nursing research article on hypertension

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Improving hypertension control and cardiovascular health: An urgent call to action for nursing

Judith a. hannan.

1 Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Chamblee Georgia, USA

Yvonne Commodore‐Mensah

2 Johns Hopkins School of Nursing, Baltimore Maryland, USA

Natsuko Tokieda

3 Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Chamblee Georgia, USA

Alison P. Smith

4 Target: BP™, American Heart Association/American Medical Association, Chicago Illinois, USA

Kate Sustersic Gawlik

5 College of Nursing, The Ohio State University, Columbus Ohio, USA

Linda Murakami

6 Practice Facilitation, American Medical Association, Chicago Illinois, USA

Jennifer Cooper

7 Association of Public Health Nurses, Hood College, Fredrick Maryland, USA

8 Preventive Cardiovascular Nurses Association, Madison Wisconsin, USA

Kathy D. Wright

9 College of Nursing, The Ohio State University, Columbus Ohio, USA

Doreen Cassarino

10 American Association of Nurse Practitioners, Austin Texas, USA

Cynthia Arslanian‐Engoren

11 Million Hearts ® Sub‐Committee of the American Academy of Nursing Health Behavior Expert Panel, School of Nursing, University of Michigan, Ann Arbor Michigan, USA

Bernadette Mazurek Melnyk

12 The Helene Fuld Health Trust National Institute for EBP, Million Hearts ® Sub‐Committee of the American Academy of Nursing Health Behavior Expert Panel, The National Forum for Heart Disease and Stroke Prevention, The Ohio State University, Columbus Ohio, USA

Associated Data

Hypertension is a leading cause of cardiovascular disease (CVD) and affects nearly one in two adults in the United States when defined as a blood pressure of at least 130/80 mm Hg or on antihypertensive medication (Virani et al., 2021, Circulation , 143, e254). Long‐standing disparities in hypertension awareness, treatment, and control among racial and ethnic populations exist in the United States. High‐quality evidence exists for how to prevent and control hypertension and for the role nurses can play in this effort. In response to the 2020 Surgeon General's Call to Action to Control Hypertension , nursing leaders from 11 national organizations identified the critical roles and actions of nursing in improving hypertension control and cardiovascular health, focusing on evidence‐based nursing interventions and available resources.

To develop a unified “Call to Action for Nurses” to improve control of hypertension and cardiovascular health and provide information and resources to execute this call.

This paper outlines roles that registered nurses, advanced practice nurses, schools of nursing, professional nursing organizations, quality improvement nurses, and nursing researchers can play to control hypertension and prevent CVD in the United States. It describes evidence‐based interventions to improve cardiovascular health and outlines actions to bring hypertension and CVD to the forefront as a national priority for nursing.

Linking Evidence to Action

Evidence‐based interventions exist for nurses to lead efforts to prevent and control hypertension, thus preventing much CVD. Nurses can take actions in their communities, their healthcare setting, and their organization to translate these interventions into real‐world practice settings.

INTRODUCTION

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality for both men and women across the United States and worldwide (GBD 2017 Causes of Death Collaborators, 2018 ). Hypertension, a leading cause of CVD, affects nearly one in two adults in the United States when defined as having a blood pressure (BP) of at least 130/80 mm Hg or taking antihypertensive therapy (Virani et al., 2021 ). Yet, in a recent study, only 77% of individuals were aware that they had hypertension, and only 44% of those with hypertension had their BP controlled to <140/90 mm Hg in 2018 (Muntner et al., 2020 ). Uncontrolled hypertension is an independent risk factor for CVD, stroke, kidney disease, and cognitive decline and significantly contributes to complications of pregnancy and mortality globally (U.S. Department of Health and Human Services, 2020b ; Whelton et al., 2018 ; Williamson et al., 2019 ).

Hypertension is mostly preventable and controllable (Mills et al., 2020 ; GBD 2017 Risk Factor Collaborators, 2018 ). In the United States, progress in improving hypertension control has stalled over the last decade. Without improvements in healthy lifestyle behaviors and healthcare delivery, the decade‐long improvements in cardiovascular health will erode (Kirkland et al., 2018 ). The ongoing COVID‐19 pandemic has disrupted preventive care and has presented barriers to hypertension control, including worsening mental health and unhealthy coping mechanisms such as unhealthy eating and decreased physical activity (Bhutani et al., 2021 ; Czeisler et al., 2020 ).

Long‐standing disparities in hypertension awareness, treatment, and control among racial and ethnic populations in the United States must be addressed (Centers for Disease Control and Prevention [CDC], 2021 ; Commodore‐Mensah et al., 2021 ; Lackland, 2014 ). Ample evidence exists for prevention and control of hypertension (Appel, 2003 ; Carey et al., 2018 ; Whelton et al., 2018 ), as well as for the role of nurses in preventing and managing hypertension (Himmelfarb et al., 2016 ; Proia et al., 2014 ).

In response to the trend of worsening hypertension control, the 2020 Surgeon General's Call to Action to Control Hypertension identified three broad goals: (1) Make hypertension a national priority, (2) Ensure places where we live, work, and play support hypertension control, and (3) Optimize patient care for hypertension control (U.S. Department of Health and Human Services, 2020a ).

Within 2 months of the publication of the Surgeon General's Call to Action , individuals from public health nursing, cardiovascular nursing, community health center nursing, nursing and medical associations, and academia formed a workgroup to develop a “Call to Action for Nurses” to improve control of hypertension and to make sure nurses can get the information and resources they need to execute this call to action.

Workgroup members reviewed the literature, synthesized the evidence, and made recommendations. This report delineates the critical role of nursing in improving hypertension control in the United States, highlights evidence for nursing interventions to improve hypertension control and cardiovascular health, and describes information and resources nurses can use to improve hypertension control.

A VISUAL TOOL SHOWING SPECIFIC ACTIONS THAT NURSING GROUPS CAN TAKE

Figure ​ Figure1 1 represents a unifying call to action for all nurses and shows the specific actions that various nursing sectors can take, keeping the individual with hypertension at the center of their actions. Figure ​ Figure1 1 provides nurses an easy way to see what each group can do. Following Figure ​ Figure1 1 is detail on the potential actions nurses can take, broken down by nursing groups or sectors.

Nursing actions to improve hypertension control and CVD risk reduction. Note . BP, blood pressure; CVD, cardiovascular disease; HTN, hypertension; QI, quality improvement; SDOH, social determinants of health

WHAT THIS CALL TO ACTION MEANS FOR REGISTERED NURSES (RNs)

Numbering almost 4 million in the United States, RNs are the largest segment of the healthcare workforce (American Association of Colleges of Nursing, 2019 ) and serve in a wide range of settings: acute care, community health centers, public health agencies, primary care practices, home health care, nursing homes, and other settings.

Accurate BP measurement, a critical step in hypertension diagnosis and treatment decision, is a fundamental nursing skill. When RNs do not measure BP accurately, it can lead to over/under diagnosis, over/under‐treatment, or lack of treatment intensification (Bundy et al., 2017 ; Johnson et al., 2018 ; Jones et al., 2003 ; Piper et al., 2015 ). The most common cause of clinical inertia (i.e., failure of a clinician to intensify treatment) is the concern that a BP is not representative of a patient's true BP, either because it is inaccurately measured or because of an insufficient number of readings. Thus, RNs need to be meticulous about accurate BP measurement, whether using a manual or an automated BP cuff (Muntner et al., 2019 ).

Specific actions for RNs include the following:

• Be re‐skilled every 6–12 months as recommended by the 2019 American Heart Association (AHA) Scientific Statement on the Measurement of BP in Humans (Muntner et al., 2019 ).
• Ensure proper positioning of patients in a supportive chair (rather than on an exam table).
• Ensure that the environment allows an accurate measurement (Pickering et al., 2005 ).
• Educate certified nursing assistants, medical assistants, and others in accurate BP measurement and technique (Block et al., 2018 ).
• In practice settings, develop protocols for when and how BP is measured and address abnormal results during healthcare encounters (Josiah Macy Jr. Foundation, 2017 ).
• In the community, collaborate with businesses, pharmacies, and payers to ensure BP monitors and screening locations are available outside of the healthcare setting.
• Review data from electronic health records to identify and address untreated or uncontrolled BP.

Evidence supports self‐measured blood pressure (SMBP) monitoring (Shimbo et al., 2020 ), so RNs should educate and motivate patients to self‐monitor their BP. This includes the following:

• Teaching patients to accurately use and calibrate their home BP monitors (Parati et al., 2021 ).
• Using motivational interviewing in serving as a health coach (Hickey et al., 2019 ).

RNs can refer patients to evidence‐based programs for preventing or managing chronic disease such as Stanford's Chronic Disease Self‐Management Education (Administration for Community Living, 2021 ), the CDC’s National Diabetes Prevention Program (CDC, 2019 ), and others.

RNs can identify social and structural determinants of health that are barriers to seeking preventive screenings and health care.

For Black or African American adults, the experience of racial discrimination increases the incidence of hypertension by 50% (Forde et al., 2020 ). Black or African American adults are more likely to have uncontrolled hypertension than other racial and ethnic groups (Carnethon et al., 2017 ). Black or African American and Hispanic adults have a higher lifetime risk of hypertension than White adults (Carson et al., 2011 ; Fryar et al., 2017 ). Nearly 50% of Black or African American women with uncontrolled hypertension have depression (Gabriel et al., 2021 ).

RNs can address social determinants of health (SDOHs) that affect hypertension, including access to transportation, health care, medication, safe places to exercise, and nutritious food. They can:

• Establish open clinic hours so that patients who rely on public transportation will not be penalized for late clinic appointments.
• Screen for SDOH using the accountable health communities screening tool (Billioux et al., 2017 ; Casey et al., 2019 ); the Protocol for Responding to and Assessing Patients' Risks, Assets, and Experiences (Weir et al., 2020 ); or other standardized screening tools.
• Work with local partners such as community health workers, social service, and other community‐based support agencies that are poised to help address SDOH.
• Establish an inventory of the above local community resources that promote clinical and community linkages and advance health equity (Ibe et al., 2021 ).

Attending to the above actions, RNs will be influencing more than control of hypertension, as such initiatives can help eliminate health disparities.

WHAT THIS CALL TO ACTION MEANS FOR ADVANCED‐PRACTICE REGISTERED NURSES (APRNs)

Nurse practitioners (NPs) are advanced practice RNs (APRNs) who blend clinical expertise in diagnosing and treating health conditions, including hypertension, with an emphasis on disease prevention and providing health education, health coaching, and counseling to their patients. As of December 2020, more than 325,000 NPs were licensed to practice in the United States, providing more than 1 billion patient visits each year (American Association of Nurse Practitioners, 2021 ). Specific actions for APRNs include the following:

• Routinely screening and diagnosing hypertension through accurate BP measurement.
• Providing patient education on the importance of hypertension prevention, control, and evidenced‐based ways to adopt and sustain a heart‐healthy lifestyle.
• Prescribing antihypertensive medications using established guidelines such as the 2017 ACC/AHA Hypertension Guideline (Whelton et al., 2018 ).
• Routinely screening for and providing early evidence‐based interventions for depression and anxiety/stress given the evidence showing the association between these factors and CVD (Gawlik et al., 2019 ; Giannoglou & Koskinas, 2015 ; Levine et al., 2021 ).
• Screening for other common comorbidities such as diabetes and initiating evidence‐based treatment regimens as needed.
• Using motivational interviewing to assist patients with healthy lifestyle behavior change (Sawyer et al., 2020 ).
• Ensuring adequate treatment, timely follow‐up, treatment intensification, and, if needed, referrals to specialists until BP goals are reached.
• Regularly assessing for side effects of hypertension medication, adherence to antihypertensive therapy, and lifestyle changes.
• Educating colleagues who measure BP in their clinics to ensure accurate BP measurement.

WHAT THIS CALL TO ACTION MEANS FOR SCHOOLS OF NURSING

Schools of nursing must ensure their graduates can execute the aforementioned strategies designed to improve BP control. They should teach the importance of early and accurate diagnosis, evidence‐based healthy lifestyle interventions, behavior change strategies to prevent CVD, assessments and steps for addressing SDOH, and team‐based care. Specific actions for schools of nursing include the following:

• Teaching accurate BP measurement at multiple points across curricula.
• Ensuring competence of students in conducting cardiovascular and mental health assessments.
• Incorporating the latest evidence‐based guidelines on exercise, nutrition, wellness, stress, anxiety and depression management, and BP diagnosis and management.
• Teaching RNs and APRNs to incorporate SMBP monitoring and healthy lifestyle prescriptions into patient care and management.
• Preparing nurses to educate patients about their CV risks, diagnosis of hypertension, treatment regimen, and adherence strategies.
• Enable students and nurses to exercise, choose healthy foods, and get care for mental health concerns.
• Integrating the Million Hearts ® Fellowship module in nursing education and public health nursing and providing students with hands‐on experience in cardiovascular screenings and cardiovascular risk reduction counseling (Gawlik & Melnyk, 2015 ).
• Including team‐based care, evidence‐based quality improvement, and population health management techniques in nursing curricula.
• Implementing a standardized, evidence‐based treatment protocol that university health centers can use to identify and treat faculty, staff, and students with hypertension.
• Teaching about SDOHs and their role on cardiovascular outcomes, how to complete a SDOH screening, and how to find and connect patients to local community resources.
• Examining the impact of structural racism/discrimination on hypertension control and mitigation of unconscious bias in the healthcare setting.
• Incorporating the assessment of depression and anxiety into curricula because these can be barriers to hypertension control.
• Emphasizing population health cardiovascular prevention including community‐based interventions, such as establishing walkable communities, and access to healthy food options.
• Teaching students how to stay current on the best and latest evidence to prevent and manage hypertension and CVD through education and skills building in evidence‐based practice (Melnyk & Fineout‐Overholt, 2019 ).
• Ensuring that students meet the evidence‐based practice competencies for RNs and APRNs by the time they graduate from their academic programs (Melnyk et al., 2014 , 2016 ).

WHAT THIS CALL TO ACTION MEANS FOR PROFESSIONAL NURSING ORGANIZATIONS

Professional nursing organizations are crucial to improving hypertension control and promoting overall cardiovascular health. These organizations include the American Nurses Association, the American Academy of Nursing, the Preventive Cardiovascular Nurses Association, the National Black Nurses Association, the American Association of Nurse Practitioners, and CV nursing affinity groups like the AHA Council on Cardiovascular and Stroke Nursing, among others. Professional nursing associations’ members can help influence their healthcare organizations and communities by sharing messaging to improve hypertension prevention, diagnosis, and treatment through education and leadership. These organizations also should prioritize actions supporting nurses adopting healthier lifestyles and attending to their cardiovascular health. Specific actions for professional nursing organizations include the following:

• Making the topic of cardiovascular health a priority for national conferences and meetings.
• At meetings, allowing for frequent recovery breaks and movement and encouraging healthy meals and snacks.
• Encouraging nurses to make healthy lifestyle choices and to prioritize self‐care.
• Promoting evidence‐based interventions and strategies to improve hypertension diagnosis and management as well as cardiovascular risk reduction.
• Encouraging members to be leaders in advocating for community interventions that lead to better cardiovascular health, such as those found in the “Guide to Community Preventive Services” (Community Preventive Services Task Force, n.d. ).
• Showcasing best practice protocols for hypertension control in newsletters, journals, and other publications.
• Developing programs that recognize and reward nursing actions to improve hypertension control.
• Creating and disseminating educational resources on the prevention, diagnosis, and treatment of hypertension to be used by healthcare professionals and patients.
• Educating nurses on SDOHs and barriers to care that affect people's ability to prevent, diagnose, treat, and manage their hypertension.
• Developing evidence‐based interventions to mitigate racism, discrimination, and structural racism in the healthcare setting, such as reviewing historical practices and policies to ensure all patients are treated equally.
• Supporting initiatives to educate members, patients, and the general public on hypertension control and lifestyle choices that promote health.
• Advancing research in hypertension prevention and treatment.
• Integrating hypertension diagnosis and management curricula into continuing education programming.
• Reinforcing BP measurement competency through training and certification programs every 6–12 months.
• Generating and supporting national campaigns to educate the public on hypertension management and prevention of CVD.
• Coverage of validated SMBP devices.
• Coverage of medication, including combination pills.
• Reimbursement for patient education regarding diagnosis, medication use, SMBP monitoring training for technique, and reporting results back to clinician, including technology assistance if needed.
• Coverage of lifestyle change programs.
• BP rechecks without co‐pay.
• Synchronization of and multi‐month medication refills without additional co‐pays.
• Reimbursement for cardiovascular risk reduction education by nurses.

WHAT THIS CALL TO ACTION MEANS FOR EVIDENCE‐BASED QUALITY IMPROVEMENT AND POPULATION HEALTH NURSES

With additional education and skills in evidence‐based quality improvement (EBQI) and population health, nurses can play a pivotal role in improving BP control within healthcare systems or populations using data to drive lasting change (Melnyk et al., 2015 ; Melnyk & Morrison‐Beedy, 2019 ). Nurses can do this using clinical practice facilitation within a specific ambulatory care setting, managerial EBQI roles within a health system, population management programs through a payer or EBQI collaborative, and public health initiatives at the local, state, and national level. Regardless of the level of involvement, nurses are skilled in team‐based care and EBQI principles requiring them to identify and engage leadership, clinical champions, and other colleagues—including primary care nurses connecting to specialty care nurses and nurses connecting to colleagues from medicine, pharmacy, social work, biomedical engineering, health information technology, and other stakeholders.

With the support from leadership making hypertension control an institutional priority and engaging a team of supportive stakeholders, health systems can equip EBQI nurses with evidence‐based tools and resources to drive practice change and improve patient outcomes (Casey et al., 2021 ). Examples of evidence‐based tools can be found in Tables S2–S5 .

Specific actions that EBQI nurses can take include the following:

• Rates of hypertension control, including rates by subpopulation such as gender, race and ethnicity, or age, as well as by individual clinician or care location.
• Frequency of follow‐up visits for patients with uncontrolled hypertension.
• Rates of treatment intensification for patients with uncontrolled hypertension.
• Rates of lifestyle interventions.
• Rates of response to treatment for patients who have had a change in their treatment.
• Rates of medication refills.
• Reporting on the frequency with which patients are using SMBP measurement.
• Performance measures, including control rates at various stages of hypertension.
• Process quality measures, including intervention, adherence, and use of SMBP
• Structural measures including use of standardized protocols for measurement accuracy, Atherosclerotic Cardiovascular Disease risk assessment, shared decision‐making, and team‐based care.
• Elevating clinical practice guidelines and evidence to drive continuing professional education, policies, and protocols (Whelton et al., 2018 ).
• Embedding evidence‐based guidelines and prompt adherence to protocols like confirmatory measurements and treatment intensification for patients with uncontrolled BP in health information technology (Whelton et al., 2018 ). A nursing informaticist is well‐suited for this role.
• Facilitating team huddles to identify patients with uncontrolled BP and considering assessments and interventions to achieve BP goals.
• Educating care teams on evidence‐based care.
• Serving as clinical practice facilitators coaching care teams in ambulatory care settings to adopt and adhere to evidence‐based, systematic care practices.

Evidence of nurses playing a role in EBQI includes examples such as follows:

• Implementation of nurse‐led community‐based chronic disease management models to engage low‐income urban residents in BP management (Sanders & Guse, 2017 ).
• Dissemination of SMBP monitoring protocols to patients to assure accurate BP measurement in the home (Parati et al., 2021 ).

CONTRIBUTIONS FROM AND CONSIDERATIONS FOR NURSE RESEARCHERS

Nurse researchers play an essential role in designing and conducting trials to improve hypertension outcomes. In 1976, the Taskforce on the Role of Nursing in High Blood Pressure Control affirmed the importance of conducting research to increase knowledge of nursing interventions targeted at improving hypertension control (National Institutes of Health, 1976 ). Nurses have since led trials that have provided the evidence base for clinical practice and trials focused on community‐based interventions to improve hypertension control.

Exemplars of nurse‐led clinical trials to improve hypertension control include the Community Outreach and Cardiovascular Health Trial (Allen et al., 2011 ), Nurse‐Managed BP Telemonitoring Among Urban African Americans (Artinian et al., 2007 ), and the Self‐Help Intervention Program for High Blood Pressure Care (Kim et al., 2011 ).

Several hypertension trials have included a nursing intervention as part of a multi‐component intervention, as described in Table S1 .

Nurse researchers should address current challenges in cardiovascular health and hypertension control, prioritizing research where there is not enough evidence to guide practice. Nursing researchers should also collaborate with nursing faculty and Doctor of Nursing Practice prepared nurses to ensure research findings are implemented into clinical practice without delay. This research‐practice time gap is estimated to be 15 years (Khan et al., 2021 ). Priority topics for cardiovascular and hypertension research should include the following:

• Lifestyle interventions to prevent the development of hypertension in high‐risk populations.
• Interventions to reduce anxiety, stress, and depression in people with CVD.
• Examination of underlying mechanisms of health behavior change.
• Culturally informed interventions to promote healthy behaviors.
• Developing and testing interventions to improve hypertension control and cardiovascular risk, including healthy lifestyle behavior change.
• Health disparities and CVD.
• Maternal health interventions to promote cardiovascular health.
• Interventions that address SDOHs and improve hypertension control.
• SMBP monitoring to reduce hypertension disparities.
• Interventions to mitigate structural racism and discrimination to increase access to care.
• Ways that informatics nurses, statisticians, and computer scientists can work together to turn big data into information that can be translated into nursing practice.
• Dissemination and implementation of studies to speed the translation of evidence‐based interventions to control hypertension and prevent CVD into real‐world clinical settings.
• How structural racism contributes to poor hypertension control and cardiovascular health and interventions to mitigate the effects of structural racism.

RESOURCES THAT NURSES FROM ALL SECTORS CAN USE

Preventing hypertension and improving hypertension control is well understood. Over the last decade, nurses have been the source of major national organizations and initiatives to improve prevention and control of hypertension. These organizations and initiatives provide tools and resources to improve control of hypertension; this paper presents these resources.

Million Hearts ® is a national initiative co‐led by the CDC and Centers for Medicare & Medicaid Services to prevent 1 million heart attacks, strokes, and other cardiovascular events over a 5‐year period. It focuses on implementing a small set of evidence‐based priorities and targets that can improve cardiovascular health for all. The Million Hearts ® website offers numerous tools for patients and providers and describes evidence‐based strategies to decrease physical inactivity, tobacco use, and salt intake. It outlines care changes needed to improve use of aspirin as appropriate, BP control, cholesterol management, and smoking cessation. It lists key actions needed to improve outcomes of specific priority populations. Nurses can join partner meetings and specific forums and read newsletters on the site.

Target: BP™ is a national initiative of the American Heart Association and the American Medical Association (AMA) in response to the high prevalence of uncontrolled BP. It helps healthcare organizations and care teams, at no cost, improve BP control rates through an evidence‐based quality improvement program and recognizes organizations committed to improving BP control.

The Preventive Cardiovascular Nurses Association (PCNA) is a nursing organization preventing cardiovascular disease through assessing risk, facilitating lifestyle changes, and guiding individuals to achieve treatment goals. PCNA is committed to the continued education and support of nurses so they may successfully rise to this challenge. PCNA offers a Cardiovascular Nursing Certificate program and numerous resources for patient education and for providers.

The AMA leads and participates in numerous efforts to improve control of hypertension. Their “About Improving Health Outcomes” web page has specific BP resources to assist healthcare practices and clinicians in building a team to focus on hypertension to measure accurately, act rapidly, partner with patients, and promote appropriate use of SMBP monitoring.

The websites of all four of these organizations offer numerous tools to assist nurses. Tables S2–S5 provide detailed lists and links to specific resources from these and other organizations sorted by the three goals of the Surgeon General's Call to Action : (1) Make hypertension control a national priority, (2) Cultivate community supports, and (3) Optimize patient care for hypertension. Given the need for all nurses to be able to provide an accurate assessment of BP, we included a fourth table with resources specific to accurate measurement.

LINKING EVIDENCE TO ACTION

• Nurses in all settings should emphasize lifestyle modification, an evidence‐based strategy to prevent, treat, and control hypertension.
• Nurses should link patients to peer support programs for physical activity and nutrition or advocate for others to do so.
• Improving food purchasing practices and walkability of communities are important to general health and to preventing and managing hypertension.
• Assessing and addressing SDOHs and psychological health can reduce health disparities in vulnerable populations.
• Nurses should ensure accuracy of BP measurement, as this is a critical step in hypertension diagnosis, treatment, and control.
• Patients should be taught to measure their BP.
• Evidence‐based guideline‐recommended care, comprehensive treatment protocols, self‐measured blood pressure monitoring, and team‐based care are all important.

CONCLUSIONS

Uncontrolled hypertension causes CVD, stroke, and kidney disease, among other health problems, which cause unnecessary human suffering and premature death. Disparities in hypertension diagnosis, treatment, and control among racial and ethnic groups in the United States should be addressed. We know what to do to prevent the development of hypertension, detect it early, and control it, yet, as a nation, we are not succeeding. Nurses are well positioned to contribute meaningfully to national efforts to improve hypertension control, using the ample evidence on how to prevent, diagnose, treat, and control hypertension.

The COVID‐19 pandemic has placed demands on nurses and the nursing profession, but as nurses, we know that our colleagues, faculty, and students can still be inspired by a new call to action to save lives. Our ask is to use the evidence and resources and seize opportunities to act. More information about how to join with other nurses in this call to action can be found at https://millionhearts.hhs.gov/ .

Supporting information

Table S1‐S5

Hannan, J.A. , Commodore‐Mensah, Y. , Tokieda, N. , Smith, A.P. , Gawlik, K.S. , Murakami, L. , et al. (2022) Improving hypertension control and cardiovascular health: An urgent call to action for nursing . Worldviews on Evidence‐Based Nursing , 19 , 6‐15. 10.1111/wvn.12560 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

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Nurse led interventions to improve control of blood pressure in people with hypertension: systematic review and meta-analysis

• Related content
• Peer review
• Christopher E Clark , clinical academic fellow ,
• Lindsay F P Smith , senior clinical research fellow ,
• Rod S Taylor , professor in health services research ,
• John L Campbell , professor of general practice and primary care
• 1 Primary Care Research Group, Institute of Health Services Research, Peninsula College of Medicine and Dentistry, St Luke’s Campus, Exeter EX1 2LU
• Correspondence to: C E Clark christopher.clark{at}pms.ac.uk
• Accepted 11 June 2010

Objective To review trials of nurse led interventions for hypertension in primary care to clarify the evidence base, establish whether nurse prescribing is an important intervention, and identify areas requiring further study.

Design Systematic review and meta-analysis.

Data sources Ovid Medline, Cochrane Central Register of Controlled Trials, British Nursing Index, Cinahl, Embase, Database of Abstracts of Reviews of Effects, and the NHS Economic Evaluation Database.

Study selection Randomised controlled trials of nursing interventions for hypertension compared with usual care in adults.

Data extraction Systolic and diastolic blood pressure, percentages reaching target blood pressure, and percentages taking antihypertensive drugs. Intervention effects were calculated as relative risks or weighted mean differences, as appropriate, and sensitivity analysis by study quality was undertaken.

Data synthesis Compared with usual care, interventions that included a stepped treatment algorithm showed greater reductions in systolic blood pressure (weighted mean difference −8.2 mm Hg, 95% confidence interval −11.5 to −4.9), nurse prescribing showed greater reductions in blood pressure (systolic −8.9 mm Hg, −12.5 to −5.3 and diastolic −4.0 mm Hg, −5.3 to −2.7), telephone monitoring showed higher achievement of blood pressure targets (relative risk 1.24, 95% confidence interval 1.08 to 1.43), and community monitoring showed greater reductions in blood pressure (weighted mean difference, systolic −4.8 mm Hg, 95% confidence interval −7.0 to −2.7 and diastolic −3.5 mm Hg, −4.5 to −2.5).

Conclusions Nurse led interventions for hypertension require an algorithm to structure care. Evidence was found of improved outcomes with nurse prescribers from non-UK healthcare settings. Good quality evidence from UK primary health care is insufficient to support widespread employment of nurses in the management of hypertension within such healthcare systems.

Introduction

Essential hypertension is a major cause of cardiovascular morbidity. 1 In 2003 the prevalence of hypertension in England was 32% in men and 30% in women. 2 Since the prevalence of hypertension increases with age it is a growing public health problem in the Western world faced with ageing populations. 3 The lowering of raised blood pressure in drug trials has been associated with a reduction in stroke of 35-40%, heart attack of 20-25%, and heart failure of over 50%. 4 To achieve these benefits, aggressive and organised treatment to attain blood pressure targets is required, yet often contacts with health professionals do not trigger changes in antihypertensive therapy 5 ; a phenomenon termed “clinical inertia.” 6

Most patients require a combination of antihypertensive drugs to reach target blood pressure. Guidelines advocate logical drug combinations, 7 and in England the National Institute for Health and Clinical Excellence has published a treatment algorithm for clinicians to follow. 8 Hypertension is a condition almost entirely managed in primary care, and in the United Kingdom is an important component of the Quality and Outcomes Framework, which rewards practices for achievement of blood pressure standards set by the National Institute for Health and Clinical Excellence. 9 Achievement between practices, however, varies considerably 10 and knowledge of guidelines among general practitioners does not necessarily translate into their implementation. 11

Doubt persists about how best to organise effective care and interventions to control hypertension by the primary care team. In 2005 a Cochrane review classified 56 trials of interventions into six categories: self monitoring, education of patients, education of health professionals, care led by health professionals (nurses or pharmacists), appointment reminder systems, and organisational interventions. The review concluded that an organised system of regular review allied to vigorous antihypertensive drug therapy significantly reduced blood pressure and that a stepped care approach for those with blood pressure above target was needed. 12 Nurse or pharmacist led care was suggested to be a promising way forward but required further evaluation. Another review found that appropriately trained nurses can produce high quality care and good health outcomes for patients, equivalent to that achieved by doctors, with higher levels of patient satisfaction. 13 Nurse led care is attractive as it has been associated with stricter adherence to protocols, improved prescribing in concordance with guidelines, more regular follow-up, and potentially lower healthcare costs. Without associated changes in models of prescribing, however, there seems to be little effect on blood pressure level. 14 At present the usual model of care is shared between general practitioners and practice nurses, with general practitioners prescribing. Our local survey of Devon and Somerset found that of 79 responding practices (n=182; response rate 43%) 53 were using this model, with only four using nurse led care, including nurse prescribing (unpublished observation). In the light of these uncertainties over models of care and whether blood pressure reduction with nurse led care can be achieved, we explored further the trial evidence for efficacy of nurse led interventions through a systematic review. To elucidate whether nurse prescribing is an important component of this complex intervention and to identify areas in need of further study, we reviewed the international evidence base for such an intervention and its applicability to primary care in the United Kingdom.

We searched the published literature for randomised controlled trials that included an intervention delivered by nurses, nurse prescribers, or nurse practitioners designed to improve blood pressure, compared with usual care. The population of interest was adults aged 18 or over with newly diagnosed or established hypertension above the study target, irrespective of whether or not they were taking antihypertensive drugs. Primary outcome measures were systolic and diastolic blood pressure at the end of the study, changes in systolic and diastolic blood pressure compared with baseline, percentage of patients reaching target blood pressure, and percentage taking antihypertensive drugs. The secondary outcome was cost or cost effectiveness of interventions.

Data sources and extraction

We searched Ovid Medline, the Cochrane Central Register of Controlled Trials, British Nursing Index, Cinahl, Embase, Database of Abstracts of Reviews of Effects, and the NHS Economic Evaluation Database. Using a strategy modified from the previous review of 2005 we searched for randomised controlled trials in original English language and published between January 2003 and November 2009. 12 We identified older citations from this review, hence the choice of cut-off date for the search (see web extra). We also corresponded with authors to identify missed citations.

Two authors (CEC, LFPS) independently selected potentially relevant studies by screening retrieved citations and abstracts. Trials assessed as definite or uncertain for inclusion were retrieved as full papers. Differences were resolved by discussion; arbitration from a third author (JLC) was planned but not required. Two authors (CEC, LFPS) independently extracted details of the studies and data using a standardised electronic form, with differences resolved by discussion. Risk of bias in the generation of the randomisation sequence, allocation concealment, and blinding (participants, carers, assessors) was assessed as adequate, uncertain, or inadequate using Cochrane criteria. 15 One author (LFPS) checked the reference lists of all included studies for further potentially relevant citations, and two authors (CEC, LFPS) reviewed this list and agreed on further potentially relevant papers to retrieve in full. Searches were undertaken in June 2009 and repeated in November 2009 before final writing up.

Statistical analysis

Data were pooled and analysed using RevMan v5.0. 16 We carried out separate analyses for each intervention and outcome measure compared with usual care. Intervention effects were calculated as relative risks with 95% confidence intervals for dichotomous data. For continuous data we used a conservative random effects meta-analysis model to calculate mean differences and weighted mean differences with 95% confidence intervals. When a study included more than one intervention group with a single comparator arm, we included both intervention groups and split the number of patients in the common comparator arm across the separate intervention arms. 15 Where required we calculated standard deviations from standard errors or confidence intervals presented within papers. Heterogeneity was quantified using the I 2 statistic and the χ 2 test of heterogeneity. Using sensitivity analysis we explored heterogeneity by excluding single outlying results or restricting analysis to studies of good quality. We reported pooled data only when heterogeneity was not significant (P>0.05). Two authors (CEC, RST) reviewed the data from cluster randomised controlled trials and either extracted the data as presented when the authors were deemed to have taken account of cluster effects or first adjusted using a design factor, 15 with intraclass correlation coefficients for systolic and diastolic blood pressure derived from cluster studies in primary care. 17

Searches identified 1465 potential citations. A further 66 potential studies were identified from citations in retrieved papers. After initial screening of the titles and abstracts 71 full studies were assessed for possible inclusion in the review and 33 met the inclusion criteria (fig 1 ⇓ ).

Fig 1  Flow of papers through study

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Included studies

Table 1 ⇓ summarises the characteristics of the included studies. Seven cluster randomised controlled trials were randomised at practice 18 19 20 21 22 23 or family level. 24 Five described adjustment for clustering effects but two did not seem to have done so, therefore these were adjusted for cluster size. 23 24 One study used a two level nested design of interventions at provider and patient level; combined patient level outcomes were extracted where possible, or as separate intervention and control groups for each provider intervention. 25 Four studies had three arms. Three compared telephone monitoring and face to face nurse monitoring with usual care 26 27 28 and outcomes were extracted as separate groups; one compared nurse and general practitioner interventions with usual care and only the nurse and control outcomes were extracted. 21 The remaining randomised controlled trials were two armed studies randomised at individual patient level.

 Characteristics of included studies

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Interventions were categorised as nurse support delivered by either telephone (seven studies), 25 26 27 28 29 30 31 community monitoring (defined as home or other non-healthcare setting; eight studies), 24 26 32 33 34 35 36 37 or nurse led clinics. These were held in either primary care (13 studies) 20 21 22 23 27 28 35 38 39 40 41 42 43 or secondary care (six studies). 44 45 46 47 48 49 One study used alternate sessions with nurses at home and in general practice. 50 Fourteen studies included a stepped treatment algorithm 18 19 21 22 23 24 30 31 35 37 38 40 47 48 and nine included nurse prescribing in their protocol. 24 30 31 35 37 40 44 47 48

Although most of the studies recruited participants with hypertension, 11 also recruited participants with diabetes, 18 19 22 23 31 36 37 44 46 47 48 five with coronary heart disease, 20 21 33 39 50 and one the siblings of patients with coronary heart disease. 24 Most studies recruited predominantly white participants. Four studied hypertension care provided to African Americans, 24 26 29 40 three to Chinese, 33 34 46 two to South Asians, 19 23 one to American Indians, 37 and two to mixed non-white populations. 44 45 Thirty eight studies were excluded after review of the full paper (fig 1).

Risk of bias in included studies

Overall, study quality was moderate; random sequence generation was adequate in 70% (23/33) of studies, allocation concealment in 58% (19/33), and blinding of data collection in 43% (14/33); one study was described as an open (unblinded) randomised controlled trial. 41 Thirteen studies were assessed as adequate in two of the three domains and adequate or unclear for the third. 20 22 25 26 29 30 32 33 34 40 42 46 48 These studies were defined as of “good quality” and were used for sensitivity analysis by study quality. Only three of these reported UK trials; one of patients with ischaemic heart disease and hypertension 20 and two of people with diabetes and hypertension. 22 48 The method of blood pressure measurement was not described in 12 studies, 19 20 21 22 23 24 33 39 42 43 46 47 10 used automated monitors, 18 26 27 28 29 30 36 37 44 48 and seven referred to authoritative guidelines for measurement. 25 32 34 41 44 45 50

Effects of interventions

Pooling of data across different types of interventions was limited by noticeable statistical heterogeneity between studies, which was not explained by restriction to good quality studies. Consequently the results are presented as subgroup analyses by type of intervention (table 2 ⇓ ). (See web extra for forest plots for all comparisons; summary statistics were omitted if significant heterogeneity was present; see table 2). One study did not report any estimates of variance and did not contribute data to the meta-analyses. 42

 Summary of meta-analyses of studies using nurse led interventions to manage hypertension. Values are for weighted mean differences unless stated otherwise

Use of a treatment algorithm

Fourteen studies included a stepped treatment algorithm in their intervention 18 19 21 22 23 24 30 31 35 37 38 40 47 48 and for nine it was the main focus of the intervention. 18 19 21 22 35 37 38 47 48 Two studies of good quality 30 40 showed greater magnitudes of reductions in blood pressure with the use of an algorithm compared with usual care: weighted mean difference, systolic −9.7 mm Hg (95% confidence interval −14.0. to −5.4 mm Hg) and diastolic −4.3 mm Hg (−7.4 to −1.2 mm Hg). Pooling of all four studies also showed a greater magnitude of reduction in systolic blood pressure (−8.2 mm Hg, −11.5 to −4.9; fig 2 ⇓ ) 23 30 37 40 with the use of an algorithm compared with usual care.

Fig 2  Change in systolic blood pressure with nurse led use of algorithm compared with usual care

Pooling of three good quality studies 22 40 48 showed no significant difference in achievement of study blood pressure targets in favour of an intervention including an algorithm (relative risk 1.09, 95% confidence interval 0.93 to 1.27). Although a total of 10 studies reported this outcome, 18 19 22 31 35 38 40 42 47 48 statistical and clinical heterogeneity between them was significant.

Nurse prescribing

Nine studies included nurse prescribing in their protocol; three in secondary care settings, 44 47 48 three using community interventions, 24 35 37 two using telephone monitoring, 30 31 and one based in primary care. 40

Two good quality studies 30 40 showed greater magnitudes of blood pressure reductions for nurse prescribing than for usual care: weighted mean difference, systolic −9.7 mm Hg (95% confidence interval −14.0 to −5.4) and diastolic −4.3 mm Hg (−7.4 to −1.2). Pooling of all studies showed similar reductions: systolic −8.9 mm Hg (−12.5 to −5.3) and diastolic −4.0 mm Hg (−5.3 to −2.7; fig 3 ⇓ ).

Fig 3  Changes in blood pressure with interventions including nurse prescribing compared with usual care

Only one good quality study reported absolute blood pressure as an outcome, but pooling of four studies showed a significantly lower absolute outcome systolic blood pressure in favour of nurse prescribing: weighted mean difference −7.2 mm Hg (95% confidence interval −10.9 to −3.5). 30 31 37 40

Two good quality studies showed no difference in achievement of study blood pressure target (relative risk 1.20, 95% confidence interval 0.96 to 1.50). 40 48 Significant statistical and clinical heterogeneity precluded further pooled analysis.

Telephone monitoring

Seven studies included telephone monitoring of blood pressure by nurses. 25 26 27 28 29 30 31 Meta-analysis of four groups from three good quality studies showed no significant difference in outcome systolic blood pressure (weighted mean difference −2.9 mm Hg, 95% confidence interval −7.5 to 1.6). 25 26 29 Pooling of all studies gave a similar result (−3.5 mm Hg, −7.4 to 0.4; fig 4 ⇓ ), and pooling of three studies also showed no difference for outcome diastolic blood pressure (−1.1 mm Hg, −5.8 to 3.6). 26 29 31

Fig 4  Absolute systolic blood pressure after nurse led telephone monitoring compared with usual care

Pooled data from three studies 25 27 31 (one of good quality 25 ) showed a higher achievement of study blood pressure targets with telephone monitoring than with usual care (relative risk 1.24, 95% confidence interval 1.08 to 1.43).

Community monitoring

Eight studies involved nurse interventions delivered outside of healthcare settings. Locations included the home, 32 33 37 50 community centres, 24 26 or a choice of both. 34 One study was set in the workplace 35 and one in a pharmacy. 36 Pooled data from four good quality studies 26 32 33 34 showed a lower outcome systolic blood pressure in favour of monitoring in the community (weighted mean difference −3.4 mm Hg, 95% confidence interval −6.1 to −0.7; fig 5 ⇓ ) and two good quality studies showed greater magnitudes of blood pressure reduction with community monitoring than with usual care: systolic −4.7 mm Hg (−8.3 to −1.2) and diastolic −3.1 mm Hg (−4.8 to −1.3). 32 34 Pooling of data from all four studies also showed a greater magnitude of reductions in favour of the intervention: systolic −4.8 mm Hg (−7.0 to −2.7) 32 34 36 37 and diastolic −3.5 mm Hg (−4.5 to −2.5). 32 34 35 37

Fig 5  Absolute systolic blood pressure after community nurse led interventions compared with usual care for good quality studies

Four studies, 32 35 36 50 including one of good quality, 32 reported significantly better achievement of blood pressure targets in favour of the intervention, but significant heterogeneity precluded pooled analysis.

Nurse led clinics

Fourteen studies were of nurse led clinics in primary care 20 21 22 23 27 28 35 38 39 40 41 42 43 50 and six in secondary care settings. 44 45 46 47 48 49 For primary care studies, two of good quality showed no difference in diastolic blood pressure (−2.9 mm Hg, −6.9 to 1.1). 20 40 Pooling of all studies showed a greater magnitude of reduction in blood pressure for nurse led clinics compared with usual care (systolic −3.5 mm Hg, −5.9 to −1.1 and diastolic −1.9 mm Hg, −3.4 to −0.5; fig 6 ⇓ ), 23 27 28 40 41 and two good quality studies showed no difference in achievement of blood pressure targets with nurse led clinics (relative risk 1.14, 95% confidence interval 0.83 to 1.57). 22 40

Fig 6  Changes in blood pressure with primary care nurse led clinics compared with usual care

For secondary care clinics, only two were of good quality and did not report comparable outcomes. 46 48 For all studies, pooling of data from three studies showed no difference in outcome diastolic blood pressure (weighted mean difference −1.4 mm Hg, −3.6 to 0.86) 44 46 49 and no greater achievement of study blood pressure targets (relative risk 1.47, 95% confidence interval 0.79 to 2.74) 44 47 48 in nurse led clinics compared with usual care.

Significantly lower systolic blood pressure was achieved for any nurse led intervention for four groups from three good quality studies recruiting African American participants (weighted mean difference −7.8 mm Hg, 95% confidence interval −14.6 to −0.9) 24 29 40 but neither systolic nor diastolic blood pressure was lower on pooling of three good quality studies of Chinese participants (systolic −2.6 mm Hg, −7.5 to 2.3 and diastolic −0.5 mm Hg, −2.3 to 1.3; fig 7 ⇓ ). 33 34 46 Pooling of two studies, neither of good quality, showed no significant increase in the use of antihypertensive drugs in South Asian participants (relative risk 1.22, 95% confidence interval 0.90 to 1.65), 19 23 but pooling of four studies across different ethnic groupings did show a small increase in favour of any nurse led intervention compared with usual care (1.22, 1.02 to 1.47). 19 23 24 44

Fig 7  Systolic blood pressure readings for participants from ethnic minority groups

Cost and cost effectiveness

Only four studies presented any data. From the United Kingdom one study reported a cost per patient of £434 (€525, $632) over two years to provide additional nurse clinics and support from specialist nurses, representing £28 933 per quality adjusted life year gained 19 and another study found that primary care costs were £9.50 per patient compared with £5.08 for usual care. 43 In the United States a study reported a 50% higher total cost of staff at $134.68 (£92.65, €111.90) per patient treated in a nurse led clinic compared with $93.70 for usual care, 47 but a Mexican study reported $4 (£2.75, €3.32) per patient or $1 per 1 mm Hg reduction of systolic blood pressure. 32

In comparison with usual patterns of care, nurse led interventions that included a stepped treatment algorithm showed significantly greater reductions of systolic and diastolic blood pressure, but this was not associated with higher achievement of blood pressure targets. Studies incorporating nurse led prescribing also showed bigger reductions of systolic and diastolic blood pressure. Telephone monitoring was associated with higher achievement of study targets for blood pressure. Community monitoring showed lower outcome systolic blood pressure, greater reductions in systolic and diastolic blood pressure, and, although pooling of data was not possible, greater achievement of study blood pressure targets. Nurse led clinics in primary care achieved greater reductions in systolic and diastolic blood pressure compared with usual care. No clear beneficial effects on our primary outcomes were observed from secondary care clinics.

Pooled interventions showed significantly lower systolic blood pressure in African American participants with nurse led interventions than with usual care, but little difference for other ethnic minority groups.

Strengths and limitations of this review

Since blood pressure was reported variously as final blood pressure or change from baseline for systolic or diastolic readings, less pooling of results was possible than may have been anticipated.

Thirteen of the 33 included randomised controlled trials met our quality criteria. Only three of these were from the United Kingdom 20 22 48 and none investigated an unselected primary care hypertensive population. Therefore the evidence base for nurse led care of hypertension in the United Kingdom relies on generalisation of findings from other, principally American, healthcare systems. In total, 12 trials were identified from the United Kingdom, of which six studied blood pressure control in people with diabetes 18 19 22 23 44 48 , four in patients with ischaemic heart disease, 20 21 39 50 and two in people with uncontrolled hypertension. 38 43

We restricted our search to articles in English, which may have excluded some potential international data; however, we consider it unlikely that significant evidence applicable to UK health care would have only been published in another language.

The usual reason for judging a trial’s quality as inadequate was weakness of blinding. As it was not possible for the participants to always be blinded to whether they were seeing a doctor, nurse, or other health professional, this limitation must be accepted for any face to face intervention. We aimed to assess blinding of the researchers collecting outcome data to the intervention; these were often the same nurses who delivered the intervention and therefore were open to bias. This lack of formal blinding in trials is recognised as a methodological challenge 51 but need not be seen as a limitation because implementation of these findings would also necessarily be unblinded, so a pragmatic approach to studying these interventions can be relevant. 52 Future trials will, however, need careful design to minimise bias.

One third of studies gave no description of the method used to measure blood pressure and only seven referred to published guidelines on blood pressure measurement, therefore the reliability of reported outcome measures cannot be judged easily.

Although interventions such as use of algorithms and nurse prescribing were associated with meaningful blood pressure reductions there was not a concomitant rise in achievement of target blood pressure. Although apparently inconsistent this could be a sample size effect, with some studies underpowered to show differences in dichotomous outcomes. It may also be explained by the noticeable variation in individual blood pressure targets in the studies, which were sometimes composite or multiple. 18 19 35 44 Therefore reporting of absolute blood pressure reductions may be the more robust outcome measure for comparison in future reviews.

Many studies combined the use of a treatment algorithm with the nurse intervention; therefore the results contributed to both analyses. It was not possible within this review to separate out thoroughly the components of each intervention that were or were not effective.

For most studies the duration of follow-up was relatively short; only five followed participants for more than 12 months. 19 21 25 40 41 Therefore it is not possible to extrapolate the findings as sustained benefits of the interventions.

We present evidence of benefit in some studies of ethnic minority groups because hypertension is recognised to carry higher levels of morbidity and mortality in some such populations. 8 These findings, however, pool different types of intervention so cannot identify specific nurse led interventions of benefit in these groups. Furthermore, the “usual care” arm of some studies, predominantly from America, 24 26 29 40 represented minimal care; therefore the benefits shown may be larger than could be expected if introduced to more inclusive healthcare systems, such as are found in the United Kingdom.

We included cost and cost effectiveness as a secondary outcome measure. It is, however, possible that other papers discussing this outcome (that is, non-randomised controlled trials) were not retrieved by our search strategy. Therefore a more thorough primary review of cost data may be needed.

Comparison with existing literature

The traditional view of the nurse’s role in hypertension care is to educate, advise, measure blood pressure, 51 and enhance self management. 53 Previous reviews have suggested that nurse led care may achieve better outcomes by increased adherence to protocols and guidelines, but we found insufficient evidence to confirm this. 14 The most recent review 12 identified an organised system of regular review and stepped care as essential components of successful interventions. This updated review supports this view, showing benefits in blood pressure reduction with the use of a treatment algorithm. No previous review has found sufficient evidence to support the assertion that nurse prescribing should be a key component of nurse interventions for hypertension 14 ; however, this review has shown better blood pressure outcomes in favour of nurse prescribing based on studies in American healthcare systems.

Interventions varied greatly in intensity and presumably therefore in cost. Lack of information on cost effectiveness has been identified previously, 54 and although this was only a secondary outcome measure for this review we noted that only four studies, including one of good quality, 32 reported on costs. 19 32 43 47 All four showed higher costs for the intervention, approaching 50% higher in two cases. 43 47 Only one study seemed to be cost effective, 32 but costs depend on the healthcare system within which the intervention is delivered, so we were unable to show any cost benefit that could be generalised across differing systems. Although nurses may save on salary costs, the evidence is conflicting, with potential savings being offset by an increased length of consultation. 55 Evidence of cost benefit in acute self limiting conditions 56 cannot be assumed to translate to the management of chronic disease, so future trials should incorporate a formal cost effectiveness analysis within their design.

Hypertension is identified with higher prevalence and morbidity levels in some ethnic minority groups such as African Americans and South Asians. 57 Studies recruiting from these populations found significant reductions in blood pressures with any nurse led intervention. For studies from non-UK healthcare systems, “usual care” represented minimal or absent care. 29 40 We therefore interpret this with caution.

Implications for clinical practice

The delivery of nurse led care in chronic conditions is a complex intervention. This review suggests that such care can improve on doctor led or usual care of hypertension. The key component of an intervention seems to be a structured treatment algorithm, and we have found evidence in favour of nurse prescribing. Although no clear benefits were seen for secondary care clinics improvements were found in both primary care and community based settings, suggesting that these findings can be applied to primary care clinics in the United Kingdom, or equivalent community settings in other healthcare systems. Although the absolute differences in blood pressure seem small—for example, a 4 mm Hg greater reduction in diastolic blood pressure with nurse prescribing than with usual care, a 2 mm Hg reduction in diastolic blood pressure is associated with a 15% reduction in risk of stroke or transient ischaemic attack in primary prevention. 58 Similarly a 20-30% reduction in frequency of stroke, coronary heart disease, major cardiovascular events, and cardiovascular death is seen with a 3 mm Hg reduction in systolic blood pressure, 59 and differences of this magnitude or greater are seen with nurse led clinics, nurse prescribing, and the use of an algorithm.

Implications for future research

In this review we found international evidence of benefit from nurse led interventions but no evidence of good quality was derived from an unselected UK population with hypertension in primary care. Evidence from other healthcare systems cannot necessarily be generalised, therefore further studies relevant to the United Kingdom are needed. Such studies should ideally include a structured algorithm, examine the role of nurse led prescribing, and include a robust economic assessment. They should report absolute measures of blood pressure as this would best permit comparison with the existing literature and take care to minimise bias by blinding outcome assessors to the intervention.

Conclusions

Nurse led interventions for hypertension in primary care should include an algorithm to structure care and can deliver greater blood pressure reductions than usual care. There is some evidence of improved outcomes with nurse prescribers, but there is no evidence of good quality from United Kingdom studies of essential hypertension in primary care. Therefore, although this review has found evidence of benefit for nurse led interventions in the management of blood pressure, evidence is insufficient to support the widespread use of nurses in hypertension management within the UK healthcare systems.

What is already known on this topic

Nurses are integral members of the primary healthcare team and are involved in the management of hypertension

Previous literature reviews have suggested that nurse led care may be beneficial in the care of hypertension but the data are conflicting

What this study adds

This review presents evidence to support structured algorithm driven nurse led care of hypertension, and nurse prescribers

There is little directly applicable evidence for benefits of nurse involvement in hypertension within the UK National Health Service

Cite this as: BMJ 2010;341:c3995

We thank Kate Quinlan (East Somerset Research Consortium) for carrying out the searches and retrieving articles, Joy Choules (Primary Care Research Group) for helping retrieve articles, and Liam Glynn (Cochrane Hypertension Group) for sharing citation lists.

Contributors: CEC and LFP reviewed the literature search results, identified papers for retrieval, reviewed full papers for inclusion, and extracted data for meta-analysis. CEC and RST undertook the meta-analysis. JLC acted as study supervisor. All authors contributed to the interpretation of the findings and drafting of the manuscript. CEC is guarantor for the study.

Funding: This research was supported by the Scientific Foundation Board of the Royal College of General Practitioners and by the South West GP Trust.

Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any company for the submitted work; no financial relationships with any companies that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work.

Ethical approval: Not required.

Data sharing: No additional data available.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode .

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• Open access
• Published: 17 January 2023

Nurse-led telehealth intervention effectiveness on reducing hypertension: a systematic review

• Maria Kappes   ORCID: orcid.org/0000-0001-8101-3898 1 ,
• Pilar Espinoza   ORCID: orcid.org/0000-0003-2533-6566 2 ,
• Vanessa Jara   ORCID: orcid.org/0000-0002-2224-7317 3 &
• Amanda Hall 4  

BMC Nursing volume  22 , Article number:  19 ( 2023 ) Cite this article

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Hypertension is a public health concern for many countries. The World Health Organization has established a global objective to reduce the prevalence of non-communicable diseases, including hypertension, which is associated with cardiovascular disease. Remote nursing interventions can potentially lessen the burden on the healthcare system and promote a healthier population. This systematic review aims to synthesize available evidence on the effectiveness of nursing-led telehealth interventions in reducing blood pressure in hypertensive patients.

A systematic review was conducted. The search was performed from May to June 2021, in the databases: PubMed, Scopus, Cochrane Library, Web of Science, CINAHL, and ProQuest within 2010–2021 in English, Spanish and Portuguese. Randomized controlled trials and Quasi-experimental studies were considered. This systematic review followed the criteria of the Cochrane Handbook for Systematic Reviews of Interventions, with the support of the PRISMA guidelines and registered in PROSPERO. For critical analysis, the tools of the Joanna Briggs Institute were used.

Of the 942 articles found, six controlled clinical trials and one quasi-experimental study were selected. Different nurse-led interventions (telehealth devices, remote video consultation, calls and email alerts) have demonstrated a significant decrease in blood pressure (especially systolic blood pressure) in the intervention groups. Nurse-led interventions also effect hypertension awareness, self-efficacy, and self-control. Positive effects on lowering cholesterol, consumption of fruits and vegetables, physical activity and adherence to medication were also described.

Nurse-led interventions delivered remotely have a positive effect in lowering the blood pressure of patients with hypertension. Further research is required to support strategies that will deliver the best continuous, quality, and cost-effective nursing care.

Peer Review reports

Introduction

In 2019, 17.9 million people died from cardiovascular diseases (CVDs) which represents 32% of all global deaths [ 1 ]. Hypertension is one of the most important risk factors in the development of CVD [ 2 ] and currently, 30% of the world’s population, or approximately one billion people are affected by hypertension [ 3 ]. Given hypertension’s relationship to CVD, the World Health Organization (WHO) (2021) established a goal to reduce hypertension by 25% by 2025 [ 1 ].

Worldwide, the prevalence of hypertension is higher in low- and middle-income countries, due to the presence of more risk factors associated with diet (consumption of saturated fat and salt) and lifestyle (smoking, sedentary behavior) [ 2 ]. The prevalence of complications from hypertension is also greater in low- and middle-income countries, where 50% of mortality from cardiovascular causes occurs between 30 and 69 years, 10 years earlier than in higher-income countries [ 4 ]. This problem is especially important in countries that have a rural or dispersed population or those with small numbers of health care providers [ 5 ].

Hypertension, defined as systolic blood pressure (BP) of 130 mmHg or above or diastolic BP of 80 mmHg or above is the main risk factor for CVDs [ 6 ], including coronary heart disease, stroke, chronic kidney disease [ 7 ], heart failure, arrhythmia, and dementia. Healthy diet (normal salt consumption, low saturated and trans-fat consumption, a high intake of fruits and vegetables), physical activity, and normal weight decrease the risk of developing hypertension. Lifestyle change is a main component in decreasing blood pressure and the related cardiovascular risk [ 8 ].

The COVID-19 pandemic has increased barriers of face-to-face interactions between patients and healthcare providers, particularly in primary health settings. To continue to provide care for patients, nurses have begun incorporating different strategies to care for their patients, such as telehealth interventions to monitor and support patients with chronic conditions like hypertension [ 9 , 10 ].

The concept of telehealth has been in use for more than 30 years, but it was not given a definition by WHO until 2007. The WHO defines telehealth as the deliberate use of communication technologies by healthcare professionals for the diagnosis, treatment and prevention of diseases, as well as the research and continuing education of patients, families and communities where distance between the user(s) and health professionals is a critical factor. According to Mann et al. [ 11 ] and Omboni et al. [ 12 ], telehealth (also called telemedicine) can be defined as the use of electronic resources to provide efficient and high-quality healthcare. It includes the diagnosis and treatment of patients, as well as the enhancement of patient monitoring techniques such as checking vital signs or reporting symptoms, all with telecommunications technology like smartphones and computers [ 1 , 13 ]. With the telehealth model, patients do not have to leave their homes to receive a diagnosis or testing results. Telehealth delivery is practiced in all settings and requires the support of different healthcare professionals. The nurse has a vital role in much of this delivery.

The COVID-19 pandemic, declared as such by WHO in March 2020, increased the use of telemedicine to treat patients in many countries [ 14 , 15 , 16 ]. Telehealth made it possible to provide diverse care services for patients with chronic diseases. These remote services were fundamental during the pandemic, alleviating the shortage of medical resources and reducing the risk of infection in hospitals and medical centers [ 17 ]. In regard to hypertensive patients, telehealth is presented as an opportunity for routine care and continuation of treatment at home even beyond the pandemic [ 13 ]. The increased demands for telehealth during the COVID-19 pandemic show the need to prepare nurses to support telehealth and to take the lead in its integration within the healthcare system.

Nursing-led interventions are based on a care delivery model that incorporates assessment, evaluation, education, counseling, treatment and other procedures using a comprehensive nurse-patient (family) approach, with the nursing professional working independently or in interdisciplinary teams [ 18 ].

Multiple systematic reviews completed in the last decade have investigated the impact of nursing-led interventions in patients with hypertension, with the incorporation of new roles such as advanced nursing practice [ 6 , 19 , 20 , 21 ]. Jointly with advanced nursing practices, nursing-led clinical practices emerge, with interventions that, in addition to counseling and education for patient self-management, incorporate the diagnosis and prescription of medications [ 19 ]. Patients express a greater satisfaction and adherence to treatment when guided by nursing-led interventions [ 21 ], especially compared to medical management alone [ 22 ]. A decrease in cardiovascular adverse events and mortality have also been reported with the use of nursing-led interventions [ 20 ], where continuity of care has shown a reduction of hospitalizations and readmissions [ 21 ]. Since the onset of the COVID-19 pandemic, improvements in remote monitoring of BP coordinated by nurses compared to usual care have been reported [ 6 ]. Additionally, the global costs associated with hypertension mortality have increased exponentially in recent years [ 23 ]; self-monitoring of BP has been reported as a cost-effective measure to reduce arterial hypertension morbidity and mortality indicators [ 24 ].

This systematic review will synthesize recent evidence of the effectiveness of nursing-led telehealth interventions on hypertensive patients to reduce their high blood pressure, actively exploring the potential of telemedicine to solve the current and future health problems.

This study will explore the effectiveness of nurse-led telehealth interventions in adult patients with hypertension. Randomized controlled trials (RCTs) and quasi-experimental studies that explored the effectiveness or impact of telehealth nursing-led interventions on high blood pressure were included in this review. Secondary outcomes of the review included adherence to the antihypertensive therapy and healthy lifestyle behaviors such as smoking, drinking, exercise, and sleep hours.

A systematic review was performed according to the protocol and extraction form in the Cochrane Handbook for Systematic Reviews of Interventions, version 6.0. [ 25 ] The review protocol was registered in PROSPERO (ID: CRD42021262081) and the PRISMA statement was followed to guide this review [ 26 ]. Our initial research question was, are nursing-led telehealth interventions effective in lowering blood pressure in hypertensive patients?

Search methods

The literature search was conducted on PubMed, Scopus, Cochrane Library, Web of Science, CINAHL, and ProQuest from May to July 2021, using the following keywords: Search (Nursing Interventions) AND (Telehealth)) AND (high blood pressure) Filters: Clinical Trial, Randomized Controlled Trial, from 2010 to 2021 Languages English, Spanish and Portuguese.

Reference lists of publications were searched for potentially relevant articles. Grey literature and thesis were also included. The authors consulted a medical librarian in order to help expand the search as noted in Additional file 1 : Appendix 1.

Inclusion criteria and study selection

To identify all eligible studies, this review considered the following study designs, populations, interventions, and outcome(s):

Study design: Randomized Controlled trials and quasi-experimental studies.

Population: Hypertensive adult patients, with or without other comorbidities like diabetes, obesity, and dyslipidemia.

Interventions: All types of telehealth or phone technologies conducted by nurses, including M-health, telehealth, telemonitoring, virtual interventions, e-coaching, panel monitoring.

Outcomes: The primary outcome was change in blood pressure, systolic (mmHg) and diastolic pressure (mmHg) or mean arterial pressure (mmHg).

Exclusion criteria

Review articles, letters to the editor, book chapters, protocols, and prospective observational designs were excluded. Articles on telehealth interventions done by professionals other than nursing were not considered.

Search outcomes

According to the inclusion and exclusion criteria, three authors (MK, PE, and VJ) each independently extracted data to check and compare against each other’s work. Microsoft excel (version 16.0) was used to collate the extracted data.

A standardized data extraction form was used to extract data from each study, which included the following criteria: author’s names, country, participants, sample size, intervention/control groups, follow-up period, measurement tools, and results. Rayyan software was used to manage and organize the articles used in this review.

Nine hundred and forty-two articles were identified with the search strategy. (Fig.  1 ) In the first stage, duplicate articles and those that did not agree with the objective of the study were excluded based on reading the abstract and title. Of the 24 articles that remained, 16 were excluded because nurses were not involved in the intervention. One article was excluded because it did not describe a nursing-led intervention. Therefore, 7 articles were included in this review.

PRISMA article selection flowchart

Quality appraisal and data extraction

Quality assessment was based on the use of the critical analysis tools of the Joanna Briggs Institute [ 27 ]. These tools were selected because each checklist contained an explanation of how to respond appropriately to each item. This tool has also been well evaluated compared with others and is appropriate to use in nursing research [ 28 ].

In this review, we used different tools to evaluate controlled clinical trials and quasi-experimental studies (Additional file 2 : Appendix 2). These tools consisted of 13 and 9 points, respectively. Each question on the list was answered with “yes,” “no” or “unclear.“ When using the critical analysis tools, we used 2 criteria to decide to include the studies thereby ensuring quality. First, the studies needed to meet at least 60% of the criteria outlined by Chan et al [ 29 ] for controlled clinical trials. Second, they also had to meet the following criteria from the tool:

“Was true randomization used for assignment of participants to treatment groups?”

“Were treatment groups similar at the baseline?”

“Were outcome assessors blind to treatment assignment?”

“Were outcomes measured in the same way for treatment groups?”

The authors required the use these criteria as mandatory elements in order to accept the study for inclusion because they are critical for identifying the risk of bias [ 25 ].

Two independent reviewers performed the critical evaluations. In the event of a disagreement between evaluators, a third evaluator was asked to review the study. Following this critical analysis, the studies were included in this review (Fig.  1 ).

The data from the included studies information was transferred into an excel table with the items: authors, the aim of the study, population, design, duration, intervention, outcomes, and findings. Although the population and outcomes of the studies were comparable, there was great heterogeneity within the interventions performed, which is why it was impossible to conduct a meta-analysis. Therefore, results are presented in narrative form.

Through the search strategy, 942 articles were identified. After applying the inclusion and exclusion criteria, 7 articles were included in the final analysis. Figure  1 summarizes the search, identification and selection process of the articles included in this review. The results of the critical evaluation of these 7 studies are summarized in Additional file 3 : Appendix 3. Of the 7 studies included in the systematic review, 6 were RCTs and 1 was a quasi-experimental study. A total of 2102 participants completed the studies, and their data were included in the analysis. Age of patients ranged from 54 to 77 years old. The number of female participants was slightly larger than male, and the races included were primarily White, Hispanic and African American. Educational level, familiar arrangements and Body Mass Index (BMI) were reported in all of the studies.

Sample sizes of some of the included studies were calculated using power analysis [ 6 , 30 ], while the others didn’t mention how they were calculated [ 31 , 32 , 33 , 34 , 35 ]. Wakefield et al. [ 31 ] and Bosworth et al. [ 30 ] used a random number generator to select participants, in the other 5 studies sampling was done with purpose [ 6 , 32 , 33 , 34 , 35 ]. Four studies used a randomization process to allocate participants into different groups [ 6 , 31 , 32 , 33 ]. Brennan [ 32 ] used a blind recruitment process, as a blind allocating process was used in 3 studies [ 33 , 34 , 35 ].

All 7 studies (Table  1 ) included 1 control group and a different number of intervention groups. Some of them had 1 group [ 6 , 32 , 33 ], some 2 [ 31 , 34 ], and others 3 groups of participants [ 30 , 35 ]. While the majority of the studies included single set type of intervention, 2 studies involved mixing intervention content [ 30 , 35 ]. One study used different levels of monitoring and educational content with all the participants [ 31 ], and every study included one control group that received normal care. In terms of follow-up, two studies had a follow-up time of 2 months [ 6 , 35 ], three studies a 6-month follow-up period [ 32 , 33 ], one a 12 month follow up [ 31 ] and two 18-months follow up [ 30 , 34 ].

In terms of intervention, one offered home telehealth devices to improve blood pressure, while a nurse manager reviewed daily data from a blood pressure monitoring device and responses of participants to decide if a closer follow-up, information, reinforcement or referral to health care provider was needed using inbound–outbound remote video consultation [ 31 ]. Cicolini el al. [ 33 ] and Hebert et al. [ 34 ] offered a one-time educational program about using the home BP monitor, strategies to improve medication adherence and healthy lifestyle done by a nurse care manager, plus phone calls, and email alerts to reinforce the information and do a follow-up of participants. Brennan et al. [ 32 ] did monthly telephone follow ups of about 15 to 20 min to reinforce hypertension knowledge, medication adherence and support lifestyle changes such as smoking cessation, regular exercise, and healthy diet. Kim [ 35 ] and Bosworth et al. [ 30 ] used long message service and phone-based health coaching to provide evidence-based recommendations regarding hypertension related behaviors. Kim [ 35 ] used an 8-week coaching program and monthly long-distance message, while Bosworth et al. [ 30 ] used a behavioral management program of 11 weeks with reinforcing messages, e-mails and calls. Choi’s et al. [ 6 ] intervention consisted of a remote consultation twice a week for 8 weeks done by licensed and trained nurses.

Some of the studies’ interventions used algorithms based on guidelines about disease management, lifestyle modification, and treatment, to provide educational content [ 30 , 31 , 32 , 33 , 34 ]. The only one reporting a theoretical framework for the intervention was Kim [ 35 ] using Cox’s Interaction Model of Client Health Behavior to develop phone-based health coaching. Only one study did not provide a clear description to support their intervention [ 6 ].

Concerning the professional nurses participating in the 7 studies, some were nurses [ 30 ], registered nurses [ 34 ] with some with previous experience in delivering home telehealth and nursing care management [ 31 , 33 ], while others were trained licensed nurses [ 6 ]. The disease management nurses received training in cardiac care and cultural care competency before the study [ 32 ], and registered nurses were required to complete over 40 h of training in phone-based health coaching [ 35 ]. Herbert et al. [ 34 ] used a trained nurse for the intervention arm without providing details in terms of the type of training or education that was delivered. None of the studies described if the intervention nurses had any postgraduate education such as a BSN, MSN or doctoral degree.

Nurse-led interventions included educational interventions [ 6 , 30 , 32 , 33 , 34 ], such as training the patient to measure blood pressure [ 6 , 30 , 32 , 33 , 34 ], performing patients remote consultation, undertaking video conferences with the participants [ 30 ], taking responsibility for phone calls and email [ 31 , 32 , 33 , 34 , 35 ] doing long message service and delivering phone health coaching to participants [ 35 ] or using a software application to deliver educational scripts and algorithms [ 30 ]. In Herbert et al. [ 34 ] study, nurses contacted patient’s clinicians to address medications problems and arrange any prescription changes.

Effects of interventions on patients’ blood pressure

The Wakefield et al. [ 31 ] study compared two remote monitoring intensity levels and usual care in hypertensive patients with type 2 diabetes being treated in primary care. The high-intensity group received a set of messages based on a disease management algorithm programmed into an electronic device focusing on diet, exercise, smoking cessation, foot care, advice for sick days, medications, weight management, preventive care, and behavior modification and lifestyle showed significant improvement ( p  = 0.001) on the blood pressure compared with the low intensity group (not set of messages or algorithm) and the usual care group. The Choi et al. [ 6 ] study compared remote video consultation and blood pressure monitoring vs. only blood pressure monitoring. The difference in resulting systolic BP between the control and experimental groups was statistically significant, although the difference in diastolic BP was not statistically significant. The strategy used in the study by Cicolini et al. [ 33 ] consisted of an educational program for both groups and was added to the experimental group weekly email alerts and phone calls from a nurse care manager. Systolic and diastolic blood pressure significantly decreased in both groups (all p  < 0.01) but in the intervened group, obesity, low fruit consumption, total cholesterol and uncontrolled arterial pressure decreased more significantly.

A study conducted by Kim [ 35 ] reviewed the efficacy of telephone messages on patients’ blood pressure. Phone-based health-coaching with long message service was effective in decreasing systolic BP as compared to long message service only ( p  < 0.05). In another study, the systolic BP adjusted mean of the intervention group was significantly lower than of the control group (123.6 vs. 126.7, P.0.03) post-intervention, nevertheless, there was no statistically significant difference in diastolic BP between the groups at the end of the intervention [ 32 ].

All patients of the intervention arm (3 groups) of Bosworth et al. [ 30 ] study used telemedicine and home BP monitoring compared to the usual care group. The improvement in BP control to usual care at 12 months was statically significant in the first group that received behavioral management by nurses with 12.8% (95% CI, 1.6–24.1%; P  = 0.03) and also on the medication management group with the physician and the nurse working together with 12.5% (95% CI, 1.3–23.6%; P  = 0.03). Differences on BP with the third intervention (combination of intervention 1 and 2) and usual care were not statistically significant.

Herbert et al. [ 34 ] divided participants into three groups, the first involved BP monitoring and registered nurse counseling and telephone follow up for 9 months, the second only received the BP monitor, and the third group received usual care. The statistically significant changes on BP from intervention groups to usual care were only at 9 months. On the first intervention was − 7.0 mm Hg (Confidence Interval [CI], -13.4 to − 0.6) and in the second was + 1.1 mm Hg (95% CI, -5.5 to 7.8).

Effects of intervention on patient adherence to medication and healthy lifestyle

Adherence to medication was assessed using one question of the Morisky Medication Adherence Scale [ 36 ], and improved over time for both groups, although there was no significant difference among them [ 33 ]. In the Wakefield et al. [ 31 ] study, adherence to the antihypertensive therapy was measured using two scales and reported no significant differences between the 3 groups. Medication adherence in Kim study [ 35 ] was measured using a scale developed by Morisky et al. [ 36 ] and the results showed significant differences between the 4 groups. An adjusted version of Healthy Lifestyles and Lifestyle Behavior tool were used in the Choi et al. [ 6 ] study, and the results indicated that the only significant difference found was in sleep patterns and hobbies. Physical activity was evaluated through a questionnaire previously validated by the authors and was compared between the intervention and control group showing a statistically significantly greater improvement in BMI, alcohol consumption, cigarette smoking, fruit consumption, and physical activity on the intervention arm of the study [ 33 ].

The purpose of this systematic review was to explore the effectiveness of nursing-led telehealth interventions on adult patients with high blood pressure. This systematic review indicates that different nurse-led interventions (telehealth devices, remote video consultation, calls and email alerts) demonstrated a significant decrease in blood pressure (especially systolic blood pressure) in intervention groups. Nurse-led interventions also effect hypertension awareness, self-efficacy, and self-control. Positive outcomes related to lowering cholesterol, improving consumption of fruits and vegetables, increased physical activity and adherence to medication were also described.

The findings of the systematic review included different populations, all of them reported interventions guided, managed, and performed by nurses. These results are consistent with a systematic review completed in 2021 which reported that nurse-led interventions provided coordinated interventions that support continuity of care for people with chronic disease [ 18 ].

The interventions included in this systematic review were effective primarily in achieving changes in blood pressure and as well as improving patients’ knowledge acquisition related to a healthy lifestyle [ 30 , 32 , 33 , 35 ]. When reviewing the content of these interventions, common elements were noted such as the quest for medication adherence and the focus on education in healthy lifestyles habits like food consumption, frequent exercise, smoking cessation, etc. The sources of information delivered to patients through the interventions in this systematic review have also been reported in other studies [ 32 , 37 , 38 ] and were based on nationwide guidelines and evidence regarding a healthy lifestyle and blood pressure management.

The technologies used in the present study included electronic devices to measure blood pressure and telehealth devices to enable data transmission. Some of the studies used personalized messages, videoconferencing and videos with information for patient education, however, the majority used emails and telephone calls to provide efficient and high-quality healthcare. Findings from two systematics reviews that studied the use of mobile applications and multiple media (SMS, email and telephone call) to take care of chronic conditions reported different level of outcomes effectiveness [ 39 , 40 ] and disparities in the quality of the evidence provided [ 39 ].

The results of this systematic review have shown that intensity, defined as the frequency of interactions with the participants or in the amount of material delivered to some groups, resulted in differences in blood pressure results. Interactions with participants during the study showed significant variability among the 7 studies and within the studies. For example, one study sent text messages more than once a day depending of the of the BP results [ 31 ], others offered remote videoconferencing consultation twice a week [ 6 ], one receive email alerts with a reminder of the compliance with heathy lifestyle and occasional phone calls [ 33 ] one had monthly telephone interactions with a specific attention to the cultural aspects of care while improving their hypertension knowledge [ 32 ] or nursing health coaching for 30 min once a week [ 35 ]. Bosworth’s study [ 30 ] used 3 types of alert messages triggered by readings of high BP and those messages included elements of a behavioral management intervention. Herbert et al. [ 34 ] used regular telephone follow-up (frequency not reported) to reinforce messages on adherence to medication and healthy lifestyles. Findings from a recent systematic review support the findings of the present study reporting improvements in hypertension self-management behavior and medication adherence using interventions that combined tailored messages, interactive communication, and multifaceted functions [ 41 ].

Follow-up time in this systematic review ranged from 6 months to one year and nurses were responsible of sending emails or completing phone calls to patients requesting information regarding BP and/or answering questionnaires. All studies reported a loss of participants during the follow-up which may have influenced the results. Perhaps therapeutic relationship building and communication between nurses and their patients on the telehealth context needs different patterns of interaction to build empathy and rapport to facilitate the continuity of care.

Findings of this systematic review specified the nurse’s background and preparation for each study. Four of the studies reported including experienced nurses in the field of chronic disease management [ 6 , 30 , 31 , 33 ], one included a nurse manager [ 34 ], two studies highlighted the need to have the nurses go through a special course on cultural competency [ 32 ] and formal training on telephone health coaching [ 35 ] prior to participating in the study. Other studies have reported that Registered Nurses (RN) have the undergraduate preparation to promote healthy lifestyles, prevent the development of disease and deliver care and follow-up to different health conditions on community heath setting [ 42 , 43 ], never the less, telehealth content and experiences among different levels of nursing education appeared to remain low [ 44 ].

Implications for nursing

Health services recognize that interventions developed and performed by nurses support hypertensive patients in controlling their disease and preventing complications, especially in primary care and developing countries. Telehealth has been gaining ground recently as an effective and efficient strategy to deliver health care, especially in remote geographic areas, with an insufficient number of health professionals and a lack of specialized care. The COVID-19 pandemic limited nurse-patient interactions in the health center context and forced the exploration of new strategies that would allow continuity of care, especially in patients with chronic diseases such as hypertension. It is in this context that telehealth is emerging with great force. The results of this systematic review will provide a foundation from which to build standardizing successful nurse-led interventions for patients with hypertension, using the technological resources already available in their healthcare centers including computers, telephones, and smart phones to send e-mails, messages and/or telephone calls. It is hoped that some lessons learned from the COVID-19 pandemic will be transformed into a quality and safe care for all, reaching all who need it, regardless of where they are.

Limitations

There were some limitations to this review. Given the small number of articles found searching the 6 databases, it is possible that the search terms may not have covered all possible terms, though we searched for studies in English, Spanish and Portuguese. As the nurse-led interventions were heterogeneous, especially regarding the type of online resources used, intensity of intervention and follow-up, it was difficult to quantify their benefits and compare one intervention to another. Therefore, most of the results were presented in a narrative summary. Additionally, the effects of the nursing-led interventions delivered remotely might depend upon the nature of the content delivered and the online resources used. The patient’s cultural and educational backgrounds, state of the disease and its complications, and baseline blood pressure level measurements may have influenced the assessment accuracy of nurse -led interventions.

This analysis was limited to a population of adult hypertensive outpatients, and nurse-led interventions may not be able to be generalized to other patients with chronic conditions. More research may be needed to establish a consistent online nurse-led intervention program for patients with hypertension and to test the effectiveness of using different telehealth resources.

Although nurse -led interventions for the management and control of high blood pressure in primary care are effective, it is important to resolve whether they continue to be effective when using technological resources to deliver this care remotely. With the tools used, the selected studies were of high quality, however, the small number of subjects who were evaluated does not allow for generalization of the results.

After searching the scientific literature from the last 10 years, in multiple databases and different languages, and after critically reviewing all relevant studies, this systematic review analyzed only 7 studies to evaluate the effectiveness of nurse -led interventions in controlling high blood pressure in patients diagnosed with hypertension. This study describes the best evidence for making informed decisions regarding the strategies that will deliver the best continuous, quality, and cost-effective nursing care.

Availability of data and materials

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

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Study design: PE, MK, VJ, AH. Literature search: PE, MK, VJ. Quality assessment: PE, MK, VJ. Analysis and interpretation: PE, MK. Manuscript writing: PE, MK, VJ, AH. Critical revisions for important intellectual content: PE, MK, VJ. All authors read and approved the final manuscript.

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Nurse management for hypertension * : A systems approach

Supported by a grant to Stanford University from CorSolutions, Inc. (Buffalo Grove, IL).

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Peter Rudd, Nancy Houston Miller, Judy Kaufman, Helena C. Kraemer, Albert Bandura, George Greenwald, Robert F. Debusk, Nurse management for hypertension: A systems approach, American Journal of Hypertension , Volume 17, Issue 10, October 2004, Pages 921–927, https://doi.org/10.1016/j.amjhyper.2004.06.006

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Standard office-based approaches to controlling hypertension show limited success. Such suboptimal hypertension control reflects in part the absence of both an infrastructure for patient education and frequent, regular blood pressure (BP) monitoring. We tested the efficacy of a physician-directed, nurse-managed, home-based system for hypertension management with standardized algorithms to modulate drug therapy, based on patients’ reports of home BP.

We randomized outpatients requiring drug therapy for hypertension according to the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) criteria to receive usual medical care only (UC, n = 76) or usual care plus nurse care management intervention (INT, n = 74) over a 6-month period.

Patients receiving INT achieved greater reductions in office BP values at 6 months than those receiving UC: 14.2 ± 18.1 versus 5.7 ± 18.7 mm Hg systolic ( P < .01) and 6.5 ± 10.0 versus 3.4 ± 7.9 mm Hg diastolic, respectively ( P < .05). At 6 months, we observed one or more changes in drug therapy in 97% of INT patients versus 43% of UC patients, and 70% of INT patients received two or more drugs versus 46% of UC. Average daily adherence to medication, measured by electronic drug event monitors, was superior among INT subjects (mean ± SD, 80.5% ± 23.0%) than among UC subjects (69.2 ± 31.1%; t 113 = 2.199, P = .03). There were no significant adverse drug reactions in either group.

Telephone-mediated nurse management can successfully address many of the systems-related and patient-related issues that limit pharmacotherapeutic effectiveness for hypertension.

Am J Hypertens 2004;17:921–927 © 2004 American Journal of Hypertension, Ltd.

The control of blood pressure (BP) remains a major challenge in clinical practice. Only half of those individuals with hypertension receive the diagnosis, and only half of these achieve BP goals established by the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC VI) and other scientific organizations. 1 , 2 Contributing factors for the failure to achieve goal BP cluster as patient related, provider related, and system related. Patient factors include medication side effects, drug regimen complexity, and unawareness of the need for long term therapy. 3 Physician-linked issues may involve timely access to relevant clinical data, ignorance of evidence-based management guidelines, and sense of nonaccountability for patient outcomes. The system-related factors reflect little if any attention or resources to design, implement, evaluate, and refine systems for guiding individual and groups of patients. Specialized hypertension clinics staffed by nurses have shown significant improvements in hypertension control compared with usual care. 4–6 The present study extends the model of nurse management to home-based treatment.

Study population

We conducted a randomized controlled trial in which patients received either usual care alone (UC) or usual care supplemented by nurse management for hypertension (INT). For initial screening purposes we defined hypertension as BP ≥140 mm Hg systolic or ≥90 mm Hg diastolic, recorded in the medical record at least once in the previous 6 months, or a history of drug treatment for hypertension. In addition, patients had to be eligible for hypertensive drug therapy according to JNC VI criteria. 2 Clinical risk criteria assessed the presence of coronary risk factors (smoking, dyslipidemia, or diabetes mellitus), age >60 years, or a family history of premature cardiovascular disease or target organ damage. According to JNC VI criteria, 2 only patients with elevation of BP to levels greater than 140 to 159 mm Hg systolic and/or 90 to 99 mm Hg diastolic are considered eligible for BP lowering drug therapy. We adopted a more stringent BP threshold for hypertension: 150 mm Hg systolic, 95 mm Hg diastolic, or both.

Baseline BP measurement

During the baseline clinic visit, before randomization, the nurse care manager measured BP with a mercury sphygmomanometer using the arm with the higher reading as the “reference” arm for all subsequent BP recordings. The nurse used a second BP measurement, taken 5 min later, to establish the mean baseline BP. For study entry, subjects needed the mean of two BP values to be ≥150/95 mm Hg on two screening visits conducted on separate days at least 1 week apart.

We screened a total of 1580 patients, finding 743 (47%) who were ineligible because they lacked the risk factors specified by the JNC VI or had major medical comorbidity. An additional 603 (40%) either could not be contacted or refused participation after contact, and 84 (5%) had mean baseline BP values below the criterion of 150 mm Hg systolic or 95 mm Hg diastolic. We ended with 150 patients, representing 10% of the screened population, for randomization.

Recruitment and randomization

The same research staff implemented the same protocol for screening and enrollment of patients at each of two participating medical clinics, the Kaiser Permanente Mountain View Clinic and the Primary Care Clinics of the Stanford University Medical Center in California. We identified patients by physician referral or review of medical records. Patients received a postcard indicating their physician’s knowledge of the study and inviting study participation. Research staff telephoned patients to establish their medical eligibility and willingness to participate in the study.

After establishing eligibility, patients gave written informed consent and underwent randomization using computer-generated assignment. All patients provided baseline measurements of nonfasting blood urea nitrogen, creatinine, glucose, and potassium. These measurements guided drug therapy. At 3 and 6 months after randomization, a research assistant blinded to group assignment measured clinic BP and interviewed patients about medications taken since the previous visit.

Nurse management protocol

The nurse care manager conducted baseline counseling on intervention (INT) patients’ correct use of the automated BP device, regular return of the automatically printed BP reports, tips for enhancing drug adherence, and recognition of potential drug side effects. Printed materials extended this instruction, and patients confirmed their ability to operate the BP device. The nurse initiated follow up phone contacts at 1 week and at 1, 2, and 4 months. The calls averaged 10 min in duration, or 40 min in all. During phone contacts, the nurse asked INT patients about each medication dosage and any problems experienced since the previous contact. The nurse also encouraged patients to telephone anytime during regular hours with questions or concerns.

The nurse care manager contacted physicians to obtain permission to initiate any new BP drug but did not contact physicians regarding changes in medication dosage. Changes in drug therapy were categorized as either an increase (a drug added or dose of drug increased) or as a decrease (a drug withdrawn or dose of drug decreased). The nurse care manager implemented a management algorithm based on patients’ current medications, laboratory values, and BP measurements.

From prior studies, systolic pressures measured at home generally run about 10 mm Hg lower than those measured in the office, and diastolic pressures are approximately 5 mm Hg less. 7 Accordingly, we chose a treatment goal of 130/85 mm Hg, as measured with the home BP device over a 2-week period. 8 , 9 When 80% of the home BP readings achieved this treatment goal, the nurse made no further changes in drug therapy. When <80% of measurements met this criterion, the nurse increased drug dosage to the maximal level recommended for each drug or added one or more additional drugs in accordance with the protocol. The project cardiologist consulted by phone with the nurse care manager about problematic cases as needed.

Measurements of BP

We used the same semiautomated portable device to measure BP at home and during each clinic visits. This device (UA 751; A&D, Milpitas, CA), validated with a random zero mercury sphygmomanometer, 10 provided a digital display of BP values. At the end of each week, the device generated a printed report of up to 14 measurements. Patients recorded BP twice-daily at the same times each day. Every 2 weeks, patients mailed the values printed by the BP device to the nurse care manager, who used these BP data to guide drug therapy.

Physician review of protocol

Before the study, the investigators met with the medical staffs at the two sites to discuss the study protocol and management algorithm, based on the JNC VI report, 2 that were used by the nurse care manager for INT patients. After the 6-month clinic visit, all physicians received a final report of their patients’ medications and BP values. The Stanford University institutional review board reviewed and approved the project protocol.

Usual care patients in both groups continued to receive the routine care that they had received before the study. No attempt was made to alter the frequency of office visits or any other aspect of doctor-patient interactions. Only patients randomized to nurse management received portable BP monitors.

Patient monitoring

Patients in both groups returned to the clinic at 3 and 6 months for BP measurements, which were performed by study staff blinded to group assignment. Patients in both groups received instruction in the use of the electronic drug event monitor (eDEM; AARDEX-USA, Union City, CA). Each monitor contained a microchip in the pill bottle lid 11 , 12 to dispense the BP medication used most frequently. At 3- and 6-month clinic visits, project staff downloaded the data from the electronic drug event monitor but provided no feedback on drug adherence to patients, physicians, or nurse care managers.

Statistical analysis

The primary outcome measure was change in BP from baseline to 6-month visit, considering both systolic and diastolic BP and using a wall-mounted clinic sphygmomanometer. The primary statistical analysis was a two-sample t test comparing the change in BP measured between baseline and 6 months. We performed secondary analyses of BP medication, frequency of drug changes, and adherence to medication with the Student t test. The level of significance was a two-sided probability value of P < .05.

Population characteristics

The two patient samples, representative of hypertensive patients in the two participating clinics, exhibited similar sociodemographic and clinical characteristics, so data were pooled ( Table 1 ). Patients were typically of middle age, high educational status, and modest rates of cardiovascular comorbidities. The usual care only (UC) and usual care plus nurse care management intervention (INT) randomization successfully produced similar groups except for higher rates of married status and dyslipidemia among usual care patients. A total of 13 patients (9%), eight in the UC group and five in the intervention group, did not return for the 6-month visit and were classified as dropouts. Five of the eight dropouts in the UC group moved out of the area; the remainder declined to return for the 6-month follow-up visit. Two of the INT patients experienced difficulty in using the BP device and declined continued participation; three moved out of the area.

Study Population

CAD = coronary artery disease.

P < .05 by 2 analysis.

Patterns of BP

The UC and INT groups displayed similar patterns of baseline BP: 36% had elevation of both systolic and diastolic pressure, 55% had elevation of systolic pressure only, and 9% had elevation of diastolic pressure only. Between baseline and 6 months, systolic BP fell by 14.2 mm Hg in the INT group (95% CI −18.1 to −10.0) and by 5.7 mm Hg in the UC group (95% CI −10.2 to −1.3; P < .01). One-way ANOVA confirmed significant decreases in both systolic (F 212 = 17.30; P < .01) and diastolic BP (F 212 = 6.22; P < .01) among INT patients but nonsignificant changes among UC patients. Figure 1 depicts changes in office-based systolic BP.

Change in office-based systolic blood pressure (SBP). INT = usual care plus nurse care management intervention; UC = usual care only.

Between baseline and 6 months, diastolic BP fell by 6.5 mm Hg in the intervention group (95% CI −8.8 to −4.1) and 3.4 mm Hg in the UC group (95% CI of −5.3 to −1.5, P < .05). Figure 2 depicts changes in office-based diastolic BP.

Change in office-based diastolic blood pressure (DBP). INT = usual care plus nurse care management intervention; UC = usual care only.

Blood pressure measured with the mercury sphygmomanometer during clinic visits averaged 1 to 2 mm Hg higher than that measured with the semiautomated device. Blood pressure measured at home over a 2-week period using the semiautomated device was approximately 10 mm Hg lower than that measured with the same device during clinic visits. This pattern was consistent throughout the 6 months of the study.

Figure 3 summarizes differences between office versus home-based systolic BP. The INT subjects performed most scheduled home BP measurements (range 89% to 94%). Systolic and diastolic BP measured at home fell rapidly during the first 3 months of the study and remained relatively constant through month 6.

Office versus home-based systolic blood pressure: intervention patients only.

Antihypertensive medications

Patients in both INT and UC groups reported similar numbers of BP medications at baseline. At baseline, 22% of intervention patients and 30% of UC patients were taking no BP medications (NS). By 6 months, INT patients had significantly increased the number and variety of antihypertensive medications. The proportion of patients reporting two or more drugs at 6 months was 70% and 46%, respectively, among INT and UC patients. Similarly, the proportion of patients reporting no drug therapy at 6 months was 4% and 22%, respectively, among INT and UC subjects ( P < .01). The maximal dose of each individual medication was similar in the two groups.

Figure 4 summarizes the pattern of medication use in the study subjects. The distribution of medications remained similar in both groups at baseline and at 3 and 6 months. The proportion of patients taking angiotensin-converting enzyme inhibitors, diuretics, -blockers, and calcium blockers approximated respectively 40%, 25%, 20%, and 15% at the three assessment points. Among UC patients, 43% reported one or more changes in drug therapy during the 6-month study period, mostly initiated during office visits. In contrast, the rate of patients reporting changes in drug therapy was more than doubled (97%) among those receiving nurse management. Most therapy changes among INT patients arose from scheduled phone contacts. The number of medication changes (mean ± SD) reported by UC patients was 52 ± 1 (mean 0.69 changes/patient). The INT patients noted 223 ± 6 medication changes (mean 2.97 changes/patient; P < .01). Less than 5% of treatment decisions made by the nurse care manager required telephone discussion with a physician. Participating patients rarely telephoned the nurse care manager.

Pattern of medication use.

Medication adherence

Drug adherence, tracked by the electronic drug event monitor, assessed daily adherence (that is, the average number of days on which patients took the correct number of doses as prescribed). The INT patients’ rate of daily adherence during the 6-month study period was 80.5% ± 23.0% (mean ± SD, with 25th and 75th percentile values 77% to 95%), whereas the rate of UC patients was 69.2% ± 31.1% (25th and 75th percentile values 50% to 93%; t 113 = 2.199, P = .03).

In both groups, once-daily regimens yielded higher daily adherence rates than for more frequent dosing. The respective adherence rates were 82% ± 28% and 75% ± 27% for once-daily dosing and 69% ± 34% and 49% ± 41% for twice-daily or more than twice-daily dosing in the INT and UC groups. None of these differences reached statistical significance.

In this randomized controlled trial, we found that home-based, physician-directed, nurse-guided drug therapy proved superior in BP control to standard office-based management among eligible hypertensive patients by JNC VI criteria. The size of achieved reductions in systolic and diastolic BP approximate those reported for intensive interventions in other trials. 13 Pill-taking adherence by the electronic drug event monitor remained high in both groups but reached statistically higher levels among INT subjects. The greater variety of BP drugs, the greater proportion of patients on antihypertensive therapy, and the progressive medication adjustment contributed to the superior INT outcomes.

Most hypertension management studies reflect ambulatory settings. 14–16 Inauspicious characteristics include large numbers of patients, diverse comorbidities, no consistent standards for antihypertensive management, and providers’ nonaccountability for clinical outcomes. Berlowitz et al 14 reported that physicians defer changing drug therapy, even when BP remain elevated: “clinical inertia” from infrequent assessments, ignorance of established clinical guidelines, and distraction by unrelated medical priorities. 17

The nurse management system in this study addressed some of the relevant obstacles. The system used external clinical guidelines (JNC VI 2 ) to define entry criteria, treatment goals, preferred medications, and management of side effects. It closely linked ongoing surveillance of BP values and responsive changes in drug therapy. By periodic phone contacts, the nurse managers made timely medication changes, adjusting treatment intensity as needed. Over the 6-month trial, INT patients underwent more than four times the number of drug changes than UC patients and usually achieved control in less than 3 months. These results approximate those of Mehos et al applying pharmacists’ regulation of BP medications in a home-based intervention. 18

Most prior studies of home BP measurement reported BP sampling over only a few days. 7 In the present study, sampling twice daily over several months, commonly >300 measurements in all, offered more confidence about central tendency with day-to-day BP fluctuations. Home BP determinations closely approximated clinic BP with both portable device and mercury sphygmomanometer.

This study supports using home BP measurement as a reliable alternative to office BP measurement 19 and suggests that it provides a more representative indicator of BP status, when the number of home determinations is large. 20 , 21 The accuracy of clinic measurements may suffer from nonstandardized measurement and brief sampling. Training patients can standardize BP measurement 19 and minimize so-called white coat effects. 22

The theoretical underpinning for the current study comes from social cognitive theory. 23 The behavioral model reflects self-regulation, enabling patients to differentially select health promoting behaviors. The core features of effective self-regulation of health habits include knowledge, self-monitoring, goal setting, and corrective self-regulation when most needed rather than at fixed intervals. Ongoing interactivity permits adjustment of interventions contingent on the progress being made.

This study assessed the efficacy of the home-based management system as a whole rather than the relative contribution of the various components: baseline instruction, patients’ measurement and reporting of home BP, modulation of drug therapy by standardized protocol, and systematic phone contacts. Despite its relative complexity, the management system was readily understood and accepted by physicians in both managed care settings (Kaiser) and fee-for-service academic settings (Stanford).

The study inescapably includes some limitations. The participating patients, given the larger recruitment pool, may be atypical in their willingness or ability to monitor home BP. By sociodemographic characteristics, the participants represent an affluent and well educated cohort. The two clinical facilities are typical of similar settings, even if not representative of all primary care practices.

Several implications emerge for optimizing future antihypertensive management. Clinical inertia will likely continue in the absence of efforts toward standardization and accountability for outcomes. Individual clinicians— however devoted, knowledgeable, and skilled—may still fail to implement consistent and optimally effective guidelines of diagnosis, monitoring, and treatment adjustment. The present study provides a successful example of moving from general guidelines, as in JNC VI, to an operational protocol for nurses working with a consultant cardiologist.

Medical measurement devices for home use will soon permit guidance via the Internet similar to nurse-mediated case management. These technological innovations do not diminish the need for physicians’ active involvement in the creation, critical appraisal, and periodic refinement of management protocols. Physicians will remain vital to evaluating comorbid risk factors and to prescribing appropriate antihypertensive therapies.

The present care management system facilitates and expands the reach and scope of traditional health care by three interdependent means. First, it reduces the need for physicians to mediate the routine tasks of managing antihypertensive therapy. Second, the management system encourages physicians to focus their energies on problem cases, such as those individuals who fail to achieve satisfactory control. Third, the management system reinforces the value of collaboration among teams of health professionals. Formal study of such hypertension case management will likely confirm its cost-effectiveness. 24

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Author notes

• hypertension
• pharmacotherapy
• patient care management
• medication adherence

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• Mini Review
• Mini review series: Current topic in Hypertension
• Published: 16 January 2023

Emerging topics on basic research in hypertension: interorgan communication and the need for interresearcher collaboration

• Keisuke Shinohara 1  

Hypertension Research volume  46 ,  pages 638–645 ( 2023 ) Cite this article

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The pathogenesis of hypertension is multifactorial and highly complex. Basic research plays critical roles in elucidating the complex pathogenesis of hypertension and developing its treatment. This review covers recent topics in basic research related to hypertension in the following six parts: brain/autonomic nervous system, kidney, vascular system, potential treatments, extracellular vesicles, and gut microbiota. The brain receives afferent nerve inputs from peripheral organs, including the heart, kidneys, and adipose tissue, and humoral inputs from circulating factors such as proinflammatory cytokines and leptin, which are involved in the regulation of central sympathetic outflow. In the kidneys, changes in Wnt/β-catenin signaling have been reported in several hypertensive models. New findings on the renin-angiotensin-aldosterone system in the kidneys have also been reported. Sirtuin 6, which participates in various cellular functions, including DNA repair, has been shown to have protective effects on the vascular system. Skin water conservation, mediated by skin vasoconstriction and the accumulation of osmolytes such as sodium, has been found to contribute to hypertension. Studies of rivaroxaban and sodium-glucose cotransporter-2 inhibitors as drug repositioning candidates have been performed. Extracellular vesicles have been shown to be involved in novel diagnostic approaches and treatments for hypertension as well as other diseases. In gut microbiota studies, interactions between microbiota and antihypertensive drugs and potential pathophysiology linking microbiota and COVID-19 have been reported. It can be seen that inter-organ communication has received particular attention from these recent research topics. To truly understand the pathogenesis of hypertension and to develop treatments for conquering hypertension, interresearcher communication and collaboration should be further facilitated.

This mini-review focuses on recent topics on basic research in hypertension from the several points of view. The recent topics indicate that inter-organ communication has received particular attention. Interresearcher communication and collaboration should also be further facilitated to truly understand the complex pathogenesis of hypertension and to develop the treatments.

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Introduction

The pathogenesis of hypertension is multifactorial and highly complex. Basic research plays critical roles in elucidating the complex pathogenesis of hypertension and developing treatments for hypertension. It would be ideal to link all of the pathophysiology and the organ changes associated with hypertension and describe these associations systematically, but our understanding of the pathophysiology of hypertension has not been sufficient to reach that goal. Therefore, the present mini-review focuses on recent and emerging topics in basic research on hypertension from several points of view (Fig. 1).

Recent topics in basic research. Each ref. number indicates the reference paper cited in the text. LVH left ventricular hypertrophy, BDNF brain-derived neurotrophic factor, NTS nucleus tractus solitarius, RDN renal denervation, BP blood pressure, BAT baroreflex activation therapy, IL interleukin, RAS renin-angiotensin system, SIRT6 sirtuin 6, Runx2 runt-related transcription factor 2, CKD chronic kidney disease, SGLT2i sodium-glucose cotransporter-2 inhibitor, EV extracellular vesicle, FNDC5 fibronectin type-III domain-containing protein 5, miR microRNA, ACEI angiotensin-converting enzyme inhibitor, ACE2 angiotensin-converting enzyme-2, SHR spontaneously hypertensive rat, COVID-19 coronavirus disease 2019

Brain/autonomic nervous system

The brain receives various inputs from the peripheral system, organizes them, and determines central sympathetic outflow [ 1 ]. The sympathetic nervous system plays a major role in the control of diverse organs, including the heart, kidneys, and vasculature. Sympathetic overactivity is often accompanied by an imbalance of autonomic tone with decreased parasympathetic activity, which is a hallmark of the pathophysiology of hypertension and hypertensive organ damage.

In clinical practice, autonomic neuromodulation for cardiovascular diseases, such as renal denervation, has attracted significant attention [ 2 , 3 ]. Renal denervation and the involvement of renal sympathetic nerves in hypertension are discussed in another mini-review in this journal, so I describe recent studies investigating the other neural mechanisms that may modulate sympathetic activity. In particular, the role of afferent nerves carrying signals from peripheral organs to the central nervous system as well as efferent sympathetic nerves innervating the organs in cardiovascular regulation has recently been investigated. The stimulation of cardiac sympathetic afferent nerves increases sympathetic outflow and blood pressure. This sympathoexcitatory reflex is called the cardiac sympathetic afferent reflex (CSAR). CSAR is reported to be enhanced in experimental models of hypertension and chronic heart failure [ 4 , 5 , 6 ]. Transient receptor potential vanilloid 1 (TRPV1)-expressing cardiac afferent fibers are responsible for sensing and triggering CSAR activation [ 7 ]. Our recent study showed that cardiac TRPV1 expression and CSAR were increased in mice with pressure overload-induced cardiac hypertrophy and that TRPV1 knockout and selective denervation of TRPV1-expressing cardiac sympathetic afferent nerves similarly attenuated pressure overload-induced cardiac hypertrophy [ 8 ]. The activation of TRPV1-expressing cardiac afferent nerves was presumably associated with increased brain-derived neurotrophic factor in the brainstem nucleus tractus solitarius receiving the cardiac afferents, which could induce sympathoexcitation and cardiac hypertrophy. Afferent signals from white adipose tissue can also influence blood pressure through a sympathoexcitatory mechanism known as the adipose afferent reflex [ 9 , 10 ]. Dalmasso et al. recently demonstrated that the stimulation of afferent sensory nerves from visceral white adipose tissue could increase blood pressure in normal mice [ 11 ]. They further showed that afferent signals from visceral white adipose tissue contributed to sympathetic activation and hypertension in male mice exposed to early life stress when fed an obesogenic diet [ 12 ]. This enhanced sympathetic outflow was most likely mediated by increased afferent signals from epididymal white adipose tissue projecting to brain areas with a pivotal role in developing neurogenic hypertension, such as the hypothalamic paraventricular nucleus (PVN) and rostral ventrolateral medulla (RVLM). In addition to these studies focusing on afferent signals from organs such as the heart and white adipose tissue, the study from Asirvatham-Jeyaraj et al. focused on the celiac ganglion as another potential target for antihypertensive neuromodulation. They showed that celiac ganglionectomy, a procedure that ablates efferent sympathetic nerves to and afferent sensory nerves from the splanchnic organs, decreased blood pressure as well as renal denervation in genetically hypertensive Schlager BPH/2 J mice [ 13 ]. The depressor response to the ganglionic-blocking agent hexamethonium, which indicates global neurogenic pressor activity, was significantly decreased by renal denervation, whereas this depressor response was not altered by celiac ganglionectomy. Therefore, both renal and splanchnic nerves contributed to hypertension in BPH/2 J mice, but likely through different mechanisms. As shown in this study, renal denervation and celiac ganglionectomy both attenuated hypertension to a similar degree in Dahl salt-sensitive rats [ 14 ]. In contrast, renal denervation had no effect in the angiotensin II-salt model and mild deoxycorticosterone acetate (DOCA)-salt model, but celiac ganglionectomy was effective in lowering blood pressure [ 15 , 16 , 17 ]. The effect of selective denervation of afferent nerves, including renal afferent nerves, on blood pressure also differs between hypertensive animal models [ 2 , 18 ]. Taken together, the findings of these studies suggest that the efficacy of targeted denervation depends on the model studied and the organ systems and physiological processes affected. Finally, baroreflex activation as an antihypertensive neuromodulation other than denervation or ganglionectomy will now be described. Multiple clinical trials have shown that baroreflex activation therapy through carotid sinus stimulation is effective in decreasing blood pressure in treatment-resistant hypertensive patients [ 19 , 20 , 21 ]. However, there is currently no set of standardized electrical stimulation parameters, and the reported stimulus frequencies, amplitudes, and durations have varied widely among human trials. Domingos-Souza et al. showed that the ability of baroreflex activation to modulate hemodynamics and induce lasting vascular adaptation was critically dependent on the electrical parameters and duration of carotid sinus stimulation in spontaneously hypertensive rats (SHRs) [ 22 ]. This study provided an important rationale for improving baroreflex activation therapy in humans.

The brain receives inputs from circulating humoral factors, which affects sympathetic outflow. In particular, hypertension is associated with systemic inflammation, and the brain may play a key role in linking them. Cao et al. showed that intravenous injection, intracerebroventricular injection, or PVN microinjection of interleukin (IL)-17A similarly induced increases in blood pressure, heart rate, and renal sympathetic nerve activity [ 23 ]. Intravenous injection of IL-17A activated brain-resident glial cells and elevated the gene expression of inflammatory cytokines and chemokines through IL-17 receptor A within the PVN. The findings of this study suggest that IL-17A in the brain promotes neuroinflammation to enhance sympathetic activation and hypertension. As shown in this study, systemic administration of proinflammatory cytokines has been suggested to induce sympathetic activation and blood pressure elevation by acting on the brain [ 24 , 25 , 26 ], but it is not well understood how endogenous circulating proinflammatory cytokines are involved in the development of hypertension through the sympathetic nervous system because cytokines cannot cross the blood‒brain barrier. Brain perivascular macrophages are components of the blood‒brain barrier and are affected by circulating inflammatory cytokines. We recently showed that brain perivascular macrophages, which produce prostaglandin E2, thus activating neurons in response to circulating cytokines, contribute to the development of hypertension via sympathetic activation [ 27 ]. In addition, there is a link between obesity and hypertension. Gruber et al. showed in mice with high-fat, high-sugar diet-induced obesity, there was profound remodeling of the gliovascular interface in the hypothalamus, which includes preautonomic centers, resulting in arterial hypertension [ 28 ]. This process was driven by elevated leptin levels and an upregulation of the HIF1α-VEGF signaling axis in local astrocytes.

There is a close relationship between the kidneys and blood pressure. Kasacka et al. reported changes in the Wnt/β-catenin signaling pathway, which is a key pathway that regulates various cellular processes and tissue homeostasis and is also involved in damage and repair processes, in the kidneys of several hypertensive model rats [ 29 ]. They showed that the activity of the Wnt/β-catenin pathway was increased in SHRs and two-kidney, one-clip (2K1C) hypertensive rats, while it was inhibited in DOCA-salt rats, using kidney immunohistochemistry. The renin-angiotensin system (RAS) is increased in SHRs and 2K1C hypertensive rats; therefore, the findings of this study suggest an interaction between the RAS and Wnt/β-catenin signaling. The role of Wnt/β-catenin signaling in kidney injury and repair has been well reviewed in the recent literature [ 30 , 31 ]. The intrarenal RAS is involved in BP regulation. In damaged kidneys with an impaired glomerular filtration barrier, liver-derived angiotensinogen filtered through damaged glomeruli regulates intrarenal RAS activity [ 32 ]. Matsuyama et al. further showed that the glomerular filtration of liver-derived angiotensinogen, depending on glomerular capillary pressure, causes a circadian rhythm of the intrarenal RAS with in vivo imaging using multiphoton microscopy [ 33 ]. Aldosterone-independent activation of renal mineralocorticoid receptors (MRs) has also been discussed and studied. Maeoka et al. used aldosterone synthase knockout mice and demonstrated that MRs were activated in the absence of aldosterone along distal convoluted tubule 2 and were partially activated in the cortical collecting duct, indicating that renal MRs are normally bound by hormones other than aldosterone [ 34 ]. This supports the use of MR antagonists in patients, even when aldosterone is not elevated.

Vascular system

Vascular system impairment is also associated with hypertension. Recently, an increasing number of studies have shown the vascular protective effect of sirtuin 6 (SIRT6), which is an NAD-dependent protein deacetylase and a member of the evolutionarily conserved sirtuin family. Grootaert et al. showed that SIRT6 protein expression was reduced in human and mouse plaque vascular smooth muscle cells (VSMCs) and was positively regulated by ubiquitin ligase C-terminus of HSC70-interacting protein (CHIP) [ 35 ]. SIRT6 regulated telomere maintenance and VSMC lifespan and inhibited atherogenesis, all of which were dependent on its deacetylase activity. Liu X et al. found that SIRT6 expression was downregulated in the aortae of aged rats and showed that SIRT6 knockdown enhanced Ang II-induced vascular adventitial aging by activating the NF-κB pathway in vitro [ 36 ]. Li et al. demonstrated that SIRT6 was markedly downregulated in peripheral blood mononuclear cells and in the radial artery tissue of patients with chronic kidney disease with vascular calcification [ 37 ]. They further showed that SIRT6 suppressed VSMC osteoblastic transdifferentiation and attenuated vascular calcification both in mice in vivo and in vitro. Mechanistically, SIRT6 deacetylated runt-related transcription factor 2 (Runx2) and promoted its ubiquitination and subsequent degradation through the ubiquitin‒proteasome system.

Skin vasoconstriction-mediated skin water conservation was newly indicated to contribute to hypertension. Ogura et al. showed that SHRs exhibited higher urine volume and lower urinary osmolality than normotensive Wistar-Kyoto rats (WKYs), without significant differences in water intake, urinary osmolyte excretion, or plasma osmolality between the groups [ 38 ]. SHRs showed higher blood pressure and skin sodium content and lower transepidermal water loss than WKYs. Skin vasodilation, induced by elevating body temperature, increased transepidermal water loss in both SHRs and WKYs; however, blood pressure was decreased in SHRs, but not in WKYs, by skin vasodilation. These findings suggest that skin water conservation, mediated by skin vasoconstriction and the accumulation of osmolytes such as sodium, may contribute to hypertension in SHRs. This concept has been indicated in other animal models [ 39 , 40 ].

Potential treatments

There have been many potential treatments for hypertension and the associated organ damage. Here, the findings of several studies that may lead to potential drug repositioning will be described. Rivaroxaban, a direct factor Xa inhibitor, has been reported to have protective effects on the cardiovascular system. Daci et al. showed that pretreatment with rivaroxaban attenuated lipopolysaccharide (LPS)-induced acute vascular inflammation and contractile dysfunction in LPS-injected rats [ 41 ]. Nakanishi et al. demonstrated that rivaroxaban protected against cardiac dysfunction after myocardial infarction in mice [ 42 ]. Reductions in protease-activated receptor (PAR)-1, PAR-2, and proinflammatory cytokines in the infarcted area were associated with the cardioprotective effects of rivaroxaban. In addition, Narita et al. showed that rivaroxaban had a protective effect against cardiac hypertrophy and fibrosis by inhibiting PAR-2 signaling in renin-overexpressing hypertensive mice [ 43 ]. Sodium-glucose cotransporter-2 (SGLT2) inhibitors have been demonstrated to have cardio- and renoprotective effects in clinical studies. In addition, a blood pressure-lowering effect of SGLT2 inhibitors has been suggested in animal studies. Kravtsova et al. showed that dapagliflozin treatment blunted the development of hypertension with increases in glucose and Na + excretion without secondary effects on the expression and function of other Na + transporters and channels along the nephron and systemic and intrarenal RAS in Dahl salt-sensitive hypertensive rats [ 44 ]. Zhao et al. showed that canagliflozin attenuated the development of hypertension by directly alleviating vasoconstriction in Dahl salt-sensitive hypertensive rats [ 45 ]. Salt-induced vascular transient receptor potential channel 3 upregulation resulted in augmented vasoconstriction in salt-sensitive hypertensive rats by facilitating sodium-calcium exchanger 1-mediated vascular calcium uptake, which could be alleviated by canagliflozin. Furthermore, although SGLT2 inhibitors may have a sympathoinhibitory effect, which might be responsible for their protective effects on the cardiovascular system, their mechanism remains unclear.

Extracellular vesicles

Extracellular vesicles (EVs) have been studied in many aspects, including disease diagnosis, biological signaling, and novel therapeutics, in this decade. Ochiai-Homma et al. showed that pendrin in urinary EVs can be a useful biomarker for the diagnosis and treatment of primary aldosteronism, and this finding was supported by studies using a rat model of aldosterone excess [ 46 ]. Lugo-Gavidia et al. indicated that circulating platelet-derived EVs were positively associated with nocturnal blood pressure at baseline and therapy-induced blood pressure changes over a 12-week treatment period with ambulatory blood pressure monitoring [ 47 ]. Platelet-derived EVs may provide an integrated measure of blood pressure changes achieved with pharmacotherapy. In addition, Chi et al. demonstrated that fibronectin type-III domain-containing protein 5 (FNDC5)/irisin-enriched EVs contributed to exercise-induced protection against vascular aging by increasing SIRT6 stability [ 48 ]. The findings of this study indicate that the exerkine FNDC5/irisin may be a potential target for aging-related vascular comorbidities. EVs also play a role as mediators of cell communication [ 49 ]. Wang et al. revealed an inverse correlation between circulating microRNA-92a levels and pulse wave velocity in humans and mice [ 50 ]. The findings of their in vitro study indicated that endothelial cell microRNA‑92a may be transported to VSMCs via EVs to regulate phenotypic changes in VSMCs, leading to arterial stiffness.

Gut microbiota

Studies on the role of gut microbiota in blood pressure regulation have also been accumulating. One of the topics in this field is the interaction between microbiota and antihypertensive drugs [ 51 , 52 ]. Wu et al. showed that the abundances of several phyla and genera, including Proteobacteria, Cyanobacteria, Escherichia-Shigella , Eubacterium nodatum and Ruminococcus , were higher in DOCA-salt hypertensive rats than in control rats, while these changes were reversed by treatment with oral captopril, an angiotensin-converting enzyme inhibitor (ACEI) [ 53 ]. Of particular interest, the genera Bifidobacterium and Akkermansia , reported as beneficial bacteria in the gut, were abundant only in hypertensive rats treated with captopril. These results provide evidence that captopril has the potential to rebalance the dysbiosis of DOCA-salt rats, suggesting that the alteration of the gut flora by captopril may contribute to the hypotensive effect of this drug. Yang et al. showed that the blood pressure-lowering effect of quinapril, another ACEI, was more pronounced in SHRs treated with antibiotics than in SHRs not treated with antibiotics [ 54 ]. The depletion of gut microbiota in SHRs with antibiotics was associated with decreased gut microbial catabolism of quinapril as well as a significant reduction in the bacterial genus Coprococcus. C. comes , an anaerobic species of Coprococcus , harbored esterase activity and catabolized the ester quinapril in vitro. The coadministration of quinapril with C. comes reduced the antihypertensive effect of quinapril in SHRs. Importantly, C. comes selectively reduced the antihypertensive effects of the ester ramipril but not the nonester lisinopril. The findings of this study suggest that human commensal C. comes catabolizes the ester ACEI in the gut and lowers its antihypertensive effect.

The risk for coronavirus disease 2019 (COVID-19) in hypertensive patients and patients treated with RAS inhibitors has been discussed [ 55 , 56 , 57 , 58 ], and there are some animal studies investigating this issue from the aspect of gut microbiota. Li et al. showed that the expression of angiotensin-converting enzyme-2 (ACE2) and transmembrane protease serine-2 (TMPRSS2), key molecules in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, in the gut epithelium was increased in SHRs compared to normotensive rats [ 59 ]. Changes in the gut microbiome associated with short-chain fatty acids, particularly butyrate, were found in both hypertension and COVID-19 [ 60 ]. They further demonstrated that butyrate downregulates genes essential for SARS-CoV-2 infection, such as Ace2 and Tmprss2 , but also upregulates toll-like receptors and other antiviral pathways [ 61 ]. These findings imply that the increased risk of COVID-19 in individuals with hypertension is partly due to the cumulative depletion of butyrate-producing bacteria in the gut.

Perspectives

In this mini-review, recent topics on basic research in hypertension were introduced. For many of these findings, the pathophysiology and underlying mechanism are not confined to a single organ. The brain receives neural and humoral inputs from the peripheral system and determines the central sympathetic outflow, which plays a major role in the control of diverse organs, including the heart, kidneys, and vasculature. Important mechanisms, such as Wnt/β-catenin signaling and SIRT6 activity, shown in this mini-review, are involved in homeostasis and pathogenesis across organs and diseases. EVs are also known to contribute to intracellular and interorgan crosstalk. The gut microbiome has become a key player in systemic diseases, including hypertension. The pathogenesis of hypertension is multifactorial and highly complex; therefore, it is reasonable that interorgan communication has recently become an important perspective in the study of hypertension and hypertensive organ damage. On the other hand, each researcher tends to focus only on his or her own area of expertise in trying to elucidate the pathogenesis of hypertension. To truly understand the pathogenesis of hypertension and to apply this understanding to treatments for conquering hypertension, interresearcher communication and collaboration should also be further facilitated (Fig.  2 ).

Interorgan communication in hypertension and interresearcher communication and collaboration in hypertension research

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I sincerely appreciate the editors of Hypertension Research for giving me the opportunity to write this review.

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Shinohara, K. Emerging topics on basic research in hypertension: interorgan communication and the need for interresearcher collaboration. Hypertens Res 46 , 638–645 (2023). https://doi.org/10.1038/s41440-023-01176-3

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Received : 05 November 2022

Revised : 14 December 2022

Accepted : 20 December 2022

Published : 16 January 2023

Issue Date : March 2023

DOI : https://doi.org/10.1038/s41440-023-01176-3

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