ACC/AHA's BP Goals Up Primary Care Workload, More So in Diabetes

Marlene Busko

June 25, 2018

ORLANDO — The 2017 American College of Cardiology (ACC)/American Heart Association (AHA) hypertension guidelines will have a much greater proportional impact on those with diabetes compared to those without and classify a substantial number of patients with diabetes seen in primary care as now having hypertension, a new study has found.

The analysis of patients in primary care practices in the US Midwest also showed that "there are many barriers to complying with the recommendations," JoAnn M. Sperl-Hillen, MD, an internist at Health Partners Institute in Minneapolis, Minnesota, reported here at the American Diabetes Association (ADA) 2018 Scientific Sessions.    

Faced with more patients being classed as hypertensive, "I really think we need to have a paradigm shift with how we deal with blood pressure in a primary care environment," she told Medscape Medical News.

"We need to be thinking about how we can use out-of-office readings and telemonitoring and new technology," she continued. "Maybe we do ambulatory blood pressure monitoring once a year in all patients rather than relying on inaccurate blood pressures at in-office visits."

She noted the "controversy over the new guideline in primary care," in general noting that "two of the large primary care organizations (American Academy of Family Physicians and American College of Physicians) have not endorsed the new ACC/AHA recommendations for a number of reasons," as previously reported by Medscape Medical News.

And blood pressure goals are particularly controversial for people with diabetes, she added. The SPRINT study excluded people with diabetes, ACCORD did not show benefit in primary cardiovascular (CV) outcomes with intensive blood pressure management, and the ADA hasn't yet endorsed this new goal of < 130/80 mmHg, although it recommends considering it for patients with high CV risk or chronic kidney disease (CKD).

"I think a big takeaway from the session is that prevention is important even before you get diabetes," said session chair Ranee Chatterjee, MD, MPH, internal medicine and primary care physician at Duke Health, Durham, North Carolina.

Over 60% of Patients With Diabetes Would Be Hypertensive, Need Attention

To examine how the 2017 ACC/AHA hypertension guideline affected primary care, researchers identified 207,163 patients aged 40 to 75 seen in 74 primary care clinics in Minnesota and Wisconsin during the year ending June 1, 2017.

Of these, 30,608 patients (14.8%) had diabetes. Compared with other patients, on average patients with diabetes were older (61 vs 56 years) and had a higher 10-year cardiovascular disease (CVD) risk (19.6% vs 7.6%). Most patients were white (84%).

Overall, about 25% of patients met the traditional hypertension criteria of blood pressure > 140/90 mmHg.

But using the lower hypertension threshold (blood pressure 130–139/80–89 mmHg), an additional 33% of patients (with or without diabetes) would be diagnosed with stage 1 hypertension, meaning that 57.1% of those without diabetes and 62% of those with diabetes would now be labeled hypertensive and "need some kind of additional attention," said Sperl-Hillen.

Percentage of Patients in Different Blood Pressure Ranges, With Vs Without Diabetes

Blood Pressure

Patients without diabetes (n = 176,555),%

Patients with diabetes (n = 30,608),%
≥ 140/90 mmHg 24.1 29.0
130–139/80–89 mmHg 33.0 33.0
 
 

For people with stage 1 hypertension already on blood pressure treatment, the guideline recommends treatment intensification to reach a target blood pressure < 130/80 mmHg.

In the current study, 39% of patients without diabetes were already on blood pressure medication and would require treatment intensification; about 6.8% would require treatment initiation based on high CV risk.

For patients with diabetes specifically, 76.8% were already receiving treatment for hypertension but would require treatment intensification; and 22.4% would require medication initiation, representing a much heavier workload than in those without hypertension.

"ADA guidelines have not yet endorsed this 130/80 mmHg [target]," Sperl-Hillen reiterated, "other than for patients with a high CV risk score or CKD."

Primary Care Workload Makes Proper Assessment of BP Impossible

"One of the main issues that I see is that blood pressure accuracy is really a problem in primary care," said Sperl-Hillen.  

Few if any primary care settings use blood pressure measuring methods that meet the research standards the guidelines are based on.

Staff doesn't have enough time to follow the ACC/AHA methodology, which would take 10 minutes; repeat readings of high blood pressure are frequently not done; and many clinics don't use automated BP devices (which are more accurate).

"The workflow is significant for primary care, with 62% of patients with diabetes and 57% of patients without diabetes having a blood pressure above goal. These are all patients that need attention."

Despite the barriers to care revealed in this study, she remains optimistic. "The technology is out there," according to Sperl-Hillen. "We just haven't figured out how to get it into the electronic health record" and how to encompass new technology in performance measures.

Sperl-Hillen and Chatterjee have reported no relevant financial relationships.

American Diabetes Association 2018 Scientific Sessions. June 24, 2018; Orlando, Florida. Abstract 173-OR.

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