Getting Blood Pressure To Goal: a Pressurized Process Grant M. Greenberg M.D., M.A., M.S.H.A.

Overview Current blood pressure treatment goals and associated quality measures Challenges of measuring blood pressure in an ambulatory setting, techniques to improve accurate measurement Current evidence-based treatment recommendations for hypertension

What is the goal?

JNC-7 Chobanian, A. V. et al. "Seventh Report Of The Joint National Committee On Prevention, Detection, Evaluation, And Treatment Of High Blood Pressure". Hypertension 42.6 (2003): 1206-1252.

But….then came JNC-8 goals If goal is different than definition, what is HTN???? Age 60 and older <150/90 Diabetes any age <140/90 Regardless of definition or threshold treatment goal: Decrease of SBP of 10 mmHg/DBP of 5-6 mmHg: Reduces the risk of stroke 35-40% Reduces the risk CHD 20-25%. James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427.

Diabetes, CKD and DBP Reduction of DBP below 70mmHG increases all cause mortality For Diabetes For CKD Tringali et al. International Journal of Hypertension Volume 2013 (2013) http://dx.doi.org/10.1155/2013/178780 Kovesdy et al. Age and Outcomes Associated with BP in Patients with Incident CKD. CJASN April 2016. http://cjasn.asnjournals.org/content/early/2016/04/20/CJN.08660815.abstract

HEDIS 2016: NCQA Patients 18-85 with a diagnosis of hypertension whose most recent blood pressure reading was controlled. Age 18-59 whose BP was <140/90 Age 60-85 with a diagnosis of diabetes whose BP was <140/90 Age 60-85 without a diagnosis of diabetes whose BP was <150/90 Exclusions: Patients with end stage renal disease (ESRD) Pregnant during the measurement year. Admission to a non-acute inpatient setting during the measurement year https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Downloads/Medicaid-Adult-Core-Set-Manual.pdf

Measuring Blood Pressure http://cnx.org/contents/FPtK1zmh@6.27:zMTtFGyH@4/Introduction 9© 1999-2016, Rice University. Licensed under a Creative Commons Attribution 4.0 License)

Devices for Monitoring Aneroid Manometer Calibrate annually (do you?) Electronic Manometer Calibrate 2x yearly (do you?)

Optimal BP Technique No caffeine or exercise within 30 minutes No alcohol for 2 hours Sit for 5 minutes with back supported and feet on floor PRIOR to testing Proper Cuff Size, over bare arm Arm supported, stethoscope at heart level 30 mm HG above systolic, deflate 2-3 mmHg/second Jimbo, M, Dorsch M, Ealovaga M, Harrison RVH, Jamerson K. Essential HTN, University of Michigan Clinical Practice Guideline. http://www.med.umich.edu/1info/FHP/practiceguides/newhtn/htn.pdf May 2014.

Incorrect BP: a true (and repetitive) story Patient running late due to traffic accident, didn’t have time for lunch so grabbed Egg McMuffin and Coffee. Forgot to take BP med. Screaming 3 year old pulling stirrups out of exam table. MA sits patient on exam table, first thing after walking down long hall into exam room. Uses Medium Cuff for patient with BMI 37 kg/m2. Records number (high) Patient states: “I have white coat HTN”. Repeat BP not taken prior to departure

Incorrect BP: Multiple Root Causes

Home/Ambulatory Monitoring Home Blood Pressure Monitoring is recommended (but doesn’t ‘count’ for HEDIS) Helpful to differentiate White Coat HTN or Identify Masked HTN Technology Revolution Proper Technique and Cuff Size teaching

Treatment Algorithm JNC-8 Treatment Algorithm. https://www.ahcusaweb.com/ProviderWeb/downloadfs.aspx?category=8&title=3%20&fromsite=1 (accessed 5/2/2016)

Lifestyle Interventions- ”DASH” DIET and EXERCISE SBP reduction 5 mmHg, DBP reduction 2 mmHG 13% reduction in 10 year Framingham Risk EXERCISE: reduction of both SBP and DBP up to 5 mmHG short and long term with both intense and moderate activity Siervo, M., Lara, J., Chowdhury, S., Ashor, A., Oggioni, C., & Mathers, J. C. (2015). Effects of the dietary approach to stop hypertension (DASH) diet on cardiovascular risk factors: A systematic review and meta-analysis. The British Journal of Nutrition, 113(1), 1-15. doi:http://dx.doi.org/10.1017/S0007114514003341 Santos LL. Effects of aerobic exercise intensity on ambulatory blood pressure and vascular responses in resistant hypertension: a crossover trial.. Journal of hypertension. 2016-06;1.

Treatment-Initial (JNC-8) BP not at Goal, NO CKD CKD JNC-8 Treatment Algorithm. https://www.ahcusaweb.com/ProviderWeb/downloadfs.aspx?category=8&title=3%20&fromsite=1 (accessed 5/2/2016)

Treatment: Subsequent JNC-8

Summary Recognize that BP goals, like many other measures, are a moving target Technique and process matter in determining if patient has HTN or if BP under control Optimal treatment includes diet, exercise (e.g. lifestyle modification) concurrent with medication