Urgent need to increase the rates of diagnosing, treating and controlling hypertension in older women.
A call for all levels of government, health professional associations, health charities and clinicians to reengage and to take action.
Supported by Supported by the Nurse Practitioner Association of Canada, Nurse Practitioner Association of Alberta Hypertension Canada, the Heart and Stroke Foundation of Canada, Canadian Pharmacists Association, and College of Family College of Canada. A shorter version is supported by the Canadian Nurses Association.
Norm RC Campbell
Norm RC Campbell MD. Emeritus Professor, Department of Medicine, Physiology and Pharmacology and Community Health Sciences, O’Brien Institute for Public Health and Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada, email: firstname.lastname@example.org
Ross T. Tsuyuki, BSc(Pharm), PharmD, MSc, FCSHP, FACC, FCAHS.
Professor and Chair, Department of Pharmacology
Professor of Medicine (Cardiology) and Director, EPICORE Centre
Faculty of Medicine and Dentistry, University of Alberta
9-70 Medical Sciences Building
Canada T6G 2H7
Alan Bell MD, FCFP
Department of Family and Community Medicine
University of Toronto
Mark Gelfer, Clinical Assistant Professor, Department of Family Practice, University of British Columbia, Vancouver British Columbia
Lyne Cloutier RN PhD
Professor, Departement of nursing
Université du Québec à Trois-Rivières
Alexander A. Leung, MD MPH
Assistant Professor, Departments of Medicine and Community Health Sciences
Cumming School of Medicine, University of Calgary
Donna McLean RN, MN, NP, PhD CCN(C)
MacEwan University, Faculty of Nursing
9-407, 10700 – 104 Avenue
Edmonton, AB T5J 4S2
Covenant Health-Misericordia Hospital, Nurse Practitioner
Internal Medicine/Emergency 16940-87 Ave
Edmonton, AB T5R 4H5
Phone: (780) 493-0677
Janusz Kaczorowski PhD
Professor and Research Director
Department of Family and Emergency Medicine
University of Montreal and CRCHUM
Montreal (Quebec) Canada
Increased blood pressure is the single leading reversible risk for death globally accounting for approximately one half of cardiovascular events (1). Hypertension, the clinical manifestation of increased blood pressure, is both highly preventable and controllable (1). Up to 80% of hypertension is directly (through excess sodium and deficient potassium) or indirectly through obesity related to diet (1). Preventing hypertension by public health policies such as reducing dietary salt is not only highly effective but has a return on investment for governments of up to $78 for each dollar invested (1-3). Controlling hypertension clinically has arguably the strongest evidence for benefit of any clinical intervention and the drug treatments to achieve control are very cost effective to cost saving when applied to individuals at moderate to high cardiovascular risk (>10% 10 year risk of a cardiovascular event) (1, 4-6).
Canada has been a global leader in controlling hypertension (7). In fact, hypertension is the third leading reversible risk for death in Canada and Canada has had the world’s highest reported national rates of controlling hypertension since 2006 (8). Unfortunately, since 2011, it was noted that the control rate of hypertension in older women was lower than in older men, in contrast to nearly all other countries where women have higher rates of awareness, treatment, and control than men (9-12). Recent data found disturbing tendencies to decreasing rates of hypertension awareness, treatment and control in older Canadian women since approximately 2010-11 (figure 1) (10). In a review of hypertension control in high income countries it was noted that 4 other countries now had higher rates of hypertension control in women compared to Canada and that Canada stood alone in having a higher rate of hypertension control in men than women (11). More disturbing is a reversal of the more than 60 years of declining rates of cardiovascular death in Canada since 2010 (figure 2a) (8). Age standardizing the data (figure 2b) show some of the increases in cardiovascular deaths are related to increasing age of the population. The rest of the increase in cardiovascular disease is undoubtedly attributable to the well established, mostly modifiable causes of cardiovascular disease not being effectively prevented and controlled in Canadians (hypertension, dyslipidemia, high glucose, diet, tobacco, lack of physical activity and obesity) (13). Perhaps even more disturbing than deaths is the rapid increase in disability-adjusted life years (DALYS) after 2010 which will reflect a major decline in quality of life for mostly older Canadians. Declining rates of hypertension control in women over age 60 years are likely an explanation for some of the increase in cardiovascular deaths and disability but the death rate is also increasing in men, highlighting the need to control hypertension and other vascular risk factors (diet, lack of activity, smoking, excess alcohol consumption, lipids etc.) in both sexes (8).
This article is specifically to highlight the need to screen for, diagnose, treat and control hypertension in older women as a core standard of care, where we could greatly improve. The call should also be regarded as a reminder of the importance of hypertension and increased blood pressure in both men and women and of the need for greater public health policy interventions to prevent and control hypertension and other cardiovascular risks. Globally, control of hypertension has been seen as a critical entry point to the prevention of non communicable disease (NCD) and a core mechanism for enhancing and evolving primary care to focus on NCDs as the cause for more than 80% of deaths in countries like Canada (4, 6).
The World Health Organization with partners developed the HEARTS program to provide guidance to countries to implement best practices in hypertension control and cardiovascular disease prevention (4). The best practices for controlling hypertension were established based on available evidence including implementation research on effective programs for controlling hypertension and other chronic conditions. The best practices involve using standardized public health approaches to clinical care, implementing simple interventions, done properly in a highly systematic fashion and incorporating registries with performance reporting at the clinic and clinician level (1, 4, 6).
Identifying people with hypertension:
There is a declining rate of diagnosis of hypertension in older women (10). It is recommended that all adults have their blood pressure assessed at all relevant clinical encounters (14). By age 60-69, 47% of Canadian men and women will have hypertension (10). It is estimated that 9 in 10 people with normal blood pressure at age 55 to 65 will develop hypertensive readings if followed for an average life span (approximately 20 years) (1). For those with office blood pressures of 130-139 / 85-89 mmHg over half will develop hypertension within 4 years (15). Therefore, people with office blood pressures 130-139/85-89 mmHg need to have regular follow-up of their blood pressure (14). Home blood pressure and ambulatory blood pressure monitoring are recommended to make the diagnosis of hypertension in those suspected of having hypertension with high office readings. Home blood pressure, unattended automated office device (AOBP) and daytime ambulatory blood pressure device readings > 135/85 mmHg are considered high.
It is important that blood pressure is assessed accurately as misclassification of an individual’s blood pressure is common and can lead to inappropriate management (16). When feasible, generally blood pressure measurement should be allocated to a non physician as this results in less white coat hypertension (17, 18). The person measuring blood pressure, should be (re)trained and certified in blood pressure measurement every six months and the measurement conducted using an accuracy validated oscillometric device. A brief (10 minute) and free online training and certification program for automated blood pressure measurement will be available shortly through Hypertension Canada (www.hypertension.ca). A list of validated devices available in Canada can be found at https://hypertension.ca/bpdevices. When aiming for systolic blood pressure targets of less than 120 mmHg it is recommended to use an AOBP that measures and averages several blood pressures (14).
Partnering with community programs that screen for hypertension can be very useful. A made in Canada program, Cardiovascular Health Awareness Program (CHAP, www.CHAPprogram.ca), was associated with a reduction in cardiovascular events and has been adopted in several communities in Canada (and other countries) (19). Pharmacy based screening and hypertension management has also been associated with enhanced hypertension control and is likely to identify many individuals who do not otherwise access the health care system (20).
Identifying and intervening on related cardiovascular risks:
Most people with hypertension will have additional cardiovascular and health risks that can include diet, physical inactivity, adiposity/obesity, smoking, excess use of alcohol, dyslipidemia and diabetes (1, 13). These risk factors need to be assessed, monitored and interventions individualized and optimized (14).
Team based assessment, monitoring and care enhances outcomes:
In Canada, people with hypertension often have suboptimal management of their other cardiovascular risks, have significantly higher mortality than those without hypertension and this is amenable to optimized clinical risk factor management (21, 22). In fact, in Canada achievement of glucose and lipids targets is significantly lower than in the United States (21). Comprehensive care such as that required by most people with hypertension is enhanced by team-based care with task sharing (23).
Treating to target:
In those without other compelling considerations, when the usual office blood pressure is 140/90 mmHg or higher, antihypertensive drug treatment should be prescribed (14). This is one of the most important preventative clinical interventions that can be done to reduce the risk of death and disability on a population basis (1, 4). With appropriate patient consultation, those who are young and without other risk factors and the office blood pressure stays <160/100 mmHg may be followed without pharmaceutical intervention (14). A person with diabetes and an office blood pressure of 130/80 mmHg or higher is greatly benefited by antihypertensive therapy (14). Over 40% of deaths in people with diabetes is related to hypertension (24). For individuals at high cardiovascular risk (e.g. aged 75 years or higher, Framingham risk score of > 15%, clinical or subclinical cardiovascular disease, chronic kidney disease) consideration should be given to reduce the systolic blood pressure below 120 mmHg (14). When treating a persons systolic blood pressure to less than 120 mmHg using AOBP, a fully automated blood pressure device that takes several readings in the absence of an observer is recommended (14). It is recognized that the lower blood pressure targets can be difficult to achieve, especially in older patients with complex comorbidity, and that therapeutic targets require individualization based on informed patient preferences. Some patients may not tolerate intensive management of blood pressure or decline treatment even with adequate education. Efforts should be considered to find the most tolerable and preferred interventions to reduce risk, when possible.
Treatment for the vast majority of patients should be provided using a simple directive standardized algorithm (protocol) (4, 25). Use of a standardized approach is associated with a lower death rate and improved hypertension control (26). The algorithm preferably will specify use of fixed dose single pill combination antihypertensive drugs. One example of an algorithm is in figure 3. Many other examples are available through the World Health Organization (WHO) (25), Resolve to Save Lives (RTSL) (26) and the joint WHO RTSL ‘LINKS’ website (https://linkscommunity.org/toolkit/hypertension-control). Algorithms can also be developed with local expertise and experience. Individualized care should be reserved for those with contraindications to treatment in the algorithm, specific indications for alternative therapy, adverse effects or unique clinical circumstances such as pregnancy.
Use registries with reporting functions:
Global standards of care now dictate the use of clinical registries with performance reporting functions to enhance hypertension control (1, 27-29). The registries should be able to report those adults who have not had blood pressure measured within a specified time frame (e.g. 2 years), those diagnosed with hypertension, those not treated and those treated but not controlled. Reporting should be corrected for the expected number of adults with hypertension in the clinical facility. For example, some clinics or clinicians may report very high hypertension control rates but have registered few people with hypertension. In a typical Canadian clinic about 23% of adults should have been registered as having hypertension (30). Registries are used as learning tools where clinics and clinicians with high performance can teach clinics and clinicians with lower hypertension control rates.
It is notable that the clinical trials upon which we base our clinical recommendations have used simple directive algorithms and registries with reporting functions and are associated with enhanced NCD management. The Kaiser Permanente program achieved 90% hypertension control using a registry with reporting functions, team-based care and a simple directive algorithm (31).
Globally hypertension, the leading single reversible risk for death, is being used as a critical entry point for the prevention and control of non communicable disease and as a focal point for enhancing primary care (1, 4, 6). At the World Health Assembly in 2011, there was a general agreement by national governments to reduce uncontrolled blood pressure 25% by the year 2025 (32). In response the World Health Organization with partners developed the HEARTS program as a comprehensive implementation resource of best practices for control of cardiovascular disease with a focus on hypertension control (4). Internationally, many governments are playing a critical role implementing programs that locally adopt and implement HEARTS (https://linkscommunity.org/toolkit/hypertension-control, https://resolvetosavelives.org/cardiovascular-health, https://www.paho.org/hq/index.php?option=com_content&view=article&id=13755:hypertension-control-project-in-the-americas&Itemid=4327&lang=en). The national governments in United States and Mexico play leadership roles in control of hypertension but not in Canada. In the Caribbean, Central and South America, an increasing number of national governments are playing lead roles to implement HEARTs. Canada, once the world leader is stepping backwards, at least for older women, while other countries are adopting global best practices and enhancing hypertension control (10, 11). The HEARTS program specifically includes use of simple directive treatment algorithms and registries with reporting functions, which are not widely adopted in Canada (25, 33). Implementation of the interventions in HEARTS has been associated with hypertension control rates as high as 90% in clinics and a doubling of population hypertension control in just 1 year, in Cuba (31, 34).
Canadian health care professionals and specifically primary care practitioners can play a critical role to enhance hypertension control, especially in older women. Most Canadian adults visit their physician offices, and pharmacies at least once a year and hence measuring blood pressure routinely and applying a diagnostic algorithm to those with high readings is critical. Older Canadian women are more likely than not to have hypertension with elevated cardiovascular risk and hence would benefit from antihypertensive therapy (13). Using a standard treatment algorithm helps overcome therapeutic inertia and specifies specific drug titration to achieve high rates of hypertension control (26). Use of a registry with performance reporting allows care gaps to be identified, and aids learning by lower performing clinics from higher performing clinics and clinicians (29). Primary care practitioners also hold a range of health management positions and can influence or implement key policies to enhance health care delivery. Primary care practitioners in addition provide continuing health care, graduate and undergraduate education and are key opinion leaders who can alter the practices of other healthcare professionals. Adopting what are now understood to represent global standards of care, will reduce cardiovascular death and disability in one of our more vulnerable groups – older women but also all Canadians.
In 1986, a Canadian Federal Provincial Territorial Committee released a national hypertension strategy (35). The main action from the strategy was the formation of a multisectoral coalition for hypertension prevention and control. A subsequent national strategy had an annually updated, extensively implemented, monitored and evaluated clinical hypertension management program as the main action (36, 37). The clinical hypertension management program was largely attributed to an increase in hypertension control in Canada from 13% to 66% (7). The coalition subsequently developed policy positions and advocacy programs for health food policies that could reduce hypertension up to 80% if fully implemented (https://hypertension.ca/wp-content/uploads/2018/12/Final-Call-for-healthy-Food_EN_with-supporters_April-1-2016.pdf). Unfortunately, in 2011 the Canadian federal government largely stopped collaborating with the health sector in strategic approaches to enhance the management of hypertension and other critical risks for non communicable disease. Prior to 2011 the Public Health Agency of Canada collaborated and helped support a broad volunteer group of health care stakeholders to monitor and evaluate hypertension indicators, identify key clinical care gaps, develop and disseminate resources to aid hypertension management (38). Subsequently, there was a lack of emphasis on implementation, monitoring and evaluation without government collaboration and support. This has allowed almost a decade of declining rates of hypertension control in older women to occur without much attention and without specific interventions. It is time for the federal government to rethink its position on the main causes and risks for death and disability in Canada and help support the implementation of global best practices for hypertension and other major modifiable health risks in Canada. Given health care delivery is largely a provincial and territorial responsibility, the federal government needs to play a leadership and coordinating role for strong governmental action to enhance the health of Canadians. It is critical for the Canadian governments to have a strategic public health approach to the prevention and control of hypertension and to collaborate with the health scientific sector on monitoring and evaluation and implementation. Resources including incentives to transform current clinical practices to adopt a systematic comprehensive best practices public health approach need to be considered.
Figure 1. Hypertension awareness, treatment and control rates in Canadian women from 2007 to 2017*
The data are from the Canadian health measures surveys (10).
Figure 2a: Cardiovascular death rates per 100,000 population in Canada 1990-2017.
The data show changes in the rate of cardiovascular disease (total, ischemic heart disease and stroke) deaths in Canada from 1990 to 2017 using data from the Global Burden of Disease Study 2017. Global Burden of Disease Study 2017 (GBD 2017) Results. Seattle, United States: Institute for Health Metrics and Evaluation (IHME), 2018. Available from http://vizhub.healthdata.org/gbd-compare/
Figure 2b: Age standardized cardiovascular death rates per 100,000 population in Canada 1990-2017.
The data show changes in the rate of age-standardized cardiovascular disease (total, ischemic heart disease and stroke) deaths in Canada from 1990 to 2017 using data from the Global Burden of Disease Study 2017. Global Burden of Disease Study 2017 (GBD 2017) Results. Seattle, United States: Institute for Health Metrics and Evaluation (IHME), 2018. Available from http://vizhub.healthdata.org/gbd-compare/
Figure 2c: Disability adjusted life years due to cardiovascular disease in Canada.
The data show changes in disability adjusted life years (DALYS) due to cardiovascular disease in Canada from 1990 to 2017 using data from the Global Burden of Disease Study 2017. Global Burden of Disease Study 2017 (GBD 2017) Results. Seattle, United States: Institute for Health Metrics and Evaluation (IHME), 2018. Available from http://vizhub.healthdata.org/gbd-compare/.
Figure 3: An example of a simple directive hypertension treatment algorithm
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