TAKE-HOME POINTS
■ Uncontrolled hypertension is a primary cause of renal disease, stroke, and coronary artery disease. Evidencebased guidelines for the screening, diagnosis, and management of hypertension are available; however, patient and provider adherence is low.
■ Factors that infl uence appropriate BP control can be stratified into four primary categories: Patient-related, health care provider-related, social and economic, and external.
■ Recent debate surrounds the effectiveness of monitoring therapeutic response rate versus goal BP. An approach that uses a combination of factors, including systolic and diastolic BP, ambulatory BP, and patient preferences is likely to be more prudent.
WHO SHOULD READ THIS?
This information is relevant for all physician assistants who provide screening, diagnosis, or management of hypertension in all communities.
WHY IS THIS IMPORTANT?
Antihypertensive medications were first available in the 1960s, yet uncontrolled hypertension is the leading cause of death worldwide.1 In the United States alone, 73.5 million patients have hypertension and approximately 395,000 deaths occur secondary to hypertension annually.2 Uncontrolled hypertension is a primary cause of renal disease, stroke, and coronary artery disease.3,4 Despite the availability of evidence-based guidelines for the screening, diagnosis, and management of hypertension, patient and provider adherence is low.5,6
Males are more likely to develop hypertension until age 65 years and older, at which point females become predominantly affected. African Americans experience a greater incidence of hypertension, with females affected more frequently than males. Disparities seen in many cultures have multiple contributing factors, including inadequate provider attention, poor communication style, and lack of resources.4
Factors that influence appropriate BP control can be stratified into four primary categories. Patient-related factors typically occur secondary to insufficient patient-provider communication. Some examples are an unclear perception of risk associated with uncontrolled hypertension, confusion regarding the need for medication, and the use of interfering medications (eg, NSAIDs). Another patient-related factor is pseudoresistance, defined as poorly-controlled BP with appropriate treatment. Pseudoresistance is largely due to improper technique, such as using an inappropriate BP cuff, or failing to support the arm at heart level.2 The white-coat effect may also fall in this category. These patients may have an intermediate cardiovascular risk and should compare office measurements with longitudinal ambulatory BP measurements.2
Health care provider-related factors occur secondary to therapeutic inertia, ineffective patient-provider communication skills, or lack of awareness regarding the current guidelines. Therapeutic inertia occurs when health care providers fail to manage poor BP control in patients with documented hypertension. This is attributed to the health care provider's decreased reliance on office BP measurements, lack of clarity regarding the current guidelines, and a belief that prescribed pharmacologic agents take several weeks to become effective.2,7,8
Social and economic factors influence quality health care, and may include access to health care, race or ethnicity, and educational and socioeconomic status. Finally, external factors include systems-based factors, such as reimbursement for patient education and the need to address acute concerns in a time-compressed environment.7
WHAT ARE THE CURRENT RECOMMENDATIONS?
The Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7) classifies BP diagnosis and treatment goals9 (Table: JNC7 classification of hypertension, by BP measurement in the online version of this article). Appropriate treatment of hypertension has been demonstrated to reduce the risk of stroke by approximately 35%, heart failure by 42%, and coronary heart disease by 28%.10 Lifestyle changes are a vital component of effective BP control. The Dietary Approaches to Stop Hypertension diet, sodium reduction, limited alcohol consumption, and regular exercise should routinely be discussed during management planning.3,11 Sodium should be restricted to less than 2.4 g/d, alcohol consumption limited to no more than one drink per day for women and no more than two drinks per day for men, and patients should be encouraged to exercise at least 30 minutes a day on most days of the week. PAs should also encourage patients to maintain a normal body mass index.9
