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

2. 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

3. What is the goal?

4. 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):

5. 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 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): doi: /jama

6. 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)
Kovesdy et al. Age and Outcomes Associated with BP in Patients with Incident CKD. CJASN April

7. HEDIS 2016: NCQA
Patients with a diagnosis of hypertension whose most recent blood pressure reading was controlled. Age whose BP was <140/90 Age with a diagnosis of diabetes whose BP was <140/90 Age 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

8. Measuring Blood Pressure
9© , Rice University. Licensed under a Creative Commons Attribution 4.0 License)

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

10. 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. May 2014.

12. 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

13. Incorrect BP: Multiple Root Causes

14. 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

15. Treatment Algorithm
JNC-8 Treatment Algorithm. (accessed 5/2/2016)

16. 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), doi:
Santos LL. Effects of aerobic exercise intensity on ambulatory blood pressure and vascular responses in resistant hypertension: a crossover trial.. Journal of hypertension ;1.

17. Treatment-Initial (JNC-8)
BP not at Goal, NO CKD
CKD
JNC-8 Treatment Algorithm. (accessed 5/2/2016)

18. Treatment: Subsequent JNC-8

19. 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