The last two posts have been about terrible control rates for high blood pressure in the United States. Hypertension is the most common cardiovascular risk factor and it is responsible for about half of all heart attacks and strokes. That means poor hypertension control is creating a huge burden of premature death, disability, hospitalization, ER visits, and cost in the United States. This is especially frustrating because controlling hypertension is so easy.
The Path to More Effective Hypertension Control
Focus on High Blood Pressure. Hypertension control is so poor in usual care—the care that most patients receive—because our system is designed to address acute events and rescue patients late in the course of the disease. Hypertension is a chronic disease with no symptoms and it is one of a host of issues the primary care provider faces. It gets lost in the shuffle. For high blood pressure to be less than 130 on the top number consistently, focus on the problem is critical. A single primary care provider who is especially interested in and focused on cardiovascular risk factor control and optimal medical therapy (OMT) is one answer. A better answer is a team focused on cardiovascular and related conditions manned by nurse practitioners, physician assistants, and/or pharmDs who are allowed to make changes in treatment in real time without checking with a physician. Hypertension can be controlled remotely and conveniently with a supportive payment model.
An Evidence-based Protocol Consistent with Best Practices. Patients who have hypertension often need three or four medications to control their blood pressure. Individuals with inadequate control on three medications (one of which is a fluid pill) by definition have resistant hypertension. There is general agreement that the first three drugs should be an ACE inhibitor like losartan or an ARB like losartan, a thiazide-type diuretic like hydrochlorothiazide, and a calcium channel blocker like amlodipine. The fourth drug should be spironolactone or eplerenone. Following the protocol is very simple. Begin with lisinopril and add hydrochlorothiazide followed by amlodipine and spironolactone until the pressure is at goal. If you go through that sequence and the pressure is still not controlled, just double the dose and repeat the sequence until the pressure is at goal.
Singapore has one-stop primary care clinics across their country with special operations teams focused on hypertension, diabetes, and cholesterol embedded within the facility. They live longer for 5% of gross domestic product. That is the path to better health at lower cost. Our American healthcare system consumes almost 20% of gross domestic product. Let’s get started now!