we lessen the vulnerability for COVID-19. Lowering the cardiovascular disease risk profile and reducing the exposure to the novel coronavirus—and/or future iterations of the same— would be for the good.
AMA: How do we achieve that prevention?
Dr. Yancy: Primordial prevention, by orders of magnitude, is more challenging than goal blood-pressure reduction, which has already proven to be hard enough. Moving our prevention efforts further upstream requires a root cause analysis of hypertension. The targets become quite familiar: the traditional CVD risk factors.
If we control obesity, maintain appropriate physical activity, refrain from tobacco use altogether, avoid excess alcohol use, and embrace a diet that is heart healthy, an opportunity emerges to fundamentally change the likelihood of becoming hypertensive and to experience a remarkably better quality of health.
Certainly, there are familial trends in hypertension but the genetics do not explain the entirety of risk. It is rather genetics in a permissive environment that leads to hypertension. Whether it's diet, lifestyle, lack of exercise, smoking or any combination of the foregoing risks, when combined with familial tendencies, hypertension emerges. What intrigues most about this idea is that public policy may more easily target many of the needed interventions and yield better outcomes than widespread population screening, comprehensive multi-drug treatments and costly follow up.
The important sentiment is this: Think about the primordial prevention of hypertension as a very just and a very appropriate public health initiative. It is certainly worthy of our investment.
AMA: The nation is already struggling, despite major efforts such as Target: BP™, to help patients with hypertension get their high BP under control. Is adding prevention to the plate too tall an order?
Dr. Yancy: Of course, it is a challenge, but given our current burden, it is not sufficient only to target blood-pressure screenings. It is helpful, but at a population level, it is important for everyone to understand how this condition and all of the downstream consequences evolves; and the importance of trying to prevent the development of hypertension over the lifespan.
Consider this truism: we know that 90% of all adult Americans will experience hypertension sometime in their life. Hypertension has become an inevitability, like taxes and death, and it should not be. There ought to be appropriate strategies to avoid this burden.
AMA: The U.S. surgeon general’s call to action to make hypertension control a national priority also touches on prevention, or whole-body focus. Does that help push this more into the limelight?
Dr. Yancy: It takes more than a singular office of any kind to recommend more vigilance in hypertension screening and treatment. Every effort helps. I am arguing that we should go beyond that. Targeting the source of the problem will give us the greatest return on investment. Once we recalibrate our emphasis, there will be more awareness of important steps that are easy to halt the risk in blood pressure.
These concepts are in keeping with current global recommendations for the treatment of hypertension; we start with lifestyle, not drug therapies. With effective lifestyle decisions, we can control high blood pressure without drugs. These same strategies when moved upstream prevent hypertension. So, the opportunity is there through raising awareness, active surveillance and lifestyle changes to both prevent and treat hypertension without drugs.
AMA: How do we move forward with getting people more aware of their BP numbers?
Dr. Yancy: A new campaign, “know your numbers.” Not my idea but the idea of my colleagues at Northwestern Medicine. Think about this—who does not know their cell number, social security number and a dizzying array of passwords? We argue that a campaign should be launched—know your numbers—appropriate body weight, cholesterol values, blood sugar and especially your blood pressure, (perhaps your nightly hours of sleep as well). These numbers matter for your health. Imagine a viral social media campaign that engages the majority of the population—a very laudable goal.
Why discover and discuss these important numbers only when you are ill? These “numbers” should not be absent in our usual discourses. We often discuss our health with family and friends but those conversations are not well informed and should be. Discussing our lifestyle matters and carries implications on our health. Finding a way to get informed conversations initiated within communities, within networks and within families would be a very wise thing.
AMA: Why is it that hypertension and high BP don’t get the attention they really deserve?
Dr. Yancy: Hypertension is not sexy. There is no dazzle and very little tech. And there is a resignation that many of us will inevitably experience hypertension. Moreover, end organ consequences, kidney disease, heart disease, and brain disease don’t qualify as riveting conversations, until it happens to you. This is why I am advocating for a pivot. We should be willing to think disruptively; we cannot ignore what hypertension has enabled in so many people during the pandemic. We have all the impetus we need to enter deliberately into the space of prevention.
AMA: COVID-19 has also had a deeply inequitable impact and laid bare existing structural inequities, particularly for many Black, Hispanic and Native American patients with high BP, obesity and type 2 diabetes. How do we improve health equity in these populations?
Dr. Yancy: This is a key consideration and maybe the most important takeaway from the pandemic. There are now innumerable reports in the scientific literature describing the stark absence of health equity and highlighting disparities as a function of race and ethnicity. It is beyond sobering and represents a national failure. The outsized price paid by vulnerable communities has been nearly incomprehensible. These groups—Black, Hispanic, and Native American—continue to experience a three-fold increased likelihood of death due to COVID-19.
In more clear terms, this translates to one of every 800 Blacks in the United States is now dead due to COVID-19. The root causes are several but the pernicious and still persistent effect of systemic racism in our communities leads the way.
Moving from the plaintive mode to a contemplative mode, economic investment emerges as a candidate solution. It is very compelling to recognize that our sustenance of life—our socioeconomic status, our housing, our jobs our education, our income—associates strongly with our health. More than race or ethnicity, it is place and privilege or the absence thereof that place people at risk for excessive vulnerability at the time of crisis. This is especially onerous for abjectly poor people.
This may appear to be a nonexecutable strategy and it would indeed require a different kind of business incentive but what else might have immediate impact? It will take generations to unravel systemic racism and its decades long wound in vulnerable communities but an economic lever in those same communities that improves education, jobs, housing, food supply and transportation and would eventually yield better health.
AMA: What would you encourage physicians and other leaders in health care to do to help address hypertension, high blood pressure, cardiovascular disease, beyond COVID-19?
Dr. Yancy: Everybody has skin in this game. This is no longer an issue that affects a certain community or a safety-net hospital; a certain city; or a certain race or ethnicity. It affects us all. Our social networks are fragile—a weak link anywhere affects our wholeness everywhere. If COVID-19 taught us anything, it was this interconnectedness and how it matters to everyone.
However, the concerns go beyond COVID-19. On a daily basis, we are reminded of the terrible, painful loss of life due to COVID-19, but that's just due to COVID-19. There has not been as much press as there should be on the indirect deaths. People who fail to seek care because of concerns of an infection; those with strokes and heart attacks that stayed away from the hospital out of fear of COVID-19; those who probably had COVID-19 but it wasn't diagnosed and succumbed at home or in places other than hospitals; for people who—because of the economic impact of COVID-19—weren't able to make their dialysis appointments, weren't able to get prescriptions filled or provide for their family needs; the totality of death and disease, both direct and indirect, due to COVID-19 is staggering. And then there is the economic disruption from which many businesses and municipalities will not be able to recover.
As health care leaders, physicians and nurses, we need to grasp this burden. Now more clearly than ever before, we understand the preciousness of health. It is no longer appropriate to compartmentalize or partition health problems in one community versus another community. It is our issue to own and our responsibility to intervene.
AMA: What else should be physicians and others be thinking about, in terms of the less-noticed health impacts of the pandemic?
Dr. Yancy: Think of the one thing that has created a degree of angst that was not expected. Social isolation, disruption of social networks, loss of the personal connection, the personal touch has been our shared pain. Perhaps the hierarchy of our personal priority schemes has changed—it is no longer about what we have or what we do but whom we engage.
If we emerge from all of this as more connected, more patient, more kind and, yes, more healthy, then our future will be more hopeful.