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How's Your Blood Pressure?
How's your blood pressure? Are you at "goal?" Controlling blood pressure is critical to one's cardiovascular health. It is a well-established fact that when a person has uncontrolled hypertension (blood pressure or B/P) there is a significant increase in the risk of heart attack and stroke. Yet despite this well-known fact, the rate of good B/P control has reached a plateau in men in the US, and rates of uncontrolled hypertension in women are actually rising! In Washington, DC and many southern states one in four women has high blood pressure that isn't well controlled, a deplorable fact given how much we know about blood pressure management, how many inexpensive medications we have available to us, and how many options there are to health care providers to refer their patients to dietitians and exercise programs such as cardiac rehabilitation to learn the lifestyle changes that will lower blood pressure!
In the study that documented these trends, which appears in the February 11th edition of Circulation, study author Dr Majid Ezzati (Harvard University, Boston, MA) notes that while some states are doing better than others with blood pressure control, the trend is consistent: Men are not gaining any better control and women's blood pressures are actually worsening overall.
Dr. Ezzati speculated that some of the contributing factors may be the obesity epidemic, which is hitting women harder than men, and the fact that women are less likely to have access to good health care. Dr. Ezzati also suggests that health care providers may have become complacent about measuring B/P at office visits and addressing numbers that are out of range.
He notes that providers can be reluctant to add medications to the patient's regimens and that they often don't address lifestyle changes. I know that I often hear from my colleagues that they don't have time to address lifestyle changes in a short office visit or that they don't bother, because they don't believe that patients are likely to make behavioral changes. I don't buy that though, as there is evidence that that when a health care provider takes the time to address a needed behavioral change and links that need to the patient's current health status, the patient is more likely to make that change. As an example, I am more likely to get someone to consider stopping smoking if I say to them, "Your chest x-ray shows evidence of damage to your lungs from your years of smoking. You should talk to your health care provider about how s/he can help you to quit smoking." I do this all the time in the ED, and I said something similar to people when they were under my care as a primary care provider.
One of Dr. Ezzati's theories may have been upheld in another recent study, which suggests that both gaining a patient's agreement to follow a medication plan and increased medication prescriptions are needed in order to control B/P. In a study designed to examine barriers to blood pressure control over time, lead investigator Dr Michael Ho (Denver Veterans Affairs Medical Center, CO) reported that although it is important to increase therapy by adding medications, it also matters whether or not a person is actually taking their medications as they are prescribed.
The study looked at 10,000 individuals with hypertension and cardiovascular disease in a managed care setting. The results indicated that approximately 1/3 of patients in the group with consistently elevated B/P did not have either an increase in the dose of their current medication or additional medications added. Another third of the patients had medication changes made by their health care provider, but did not take them as prescribed. Dr. Ho emphasizes that communication between the prescriber and patients is critical to improving outcomes. He notes, "Doctors all want to bring blood-pressure levels under control, but sometimes intensifying therapy might not be the right approach. The correct response might be to simply get the patient to take the medication."
I could not agree more and I have to point out that the best health care providers are those who encourage communication between themselves and their patients, by knowing what questions to ask and how to ask them in order to find out if the medications are being taken correctly. These include, but may not be limited to:
- "How often do you forget to take your medications?"
- "Are you able to afford the medications that have been prescribed for you?"
- "Do you have any trouble taking your medications the way they are supposed to be taken?"
These questions assume that sometimes we forget to take our medications and that it's ok, and gives one an opportunity to strategize with the person to find memory aides that will help them remember to take their medications. It also gets to the root of potential financial problems with obtaining meds and allows the provider to seek out less expensive alternatives to current prescriptions.
Finally, these questions allow for any other concerns the patient has to be brought to light, for example how to schedule medications safely. I once had a patient reveal to me that she'd been getting up in the middle of the night to maintain the medication schedule given to her in the hospital, when she could have easily adjusted her medications schedule to her usual daily home routine. She would not have done that for long, I can assure you! She would also have stopped taking the medication before she would have admitted to me that she wasn't willing to get up in the night, assuming that I'd think less of her because she didn't make her medication-taking a priority. So it pays to ask, and in an inviting manner if you want to hear the truth.
Take care, Laurie
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Technorati Tags: hypertension, heart disease, heart health, blood pressure, obesity
