"The Big Ask" - Hypertension (Part II)

In the second episode of our hypertension series, Taylor  and Dr. Gallagher discuss lifestyle modifications and medications used in the treatment of high blood pressure.

Share your reactions and questions with us at  Speak Pipe . We might feature you on a future episode!

=== Outline ===
1. Introduction
2. Chapter 1: Setting goals
3. Chapter 2: Lifestyle modifications
4. Chapter 3: Initiating Pharmacotherapy
5. Chapter 4: Adherence to Medications
6. Conclusion

=== Learning Points ===

1. Most patients with hypertension would benefit from having a low blood pressure, regardless of the degree of lowering.
2. Recognize that asking patients to start medications can be a large ask for a patient, especially if they are otherwise healthy and have several other conditions to manage. 
3. Lifestyle modifications—such as reducing salt intake and drinking water—may lower blood pressure to some degree. However, finding such “low-hanging fruit” in lifestyle modifications is difficult, and providers should not shy away from pharmacotherapies. 
4. Firstline therapies for lowering blood pressure include long-acting calcium channel blockers, ACE inhibitors/ARBs, and diuretics. Optimizing a patient’s regimen may require a combination of therapies, and combination pills may be effective in improving adherence.

=== Our Expert(s) ===

Benjamin Gallagher, MD, FACP is an Assistant Professor of Clinical Medicine (General Medicine) at Yale School of Medicine.

=== References ===

1. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018;71:e127-e248.
2. Ostchega Y, Fryar CD, Nwankwo T, Nguyen DT. Hypertension prevalence among adults aged 18 and over: United States, 2017–2018. NCHS Data Brief, no 364. Hyattsville, MD: National Center for Health Statistics. 2020.
3. SPRINT Research Group, Wright JT Jr, Williamson JD, Whelton PK, Snyder JK, Sink KM, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 373(22):2103–16. 2015.
4. Thomopoulos C, Parati G, Zanchetti A. Effects of blood pressure-lowering treatment on cardiovascular outcomes and mortality: 14 – Effects of different classes of antihypertensive drugs in older and younger patients: Overview and meta-analysis. J Hypertens 36(8):1637–47. 2018.

=== Recommended Reading ===

1. Appel LJ, Brands MW, Daniels SR, Karanja N, Elmer PJ, Sacks FM; American Heart Association. Dietary approaches to prevent and treat hypertension: a scientific statement from the American Heart Association. Hypertension. 2006 Feb;47(2):296-308. doi: 10.1161/01.HYP.0000202568.01167.B6. PMID: 16434724.

=== About Us ===

The Primary Care Pearls (PCP) Podcast is created in collaboration with faculty, residents, and students from the Department of Internal Medicine at the Yale School of Medicine. The project aims to create accessible and informative podcasts about core primary care topics centered around real patient stories.

Hosts: Josh Onyango, Maisie Orsillo
Producers: Helen Cai, Kevin Wheelock, Danish Zaidi
Logo and name: Eva Zimmerman
Theme music and Editing: Josh Onyango
Other background music: Dan Lebowitz, penguinmusic, future mono, Jesse Gallagher, VYEN, madriFan, 

Instagram: @pcpearls
Twitter: @PCarePearls
Listen on most podcast platforms: linktr.ee/pcpearls

Transcript

Introduction

[00:00:00] Maisie: Hi, welcome to primary care pearls. A podcast made by learners for learners Today.

[00:00:06] Gallagher: so I think it's important to understand the magnitude of what you're asking patients even with, to just take one um, you know, because it's really for the rest of your. And for someone who not had a chronic condition before the only medicine they may have taken may have been an antibiotic, they took for seven to 10 days. And so the idea of take something, you know, at the same time, every day is a big, uh, is a big ask.

[00:00:36] Maisie: We're continuing our conversation about hypertension. During our discussion today, we'll be joined by Taylor.

[00:00:44] Taylor: Hi, my name is Taylor. I am a patient at the, um, hypertension clinic at Yale. 

[00:00:51] Maisie: We'll learn more about her experience with starting medications for hypertension. We'll also be joined by Dr. Ben Gallagher, a faculty expert from the Yale school of medicine 

[00:01:04] Gallagher: Ben Gallagher, I am a general internist. I also work at the Yale school of medicine and I primarily work in the outpatient setting, um, in a primary care clinic in new Haven where a lot of the internal medicine residents at Yale also practice. Um, and I have a special interest in hypertension, both in diagnosis and management.

[00:01:24] Maisie: With the conversation facilitated by our resident interviewer, Dr. Kevin wheelock

[00:01:29] Kevin: My name is Kevin Wheelock. I'm a second year internal medicine residents at the Yale school of medicine.

[00:01:36] Maisie: And our medical student interviewer Helen Cai

[00:01:40] Helen: Hello, my name is Helen and I'm a first-year medical student here at the Yale school of medicine.

[00:01:45] Maisie: This discussion will be part two of a three part series that will explore initiating pharmacotherapy for hypertension and strategies to help patients adhere to their treatment plan. My name is Dr. Macy Orsillo, and I'm a second year resident in the primary care internal medicine residency at Yale and I'll be your co-host for this episode

[00:02:06] Josh: and my name is Joshua I'm a third year primary care internal medicine resident at Yale. And I'll also be your co-host for this episode. We hope through this discussion, you learn more about medication options in managing hypertension or high blood pressure. 

[00:02:20] Maisie: Before we get started, please know that this content is meant to be for learning and entertainment purposes only, and should not be used to serve as medical advice. If you or a loved one is suffering from anything discussed in today's. episode, please be sure to discuss it with a medical expert now onto the show. 

Chapter 1: Setting Goals

[00:02:40] Josh: During our last episode, we spent time understanding the importance of coming to an accurate diagnosis of hypertension. But once a patient has received this diagnosis, how can we actually convince them about the benefits of reducing elevated blood pressure? 

[00:02:56] Taylor: And in your conversations with Dr. Gallagher and Dr. Huot you probably talked about like setting a goal for your end point blood pressure. So, could you tell us what that conversation looked like? 

Um, yeah, I mean, they really wanted, um, the lower number to be like 85 or lower. So we're not quite there, but it's almost there.

[00:03:19] Gallagher: we talked about in the beginning that there's a very strong relationship between, uh, blood pressure and cardiovascular disease and mortality. Um, but an important point to consider is sort of two other important points, uh, to think about with regard to that statement.

One is that the relative risk reduction for any given blood pressure reduction in terms of, uh, cardiovascular disease and mortality is basically fixed going from very high blood pressures, even going down to blood pressures as low as one 15 or one 20. So in other words, if You take people at middle-aged people, if their blood pressure is 180 5, you're going to reduce their risk of cardiovascular disease and mortality by about 50% by decreasing it from 180 5 to 1 65, but you'll also decrease it by 50% by decreasing it from 1 35 to one 15. So that's the relative risk reduction. Right. And I bring that up to make the points that most people could stand to have a lower blood pressure and would benefit from having a low blood pressure, whether by lifestyle modifications or by, um, uh, pharmacological treatment.

Right? So that's the relative risk reduction, right. But what's the absolute risk reduction. And so the absolute risk reduction is a function of the relative risk reduction and the baseline. And so the people that you're going to, um, target for the most aggressive treatment and potentially the most timely treatment and something that you're not going to want to push off visit after visit.

If they coming in and saying, well, today my knee hurts. And the next time they say I'm depressed the people who are going to have the most absolute risk production from a blood pressure lowering, and that has also been born out by the SPRINT trial and is not reflected in our guidelines.

Right? If you look at kind of multiplying out all of those factors, right. People who had a high cardiovascular risk at baseline have a similar number of cardiovascular events, Uh, everted over time with a small blood pressure reduction as people who are at lower risk with a higher blood pressure reduction.

And there's a great graph that I could show you this, but you know, this is just a podcast, but hopefully I've explained it well enough in words. So the people who are at higher risk are the ones that you're going to target for most aggressive and most timely blood pressure lowering, but pretty much everyone else could also benefit from blood pressure lowering as well.

So to answer your question, I think the risk profile is really what helps me determine how important is this and what else is going on in their life. Again, like A1C 10, you know, I'm homeless right now, my house burned down and, uh, you know, now I'm really depressed and I don't know what I'm going to do.

Right. All those things are things that come at us in primary care. Um, but barring things like that, you know, the, the sort of. Of cardiovascular diseases. What motivates me to, to control things, uh, you know, either more aggressively or in a more timely way.

the American guidelines that are the ones that I'm most familiar with. Um, so the 2017 guidelines basically create four categories of blood pressure.

So less than a blood pressure of one 20 over 80 is considered normal. Uh, blood pressure between one 20 and 1 29 systolic and less than 80 diastolic is called pre hypertension. A blood pressure of one 30 to 1 39 systolic over 80 to 89. Diastolic is considered stage one hypertension and a blood pressure of one 40 over 90 or greater is considered a stage two hypertension.

Uh, the main rationale for that. Kind of framework, uh, is that the group of people in the stage one hypertension, um, are, uh, people in whom you would not necessarily, uh, initiate for example, pharmacological treatment, because unless they are at a higher cardiovascular risk, um, and in that group of people, if they're at elevated cardiovascular risk for a variety of reasons, which we might get into, um, then it is worthwhile to treat them to a lower target blood pressure, but otherwise, um, everyone else you're going to treat them when their blood pressure is starting at one 40 over 90 or above.

And when I say treat them, I'm talking about pharmacological treatment because anyone from pre hypertension and above will be recommended to have lifestyle modifications. And we can talk more about what those are, uh, as well. Um, the rationale for. Um, the D the sort of definition of that stage one group, uh, came from, uh, mainly the sprint trial, which was published in 2015.

And it was a very large study funded by the NIH, uh, that was looking at, in people who are at high cardiovascular risk. Um, and in particular people who are non-diabetic and Heidi carbide service, because there was a separate trial called the accord trial a few years before that it looks specifically at diabetics.

Um, they, in those high-risk people, they, uh, treated them to a blood pressure target of either one 40 systolic or one 20 systolic and looked at cardiovascular outcome. Um, like heart attacks, strokes, and death. Um, and over time they found that the, uh, more aggressive treatment group, the less than one 20 target group, um, had, uh, did better, uh, in terms of, uh, hard cardiovascular outcomes. Uh, and so that was yes, for, creating a more stringent blood pressure target for people who are at a high cardiovascular risk. 

[00:09:06] Maisie: It's clear that a reduction in blood pressure has a significant impact on cardiovascular health and mortality a finding that has since been reinforced by clinical trials. 

[00:09:16] Josh: Yeah, there was one point actually, Dr. Gallagher made that I think can be really helpful to share with patients about the relative risk reduction. It's really important to acknowledge that really any degree reduction in blood pressure, even going from 180 to 160 can be really important in reducing cardiovascular risk, even though it's not quote unquote normal. 

[00:09:38] Maisie: Yeah, I think that's super important to to share with. patients. And, you know, regardless of the guidelines, uh, we still need to keep in mind that achieving an ideal goal blood pressure for a patient will inevitably be a trade off between improving their risk for cardiovascular disease and minimizing adverse side effects from treatment. 

Fortunately, we don't have to worry about these. Trade-offs when we're starting with changes the patient can make in their life. 

Chapter 2: Lifestyle Modifications

[00:10:03] Kevin: tell us do you counsel patients on lifestyle? Um, what's your strategies. I personally find it's so hard, you know, when you have 15 or 20 minutes in a visit with someone to have these like detailed discussions about dietary changes and what they do for, you know, what to do for physical activity.

And, um, I'm. I walk away a lot of times unsure if I'm really being helpful, or if I'm just kind of going through the motions of like telling people, you know, that they need to eat healthy and move more. So I'm curious, what are some sort of specific, uh, you know, tools that you might give people, you know, things that you tell them that sort of help from a lifestyle standpoint?

[00:10:48] Gallagher: Yeah. I mean, what you mentioned kind of resonates with me for a few reasons. One is because dietary counseling and lifestyle counseling takes time, which is what we don't have. We also tend to learn less about it in med school. And I think a lot of people go into medicine because they are looking for, uh, you know, they're scientifically minded and it's kind of appealing to, uh, fall back on pharmacology as a way to fixing problems.

And so I think as a group, physicians probably don't spend enough time counseling people about lifestyle. Now that having been said, I find. That it's hard for me to find a kind of low hanging fruit in patients' diets to help them, uh, modify. And that has less to do with what their diet is and more to do with the limitations on them getting healthy food.

So again, I come back to the comparison with diabetes, right? So I have a lot of patients or even just obesity and trying to help people lose weight. I have a lot of patients who have a new diagnosis, diabetes, their A1C is in the double digits and they'd been having polydipsia and polyuria, and they've been slicking their thirst with like bottles and bottles of Coke and Pepsi.

Right? So if you cut that out, uh, you know, they can have significant, you know, weight loss and improvement in their blood sugar just by cutting those things out. Right. Uh, and there's lots of other alternatives to that, right? You can drink diet soda, you can drink water. You know, it sounds to me that you have to drink right for hypertension.

A lot of it has to do with salt intake and a lot of our assaults. Comes from packaged and prepared foods. And those are the things that tend to be cheaper for patients than cooking fresh food at home. Right. And it's not that they couldn't make those changes. It's that in that kind of low income, uh, low resource, uh, urban population, there's not a lot of resources for those kinds of things.

[00:12:35] Taylor: One of the big things that they, you know, have told me like consistently is to, uh, I mean, I definitely don't drink enough water and also to like really try to not eat salt. Um, I've that helped. Uh, right off the bat, I felt like that was a good big thing.

[00:12:51] Helen: Um, so let's see drinking more water. Yeah. Cutting down on salt. Do you have like specific examples of things that you stopped eating? 

[00:12:58] Taylor: Um, yeah. I stopped eating like chips and fries, which was so sad, but, um, I know almost crying now, but, um, uh, the only plus to that was like within a month I lost like 18 pounds.

I know, and I dropped a stop drinking soda, which I know isn't totally just like salt, but there's obviously a salt and a lot of that. Um, so those like things like kind of immediately helped. Uh, I mean, definitely I'll be honest before it was like, not trying really hard to like, do anything in terms of diet.

Um, I, like I said, I don't like go to the gym like very often or anything, but I do pretty routine like pretty long walks around new Haven. So that's kind of like where I was at like five to six miles at like three times a week I was doing. But, um, so I still try to do that to keep up with it. But, um, it was mostly like the diet side of things that they said keep up a little more on 

[00:13:53] Josh: I very much agree about this whole conversation regarding lifestyle. And sometimes I think we really miss opportunities to dig deep into different dietary and lifestyle modifications that patients can make to improve their hypertension management. 

And I don't know about you, but I personally really identify with the time limitations and the pressure that we often feel, when we're with a patient and having to address a very limited number of topics and sometimes it can be really hard to really get into the daily habits that people have in order to optimize their lifestyle to improve their blood pressure. 

[00:14:30] Maisie: Um, but, you know, when, when you are able to to dig into some of that, I'm I'm always surprised at how insightful discussing people's habits can, can be with them. And inevitably, if we are able to get into this, I can usually find one or two things that, uh, could be improved upon or modified to have a positive impact on my patients. 

[00:14:52] Josh: health. Yeah. And it's amazing when patients can also see their blood pressure change as they make those changes in their lives. I think it's really rewarding for both the provider and the patient.

But sometimes, you know, wild dietary modifications, like drinking more water, eliminating excess salt. You know, they might be really important, but sometimes they're not really maybe feasible for a patient or maybe not enough to really make a solid enough impact in someone's blood pressure.

And at this time, medications can really make a big difference in helping bridge patients blood pressure into the goal range. So finding the correct dosage and combination for each patient is really important and can be a really time-intensive process. Sometimes frustrating for patients too.

Chapter 3: Initiating Pharmacotherapy

[00:15:39] Kevin: you're thinking if they're pharmacotherapy at this point, how do you approach starting someone on, on something and how do you decide what agent you're going to have? You're going to pick.

[00:15:48] Gallagher: sure. So I think there are basically two scenarios in which that you would start pharmacotherapy right off the bat, by the time that your company and your diagnosis. One of those is people with stage one, hypertension and again, and blood pressure of one 30 to 1 39 over 80 to 89. Who either have a known high risk cardiovascular conditions, um, including diabetes and CKD or people who is calculated cardiovascular risk over 10 years is greater than 10%.

So that's a large bucket of kind of high risk patients in whom with stage one hypertension, you're going to want to recommend a pharmacotherapy plus lifestyle modification right off the bat. The other group is people who have, uh, stage two hypertension, uh, at the time of diagnosis. So again, a blood pressure of greater than one 40 over 90 in those stage one people you're going to give them a trial of lifestyle modifications.

And if they're not successful, then you start medications, but you give them a little bit more time to kind of prove that they can't get it under control just by modifying their lifestyle. So in terms of. First-line medications. There are three broad classes that we think of as first-line medicines. And they're basically equivalent in terms of blood pressure lowering and in cardiovascular disease and mortality reduction, there are specific reasons that you would choose one or the other based on their comorbidities, based on the side effect, profiles, potential ancillary benefits, or potentially their costs.

Although that the vast majority of these are developed as are available as low cost generics. But, um, all other things being equal, these three classes are equivalent. So these are the long acting calcium channel blockers. Uh, dihydropyridine calcium channel blockers like amlodipine, and nifedepine.

The ACE inhibitors or angiotensin receptor blockers. The second class are kind of considered as the same cause they act in the same pathway. And the third are diuretics. And for most people with normal kidney function or without, you know significant edema, that's going to be a thiazide diuretic. Um, the most important thing, and this has been born out in multiple studies, in getting blood pressure under control is the degree of blood pressure reduction, not the specific agent.

So these are the three agents that we found are generally most effective as monotherapy. And there are specific reasons to use them outside of blood pressure lowering, but really the name of the game is getting the blood pressure lower. And it doesn't really matter that much how you do it. You want to do it in a way that's not so complex and going to cause a lot of side effects or cost too much money for the patient, but otherwise what, however you do it is going to be lead to an equivalent outcome. 

[00:18:41] Helen: could you take us through what your management is like now?

[00:18:44] Taylor: Sure. Um, so I take nifedipine and one other one also starts with an L. So I take one of them in the morning and one of them at night, I was taking both the medications at one point at the same time. But it was finding that I would wake up in the morning and it was like pretty high again. So they just wanted me to split them.

And, um, a lot of different medication trials and things, um, with a couple of the trials of medications, one of them we think maybe brought the blood pressure too low. So it kind of passed out at work twice. I mean, it was okay. It's all fine. I mostly, it was like a really weird feeling. Um, and I think it was when I was on my fed a pain, it was like they had meant like a double dose of it.

And. It felt like my limbs were like really heavy. Like to lift. I was like, felt like I was having a hard time walking and then that, and a combination of probably starting to panic a little bit

 like I looked at my coworker, I remember he was talking to me and his lips, like were not lining up with what he was saying. And I was like, oh, this isn't good. And anyway, so I went to the ER that. I, I didn't love going to the ER, I'll be honest. I mean, who likes that? Of course, but the thing that I didn't like about it, and I know it makes sense for an ER, but they're obviously just looking for like a quick fix to make you so like you can go home, obviously.

[00:20:06] Helen: it sounds like you had a lot of changes, any medication regimen.

Um, so tell me about that. Was that frustrating? 

[00:20:14] Taylor: Um, I mean, it was fine. I feel like it got a little confusing. I mean, even now, I can't remember the name of the one I'm taking currently because it's changed so many times, um, nifedipine. I know, cause that one was like pretty consistent. It was like, we started out with that.

We took it away. We added it. We took it away. We added like a double dose and now it's back again. So that one, um, I know there was like Metoprolol Metoprolol, something in the beginning. Um, there were, there was, I feel like there was one other one too. I just, I don't know why. I can't think of t he names of it.

It was more just like frustrating. Cause I felt like. Every day I was like calling or, you know, going back to the same, um, Walgreens and like, I like pull up like, um, obviously they don't care. They're like, whatever. Um, no, I mean, it wasn't like that big of a deal. It was like, I guess just sort of frustrating.

[00:21:18] Helen: do you have like any specific goals for your treatment?

[00:21:22] Taylor: Um, I mean, yeah, I would love eventually to just like, not have to take them, uh, the medications, not that you know, it's not a big deal. I just, uh, I F I like feel like I'm going to. All the time. So like, I, you know, I was going away a couple weekends ago, uh, just to see friends in New York city and got in my car and I started driving on a highway and I'm like, oh my God, I didn't bring them.

So like went back to get I'm like, it's not a big deal, but it would just be nice to not have to take something every day. 

[00:21:03] Kevin: One thing that I hear a lot when I'm starting someone to Novo on a new blood pressure med is they, they agree to start in. But they hopeful that with lifestyle they'll be able to stop it. 

[00:21:51] Kevin: Um, I have rarely seen that, but I also, haven't been practicing medicine very long. So I'm kind of curious, you know, what you see in your practice and how you, um, approach that conversation with patients.

[00:22:02] Gallagher: So I would say that in my experience, um, and I've spent some time the other day in response to this question, looking this up, that a minority of patients.

who are properly diagnosed with hypertension, meaning that you're measuring correctly in the office or using out of office monitoring will be able to wean off of their blood pressure medicines and remain normotensive.

It might be on the order of 20 to 30% of people. Um, they are more likely to be able to get away with that if the patient is younger, um, if their blood pressure to start out with was closer to the goal, um, or people who have made a lot of, um,

lifestyle improvements. So a lot of patients who get bariatric surgery and lose a hundred pounds.

No cure themselves. And many of their metabolic conditions, including hypertension, uh, people who, you know, were eating a ton of, uh, packaged foods and chips and, and, uh, uh, salting their food. If they then, uh, here to a low salt diet, they could have significant improvement without taking medications, but I would say that's a minority of patients.

And so it's tricky because the proposition that you are presenting them with at the time of diagnosis is this is a medication you're going to take for the rest of yourlife. And you didn't have most likely didn't have a symptom. Right? And in fact, the medications that we're asking you to take are more likely to cause symptoms than the condition that you have because every medication has a side effect.

So I think it's important to understand the magnitude of what you're asking patients even with, to just take one um, you know, because it's really for the rest of your. And for someone who not had a chronic condition before the only medicine they may have taken may have been an antibiotic, they took for seven to 10 days.

And so the idea of take something, you know, at the same time, every day is a big ask.

the thing you can tell them when you're using combinations of medicines is that there are, uh, multiple kind of single pill combination, uh, therapies where you can use two or sometimes even three drugs in the same pill.

And so right now you might be taking two or three pills a day, but once we get you to the right dose, we might be able to convert that to something that's only one or two pills a day. So give them some kind of fascinated, look forward to at the end of the tunnel

[00:24:36] Maisie: So to summarize the three first-line medications used to treat primary hypertension include calcium channel blockers, ACE inhibitors, and angiotensin receptor blockers, or ARBs and diuretics. 

However, only a small minority of patients benefit from a single drug therapy. if that's the case, then it's important to add additional therapies rather than simply uptight trading the dosage of their current medication.

[00:25:04] Josh: Right. But when a patient needs to be on multiple medications, I imagine it can become really frustrating and confusing for them. So it's important to listen to the patient, especially if they have concerns around pill burden and collaborate on ways to manage multiple medications that they can feel on top of their dosage schedule and help them reach their blood pressure goals. 

Chapter 4: Adherance to Medications

[00:26:03] Gallagher: we tend to say, and it's not clear that. Y, this is because all these blood pressure medicines have a different pharmacology and different mechanism of action. But in general, at about 50% of the maximum of the maximum dose of any blood pressure medicine, you're already getting about 75% of the blood pressure reducing effect.

And so by increasing the dose, you're not going to get that much blood pressure lowering in addition, but you will increase side effects. And so that's a motivating principle for me in deciding are we going to. Uh, you know, keep uptight trading the same medication or add a second medication. And I think it's important to tell patients too, that, that same thing, because there'll be a lot of people who say, you know, well, why don't we just increase the dose of one medicine so that I can just have to take one pill a day and explaining that to them.

I think people will understand that, um, number two, you can kind of normalize it by saying that most people with high blood pressure will need two or three meds to really get them under control. So they're not alone. Um, three that, and I've had this, this actually happens more frequent than you would think.

And I think it, it, it kind of highlights the difference in the way that doctors think versus patients think so if you're starting medication a and they're not yet at their goal, Now you're going to add medication B. The question is, uh, why are you not stopping medication? Hey, because it didn't work. So I think it's important to explain to patients that they, some of the medications can work synergistically.

And so it makes sense to continue a when you're adding B.

in terms of a statistical likelihood, you know, you could try multiple different, uh, medications in series, but that just takes more time.

And I think it may ultimately contribute to clinical inertia, both on the doctor's side and on the, uh, patient's side, uh, where people kind of give up, because it seems like they're not, um, they're not making progress. Um, that was, I guess the other thing I would say is that, you know, We, I wouldn't treat the blood pressure target as a at and T I would not let the blood pressure target create a binary, whether you're either controlled or uncontrolled, if you've reduced someone's blood pressure from one 60 to one 40, but their goal is one 30.

You've made a huge amount of progress there. Um, and even if you never got them directly to, uh, perfectly at goal, they would still be beneficial to obviously to continue that medicine. And so when you tell patients about the process of, of titrating the medicines, you want to tell them, look, we've made a lot of progress, but we still have a little ways to go, and maybe they're going to be on board.

Going for that further distance now, or maybe they've run a little bit more time to kind of, uh, they get used to this.

the one sort of data point that I think is here is that there've been several randomized control trials. Okay. single pill, combination therapies in particular, what they call these like quad pills. So they have relatively pretty low doses of four different medications in one. And when you compare that to a comparitor pill, that might has only one medication.

And then in both groups, you let the patient's doctors add second or third pills or fourth pills, right. Until they get to goal right. A year later, the people on this quad pill are better controlled. So you might say, well, the reason for using upfront combination therapy is that you'll get to go faster. But if you give them a year, they're still not at goal. And so I think in the, in the comparative group, right, you give the, the comparative groups, doctors chance to add drug B, C, D, whatever, right. Change things around. And lots of times you give them a lot of time to do that. There's still those people's blood pressure is significantly higher.

And I think what's kind of factoring in there is clinical inertia, right? You, at a certain point, you get frustrated or do you get bored with what you're doing? And you kind of give up on trying to get their blood pressure under better control and inevitably something else comes up and then maybe the patient kind of gets despondent or discourage that what you're doing is not working.

Right. So I think there's something to be said for getting people controlled faster, as a means of coming up with a regimen that is durable, that the patient is willing to take.

[00:30:40] Kevin: one thing that really resonates with me is, um, this idea of adding, adding additional agents earlier rather than later. I see patients at the VA in my primary care 

clinics, okay. I often like if someone's on one med, I favored uptight trading that one med, you know, even to the max dose before I start another agent, because I'm always worrying about compliance, um, and keeping things simple. Um, but it sounds like, um, your approach, um, is more that because, because there's data showing that, you know, you get better, I guess, bang for your buck.

So to speak of, of blocking multiple pathways and adding second agents. Even, you know, because of course these clinical trials would be taking like you're, you know, if you're randomizing, you're accounting for things like compliance, it's actually still better to add that second agent earlier, rather than like titrate all the way to the top.

Before you, you know, before you think about adding another, 

[00:31:40] Gallagher: Yeah, that's my impression. And also keep in mind that as you maximize medicines, you may, uh, cause more side effects and then that's counterproductive to adherence. Um, so, and again, I think that the, the possibility of using the single pill combinations really, um, uh, really has the potential to, um, improve adherence. 

[00:32:03] Taylor: So I have to keep telling myself like, You have like, you know, these great doctors that are helping listen to what they're saying, remember to take your medication. I had to set alarms for a couple of weeks to try to do it. Like the very, very beginning. I felt like I was so focused on it. Cause I was like, okay, I'll just figure this out.

Like it was do it. And I wasn't really forgetting. And then there was like a wall kind of for like a month where I felt like every like afternoon, it'd be like, oh my God. I didn't take it this morning 

[00:32:44] Taylor: you know, it's like sort of weird that I like basically feel completely fine. So I'm like, why am I taking like two medications every day? Um, And then I'll very quickly remember when I have forgotten and then I'm like, let me just check it cause I'm just curious. And I'm like, oh, that's why I'm still taking two medications.

[00:32:29] Kevin: tell us a little bit about how you, how you have conversations with people about, you know, that big ask of having them, you know, take one or two or three, you know, medications 

[00:32:40] Gallagher: Yeah. 

[00:32:40] Kevin: you know, for an indefinite period. Cause it is really tough for people.

[00:33:03] Gallagher: Adherence is obviously key, right? Because if the main method that we're gonna be using to lower blood pressure is pharmacology patients to take those medicines in order to get the benefit from them. Uh, and it's been estimated that for chronic conditions writ large, uh, inherence is only 50% or so.

I don't know if that means that people take half of their medicines a hundred percent of the time or a hundred percent of their medicines half the time or somewhere in between. But the point is that it's not like an antibiotic. Um, it's something you have to take every day. And, uh, and that's hard to do.

I mean, hypertension, there are data that show that only about 20% of patients who are under treatment are sufficiently adherence to get the same benefits that you get from those medicines that were shown in clinical trials. Right? So it's, um, it's really, um, a, a significant, uh, issue, um, We get in the literature on adherence, they tend to consider a 70 to 80% adherence to be sufficient.

Uh, and that is depends on the drug. Most hypertension medications are long acting and have a long half-life and they're kind of forgiving in terms of, uh, adherence. And so if you only took it five days out of the week, you're probably getting most of the benefit. Um, but the way that I ask people about it is a few, a few fold.

One is to kind of normalize things and to ask in a, in a nonjudgmental way and say, look, you've got 10 medications on your list. You know, I know that must be hard to take every day. Are there any days when you forget don't take your meds? You know, I wouldn't ask it as, are you taking this medication? Yes or no to say, look, a lot of people. have trouble taking it.

How many days a week do you take this? Or how many days a week do you forget to take this? Um, and to kind of normalize it that way, um, in different EMR is there are, um, nice tools for, um, uh, determining medication adherence based on pharmacy refill data. And so that's, Um, something that kind of gives you a signal that maybe the patient does not totally adherent.

Um, and, uh, you can have people bring in their pill bottles. 

That's always something nice. That's a little bit hard to do, but if you can get them in the habit of that, that can provide value information. 

[00:35:18] Taylor: Cause I just get confused of like, I feel like I just have like pill bottles everywhere. And I kept them because I was like, there's a chance to, like, I might switch back to one of these. So I have them all. I just feel like, you know, I had a friend come over last week, showed me my like, uh, drawer, looking for a brush and she's like, Jesus, what do you like 90?

[00:35:36] Gallagher: A couple of other, um, pearls I think are that, you know, around the time of medication changes is a time to make extra sure that they're still taking it. in terms of things that you can do to adherence, you know, picking medications that are longer acting, so you only have to take them once a day, the single pill combinations, people. 90 day supply so that you don't have to go to the pharmacy every month. People, some the insurance plans use mail order pharmacies, and that makes things a little bit easier for patients.

Um, you know, often a lot of patients will get, um, pillboxes that, you know, Monday, Tuesday, Wednesday, Thursday, they're organized their pills. All of those things are, are useful to help people remember a lot of people now, cell phones, you know, use, uh, cell phone alarms to her mom's house, take their medications, that kind of thing. 

[00:36:25] Taylor: and then, you know, check my pressure again later. And of course it was high because I like didn't in the morning so I was like, oh my God, am I doing? And then like, I started like convincing myself that I was like, this is where my brain explodes. And I'm like, it's not like it was all stupid. So I was like, you know what, I'm just going to start setting alarms. I would do it, um, for a while I was doing it like, as I was about to leave for work.

And then as I would come home like nine and six, so that it was kind of just like at the same time, it was fun. Got used to it pretty quick. 

Outro

[00:37:05] Josh: hearing Taylor experience I think is so symbolic to what a lot of patients feel when we tell them to start taking a medication for life, for something they can't feel. And I think it really, uh, is a really big ask for patients. 

[00:37:24] Maisie: Totally. You know, I have several patients. I can think of one just from last week who I'm talking with about high blood pressure and, I, you know, they end up telling me, OPA I've had high blood pressure, like all of my life. And I feel totally fine. Like why, why do I need to start a medication now?

[00:37:41] Josh: I'm curious about, what you would say to this patient you know, they're feeling fine and now we're actually giving them something that could potentially give them symptoms that they've never had before. I mean, I think that's just such a weird sort of place to put a patient in.

once you start one medication and maybe you end up having to make some sort of change or maybe adding another medication to it. And patients usually have different and unique responses, to pharmacotherapy. And sometimes it can get really confusing for patients, and sometimes even frustrating as we have to make several different changes to their regimen in order to try to get them to their blood pressure goal.

[00:38:20] Maisie: But, you know, I think the combination pills are probably a little under utilized. If anything, I see a lot of folks on many different ones and, I can't name names because of branding like I'm endorsing something, but there are some great combination pills out there that can really reduce that burden.

But Yeah. I mean, I think it goes back to the point we were making earlier about, you know, you really are just treating a number. And I think one of the ways that I get into this with patients is objective information. Um, I think a lot of people don't always believe the in-office numbers, right? They think maybe the cough is inaccurate or they're just stressed the white coat hypertension piece from before.

So if I have someone who is struggling with the diagnosis, I'll usually start with ambulatory blood pressure monitor. Like we were talking about earlier. Um, you know, that way, if someone has a cuff at home and they can really see that, wow. Even when I'm sitting on my couch, relaxed, my blood pressure is one 50. Um, and they can see that maybe this is not unique to the doctor's office. 

Um, and I really do try to meet people where they're at acknowledge that this, this is hard diagnosis and we are asking you to take a new medicine. Uh, maybe they're not on any other medications right now. Like this one patient in particular I'm thinking of is very healthy, 

like walks two miles a day, drinks, green smoothies and really can't compute the diagnosis of high blood pressure at all. Uh, you know, saying, but I feel fine. And I think, you know, not scaring people, but informing that look down the line uncontrolled high blood pressure really does have consequences, cardiovascular disease, risk, stroke, risk, and trying to put that in the context for people that sometimes a single medicine can really make a difference in your overall health and risk reduction. 

[00:40:15] Josh: I think that's really great. And it can be tough to really have those conversations in a way you're really just trying to partner with a patient and not trying to scare them. Right. Cause you're bringing up the points about stroke, heart attacks, and all sorts of like really kind of scary things, that can happen on the road if the patient doesn't take you seriously. But at the same time, you're sort of trying to do it in a way where you're just trying to make sure they're well-informed. You know, this is the condition you have. This is what you can expect on the road if we don't do anything about this. And I just want to partner with you to try to avoid, you know, what might be coming down the road if we, if we really don't do anything about this, 

[00:40:57] Maisie: right. That, that collaborative spirit like we were talking about, you know, is really powerful, right? We've, we've moved away from paternalistic medicine and in a lot of ways. And I think patients respond better to that collaboration, right. And say, well, you know, this is what you, are perceiving right now about the situation. I'm so glad you're feeling really great. And I want you to keep doing all the wonderful things you're doing for your health but this is just something I think is really important. And I'd love to give you some more advice about this or or help you, you know, navigate this cause it's, it can be challenging to process

[00:42:19] Josh: And I think another motivator that we can give patients is that as they're trying to make some of these lifestyle change Really any degree of blood pressure reduction that we can get is progress. And I think it's important to remind patients of this, to help them, you know, be really motivated partners, as we're managing their high blood pressure. As Dr. Gallagher mentioned, we really don't need to get stuck in this binary of controlled versus uncontrolled hybrid. And that we should really just be aiming to try to get blood pressure improvement, because even that relative risk reduction can really do a lot in preventing a lot of downstream consequences for patients. And sometimes that can be done with lifestyle changes, but sometimes it requires medications.

[00:43:02] Maisie: So that was a lot of information that we, we went through today. Uh, so here are some key takeaways that I took away from today's episode, and I hope you will too. 

So the first point is that determining a target goal for our patients based on the current evidence and our patient's individual risk factors, uh, and communicating this with them is an important first step in management 

the second point is that the 2017 ACC aha guidelines provide us with stages of hypertension that help us risk stratify patients and best informed clinical treatment decisions. So just to recap that normal blood pressure is less than one 20 over 81, 20 to 1 29. Over less than 80 is pre hypertension, a one 30 to 1 39 over 80 to 89. Stage one and above one 40 over 90 is stage two. So treatment really comes in at stage two, unless the patient is at elevated cardiovascular risk. That would include your patients with diabetes, folks who have known cardiovascular disease or in ASCVD risk above 10%. Then you may think about starting treatment in stage one. 

The third point is that it's always a good idea to start with lifestyle modifications, to treat any chronic condition. In the case of hypertension, these lifestyle modifications can include reducing salt intake, particularly from packaged foods and increasing water intake. Additionally, losing weight and increasing physical activity can also have a big. For when initiating pharmacotherapy, it's important to keep in mind that most patients will need more than one medication to reach their target blood pressure. Remember you often achieve 75% of the benefit of any given antihypertensive medication at 50% of the max dose, uh, and to alleviate pill burden, we can offer combination. And the last point is that asking patients to take medications, especially when they're not used to doing so is a big ask. We can partner with patients to adhere to their treatment regimen by talking to them about it in a nonjudgmental way, offering single pill combinations, as we just mentioned, or helping them set alarms on their phones as reminder. 

Be sure to tune in next time, wherever you listen to your podcasts to catch part three in our three part series where we'll be discussing, treating high blood pressure in special circumstances, including in pregnancy and in patients living with chronic kidney disease.

[00:45:41] Josh: Thank you Maisie. Well, that concludes our episode for today. We hope you enjoyed this content, which is made possible by contributions from our patient Taylor, our resident interviewer, Dr. Kevin Wheelock and Dr. Ben Gallagher, who served as our faculty expert and provided peer review for the project special. Thanks to our producers, Madison Swallow, August Allocco, Helen cai ,and Dr. Joshua Onyango that's me as well as our faculty advisor, Dr. Katie Giellisen be sure to follow us at PC pearls on Instagram, where you can expect to get sneak, peeks, additional learning content and the most up-to-date details on show release times.

If you enjoyed this episode, please share with others who are excited about primary care or friends. Who'd like to learn more about the health conditions we described about the health conditions we discussed today. 

Thanks again for joining us farewell from all of us at the primary care pearls podcast. And we'll catch you in the next one