Challenges in managing adult hypertension

Controlling hypertension is important as it can be a cause of premature cardiovascular problems, such as coronary heart disease (CHD) and stroke. However, controlling blood pressure (BP) is largely down to lifestyle changes (e.g. exercise and reduced salt intake) and a lifelong pill regimen. As both these options are difficult to commit to, many people with hypertension do not have it under control, and it is estimated that up to 30% of the hypertensive population in the UK do not have proper control of their BP. Dr Melvin Lobo, a hypertension expert, goes into detail.

The main factors thought to contribute to this are:

• An inability to make necessary lifestyle changes (diet and exercise).
• Physician inertia (the failure of a healthcare professional to introduce or change treatment when health goals (i.e. controlled BP) are not achieved).
• Failure to adhere to a medication plan.
• Resistant hypertension (medications do not help).

How is hypertension diagnosed?

Traditionally, hypertension has been diagnosed by taking blood pressure readings in a medical setting. These are known as a clinical BP measurement (CBP). However, due to factors such as the ‘white-coat effect’, which is when patients display high BP in a clinical setting but not in other settings, obtaining a BP measure by other means is important in order to gain a true hypertension diagnosis.

This is made possible by the availability of home BP (HBP) and ambulatory BP (ABP) monitors. HBP involves measuring your own BP regularly at home using a monitor device. ABP is when your BP is being measured throughout the day, whilst you go about your daily activities, using a small digital device that can be worn as a belt or watch. These can help discriminate between true hypertension and the white-coat effect.

Another challenge of diagnosing hypertension is the ongoing debate about what defines high BP and also what defines optimal BP, both of which vary globally.

Why don’t hypertension patients stick to their medication?

Long-term commitment to hypertension medication is known to be low, and this can happen with or without the specialist’s knowledge, however, non-adherence to medication would be revealed by either urine or blood tests and ABP measurements.

The following reasons are common causes of non-adherence to high BP medication:

• The patient has a limited understanding and appreciation for the life-long nature of their disease.
• The physician does not have the time or resources to educate their patient.
• The patient cannot cope with the burden of taking daily medication.
• The patient experiences adverse drug reactions.

What considerations should we be making when treating hypertension?

Firstly, it is important to consider that perhaps not all patients with high BP require medication to treat their BP, and non-pharmacological therapies would benefit them a lot.

Non-pharmacological intervention includes:

• Dietary assistance- in particular restricting salt intake
• Regular dynamic cardiovascular exercise (jogging / cycling / swimming / rowing / X-trainer)
• Yoga / deep breathing / meditation
• Identifying personal/professional stress as a cause of hypertension and finding ways to manage this

It may also be beneficial to screen BP patients under the age of 40 for secondary causes of hypertension (such as adrenal or kidney problems). This would allow us to treat the underlying illness instead.

Additionally, importance should be placed on patient engagement, because having this is essential for ensuring their life-long management of a predominantly asymptomatic disease. This could translate into personalised treatment plans and making sure that any barriers to achieving these plans are considered between the patient and specialist. It has been argued that a holistic approach that includes pharmacology, non-pharmacological intervention, and the support needed to achieve these is key to managing hypertension.

If you are concerned about your blood pressure, or suffer from hypertension and would like to discuss your treatment options, make an appointment with a specialist.