Hypertension Guideline

Tick, tick, tick. Cheryl Dennison Himmelfarb, PhD, RN, ANP, FAAN, professor and associate dean of research, was counting the seconds until a fresh, more proactive Hypertension Guideline was to be published.

Himmelfarb, co-author of the Guideline, knew it would be a game-changer and a life saver. But until it was in print—advocating intervention much sooner and a “high blood pressure” label for lower readings, among other key measures—it couldn’t be adopted, leaving people at higher risk of stroke, cardiovascular disease, and death.

She knew the research was solid and the approach was right … right now.

With that wait over, Himmelfarb took a few moments to share the thinking behind the Hypertension Guideline, why time remains of the essence, and why nurses are critical in the education and team-based care of patients.

“The term ‘prehypertension’ was a well-intentioned way to nudge patients toward healthier choices,” explains Himmelfarb, who also directs the Helene Fuld Leadership Program for the Advancement of Patient Safety & Quality. “Instead, it could give a false sense of security, and a reason to stall. ‘I’m not in danger yet.’ By the time you actually started calling it hypertension, avoidable damage might have occurred. So ‘prehypertension’ needs to go.”

The new definition of hypertension (anything at or above 130/80) will translate to an increase to almost 50 percent—from 1 in 3—of the adult population in the United States with hypertension. However, the vast majority of those newly diagnosed would not be prescribed medication but rather guided to modify their lifestyles immediately to lower blood pressure.

In addition to more aggressive treatment, the Hypertension Guideline emphasizes an individualized approach that involves shared decision-making and support. That’s where nurses come in, Himmelfarb says: “Patient education must begin immediately. Communication must be consistent and frequent. We need to empower patients to know their numbers—their blood pressure levels vs. the goals, their atherosclerotic cardiovascular disease (ASCVD) risk—and offer strategies for self-managing high blood pressure.”

On this, the clock is still ticking. Here, from Himmelfarb, are 10 things Nurses Need to Know:

1. 1. Increased risk for heart attack, stroke, and other consequences of high blood pressure begins at a systolic level above 120. (It doubles at 130 vs. 120.)

   2. Normal blood pressure is below 120/80. Systolic 120-129 and diastolic below 80 is now classified as elevated. Hypertension is blood pressure above 130/80—as Stage 1 (systolic 130-139 or diastolic 80-89) or Stage 2 (systolic above 140 or diastolic above 90).

   3. Nonpharmacologic therapy (weight loss, a low-sodium, high-potassium diet, limited alcohol, and physical activity most days of the week) is now recommended for ALL with elevated blood pressure and Stage 1 and Stage 2 hypertension. This extends to those who are also prescribed medication(s) to lower blood pressure.

   4. Clinicians will need to build their repertoire of skills and tools to promote lifestyle modification.

   5. The new approach involves calculation of ASCVD risk to guide treatment at Stage 1. Those with low risk, or a 10-year ASCVD risk of less than 10 percent, are recommended for nonpharmacologic therapy. Those with a risk of 10 percent or greater, are recommended for blood pressure-lowering medication as well.

   6. Stage 1 is the threshold for recommending blood pressure-lowering medication in addition to nonpharmacologic therapy for those with comorbid conditions such as diabetes, chronic kidney disease, heart failure, stable ischemic heart disease, and peripheral arterial disease.

   7. First-line medication agents include thiazide diuretics, calcium channel blockers, and angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers. For adults with Stage 2 hypertension and an average blood pressure more than 20/10 above their target, antihypertensive drug therapy with two first-line agents of different classes, either separate or in a fixed-dose combination, is recommended.

   8. The Guideline recommends a health system-level intervention by a multidisciplinary team (may include a primary care provider, cardiologists, nurses, pharmacists, physician assistants, dietitians, social and community health workers). Approach should include support for clinical decision making (i.e., treatment algorithms), collaboration, adherence to regimen, blood pressure monitoring, and self-management.

   9. Home blood pressure monitoring is an important method to confirm and manage hypertension.

   10. The Guideline emphasizes an individualized approach that involves shared decision making through frequent communication to assess patients’ preferences, goals, and how medications may affect daily activities. This may be of particular importance among older adults with a high burden of comorbidity or limited life expectancy.