Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.

COVID-19 Oct. 5, 2020 update

In today’s COVID-19 update, AMA Chief Experience Officer Todd Unger and health experts discuss the importance of maintaining cardiovascular health during COVID-19, and what can be done following new research that indicates blood pressure control has stagnated in patients.

Learn more at the AMA COVID-19 resource center.

Speakers

  • Michael Rakotz, MD, vice president, Health Outcomes, AMA
  • David Goff, MD, PhD, director, Division of Cardiovascular Science, National Heart, Lung and Blood Institute
  • Rear Admiral Betsy L. Thompson, MD, MSPH, DrPH, director, Division for Heart Disease and Stroke Prevention, CDC

AMA COVID-19 Daily Video Update

AMA’s video collection features experts and physician leaders discussing the latest on the pandemic.


Unger: Hello, this is the American Medical Association's COVID-19 Update. Today, we're discussing the importance of maintaining cardiovascular health during COVID-19 I'm joined today by Dr. Michael Rakotz, vice president of health outcomes at the AMA in Chicago, Rear Admiral Betsy L. Thompson, director of the Division for Heart Disease and Stroke Prevention at the Centers for Disease Control and Prevention, and assistant surgeon general in the U.S. Public Health Service in Atlanta, and Dr. David Goff, director of the Division of Cardiovascular Sciences at the National Heart, Lung and Blood Institute in Bethesda, Maryland. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Goff, new research about blood pressure came out earlier this month. What does that research tell us and why is it so important?

Dr. Goff: Well, thanks for having me here. First, I need to say that these are my views and not necessarily the views of the NHLBI, NIH or Department of Health and Human Services. This recent report is based on nationally representative data from the NHANES study on long term trends of blood pressure control. After several decades of progress, this report shows stagnation and really decline in control. Fewer than half of adults in the U.S., just over four out of 10 with hypertension, had it under control in the most recent period, 2017 to 18. This was a drop of almost 10%, and that's a big and important drop because elevated blood pressure is a major risk factor for heart disease and stroke and the leading cause of death on our planet.

Unger: Dr. Rakotz, why do we seem to be losing ground here?

Dr. Rakotz: Yeah, I mean, I think that's a great question. I echo the strong concern that we're trending in the wrong direction with awareness treatment and blood pressure control and that this is the leading modifiable risk factor for the leading cause of death in this country. I personally think that we need a call to action for all doctors and all patients to really renew efforts to prioritize blood pressure control. Again, trending down, awareness, treatment and control. For patients, I think when you, when you ask, why is this happening, I think that adherence to treatment is a huge factor, and there are many, many reasons patients are having a hard time adhering to treatment, and there are many things that physicians can do to try to improve adherence to medications.

Physicians need to obtain more accurate blood pressure measurements, trust them to make quick diagnosis and quick treatment decisions. We know that using single pill combination therapy is a fast and effective way to get blood pressure to control. Yet, we know that only about 40% of people with uncontrolled high blood pressure, 40% of them are actually, continue to be on monotherapy instead of combination therapy. These are some basic things that we can do to try to improve blood pressure control.

Dr. Goff: Yeah, that's a really important point because for people who need blood pressure medication, it often takes several different drugs because of the body's system of preserving blood pressure. These combination therapies are really important and that means people need to have access to health care. One of the findings in this report was that access to health care was really important in determining who had blood pressure control and who didn't. That particularly played out that some of the race and ethnic groups, black Americans, the Latin-X population, Asian-Americans, were much less likely to have their high blood pressure controlled, due to these lack of access to care.

Unger: That's just yet another impact where we see, preexisting conditions like that exacerbated by COVID-19. Dr. Thompson, why are these findings so important to understand during the pandemic?

Dr. Thompson: Well, that does make it even more important, but I want to go back to just say that even before the pandemic, we considered hypertension control the number one priority, in terms of the work that we're doing in the Division for Heart Disease Prevention and Stroke. The thing that I would like to add though, around that, is that we had started this year thinking that this was going to be the year for hypertension control and we'd launched a national hypertension control round table, which my co-panelists are well aware of. Part of this work is so important and the pandemic has just made it more so.

National trends in heart disease mortality were, as Dr. Goff said, they were leveling off, even stagnating prior to this. We knew this prior to the most recent report, that just extends the period that we can look out a little bit longer, in terms of those trends that were worrying us. But right now we're particularly concerned, because serious heart condition is a major risk factor for COVID-19, for both hospitalization from COVID-19 as well as severe illness. While we're not sure that hypertension itself is directly linked to increased risk. We think it may be. We know that hypertension is one of the leading risk factors for serious heart disease.

So, it's really, really critical now, more than ever that people are aware of their blood pressure and that they and their care teams are doing everything they can control it. I will say one other thing. We know that we can get out of the basement of hypertension control rates. As David and Mike both said, we're down well below 50% of people with known hypertension, having an under control. Yet, when a health care system, when a clinic, when a private doc on his or her own, or even a community decide that they're going to make it a priority, they can get those rates up to 80 or even 90%.

Mike, thanks for setting up the call to action. We had felt like we had thrown out a call to action a year ago with the National Hypertension Control roundtable. By the time this airs, I certainly hope that the Surgeon General will have launched a real call to action at the national level for hypertension control.

Dr. Rakotz: Yeah, and Todd, one of the things that is a major concern with COVID-19 and hypertension control is that so many people at high risk or are limiting their travel to see their doctors because of the risk of infection. Telehealth has reduced that exposure risk for many people, but doctors everywhere immediately started to struggle with rapidly having to figure out, how do I manage somebody with a chronic condition when I don't have all the data that I'm used to having? Perfect example, are vital signs and hypertension, if you don't have a blood pressure, how are you going to manage a condition that's based on knowing what the blood pressure is?

That's where self-measured blood pressure monitoring or SMBP plays an extremely important role. This is a known strategy for improving blood pressure control, if done right. While nearly 97% or more of primary care providers report that they use SMBP, only about 40 to 50% of patients with hypertension say they use it. There's a little bit of a disconnect there and it's something that we could really focus on, that I think in the pandemic and beyond, I don't think it's going away anytime soon. I think the more we can widely disseminate SMBP as a strategy, the better off we'll be.

Unger: How do we close that gap, Dr. Rakotz?

Dr. Rakotz: Well, I can tell you that the AMA has been helping physicians and care teams use an evidence-based approach for improving blood pressure control, leveraging SMBP as part of that AMA M.A.P. BP Program, where we've created some clinically useful tools, from longer guidelines and scientific statements to make it easier for physicians and care teams to actually implement SMBP. We've put up on the AMA website, a seven steps, quick guide for implementing SMBP. We've got ongoing collaborations with Cr. Thompson and the CDC, the Million Hearts Team, the American Heart Association, and the National Association of Community Health Centers to try to increase the collective impact of all that we're doing to try to prevent cardiovascular disease, including improving blood pressure control.

Dr. Thompson: I will add that on if people are interested in really what works, because Mike knows that his package works, but a lot of it is very much similar to the things that we would advise through the Million Hearts Initiative. But on our website at CDC or the Million Hearts Website, you can get to the hypertension control change package. We also have a best practices guide on our division website at CDC. All of those are probably easier to find by your friend, Google than going into the CDC website, but they're there they're very readily available.

Dr. Rakotz: Yeah. I know that David wants to jump in here, but what I'll say is that what's great about the collaborations that we all have going, is that in that hypertension change package, there are tools and resources from the AMA, tools and resources from the American Heart Association, along with the VA and other organizations across the country. Between the AMA's website, the CDC's website, and I'm sure that NHLBI and NIH websites there is a lot of useful information out there.

Dr. Goff: Yeah, well, there, there's certainly a lot of great information, and yet we still have this challenge that we're facing with only about 40, 43% of people with hypertension having it controlled. There's a big role for physicians, certainly as we've discussed, avoiding treatment inertia, it's really important. The most common thing done in medical practice when a patient shows up with a blood pressure above goal is to schedule another visit, not to change the therapy. So, we physicians need to act more on the information that they get.

Home blood pressure monitoring can help, because sometimes physicians are skeptical and patients are skeptical about the blood pressure that's measured in practice, especially when it's not measured well. Physicians should use combination therapy more often because it often takes two, three or more medications to control blood pressure. We're supporting research that's looking into this. We have a study going on now that's testing a four-medication combination pill with each of those medications at very low dose. The idea is to be able to prevent some of the body's systems of counter- regulating blood pressure, so that one is able to get the blood pressure down with low doses of multiple agents, maximizing blood pressure control, while minimizing adverse effects.

This is something that we think is quite promising, but as Betsy said, we can do things inside the clinic and inside the practice, but many people don't have access to care. We need to figure out how to take care of the patients where they are. We've supported research such as done by Dr. Ron Victor in black barbershops, where pharmacists with prescribing authority went into black barbershops with blood pressure measurement machines, and were able to improve control of hypertension in black men from about a third to about 90%. We can get care to people through innovative approaches like this. This is the sort of thing that we need to test in more of an implementation and dissemination strategy and get it rolled out more widely across our country, so that we can get care to the people where they are, when they need it.

Dr. Rakotz: Yeah, that's a great point. We're working in practices and health systems every day across the country, trying to implement practice levels change, and systems change. What really struck me from the study more than anything else I think, I was saddened that blood pressure control is dropping. If you had health insurance, you were about twice as likely than someone who verses didn't, it was about twice as likely to have control. If you had a usual source of care, same thing, about twice as likely to be controlled. But if you had a visit to your doctor within the last year, you were five times more likely to achieve blood pressure control than someone who did not have a health care visit in the last year.

That I think, was the most, very powerful statement, that if that doesn't speak to the importance of seeing your doctor regularly when you have a chronic condition, I really don't know what does. The important thing when you do go in, and I think this is why, while you could get to a higher level of blood pressure control, if you went into 46%, imagine if when you went in, you had all physicians doing the right thing, measuring blood pressure accurately, adding therapy appropriately, using single pill combinations, all the things that we know work to improve blood pressure control more quickly. So, I absolutely agree with your comments,

Unger: Go ahead, Betsy.

Dr. Thompson: I'd like to go back to a couple of things that, because we are talking about blood pressure control during a pandemic, and I think it was Mike that alluded to the importance of telehealth, and also that very early on, in particular, we were seeing dramatic decreases in the use of certain services and including life-saving services for heart attacks and stroke, that were quite alarming. I just want to foot stomp on the telehealth and what it potentially offers, particularly at this time, but also going forward, in terms of the blood pressure, the self-monitor, blood pressure monitoring, improving access to at least some of those groups that have a hard time getting access, in rural communities and certain other disadvantaged populations, African-Americans and others that have a hard time sometimes with transportation and other barriers.

I think that's actually an opportunity that's presented by COVID-19 and another opportunity, which you all will indulge me a little bit, because I'm wearing the public health uniform, is around influenza this season. I'd be remiss to not say something about influenza and how critical it is this year, for a number of reasons for us to do a really great job with vaccination. But many of us, and I know many of my colleagues, physician colleagues are unaware of the association between influenza and cardiac disease, in terms of having influenza can increase your risk for subsequent cardiovascular events in the near term, but also having cardiovascular and serious heart conditions can and increase your risk for serious influenza illness. Thank you for letting me give my spiel on, get your flu shot and get all your patients vaccinated this year.

Unger: Well, Dr. Thompson, before we close, I did want to give you a chance to talk about the CDC's campaign to raise awareness about the relationship between COVID-19 and cardiovascular disease. Any comments on the CDC's PSA campaign?

Dr. Thompson: I just can't stress it enough, how important it is, more important than ever to improve the cardiovascular health of our nation, of our patients and our own. The importance of maintaining heart health during this pandemic, along with the risk of neglect, emergency medical attention for heart attack or stroke was highlighted in two PSA's that CDC created. One is called heart disease can be life-threatening, and during the COVID 19 managing heart disease is essential and reach out to your medical team for questions, concerns, and continued care.

Unger: Thank you so much, Dr. Thompson, Dr. Goff, Dr. Rakotz, for being in here today and sharing your perspectives and for all your important work. We'll be back soon with another COVID-19 update. For updated resources on COVID-19 visit the AMA site, ama-assn.org/COVID-19. Thanks for joining us today and please take care.


Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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