You Can Easily Control Hypertension in 90% of Your Patients!
High blood pressure is the most common risk factor for cardiovascular complications like heart attack, stroke, and congestive heart failure. It is the most common reason for a primary care clinic visit. It only makes sense that the primary care should have the highest level of expertise in managing this condition. Here’s the thing though. Only 44% of Americans with high blood pressure achieve a blood pressure of 140/90 or less. If a person has any other cardiovascular disease or diabetes, their pressure should be 130/80 or less. For those people, the percentage control is much worse. Yet, Kaiser Permanente in Northern California has achieved a hypertension control rate of 90% in 750,000 patients. They have proved it can be done. That is the benchmark!
Here is a very simple protocol for medical management in hypertension:
Begin with losartan/hydrochlorothiazide 50mg/12.5mg at 1 tablet daily ($4/mo). Alternate choice (lisinopril/hydrochlorothiazide 20/25. ($4/mo) If pressure not at goal in 2 weeks, add:
Amlodipine 5 mg daily ($9/mo).
If pressure not at goal in 2 weeks, add:
Spironolactone 12.5 mg daily. ($4/mo). Alternate choice eplerenone 25 mg. daily. ($18.45/mo) (spironolactone may cause gynecomastia at higher doses)
If pressure not at goal in 2 weeks, circle back and double the dose in each step until you achieve the target blood pressure.
Aggressive care with these medications early slows development and progression of chronic kidney disease that may make using these medications more challenging. Of course, you must take the proper precautions when using any medication. By using a standard protocol you get teams, case managers, and navigators on the same page. You avoid confusing messages. By using this protocol, you should achieve a control rates to less than 140/90 in 85-90% of your patients. It takes multiple medications to control blood pressure in most patients. If patients object to the number of pills I would say: “High blood pressure is very dangerous. It tends to become higher and damage the heart and kidneys if we don’t get it down. Let’s get it down and keep it down. We may be able to back off on some of the medication later when your pressure is controlled for a while.”
Small doses of lisinopril, losartan, spironolactone, and eplerenone inhibit the signaling that causes heart enlargement, chronic kidney disease, congestive heart failure and other complications. These medications protect every cell and organ in the body. Once the pressure is elevated, the genes that produce aldosterone and angiotensin II are switched on. Continue small doses of these medications to block the signaling that causes cardiovascular disease. It is not just about the blood pressure.This protocol will cover 80 to 90% of your patients.
Many of you don’t know your percentage hypertension control. You can’t improve what you don’t measure. I have never seen an 85-90% control rate in the absence of a protocol. Teams and population health tools improve performance even more. If you need help with measurement and analytics. let me know. wbestermann@congruityhealth.com.