1. High Blood Pressure (Hypertension) Prevention and Control SASH – September 25, 2012 Suzanne Lapointe, RN, BA, CNN Fletcher Allen Health Care, Nephrology Robin Edelman, MS, RD, CDE Vermont Department of Health

2. Topics for Today How are we doing with blood pressure control? Measuring and monitoring blood pressure Management of high blood pressure –Medications –Lifestyle changes Self-management options for SASH enrollees Self-management support by SASH staff

3. Blood pressure during each cardiac cycle Systole (larger number) Diastole (smaller number)

5. YouTube video link for measuring blood pressure http://www.youtube.com/watch?v= ixG8R6LY9qU

6. December 2003 in Hypertension. 2003;42:1206

7. High blood pressure is an independent risk factor for CVD*, Stroke and Kidney Disease = Vascular Disease Hypertension can affect the heart, brain, and kidneys Hypertension promotes atherosclerosis and arteriosclerosis *CVD = cardiovascular disease 7

8. High Blood Pressure in US– “a neglected disease” Institute of Medicine (IOM) February 2010 “High blood pressure is out of control for too many Americans” Centers for Disease Control and Prevention (CDC) September 2012  1/3 adults have it; 1/2 > 60y, 3/4 >70y  More than half have uncontrolled high blood pressure  ~ 40% aren’t aware that they have high blood pressure  1/6 die from uncontrolled blood pressure (~ 1000 per day)  easy to prevent, simple to diagnose, inexpensive to treat

9. The Lancet, 361:2149-2151 genetic predisposition environmental factors Causes of high blood pressure are multi-factorial salt obesity smoking

10. Management of Blood Pressure  Goal  Individual strategy  Group strategy  physicians, patients, systems

11. Blood Pressure Numbers What’s more important (the big number, or the smaller one)? And why?

12. Lifestyle modification – patient specific achievable goals  Weight reduction (10 - 20 lbs helps) – SBP 5-20 mmHg  Physical activity (30 minutes/day as part of ADL) – SBP 4-9mmHg  Avoid excessive alcohol ingestion, stop tobacco – SBP 2-4 mmHg  Avoid high sodium intake – SBP 3-5 mmHg for 2 g reduction  DASH diet – SBP 8-14 mmHg

13. Avoid high sodium intake – shop around the edges of the supermarket except for the deli 12% 6% 5% 77% CDC

15. Optimal medication regimen should…  Reduce volume thiazide diuretic (for all unless eGFR 30 m/min) in addition to thiazide loop diuretics in CKD patients (edema, eGFR < 30 m/ml)  Reduce renin/angiotensin effect ACEi/ARB; renin inhibitors (DM, CKD, proteinuria/albuminuria, CAD, LVH)  Reduce myocardial activity Beta or Alpha/Beta blocker (titrate dose to keep HR in the 60’s)  Vasodilate CCB (dihydropyridines best for BP) or vasodilator (hydralazine, minoxidil)  Add central or peripheral SNS agents as fifth line Clonidine, alpha methyldopa, alpha blockers  Use medications in multiple classes. Two to 4 are commonly needed. (e.g. Diuretics + ACEi/ARB + Beta and alpha blockers + CCB)

16. Inadequate Response to Therapy  Volume overload: medications (NSAIDs), excessive salt intake, kidney dysfunction  Non adherence to therapy: too frequent dosing, expense, intolerable side effects. - Use several drugs in low doses to maximize effectiveness and minimize side effects rather than maximum doses of one drug  Drug problems: wrong drug or dose; combinations of drugs that don’t work well together  Other medical conditions: smoking, excess alcohol, anxiety, pain, sleep apnea, obesity

17. Approaches to improving BP Control  patient participation and ownership having a goal knowing when not at goal (measuring BP at home) having a way to modify treatment to get to goal

18. http://intranet.fletcherallen.org/Pages/Home.aspx http://www.youtube.com/watch?v=ixG8R6L Y9qU

19. Self-management is what people do to take care of themselves. Self-management support is what staff do to help people take care of themselves.

20. Steps in Self-Management Support Collaborative setting of goals and action plans Identification of barriers and challenges Personalized problem-solving Follow-up support

21. Action Plan (a short term plan for doing something measurable) that fits into a longer range goal 1. Something a person WANTS to do 2. Describes:  What (the doable behavior)  How Much  How Often (# of days)  When (time of day) 3. Confidence rating (1-10) 1 = no confidence; 10 = total confidence

22. Examples: (Long range) Goals & (shorter term) Action Plans Improve fitness to lower blood pressure –Walk for 20 minutes in the morning on 4 days this week –Ride the stationary cycle after lunch on 5 days this week Eat better to lower blood pressure –Have 1 cup of vegetables at lunch & supper on 3 days this week –Have 1 cup of oatmeal in place of salty breakfast sandwich on 4 days this week

23. Benefits of self-monitoring blood pressure Avoid faulty high readings from “white coat hypertension” See quicker changes in response to improved behavior Easy and safe to measure Encourages behavior improvement Builds self-efficacy (self-confidence in one’s ability to self-manage)

24. Recommended Website http://www.nhlbi.nih.gov/ U.S Department of Health and Human Services National Institutes of Health National Heart, Lung, and Blood Institute