Notes from the Field | Living with Hypertension

This article represents findings from interviews with 20+ individuals with hypertension. The lack of understanding of hypertension prior to diagnosis has motivated us to share more and bring awareness to this chronic condition. For the sake of privacy and anonymity, names are not shared.

The Hypertension Journey

Hypertension is often referred to as the silent killer. For the majority of the disease’s lifetime, high blood pressure is asymptomatic, meaning that there are few symptomatic warning signs that alert someone that they are suffering from hypertension. Therefore, early detection is critical; whether you proactively or reactively address your high blood pressure can greatly influence the trajectory of hypertension and other associated chronic conditions.

The hypertension journey is referring to patients who are struggling with high blood pressure, but this does not mean that the experience is uncommon for other chronic conditions. Nearly half of Americans have some form of hypertension and of those, over 70% do not have their hypertension under control. Control, being the predominant goal and theme for patients diagnosed with hypertension.

How it Begins

“You go to the doctor for your regular visit, and that’s the only way you’re going to know if you have hypertension... because it’s the silent killer.”
“You really don’t know you have it… high blood pressure has no symptoms.”

For nearly all of the interviewees, prior to diagnosis, hypertension was not a top-of-mind concern. In fact, most found out about their high blood pressure reactively during a regular check-up with their primary care physician (PCP).

There are four categories of high blood pressure in adults as defined by the American College of Cardiology & American Heart Association: Normal, Elevated, Stage One Hypertension, and Stage Two Hypertension.

The Comorbidity Complications

"I had high blood pressure my whole life because of kidney disease. My doctor diagnosed me with Fibromuscular dysplasia [a progressive twisting of the blood vessels throughout the body]... I didn’t know much about any of this back then. It made it all more complex to manage."

Comorbidities describe when a patient has two or more medical conditions at one time. For patients with prehypertension, the prevalence of adults with 2 or more comorbidities is 29.8%. Among hypertensive patients, the prevalence of people with 2 or more conditions is 42.2% and 3 or more diseases is 17.7%. [1] As a result, hypertension is rarely the only concern for patients and physicians when developing a care plan for people managing hypertension. The complexities of varied health circumstances can make it difficult to find the right balance for an individual.

It’s important to acknowledge the goal for balance when managing people with hypertension. If patients are over- or under-medicated, their health could be at risk. For this reason, doctors recommend consistent physiological (physical) monitoring to determine the effectiveness of prescription medications and whether adjustments are needed. Whether or not patients adhere to these recommendations is another challenge altogether.

Lifestyle Changes / Nonpharmacological Treatment

“I have to manage my diet and exercise, everything has to be in moderation. It’s something that has to be monitored consistently in order to maintain my health.”

Before prescribing medication to help manage mild forms of high blood pressure, the American Heart Association guidelines recommend that doctors first implement nonpharmacological treatments, also known as lifestyle changes, such as diet, exercise, and lower sodium intake.

While these changes can have significant positive effects on blood pressure control, they are also challenging for patients to track and sustain. Adherence to these changes often falls off by over 25% during the course of a year. Despite best efforts, sometimes lifestyle changes alone, unfortunately, aren’t enough and medications are necessary. [2]

The Pharmacological / Medication Journey

“The hospital tested me and couldn’t find anything wrong, so they put me on a buffet of high blood pressure meds until mine was lower. I left the hospital on five blood pressure meds, and the side effects were awful."

“There were definitely growing pains when starting a new medication. My doctor said it was going to take a year or two to adjust to my new needs. The first six months were the worst of it, but after that point, they started to improve."

Depending on the severity of a patient’s hypertension, doctors will decide whether it is safe to try nonpharmacological treatments first or if medication should be prescribed right away. Hypertension medications, also known as antihypertensives, are divided into eleven classes of blood pressure medication.

Prescribing pharmacological treatment is often described as a “trial and error” process by people who are going through it. Doctors often have to use limited physiological data to make an educated recommendation as to which medications, and how much, should be prescribed to their patients. It is typically only once the desired results are not reached that adjustments are made. After an initial prescription, reassessment is typically recommended within three to six months due to the length of time it takes for tangible results to manifest, though this varies greatly from medication to medication and patient to patient.

Part of the prescription process involves balancing the benefits of controlling a patient’s condition with the drawbacks of certain side effects.

The Bear of Side Effects

“Most of the medications I’ve been on, I’m allergic to. I can’t take many pills. I was on three blood pressure pills, which made my ankles swell, and they couldn't fix that.”
“It takes a couple of weeks to get used to the medication. It’s not worth it to be unable to do anything during that time."

Medication can have varied side effects that impact people’s lifestyles, ranging from mild to severe. The duration and severity of side effects are a concern for many doctors and patients. Each new prescription comes with an adjustment period that can last for prolonged periods of time.

Consistent communication during this adjustment period can support the ability of doctors to make modifications in the care plan that may help acclimate patients to their new prescriptions.

Beyond In-person Doctor Visits

"My doctor recommended that I have follow-up visits after our initial evaluation. The PCP had me in three times and I had to wait in the office for twenty minutes each time to mitigate the chance of white coat hypertension [when blood pressure readings at the doctor’s office are higher due to stress or anxiety associated with the visit].”
“I went onto the patient [web] portal to tell my doctor that I needed to change medications.”

As a result of the COVID-19 pandemic, telemedicine—the distribution of health-related services and information via electronic and telecommunication technologies—has expanded further into the realm of healthcare in the form of patient and clinician communication, education, and monitoring.

Patients we spoke to feel more connected to their physicians than ever before. A typical hypertension screening, before the advent of telemedicine, was described by one of our interviewees:

Now patients feel more comfortable taking their blood pressure from the comfort of their own home, using a wide variety of devices, and sending that data directly to their doctor, avoiding white coat hypertension altogether. Patients who once struggled to get to their physician’s office now reach out and report to their doctor regularly online, making the care process more real-time and in some cases, more proactive.

Ongoing Care Management and the Adherence Challenge

“It’s so stressful to take your blood pressure every day, and it’s high, and it stresses me out… I’d rather forget it.”

Even after someone has their hypertension under ‘control’, there are still many things to monitor, manage, and think about regarding ongoing care management. The most challenging aspect of care management that we heard about is adhering to the regiment of medications and home blood pressure measurements. Remembering to take home measurements and do so consistently over time to be able to catch any trends that may warrant medication changes (also known as titration) is key to managing hypertension.

The Heart Seat was built to make managing hypertension easier for people to address many of these challenges head-on. Casana remains dedicated to improving health outcomes by empowering the world’s caregivers and patients with access to reliable, consistent vital signs. To share your own insights please contact us at info@casanacare.com.


References:

[1] Noh, J., Kim, H. C., Shin, A., Yeom, H., Jang, S.-Y., Lee, J. H., Kim, C., & Suh, I. (2016,

September). Prevalence of comorbidity among people with hypertension: The Korea National Health and Nutrition Examination Survey 2007-2013. Korean circulation journal. Retrieved October 21, 2021, from https://www.ncbi.nlm.nih.gov/p...,%25%20and%2017.7%25%2C%20respectively.

[2] Burnier, M., Wuerzner, G., Struijker-Boudier, H., Urquhart, J., & Al., E. (2013, June 10).

Measuring, Analyzing, and Managing Drug Adherence in Resistant Hypertension. Hypertension. https://www.ahajournals.org/do...;

[3] Fuller JM, Barenfeld E, Ekman I (2021) Why do patients struggle with their medicines?—A

phenomenological hermeneutical study of how patients experience medicines in their everyday lives. PLOS ONE 16(8): e0255478. https://doi.org/10.1371/journal.pone.0255478

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