Give It a Rest

I heard the hurried footsteps and refreshed my screen. Ha! Nailed it. My team had just checked my new patient’s vitals and were eager to tell me that her blood pressure was high.

Until recently, the treatment plans for patients with hypertension were as complex as a 5-course French meal (and the resultant renin–angiotensin cascade its salt- and butter-laden dishes triggers). However, these days, the American Heart Association and American College of Cardiology have hypertension management on a diet.

The Annals of Internal Medicine updated its In the Clinic series on hypertension (1) accordingly, interpreting the latest guidelines and literature, which are much more of a smorgasbord than a prix fixe menu. As a primary care physician for older adults, I appreciate the options and Annals’ digest of them. 

My medical experience from training through practice has been in the American South. Hypertension is my bread, butter, appetizer, entrée, and dessert. As a result, of all those things on a bed of social determinants of health, we unfortunately have a lot of high blood pressure to learn from.

The new guideline diet is refreshingly down-to-earth in many ways. As a result, a few of the new guidelines are welcome acknowledgments of hypertension in the wild—as opposed to the “farmed” feeling of blood pressure readings in the office. Blood pressure goals are now more uniform across populations (<130/80 mm Hg), allow for patient-centered choice of first-line medications (angiotensin-converting enzyme inhibitor/angiotensin-receptor blocker, thiazide, or calcium-channel blocker), and acknowledge the variability of patient comorbidities and testing settings (encouraging use of overall cardiovascular risk assessment to guide treatment, including ambulatory blood pressure monitoring, and reinforcing the role of lifestyle interventions in prevention and treatment).

My personal favorite is the suggestion to use only a systolic blood pressure goal (130 mm Hg) for adults older than 65 years because of the stiffening of vasculature as it ages and the risks for diastolic pressures that are too low. This is particularly useful given that I am lucky enough to work with a team that assists with blood pressure follow-ups without requiring physician input at every visit. I can give them parameters for next steps (e.g., “If systolic blood pressure is >130 mm Hg, increase amlodipine to 10 mg daily."), and the instructions are much easier with just a single number to go by.

The guidelines also emphasize the importance of accurate blood pressure reading technique. Some of these techniques—like using the correctly sized cuff—are relatively easy to adopt. This is akin to asking a chef to use the right type of pan; most basic kitchens will be able to accomplish this task.

However, another recommendation to “have the patient sit quietly for 5 minutes before a reading is taken” is much harder to achieve in a typical primary care clinic. The goal of waiting 5 minutes before testing is to ensure that the measurement reflects the blood pressure at rest, not at pause. However, is anyone able to truly rest in a primary care clinic? Time is so often our rate-limiting factor in attaining health.

My new patient’s blood pressure was admittedly very high, but she had also just come into a new space, anxiously signed forms, and acclimated to a host of new faces. I’m lucky enough to work in a clinic that often can afford a few extra minutes to obtain the elusive free-range blood pressure reading “at rest,” but even then, we feel the pressure of staying on time and getting to the remainder of our visit. I asked my team to wait a bit and then recheck the patient's blood pressure.

Although her blood pressure did decrease some, she still insisted that it was usually better when she hadn’t recently run out of her medications, and even better when she checked it at home. Perhaps in the future, more practices will be reimbursed like mine, so they can have more time to allocate for things like accurate blood pressure reading. Or, maybe the integration of effective and widely available ambulatory blood pressure monitoring systems will help us avoid the need to estimate resting, out-of-office blood pressure. Maybe we’ll have more equitable access to a health care system that helps people afford and receive medications without interruptions.

Until then, primary care clinics may still be missing the secret ingredient for well-managed blood pressure. A tip we should all probably take for ourselves and our practices before making any decisions: give it a rest.

References

1. Byrd JB, Brook RD. Hypertension. Ann Intern Med. 2019;170:ITC65-ITC80. [PMID: 31060074] doi:10.7326/AITC201905070