Changing prescribing strategies may benefit hypertension patients

LAS VEGAS — Hypertension is increasingly pervasive, with 50 million patients diagnosed each year in the United States and 90% of Americans older than 55 years exhibiting symptoms, raising the nation's risk for heart attack and stroke.

But too few clinicians adopt evidence-based treatment strategies with their patients — and too frequently, clinicians fail to search for underlying causes, according to a researcher at the American Academy of Nurse Practitioners 26th Annual NP meeting.

“We need to change the way we think about BP and change our strategies for treatment,” said Amelie Hollier, DNP, FNP-BC, president and CEO of Advanced Practice Education Associates, an educational organization for NPs based in Lafayette, Louisiana. “There are loads of people out there with hypertension and it's just getting worse. One in 5 African-American and Hispanic adolescents is hypertensive.”

The difference between systolic and diastolic BP widens with age, Hollier explained. Measured as pulse pressure (calculated as systolic BP minus diastolic BP), this widening reflects the stiffening of large blood vessels.

“The development of atherosclerotic rigidity makes it harder for the left [heart] ventricle to push blood through the stiffened vessels, so BP rises,” she said. “We cannot see arterial stiffness. The best indicator is pulse pressure higher than 60 to 70 points.”

Many clinicians would be more concerned about a patient with 140/100 BP than one with 140/60, Hollier noted. But patients with 140/60 BP have higher pulse pressure, and therefore are at greater risk for MI or stroke — particularly if they are elderly.

“Just within the past week, the American Heart Association (AHA) released new guidelines for systolic and diastolic BP for elderly patients. For patients aged 65 to 79 years, it is still okay to keep systolic BP lower than 140, but we want to avoid diastolic BP less than 60 because of the risk of MI and cardiovascular events,” Hollier said.

For diastolic BP the AHA advises clinicians avoid diastolic BP lower than 65 in patients with coronary heart disease. Among very elderly patients aged 80 years and older, those with systolic BP between 140 and 145 have the best health outcomes. “These are brand-new guidelines, hot off the presses, based on loads of data,” she said.

Another problem Hollier identified with treatment approaches is that even though hypertension is a well-known red flag for other underlying diseases, many clinicians treat the disorder without exploring its real causes.

“How many people do you know who only have hypertension – who have no hyperglycemia, no diabetes,” Holier asked. “When you see patients with hypertension as the presenting diagnosis, you should go looking for more trouble. There is always something more behind it.”

Clinicians should also keep in mind that certain drugs affect the physiological pathways that underlie hypertension differently. “A patient may check BP during the daytime and be doing great, but then the medication tapers out and BP increases in the evening and nighttime hours,” she said.

Combining drugs sometimes achieves better results than simply increasing the dose of one medication,  said Hollier who advocates for “synergism,” including prescribing angiotensin-converting enzyme inhibitors or angiotensin receptor blockers in combination with thiazide diuretics. “Potassium-sparing diuretics are weak antihypertensive agents, but they work great in combination with thiazides,” she noted.

Another thing to keep in mind is the importance of medication half-lives, and that in order for ACE inhibitors to be renoprotective, they must be lipophilic.

Lisinopril, a commonly prescribed ACE inhibitor, is not lipophilic and other popular ACE inhibitors including captopril are weakly lipophilic only and have a half-life as brief as one hour, Hollier noted. Other ACE inhibitors with low half-lives, such as moexipril and quinapril, are better given twice daily rather than once.

Developing more effective prescribing strategies for ACE inhibitors present “real opportunities for change,” Hollier said.

Hollier did not report any financial conflicts of interest.

Hollier A. “Hypertension management: developing treatment strategies in primary care.” Presented at: 26th Annual American Academy of Nurse Practitioners Conference, 2011: Las Vegas, Nevada.

Bryant Furlow is a medical writer and award-winning investigative healthcare journalist based in Albuquerque, New Mexico.

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