Why do we fail in reaching pressure goals in many hypertensive patients? What means do we have at our disposal to improve these today?

Background/introduction

Hypertension (HT) is today the most prevalent cardiovascular (CV) disease (CVD), affecting about 20–50% of the general population in developed countries. Its prevalence increases with age; HT affects more than 50% of subjects over 50 years old [1]. All categories of the population (pregnant women, elderly, people with diabetes, etc.) are susceptible to developing a pathological elevation of blood pressure (BP).

High BP has been identified as a risk factor for coronary artery disease (CAD), heart failure (HF), stroke, and peripheral arterial insufficiency. HT is associated with early modifications in organ systems, such as left ventricular (LV) hypertrophy, renal failure, retinopathy and vascular dementia, which are grouped together under the term “target organ damage” (TOD) [2]. Therefore, HT is one of the most important rapidly growing public health problems worldwide. Currently, BP control is a great challenge for the World Health Organization (WHO), institutions, health systems and experts of major international and/or national referral scientific societies [3].

Inadequate treatment of HT and poor BP control drastically increase TOD. In order to achieve better CV and general outcomes, the scientific community has for some years been introducing new concepts in HT treatment strategies and/or overall BP control [4]. Notable among them are the following:

• Pseudo-resistant HT. Randomised controlled trials (RCTs) and other minor studies have demonstrated that only 5-10% of hypertensive patients show resistance to drugs [5].
• Physician inertia. Despite the effectiveness of treatments, physicians usually maintain their patients with monotherapy and/or suboptimal doses of medications contrary to the established recommendations [6-8].
• Spread combination drugs “philosophy”. Most studies have revealed the inadequacy of monotherapy; nevertheless, many patients have no combination regimens, as highlighted above [9].
• Patient adherence not assessed. It is increasingly clear that adherence is much more pivotal than previously acknowledged and so assessment of adherence is very important as well as being the first step of BP control [10].
• New methods for addressing the needs of hypertensive patients. Unmet needs are consistent in the HT “universe”. Probably the new era will have to make more use of nurses and pharmacists in order to care for people affected by HT [11,12].

Little is still known and shared about the use of non-physician co-workers for HT control and so it is pivotal to encourage the scientific community to share current knowledge about the topic and work out further applications. There seems to be an overt gap in evidence, especially about the possibility of a single pattern for the use of nurses and pharmacists.

Adherence

BP-lowering inefficiency is often due to insufficient adherence. The causes of non-adherence can be multiple. First of all, the number of pills to be taken per day adversely affects adherence. The assumption of side effects from drugs is another important limitation to adherence and gets worse on continuation of treatment. It is known that some therapeutic regimens may influence sexual performance, generating discontinuation of pill intake, especially among men [13].

Therefore, we have evidence that patients very often stop their medications and it is very common to change their doses. Moreover, it is clear that poor BP control is strictly related to poor adherence. In this regard, physicians and/or nurses and/or pharmacists may collaborate to measure a patient’s adherence to drugs. Detecting poor adherence, as indicated in the ESH/ESC Guidelines [4], is a very crucial point of modern cardiology practice as well as the engagement and empowerment of patients. Patient awareness of their own HT may contribute to better results in BP lowering. Moreover, awareness of disease may encourage people with HT to self-monitor BP values [14]. That is a “safe” form of self-management, especially when combined with education and counselling.

However, it is quite evident that the latest guidelines have introduced some new concepts in the scenario of HT such as the above-mentioned points besides the single-pill combination (SPC) strategy and simplified drug treatment algorithms. In order to perform similar tasks, the involvement of nurses and pharmacists will always be important in HT management. Despite the out-of-guidelines “attitude” which is often observed among physicians, patients generally have a more rigorous approach to recommendations, even if this assertion is still controversial and not sufficiently debated [15].

Key role of nurses and pharmacists in BP management

Insufficient adherence often results from physician inertia in following recent guidelines and recommendations. Physicians’ should prescribe more appropriate regimens and/or doses, and evaluate and/or measure the real compliance of patients by establishing a good counselling relationship with them. Therefore, the latest ESH/ESC recommendations have encouraged the major involvement of nurses and/or pharmacists for the management and follow-up of patients with HT. Obviously, health systems differ, and non-physician health workers may not perform the later controls of hypertensives everywhere. However, integration between different healthcare providers is increasing, and health systems will support such collaboration more and more, even financially.

Nurse-led options

Worldwide diffusion of nurse-led HT control has been increasing over the last few years.

Some years ago, a British review investigated the role of the nurse in the management of hypertensives [11]. In comparison with the usual strategies of treatment, nurse-led interventions that included a stepped treatment algorithm showed significantly greater reductions in BP values (both systolic and diastolic), but this was not associated with higher achievement of targets. Nurse-led prescribing also showed greater BP lowering but neutral effects on target achievement. Telephone monitoring was associated with higher achievement of BP targets as was community monitoring. Nurse-led clinics in primary care achieved greater reductions in systolic and diastolic blood pressure compared with usual care, whereas any clear beneficial effects on primary outcomes were observed from secondary care clinics. In summary, although the review confirmed a feasible role for nurses in managing HT patients, further evidence is necessary for clarification of their tasks in teamwork for the cure of hypertensives.

However, the scenario is far from the conventional idea of the nurse’s role in HT. Nurse-led options are not only education, counselling, measurement of BP and enhanced self-monitoring of patients. A task-shifting strategy for HT control may be winning, especially in low-middle income countries (LMIC) [16]. A recent study in the Chinese population has confirmed that nurse-led care of HT is a useful and suitable option. Moreover, the organisation was well accepted and found non-inferior to physician management. Furthermore, patients experienced a more relaxed communication with nurses rather than with physicians [17]. The background in developed Western countries may be slightly different but nowadays the lack of information is the real topic of interest. Unfortunately, a substantial gap in evidence is still present and we are far from the systematic delivery of nurse-led interventions in HT and in chronic diseases in general.

Pharmacists and HT control

Another physician HT co-worker to be considered is the pharmacist. In this setting also, the differences among health systems may generate various types of pharmacist care delivery.

Some years ago, a US clinical trial demonstrated that home BP remote monitoring (and patients’ overall management) achieved better BP thresholds compared with traditional care. This result was maintained over time [18].

It is certain that the first step should be a collaboration between pharmacists and physicians in order to tailor better medication for each hypertensive. Pharmacists as well as nurses are very often the first contact for hypertensives and the literature emphasises recognising a multi-faceted central role for these co-managers of chronic diseases [12]. Several countries (both Western and Eastern) have given the pharmacist an active role in chronic patient management and the promotion of health prevention programmes. For example, the SCRIP-HTN trial documented that pharmacist and nurse teams working collaboratively with patients and primary care physicians may improve suboptimal BP control [19]. Analogously, teamwork between the pharmacist and physician may obtain better reduction of BP values in patients with uncontrolled HT [20].

Table 1.  Nurses and pharmacists’ involvement in HT management.

Conclusions

The benefits of reducing BP values are well established and yet, unfortunately, a great number of patients have uncontrolled BP. Optimising BP target achievement is a critical aim for the World Health Organization and all of the leading hypertension societies have been studying the best strategies to achieve that aim for a number of years. Although it is certain that many achievements have already been made (e.g., a clear strong reduction in CV deaths as a consequence of HT), the main objective for the HT scientific community is the improvement of BP goals. Insufficient adherence to antihypertensive drugs is the main culprit. Despite multiple choices for lowering BP, global results are far from satisfactory. Many causes generating and/or contributing to the unmet need of poor HT control can be identified. Physician inertia is often the real problem.

The ESH/ESC recommendations have strongly underlined the need to reduce this inertia and, at the same time, have suggested new options for improving the achievement of BP thresholds. Increasingly, massive use of a single-pill combinations has certainly improved current BP control along with the adoption of correct dose regimens by physicians. Patient engagement and empowerment is always of great importance.

Non-physician healthcare co-workers, such as nurses and pharmacists, can play a fundamental role in HT management. Reducing BP and consequently global CV risk through the work of alternative “protagonists” will be more and more the way forward. Education, counselling and advising are often delegated to nurses and pharmacists; their involvement should be even more extensive. Nowadays, the use of simplified stepped treatment algorithms such as the different forms of “remote” adherence monitoring (e.g., telephone monitoring and/or community monitoring) seems to be the most suitable choice with nurse-led interventions. Concerning the role and involvement of pharmacists, the best strategies could include the remote monitoring of BP values, counselling and widespread educational programmes to extend the awareness of the disease among the population (including those affected and not affected by HT).

Finally, a closer collaboration among physicians, nurses and pharmacists could be the most useful worldwide strategy to improve current BP targets. Such integration among different “health providers” will increasingly transform the concept of cure into care of patients. All health systems should favour similar BP control co-management, with possible financial support.