2013 Scientific Assembly Needs Assessment Body System: Cardiovascular Session Topic: Hypertension in Adults and the Elderly

Learning Category II - Interactive Needs Assessment Hypertension is the most common condition for which patients make physician office visits. According to the CDCs 2006 National Ambulatory Medical Care Survey (NAMCS), hypertension was the top-ranked medical diagnosis by physicians at office visits eight times from 1996 to 2006; the percentage of visits by adults 18 and over with chronic hypertension increased 28% over a 10-year time span.1 Family physicians alone see patients with hypertension in 17.7 million office visits more than twice as many visits for the second-most common condition, diabetes.2 Additional statistics report the staggering rates of the condition: 3,4 Thirty-four percent of adults about one in three have hypertension, defined as blood pressure of 140/90 mmHg. It accounts for more than 17 million visits to family physicians offices each year. Of the 75 million people over the age of 20 who have hypertension, it is estimated that 78% are aware of their condition, 68% are under current treatment, 44% have the condition under control and 56% do not have it controlled. It is estimated that nearly 25% of the U.S. population age 20 and older has prehypertension (defined as blood pressure between 120-139/80-89mmHg), making them 1.65 times more likely to have above-normal cholesterol levels, diabetes or overweight/obesity than those with normal blood pressure. Research indicates that the prevalence of hypertension among blacks in the U.S. is among the highest in the world. They tend to develop hypertension earlier in life, as compared to whites, and subsequently have a greater chance of developing end-stage renal disease and heart disease death. Hypertension was listed as a primary or contributing cause of death for 326,000 people in the U.S. in 2006. Hypertension is sometimes referred to as the silent killer because many people (approximately 23%) are unaware they have the condition and it often has no warning signs or symptoms. While all blood pressure levels above 120/80 mmHg can increase a persons risk for health problems related to hypertension, systolic and diastolic blood pressure ranges differ for certain groups of people. Consider the following recommendations from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC-7): 5 Individuals with a systolic range of 120-139 mmHg or a diastolic range of 80-89 mmHg should be considered prehypertensive and provided resources and guidance to make appropriate lifestyle modification.

2013 Scientific Assembly Needs Assessment Patients with diabetes or chronic kidney disease who have blood pressure of 130/80 mmHg are considered hypertensive, as opposed to other individuals whose blood pressure of 140/90 mmHg is considered hypertensive. o Patients in these ranges typically require two or more antihypertensive medications to achieve a target blood pressure of 120/80 mmHg. In patients over the age of 50, systolic pressure greater than 140 mmHg is a greater cardiovascular risk factor than diastolic pressure. It should be noted that revised guidelines on hypertension are currently being constructed by the Joint National Committee (JNC-8) and are expected to be released in the fall of 2011.6 In addition, the prevalence of hypertension is significantly higher in blacks than in whites39% compared to 29%, and uncontrolled hypertension may cuase up to onequarter of all deaths among black adults. Blacks also experience earlier onset of hypertension, their disease is more aggressive, and it is more difficult to treat and severe, especially when considering organ damage (e.g., renal failure).7,8 The prevalence of hypertension in Hispanics is comparable to or lower than that of whites, but the rates have been increasing, and Hispanics who have hypertension are less likely to have their blood pressure treated and controlled than are whites or blacks.8 The causes of these disparities are not completely understood, though differences in access to care, clinician management, hypertension severity and patient adherence to treatment all may play roles.7 Family physicians should be aware of these disparities when treating minority patients and pay close attention to any signs or symptoms of hypertension. Although most physicians routinely check blood pressure as part of regular office visits, hypertension remains a challenging condition for both patients and physicians. The American Heart Association (AHA) reports that interventions targeting weight loss, physical activity and dietary modification can result in behavior change that, if sustained over time, can reduce morbidity and mortality associated with CVD.9 However, because such practices take time to develop and adhere to, some patients may still require the use of medications and treatments, which family physicians can prescribe and monitor, to control risk factors (such as gender, age, family history and race/ethnicity) that cannot be controlled, or in cases in which hypertension is present with comorbidities such as hyperlipidemia and diabetes. Additionally, some patients are diagnosed with resistant hypertension, in which high blood pressure persists despite patient adherence to medications, and other patients are at increased risk of cardiovascular diseases due to chronic conditions such as diabetes for which blood pressure control is a critical component of their care.10 As a result, family physicians must be prepared to treat all different forms of hypertension in multiple types of patient encounters. In order for family physicians to understand what treatment options are available and be able to refer patients to a specialist, if necessary they must have knowledge and understanding of the various elements associated with cardiovascular conditions (not

2013 Scientific Assembly Needs Assessment just hypertension), their comorbidities and their risks. Consistency in treatment, followup and adherence to guidelines offered by a family physician may be a patients best opportunity to decrease the incidence of cardiovascular conditions and improve his or her quality of life. Providing family physicians with appropriate education and training on how to screen, diagnose, assess and treat patients with various cardiovascular diseases will help to decrease or eliminate practice gaps and lead to improved patient care. Guidelines U.S. Preventive Services Task Force. Screening for High Blood Pressure: Reaffirmation Recommendation Statement.8 (http://www.aafp.org/afp/2009/0615/p1087.html) Moyer VA; on behalf of the U.S. Preventive Services Task Force. Behavioral Counseling Interventions to Promote a Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2012.9 Current: Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)10 (http://www.nhlbi.nih.gov/guidelines/hypertension/index.htm) Future: Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8)*( http://www.nhlbi.nih.gov/guidelines/hypertension/jnc8/index.htm)

*It should be noted that revised guidelines on hypertension are currently being constructed by the Joint National Committee and are expected to be released during 2012. When it is published, course materials will be updated as appropriate to account for any changes in the guidelines.

Gaps in Knowledge, Competence and/or Performance: Family physicians may need additional training on effective counseling methods for patients to encourage healthy behavior changes to reduce their risk for developing hypertension or prehypertension. Family physicians need additional training on guideline recommendations for diagnosing and appropriately treating patients with hypertension using a stepwise approach to achieve stable tight control of blood pressure. Family physicians should recognize barriers to care that may prevent some patients from making appropriate health decisions, and they should understand ways to address them and/or offer alternative options. Family physicians should also be aware that blacks and Hispanics may have higher risk of developing hypertension, and that hypertension in these populations could be more severe, requiring enhanced physician vigilance and aggressive management. While patients who have poorly controlled hypertension do not necessarily have resistant hypertension, family physicians should still be prepared to offer

2013 Scientific Assembly Needs Assessment treatment regimens of antihypertensive medications and tools to improve patient adherence.

Learning Objectives: At the end of this session, participants will be able to: 1. Counsel patients on how to make healthy behavior changes to reduce their risk for developing hypertension or prehypertension. 2. Assess barriers to care among patients in your practice, including minority patients, and identify or develop tools to help address hypertension. 3. Prepare treatment regimens of antihypertensive medications and tools to improve patient adherence.
References: 1. Cherry D, Hing E, Woodwell D, Rechsteiner E. National Ambulatory Medical Care Survey: 2006 Summary. August 6, 2008. Advance Data from CDC Vital and Health Statistics. Available at http://www.cdc.gov/nchs/data/nhsr/nhsr003.pdf 2. National Ambulatory Medical Care Survey: 2007 Summary. National Center for Health Statistics, 2009. Hyattsville, MD. Available at http://www.cdc.gov/nchs/data/nhsr/nhsr027.pdf 3. Heart Disease & Stroke Statistics: 2010 Update At-a-Glance. American Heart Association. Available at http://dbbs.wustl.edu/dbbs/website.nsf/forms/forms/$file/HeartStrokeUpdate2010.pdf 4. High Blood Pressure Facts. CDC National Center for Chronic Disease Prevention and Health Promotion (NCCDHP), Division for Heart Disease and Stroke Prevention. February 2010. Available at http://www.cdc.gov/bloodpressure/facts.htm 5. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. National Heart, Lung and Blood Institute 9NHLBI), National Institutes of Health. December 2003. Available at http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf 6. Cardiovascular Risk Reduction Guidelines in Adults: Cholesterol Guideline Update (ATP IV), Hypertension Guideline Update (JNC 8), Obesity Guideline Update (Obesity 2), Integrated Cardiovascular Risk Reduction Guideline. NHLBI. Available at http://www.nhlbi.nih.gov/guidelines/cvd_adult/background.htm 7. Fiscella K, Holt K. Racial Disparity in Hypertension Control: Tallying the Death Toll. Ann Fam Med 2008;6(6):497-502. Available at http://www.annfammed.org/cgi/content/full/6/6/497 8. Morenoff JD, et al. Understanding Social Disparities in Hypertension Prevalence, Awareness, Treatment, and Control: The Role of Neighborhood Context. Soc Sci Med 2007;65(9):1853-1866. Available at http://www.sciencedirect.com/science/article/pii/S0277953607003097

9. Artinian, N et al. Interventions to Promote Physical Activity and Dietary Lifestyle Changes for Cardiovascular Risk Factor Reduction in Adults: A Scientific Statement from the American Heart Association. Circulation 2010;122:406-441. Available at http://circ.ahajournals.org/cgi/reprint/CIR.0b013e3181e8edf1

2013 Scientific Assembly Needs Assessment

10. Viera, A; Hinderliter, A. Evaluation and Management of the Patient with Difficult-to-Control or Resistant Hypertension. Am Fam Physician 2009;79(10):863-869. Available at http://www.aafp.org/afp/2009/0515/p863.html