Help Manage Hypertension in Underserved Communities

Nearly one-third of adults in the United States experience elevated blood pressure level. Additionally, hypertension is the most common reason for physician’s visits and the use of long-term prescription medications in nonpregnant adults.^1-3 Approximately half of individuals with hypertension do not have adequate control of their blood pressure level.² Hypertension also puts individuals at risk for a host of disorders, including cardiovascular disease and complications.³ Rates of hypertension are even higher in underserved communities.⁴

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Overview of Hypertension

The American College of Cardiology and the American Heart Association separate blood pressure into 4 general categories⁵:

• Normal blood pressure: systolic pressure level less than 120 mm Hg and diastolic pressure level less than 80 mm Hg
• Elevated blood pressure: systolic pressure level of 120 to 129 mm Hg and diastolic pressure level less than 80 mm Hg
• Stage 1 hypertension: systolic pressure level of 130 to 139 mm Hgor diastolic pressure level of 80 to89 mm Hg
• Stage 2 hypertension: systolic pressure level greater than or equal to 140 mm Hg or diastolic pressure level greater than or equal to 90 mm Hg

In clinical practice, patients who take medication for hypertension are typically defined as having hypertension or managed hypertension regardless of their observed blood pressure level.⁵ Risk factors for primary hypertension include older age, obesity, family history, race, excess sodium intake, alcohol consumption, physical inactivity, and insufficient sleep (defined as less than 7 hours per night). Hypertension also appears to be more common, present earlier in life, and be more severe in Black patients than in White patients.^6,7

Hypertension is also associated with an increased risk of adverse cardiovascular and kidney outcomes. Complications include heart failure, ischemic stroke, ischemic heart disease, intracerebral hemorrhage, and chronic kidney disease.⁵ The likelihood of a cardiovascular event increases as blood pressure level increases; in a meta-analysis of more than 1 million adults, risk began to rise in all age groups with systolic pressure level above 115 mm Hg or diastolic pressure level above 75 mm Hg.⁵ For every systolic pressure level increase of 20 mm Hg and every diastolic pressure level increase of 10 mm Hg,the risk of death from heart disease or stroke doubles.⁵

Management of hypertension can be divided into nonpharmacologic therapy and pharmacologic therapy. As part of nonpharmacologic therapy, lifestyle modifications include dietary salt restriction, weight loss, the dietary approaches to stop hypertension (DASH) diet, increased exercise, and limited alcohol intake. These modifications should be part of hypertension management forall patients.⁸

Pharmacologic therapy has shown a nearly 50% relative risk reduction in heart failure, a 30% to 40% relative risk reduction in stroke, and a 20% to 25% relative risk reduction in myocardial infarction.⁶ Guidelines should be used to choose pharmacologic therapy, and many guidelines and meta-analyses have shown hat the degree of blood pressure level reduction, not the choice of antihypertensive medication, is the major characteristic in reducing cardiovascular risk.^8-10

Management of Hypertension in Underserved Communities

Hypertension rates are more than 10% higher in rural and underserved communities than in most urban areas.¹¹ An underserved community refers to a group of individuals who do not have adequate access to medical care.

Barriers to health care access can include transportation, insurance coverage, and cost. They can also include rural areas, older age, socioeconomic status, and low literacy levels. Pharmacologic therapy is a foundation of hypertension management, but rates of medication nonadherence are high among adults with low income and multiple chronic disease states or who lack of prescription drug coverage.¹¹

There are initiatives around the country to serve these populations. One example is the Keep on Track program, which is based on the premise that ethnic and racial minority individuals, including Asian Americans, face disparities in hypertension compared with non-Hispanic White individuals. The New York City Department of Health and Mental Hygiene developed this program as a low-cost, sustainable, community-based blood pressure monitoring program.¹²

The CDC also has several public health programs, and the American Heart Association has an ongoing health initiative that helps support health care in rural communities. The CDC is also working with states to improve hypertension management via team-based telemedicine interventions to improve the quality and availability of care to patients.

Pharmacist’s Role

Research has shown that a team-based approach to hypertension management can be beneficial to patients.^12,13 Pharmacists are a valuable part of the health care team and are uniquely positioned and accessible in the community. Pharmacists can check blood pressure level in retail settings, encourage automatic refills, counsel on medication adherence, and provide telehealth and telemonitoring interventions such as phone calls and digital pill counts, which can help bridge the gap in underserved areas. Getting involved in current community programs or working with organizations to create programs that provide blood pressure screening and management can also be a valuable resource to underserved communities and populations.^8,13,14

References

1. Muntner P, Carey RM, Gidding S, et al. Potential US population impact of the 2017 ACC/AHA high blood pressure guideline. Circulation. 2018;137(2):109-118. doi:10.1161/CIRCULATIONAHA.117.032582

2. Yoon SS, Gu Q, Nwankwo T, Wright JD, Hong Y, Burt V. Trends in blood pressure among adults with hypertension: United States, 2003 to 2012. Hypertension. 2015;65(1):54-61. doi:10.1161/HYPERTENSIONAHA.114.04012

3. Facts about hypertension. CDC. Updated January 5, 2023. Accessed April 28, 2023. https://www.cdc.gov/bloodpressure/facts.htm

4. Hypertension. World Health Organization. March 16, 2023. Accessed April 9, 2023. https://www.who.int/news-room/fact-sheets/detail/hypertension

5. Whelton PK, Carey RM, Aronow WS, et al. 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. Hypertension. 2018;71(6):1269-1324. doi:10.1161/HYP.0000000000000066

6. Bundy JD, Mills KT, Chen J, Li C, Greenland P, He J. Estimating the association of the 2017 and 2014 hypertension guidelines with cardiovascular events and deaths in US adults: an analysis of national data. JAMA Cardiol. 2018;3(7):572-581. doi:10.1001/jamacardio.2018.1240

7. Carson AP, Howard G, Burke GL, Shea S, Levitan EB, Muntner P. Ethnic differences in hypertension incidence among middle-aged and older adults: the multi-ethnic study of atherosclerosis. Hypertension. 2011;57(6):1101-1107. doi:10.1161/HYPERTENSIONAHA.110.168005

8. Turnbull F, Neal B, Ninomiya T, et al; Blood Pressure Lowering Treatment Trialists’ Collaboration. Effects of different regimens to lower blood pressure on major cardiovascular events in older and younger adults: meta-analysis of randomised trials. BMJ. 2008;336(7653):1121-1123. doi:10.1136/bmj.39548.738368.BE

9. Hebert PR, Moser M, Mayer J, Glynn RJ, Hennekens CH. Recent evidence on drug therapy of mild to moderate hypertension and decreased risk of coronary heart disease. Arch Intern Med. 1993;153(5):578-581.

10. Mancia G, Fagard R, Narkiewicz K, et al; Task Force Members. 2013 ESH/ESC guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2013;31(7):1281-1357. doi:10.1097/01.hjh.0000431740.32696.cc

11. Samanic CM, Barbour KE, Liu Y, et al. Prevalence of self-reported hypertension and antihypertensive medication use by county and rural-urban classification - United States, 2017. MMWR Morb Mortal Wkly Rep. 2020;69(18):533-539. doi:10.15585/mmwr.mm6918a1

12. Yi SS, Wyatt LC, Patel S, et al. A faith-based intervention to reduce blood pressure in underserved metropolitan New York immigrant communities. Prev Chronic Dis. 2019;16(E106):1-8. doi:10.5888/pcd16.180618

13. Di Palo KE, Kish T. The role of the pharmacist in hypertension management. Curr Opin Cardiol. 2018;33(4):382-387. doi:10.1097/HCO.0000000000000527

14. Isetts BJ, Buffington DE, Carter BL, Smith M, Polgreen LA, James PA. Evaluation of pharmacists’ work in a physician-pharmacist collaborative model for the management of hypertension. Pharmacotherapy. 2016;36(4):374-384. doi:10.1002/phar.1727

About the Author

Joanna Lewis, PharmD, MBA, is the 340B compliance coordinator at Baptist Health in Jacksonville, Florida.