nursing research article on hypertension

• Open access
• Published: 27 April 2024

The short and long-term efficacy of nurse-led interventions for improving blood pressure control in people with hypertension in primary care settings: a systematic review and meta-analysis

• Masami Ito 1 ,
• Aran Tajika 1 ,
• Rie Toyomoto 1 ,
• Hissei Imai 1 ,
• Masatsugu Sakata 1 ,
• Yukiko Honda 2 , 3 ,
• Sanae Kishimoto 1 ,
• Memori Fukuda 4 ,
• Noboru Horinouchi 1 , 5 ,
• Ethan Sahker 1 , 6 &
• Toshi A. Furukawa 1  

BMC Primary Care volume  25 , Article number:  143 ( 2024 ) Cite this article

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Previous systematic reviews suggest that nurse-led interventions improve short-term blood pressure (BP) control for people with hypertension. However, the long-term effects, adverse events, and appropriate target BP level are unclear. This study aimed to evaluate the long-term efficacy and safety of nurse-led interventions.

We conducted a systematic review and meta-analysis. We searched the Cochrane Central Register of Controlled Trials, PubMed, and CINAHL, as well as three Japanese article databases, as relevant randomized controlled trials from the oldest possible to March 2021. This search was conducted on 17 April 2021. We did an update search on 17 October 2023. We included studies on adults aged 18 years or older with hypertension. The treatments of interest were community-based nurse-led BP control interventions in addition to primary physician-provided care as usual. The comparator was usual care only. Primary outcomes were long-term achievement of BP control goals and serious adverse events (range: 27 weeks to 3 years). Secondary outcomes were short-term achievement of BP control goals and serious adverse events (range: 4 to 26 weeks), change of systolic and diastolic BP from baseline, medication adherence, incidence of hypertensive complications, and total mortality.

We included 35 studies. Nurse-led interventions improved long-term BP control (RR 1.10, 95%CI 1.03 to 1.18). However, no significant differences were found in the short-term effects of nurse-led intervention compared to usual care about BP targets. Little information on serious adverse events was available. There was no difference in mortality at both terms between the two groups. Establishing the appropriate target BP from the extant trials was impossible.

Conclusions

Nurse-led interventions may be more effective than usual care for achieving BP control at long-term follow-up. It is important to continue lifestyle modification for people with hypertension. We must pay attention to adverse events, and more studies examining appropriate BP targets are needed. Nurse-led care represents an important complement to primary physician-led usual care.

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Introduction

Hypertension is an important issue in public health, leading to serious health complications [ 1 ]. It is a major cause of premature death worldwide and one of the greatest risk factors for the global burden of disease, afflicting 1.28 billion people worldwide [ 2 ]. The number of people with hypertension is increasing as the world population grows and ages.

The American College of Cardiology/American Heart Association, European Society of Cardiology/European Society of Hypertension, and Japanese Society of Hypertension updated their guidelines recommending that BP targets for hypertensive patients should be lower than the goals formerly set by the conventional guidelines, namely as BP targets < 130/80 mmHg [ 3 , 4 , 5 ]. However, it can be difficult to keep patient BP targets lower, and the benefits of such strict BP regulations are limited to reduced health complications. The evidence is not clear on whether lower BP targets reduce total mortality or eschew serious adverse events [ 6 ].

Previous reviews have found that allied health professional-led interventions can improve BP control for patients with hypertension [ 7 , 8 ]. Patients with hypertension need to adhere to medications, and importantly, they must modify their lifestyle (e.g., sodium restriction, smoking cessation, and alcohol use reduction) [ 5 , 9 ]. However, patients with hypertension have been found to be less likely to practice lifestyle modifications [ 10 ]. In this context, nurse-led hypertension interventions may be particularly helpful by including more individualized care, enhancing care quality, and improving patient self-control due to increased patient contacts, and thus contribute to better BP control [ 11 ]. Existing systematic reviews have not examined adverse events and their results are hard to interpret because their control groups include both usual care by physicians and no intervention, and they mix outcomes at both the long and short term [ 11 ]. Importantly, the appropriate time it takes for patients to present with clinically meaningful BP control has not been identified in the evidence base. Because behavior change varies by patient, nurses and physicians would benefit from identifying reasonable expectations for patient BP control goals.

Therefore, the present study aimed to evaluate both the short- and long-term efficacy and safety of nurse-led interventions to improve BP control for people with hypertension. Secondly, the present study explores whether adverse events reported in nurse-led interventions could be due to strict BP control targets.

The present study is a systematic review and meta-analysis. We conducted a review according to the Cochrane Handbook for Systematic Reviews of Interventions ver. 6.1 [ 12 ]. We followed the PRISMA 2020 guidelines [ 13 , 14 ]. This study has been registered with PROSPERO [CRD42021246085].

Study selection

We included nurse-led BP control interventions in addition to primary care physician-provided usual care. Types of interventions were aimed at improving BP control as lifestyle modifications. The model of primary care settings was defined as the first point of contact in the healthcare system [ 15 ], “home-based and community-based care, primary care in long-term care facilities, step-down units for rehabilitation in local hospitals, dedicated emergency care units at comprehensive health centers and first level hospitals” [ 16 ]. Nurses included any professionals with relevant state qualifications. There were no restrictions in nurses’ place of work, work settings, age, or experience. We included usual care only in primary care by physicians as the comparators. Therefore, we evaluated the added effects of nurse-led interventions to usual care.

We included all published and unpublished randomized controlled trials (RCTs). For cross-over studies, only the first phase was included. We also included cluster randomized controlled trials if the intra-cluster (or intraclass) correlation coefficient (ICC) could be estimated [ 17 ]. Participants included adults aged 18 years or over with hypertension according to each author’s use of any standardized diagnostic criteria. There were no restrictions on the presence or absence of hypertensive complications. No restrictions were made in terms of sex/gender, ethnicity, or country. We excluded studies of pregnant women.

Primary and secondary outcomes

We defined short-term as less than six months (range: 4 to 26 weeks) and long-term as more than 6 months (range: 27 weeks to 3 years) separately. We also used the point closest to one year when there were multiple time points, such as one or three years. The primary outcomes were (1) long-term achievement of BP control goals and (2) long-term serious adverse events. BP control goal was to keep BP targets or lower. Clinicians would consider long-term BP achievement important. We used the number of serious adverse events as defined and reported by the trial authors. The secondary outcomes were (1) short-term achievement of BP control goals, (2) short-term serious adverse events, and all the following both at long and short term: (3) change from baseline of systolic blood pressure (SBP)/diastolic blood pressure (DBP), (4) rate of antihypertensive drugs prescribed, (5) medication adherence, (6) incidence of hypertensive complications including cardiovascular events and strokes, and (7) total mortality.

Search strategies

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (1946 to 31 March 2021), PubMed (1966 to 31 March 2021), and CINAHL (1982 to 31 March 2021), as well as the following three Japanese article databases: Ichushi-Web (1946 to 31 March 2021), Current Index to Japanese Nursing Literature (1987 to 31 March 2021), and CiNii Articles (1923 to 31 March 2021). All searches were conducted on 17 April 2021. We did an update search in PubMed (2021 to 30 September 2023) and CENTRAL (1 April 2021 to 30 September 2023) on 17 October 2023. We did not use any language restrictions to minimise the language bias [ 18 ]. Search strategies for each database are listed in the supplementary materials (See Supplemental Table S 1 ). We also checked the references of previous studies on this topic. We asked original authors to provide the details of ongoing studies, conference abstracts, oral sessions, and unpublished data if needed.

Pairs of review authors (M.I., H.I., M.S., Y.H., R.T., S.K., and N.H.) independently identified the titles and abstracts from potentially relevant studies to be retrieved in the first stage of screening using Rayyan software [ 19 ]. We removed duplicates and obviously irrelevant reports. Next, we retrieved the full article for potentially relevant reports. The pair of review authors independently decided which studies met all eligibility criteria. The reviewers discussed any disagreement about inclusions. We consulted a third review author (A.T.) of our team if we could not resolve disagreements. We also used DeepL Translator [ 20 ] in the second stage of screening when we needed to translate other languages into English. We have finally asked the native language users to check the articles.

We constructed a data extraction form using Excel spreadsheets for this review. The following characteristics were extracted from included studies: study name, year of publication, study designs, type of setting, country, diagnostic criteria used, the group-average demographics, details of the intervention, outcome measures, BP goals, and sphygmomanometer type (See Tables 1 and 2 for details). Pairs of the review authors (M.I., H.I., M.S., Y.H., R.T., S.K., and N.H.) independently extracted data from all included studies. They also discussed any disagreements and noted their decisions. We involved a third review author (A.T.) in cases of disagreement.

Data synthesis and analysis

We used risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcome measures and mean difference (MD) and 95% CI for continuous outcome measures. We analyzed data with a generic inverse-variance approach for meta-analyses using Review Manager 5.4 software [ 56 ]. We used a random-effects model for all analyses because we anticipated clinical heterogeneity among various interventions by nurses. We used the results as reported by the authors abiding by the intention-to-treat (ITT) principle. We contacted the study authors to request missing data. We assumed that patient conditions remained unchanged when the relevant information was missing.

We analyzed outcomes from cluster randomized trials by reducing the size of each trial to its effective sample size with ICC. We contacted the original authors when ICCs were not reported. We estimated the effective sample sizes for cluster-randomized trials according to the Cochrane Handbook for Systematic Reviews of Interventions ver. 6.1 [ 12 ]. We borrowed ICCs (0.001) from other studies when the ICCs were not provided by the original authors [ 44 ]. We excluded studies from the meta-analysis when there were no events in both arms because such studies do not provide any indication of the direction or magnitude of the relative treatment effects [ 12 ]. In addition, we borrowed standard deviations (SDs) from similar studies when the SD for the change scores or the endpoint scores were missing [ 57 , 58 ].

Subgroup analysis

We performed the following pre-specified subgroup analyses: the target BP goals (< 140/90 mmHg, or 140/90 mmHg), regions (North America, South America, Europe, Asia, Africa, and Oceania), and settings (nurse interventions taking place in primary care clinics, district hospitals, in the communities, community health care centers, companies, nursing homes, and facilities for the elderly people, and others).

Sensitivity analysis

We performed the following sensitivity analyses for the primary outcome to assess the robustness of our results: 1) we excluded studies at high risk of bias, 2) we regarded the dropouts as achieving BP goals, and 3) we excluded studies requiring borrowed ICCs.

Assessment of heterogeneity

We interpreted heterogeneity using the I 2 statistic as follows: 0-40% might not be important, 30-60% may represent moderate heterogeneity, 50-90% may represent substantial heterogeneity, and 75-100% represent considerable heterogeneity [ 12 ]. The τ 2 indicated the spread of true intervention effects and was interpreted in comparison with its empirical distribution [ 59 , 60 ].

Reporting bias assessment

The pairs of review authors (M.I., H.I., M.S., Y.H., R.T., and S.K.) independently assessed the risk of bias of the included studies using the Risk of Bias Tool Ver. 2.0 (RoB 2.0), updated August 22, 2019 [ 61 ]. We assessed each risk of bias item at each intervention in the included studies with the following five domains: randomization process, deviations from intended interventions, missing outcomes, measurement of outcome, and selection of reported results. We graded each risk of bias as high, low, or some concerns for every domain. We also used the RoB 2.0 tool for cluster-randomized trials (updated March 18, 2021) if the included studies were cluster RCTs [ 61 ]. We assessed the risk of bias with a third review author (A.T.) when we disagreed. We assessed reporting biases by visual inspection of funnel plots and conducted Egger’s test for continuous outcomes with R Version 4.0.5 [ 62 ] when we had ten or more studies [ 63 ].

The search yielded 3,002 articles up to September 2023. We screened both titles and abstracts of 2,367 records after removing duplicates. In the first screening, 1,609 articles were excluded because of inapplicable titles and abstracts. We retrieved 758 full-text papers and included 108 articles. Finally, 35 studies were identified for the final quantitative synthesis in the meta-analysis. We discovered three new articles by update search in 2023. Figure  1 shows the PRISMA flow chart of the search and selection process results.

PRISMA flow chart

Table 1 summarizes the characteristics of the included studies. Half were conducted in North America. Four cluster RCTs were included out of 35 RCTs. Care settings varied, and half of the included studies were uncertain about hypertensive complications. Table 2 summarizes the characteristics of each of the included studies. Nurse-led interventions in the included studies covered many topics, such as counseling, personal and/or group education, behavioral management, coaching, remote monitoring, and motivational interviews. We tabulated which outcomes were available in each study (Supplement Table S 2 ).

Primary outcomes

Achievement of bp control goals at long-term.

Results are presented in subgroups for each BP control goal (Fig.  2 ). Nurse-led intervention demonstrated greater achievement of BP control goals compared to usual care alone (RR = 1.10; 95% CI = 1.03, 1.18; p  = 0.008; 9 included studies; 2,744 participants). The I 2 was 4%, and τ 2 was zero in the primary outcome, indicating low heterogeneity between the studies.

Forest plot of the achievement of BP control goals at long term (including the numeric data of the achievement of BP goals compared with usual care)

Included studies set various target BPs. One study [ 37 ] set below 130/85 mmHg, seven studies [ 24 , 25 , 28 , 30 , 44 , 64 , 65 ] below 140/90 mmHg, and one study [ 38 ] below DBP 90 mmHg with an unspecified SBP. However, the subgroup heterogeneity ( P  = 0.28, I 2  = 22.1%) suggested no discernible subgroup differences. The subgroup analyses by region or care settings did not suggest important subgroup differences (Figures S 3.1  and S 3.2 ).

Serious adverse events at long-term

There was only one study that mentioned serious adverse events, but the details and the numbers were not available [ 36 ]. No other serious adverse events were reported in any other study.

Secondary outcomes

Achievement of bp control goals at short-term.

There was insufficient evidence to determine the effects of nurse-led intervention on BP control goals compared to usual care in the short term (RR 1.17; 95%CI = 1.00,1.37; p  = 0.05; 9 studies; 2,063 participants; I 2  = 64%; τ 2  = 0.04; Figure S 2.1 -b).

Serious adverse events at short-term

Serious adverse events were not reported in any of the included studies.

Average change from baseline of SBP/DBP at long and short-term

The reductions in SBP and DBP were greater in the nurse-led intervention group compared to usual care at both the long-term (MD of SBP = -2.33 mmHg; 95% CI = -3.84, -0.81; p  = 0.003; 14 studies; 4,910 participants; Figure S 2.2 -a, and MD of DBP = -1.96 mmHg; 95% CI -3.10, -0.83; p  = 0.0007; 11 studies; 2,901 participants; Figure S 2.3 -a) and the short-term (MD of SBP = -4.46 mmHg; 95% CI -6.32, -2.60; p  < 0.00001; 25 studies; 4,331 participants; Figure S 2.2 -b, and MD of DBP = -3.31 mmHg, 95% CI = -4.54, -2.09; p  < 0.00001; 22 studies; 2,682 participants; Figure S 2.3 -b).

Antihypertensive drug prescriptions at long and short term

One study reported long-term effects with about 90% of participants prescribed antihypertensive drugs at follow-up, compared to about 50% at baseline; however this improvement was seen both in the intervention and the control arms [ 38 ]. Two studies reported short-term effects [ 45 , 46 ]. Participants prescribed antihypertensive drugs in the intervention group went from 70 to 96% [ 45 ]. However, in another study, neither group changed the percentage of antihypertensive drug prescriptions [ 46 ]. We aimed to report post-intervention antihypertensive drug prescription data. However, it remains unknown, as this information was not provided by any study.

Medication adherence at long and short term

Three studies reported long-term outcomes of medication adherence [ 36 , 37 , 38 ]. No significant differences were found in long-term effects of medication adherence (RR = 1.04; 95% CI = 0.99, 1.10; p  = 0.12; 3 studies; 558 participants; I 2  = 0%; τ 2  = 0.00; Figure S 2.4 ). However, medication adherence was defined by each author, such as self-report [ 37 ], pill count [ 38 ], and the medication possession into pillbox [ 36 ].

Three studies reported short-term effects of drug adherence [ 45 , 47 , 66 ]. The post-medication adherence rate was 80.5% in the intervention group. Meanwhile, it was 69.2% in the usual care group [ 45 ]. From available studies, 95.6% of all participants adhered to their doses [ 47 ]. Medication adherence was reported with Medication adherence self-efficacy scale short form (MASES-SF) [ 66 ]. We could not analyze these because of different ways of reporting at short-term.

Incidence of hypertensive complications including cardiovascular events and strokes at long and short term

No study reported the incident rate of hypertensive complications, including cardiovascular events or strokes in the included studies. Some participants were diagnosed and dropout as diabetic or hypothyroidism [ 66 ].

Total mortality at long and short term

There was insufficient evidence to demonstrate the impact of the nurse-led intervention on mortality compared to usual care for both the long term (RR = 0.93; 95% CI = 0.60, 1.43; p  = 0.74; 6 studies; 2,174 participants; I 2  = 0%; τ 2  = 0.00; Fig.  3 a) and the short term (RR = 0.44; 95% CI = 0.18, 1.11; p  = 0.08; 5 studies; 1,054 participants; I 2  = 0%; τ 2  = 0.00; Fig.  3 b).

a Forest plot of total mortality at long term. b Forest plot of total mortality at short term

Sensitivity analyses

There was insignificant evidence to determine the effects of the achievement of BP control goals at the long term when including only low risk of bias studies (RR = 1.03; 95% CI = 0.89, 1.19; p  = 0.71; 1 study; 591 participants; I 2  = 0%; τ 2  = 0.00; Figure S 4.1 ). The results of the sensitivity analyses including dropouts were consistent with the primary analysis (RR = 1.08; 95% CI = 1.02, 1.14; p  = 0.010; 2,833 participants; I 2  = 0%; τ 2  = 0.00; Figure S 4.2 ). The results of sensitivity analyses excluding borrowed ICCs also were consistent with the primary analysis (Figure S 4.3 ). The results of sensitivity analyses excluding borrowed ICCs for the average change from baseline of SBP and DBP at the long-term were consistent with the primary analysis (Figure S 4.4 and Figure S 4.5 ). Results excluding borrowed ICCs for total mortality at long and short term were consistent with the primary analyses (Figure S 4.6 -a and Figure S 4.6 -b).

Risk of bias in studies

Figure  4 shows the risk of bias of the included studies for the primary outcome, achievement of BP control goals at the long term. The proportion of studies rated at low risk of bias for each domain was as follows: 69.2% for risk of bias arising from the randomization process, 30.8% for bias due to deviations from the intended interventions, 46.2% for risk of bias due to missing outcome data, 61.5% for risk of bias in the measurement of the outcome, and 46.2% for risk of bias in the selection of the reported result. Finally, we assessed 23.1% of the studies at low overall risk of bias. Only one study was at overall low risk of bias [ 25 ]. See Figure S 1  in the Supplemental Figures for the details of the risk of bias summary at each intervention in the primary outcome of the study.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies about the primary outcome

Reporting biases

The funnel plots are shown in Figures S 5.1 -a to S 5.4 -b and were visually symmetrical. The result of Egger’s test for continuous outcomes did not indicate reporting biases (See Table S 3 .)

Comparing nurse-led intervention plus usual physician care against usual care only, the present study found that (1) the proportion of patients achieving BP control goals was greater for nurse-led intervention at long-term, (2) the average reduction from baseline of SBP and DBP were greater for nurse-led intervention at both the short- and long-term, (3) there was insufficient evidence to determine a difference in mortality between the two methods of care, and (4) there were almost no trials reporting on serious adverse events.

The present study adds to the extant literature by identifying the benefits of nurse-led interventions to achieve BP control goals at long-term. The primary outcome of this study at long-term follow-up demonstrated lower heterogeneity in comparison with previous studies [ 7 ]. This may be due to our inclusion criteria clearly comparing nurse-led care plus usual care by physicians with usual care only. However, no benefit was found in terms of BP control goals at short term. Nurse interventions also include changing health risk behaviors for people with hypertension using behavioral management programs. Nurses need to assess patient stages of change [ 67 ], and work with them accordingly. Therefore, nursing care can take more time to achieve effectiveness, as many patients are ambivalent about changing their behaviors. Thus, we suggest that importance should be placed on longer-term targets for achieving BP control goals. In addition, the lack of evidence for the impact of nurse-led interventions on total mortality at both the short- and long-term follow-ups support similar existing systematic reviews [ 6 ].

The present study provides several contributions to the literature base. First, a prior review suggested that BP should be lowered slowly to reach the target BP over a few months [ 5 ], but did not specify how long this should take. We determined the evidence distinguishing between the short and long term. It is reasonable to expect meaningful intervention effects of nurse-led interventions to begin around seven months, as lifestyle modification and improving adherence takes time. Second, not only did we investigate efficacy but also the safety associated with the primary outcome. Previous reviews did not investigate adverse events [ 7 , 11 ]. We explored serious adverse events, including death. However, we did not find sufficient evidence because adverse events were poorly reported in the included RCTs. Therefore, we suggest better safety outcome reporting for nurse-led intervention studies. We may need a guideline to collect and report safety outcomes in such RCTs. Finally, we expanded our search beyond English, while previous reviews were limited to only English. Thus, we were able to include two additional articles in Japanese.

Our study has some limitations. First, the statistical power was low because we divided the durations into short- and long-term outcomes. Thus, the number of studies in each analysis was smaller in comparison with the previous meta-analysis which did not distinguish between the durations [ 11 ]. However, the number of included studies was more than in the previous review [ 11 ]. We also found similar results for the effects of nurse-led intervention as the previous meta-analysis [ 11 ]. We highlight that the purpose of our study was originally to conduct meta-analyses by duration. We believe that distinguishing between durations is clinically meaningful. Second, there were some studies we were unsure if we should include because the primary care settings were different among countries. For example, some people see secondary or tertiary hospitals as the first step in Japan. We contacted the original authors in various countries but had to make our own decision among multiple reviewers when inquiries were not addressed. We could not divide the settings clearly for some studies. These may not have been proper primary care settings, but were included. Third, the types of nurse-led intervention are diverse, and it is difficult to distinguish from which intervention draws which effect. There were many kinds of care, and we included all nurse-led interventions. We could not distinguish between these care delivery methods, as they may include multiple elements, complex combination, and comprehensive approaches, such as medication management, diets, and weight control. Yet, the heterogeneity between the studies was low. Fourth, there are many factors that affect achievement of BP goal levels that include not only the BP target, but also the starting BP level and duration of hypertension. Our eligibility was based to the BP targets by the original authors. Therefore, in some cases there were no baseline BP levels reported and/or no reports of hypertension duration. Thus, nurse researchers may require paying attention to interpret our findings and need further investigations. Fifth, different measurements were used between studies. Those different criteria or measurements may have major impact on the results of BP control, the reduction in SBP/DBP, medication adherence and drug prescriptions. More evidence is required and we recommend future studies to report on these outcomes. Sixth, our results may not generalize to all countries and healthcare systems. Most studies included were from the USA, but nursing care varies between countries. For example, nurses in some countries cannot prescribe medications. Thus, external validity should be interpreted within the practices of individual countries. Finally, we used DeepL Translator to translate other languages into English at the phase of screening. DeepL appears reasonably accurate for technical papers, as, for example, it has been reported that the machine translation for a medical article from Japanese to English using DeepL Translator had “the mean ± SDs of the match rate for the entire article: 94.0 ± 2.9%” [ 68 ]. To assure accuracy, however, we eventually asked the native language users to check the articles.

Usual physician care plus nurse-led intervention may be more effective for the achievement of long-term BP control goals compared to usual care alone. The current research base in nurse-led interventions for BP control lacks important reporting of adverse events, limiting the clinical interpretation. Additionally, more studies examining different BP targets are needed to improve the current understanding of the effects. To achieve BP control, nurse-led care is an important complement to usual physician care in primary care settings.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Blood pressure

Confidence intervals

Diastolic blood pressure

Intra-cluster (or intraclass) correlation coefficient

Mean difference

Randomized controlled trials

Risk of Bias Tool Ver. 2.0

Risk ratios

Systolic blood pressure

Standard deviations

Zhou B, Perel P, Mensah GA, Ezzati M. Global epidemiology, health burden and effective interventions for elevated blood pressure and hypertension. Nat Rev Cardiol. 2021;18(11):785–802.

Article   PubMed   PubMed Central   Google Scholar  

World Health Organization and Imperial College London. More than 700 million people with untreated hypertension. 2021. https://www.who.int/news/item/25-08-2021-more-than-700-million-people-with-untreated-hypertension . Accessed 5 Jan 2022.

Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the american college of cardiology/American heart association task force on clinical practice guidelines. J Am Coll Cardiol. 2018;71(19):e127–248.

Article   PubMed   Google Scholar  

Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the European society of cardiology and the European society of hypertension: the task force for the management of arterial hypertension of the European society of cardiology and the European society of hypertension. J Hypertens. 2018;36(10):1953–2041.

Article   CAS   PubMed   Google Scholar  

Umemura S, Arima H, Arima S, Asayama K, Dohi Y, Hirooka Y, et al. The Japanese Society of Hypertension Guidelines for the Management of Hypertension (JSH 2019). Hypertens Res. 2019;42(9):1235–481.

Arguedas JA, Leiva V, Wright JM. Blood pressure targets in adults with hypertension. Cochrane Database Syst Rev. 2020;12(12):Cd004349.

PubMed   Google Scholar  

Clark CE, Smith LF, Cloutier L. Allied health professional-led interventions for improving control of blood pressure in patients with hypertension: a Cochrane Systematic Review and Meta-analysis. J Hypertens. 2015;33:e44.

Article   Google Scholar  

Treciokiene I, Postma M, Nguyen T, Fens T, Petkevicius J, Kubilius R, et al. Healthcare professional-led interventions on lifestyle modifications for hypertensive patients - a systematic review and meta-analysis. BMC Fam Pract. 2021;22(1):63.

Himmelfarb CR, Commodore-Mensah Y, Hill MN. Expanding the role of nurses to improve hypertension care and control globally. Ann Glob Health. 2016;82(2):243–53.

Tam HL, Chair SY, Leung ISH, Leung LYL, Chan ASW. US adults practicing healthy lifestyles before and during COVID-19: comparative analysis of national surveys. JMIR Public Health Surveill. 2023;9:e45697.

Clark CE, Smith LF, Taylor RS, Campbell JL. Nurse led interventions to improve control of blood pressure in people with hypertension: systematic review and meta-analysis. BMJ. 2010;341:c3995.

Cochrane. Cochrane handbook for systematic reviews of interventions version 6.1. 2020.

Google Scholar  

Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71.

Page MJ, Moher D, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ. 2021;372:n160.

World Health Organization. Primary Care. 2021. https://www.who.int/teams/integrated-health-services/clinical-services-and-systems/primary-care . Accessed 5 Jan 2022.

World Health Organization (WHO) & United Nations Children’s Fund (UNICEF). Operational framework for primary health care: transforming vision into action. 2020. p. 25.

Rao JN, Scott AJ. A simple method for the analysis of clustered binary data. Biometrics. 1992;48(2):577–85.

Egger M, Zellweger-Zähner T, Schneider M, Junker C, Lengeler C, Antes G. Language bias in randomised controlled trials published in English and German. Lancet. 1997;350(9074):326–9.

Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev. 2016;5(1):210.

DeepL GmbH. DeepL Translator. www.deepl.com/translator Accessed.

Amado Guirado E, Pujol Ribera E, Pacheco Huergo V, Borras JM, ADIEHTA Group. Knowledge and adherence to antihypertensive therapy in primary care: results of a randomized trial. Gac Sanit. 2011;25(1):62–7.

Beune EJ, Moll van Charante EP, Beem L, et al. Culturally adapted hypertension education (CAHE) to improve blood pressure control and treatment adherence in patients of African origin with uncontrolled hypertension: cluster-randomized trial. PLoS One. 2014;9(3):e90103.

Bogner HR, de Vries HF, Kaye EM, Morales KH. Pilot trial of a licensed practical nurse intervention for hypertension and depression. Fam Med. 2013;45(5):323–9.

Bosworth HB, Olsen MK, Grubber JM, Neary AM, Orr MM, Powers BJ, et al. Two self-management interventions to improve hypertension control: a randomized trial. Ann Intern Med. 2009;151(10):687–95.

Bosworth HB, Powers BJ, Olsen MK, McCant F, Grubber J, Smith V, et al. Home blood pressure management and improved blood pressure control: results from a randomized controlled trial. Arch Intern Med. 2011;171(13):1173–80.

Cakmak V, Pakyuz SC. The effects of education given by nurses on rational drug use and health literacy of patients receiving hypertension treatment. J Nurs Midwifery Sci. 2021;8:246–52.

Dejesus RS, Chaudhry R, Leutink DJ, Hinton MA, Cha SS, Stroebel RJ. Effects of efforts to intensify management on blood pressure control among patients with type 2 diabetes mellitus and hypertension: a pilot study. Vasc Health Risk Manag. 2009;5:705–11.

Duong D. Management of Hypertensive Patients by Clinical Nurse Specialist in a Military. TriService Nursing Research Program. 2004; Project #98–003.

Feldman PH, McDonald MV, Trachtenberg M, et al. Reducing Hypertension in a Poststroke Black and Hispanic Home Care Population: Results of a Pragmatic Randomized Controlled Trial. Am J Hypertens. 2020;33(4):362–70.

Feldman PH, McDonald MV, Barrón Y, Gerber LM, Peng TR. Home-based interventions for black patients with uncontrolled hypertension: a cluster randomized controlled trial. J Comp Eff Res. 2016;5(2):155–68.

Given CW, Given BA, Coyle BW. The effects of patient characteristics and beliefs on responses to behavioral interventions for control of chronic diseases. Patient Educ Couns. 1984;6(3):131–40.

Kabayama M, Akagi Y, Wada N, et al. A Randomized Trial of Home Blood-Pressure Reduction by Alcohol Guidance During Outpatient Visits: OSAKE Study. Am J Hypertens. 2021;34(10):1108–15.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Kastarinen MJ, Puska PM, Korhonen MH, et al. Non-pharmacological treatment of hypertension in primary health care: a 2-year open randomized controlled trial of lifestyle intervention against hypertension in eastern Finland. J Hypertens. 2002;20(12):2505–12.

Kes D, Polat U. The effect of nurse-led telephone support on adherence to blood pressure control and drug treatment in individuals with primary hypertension: A randomized controlled study. Int J Nurs Pract. 2022;28(3):e12995.

Kolcu M, Ergun A. Effect of a nurse-led hypertension management program on quality of life, medication adherence and hypertension management in older adults: A randomized controlled trial. Geriatr Gerontol Int. 2020;20(12):1182–9.

Leiva A, Aguiló A, Fajó-Pascual M, Moreno L, Martín MC, Garcia EM, et al. Efficacy of a brief multifactorial adherence-based intervention in reducing blood pressure: a randomized clinical trial. Patient Prefer Adherence. 2014;8:1683–90.

Litaker D, Mion L, Planavsky L, Kippes C, Mehta N, Frolkis J. Physician - nurse practitioner teams in chronic disease management: the impact on costs, clinical effectiveness, and patients’ perception of care. J Interprof Care. 2003;17(3):223–37.

Logan AG, Milne BJ, Flanagan PT, Haynes RB. Clinical effectiveness and cost-effectiveness of monitoring blood pressure of hypertensive employees at work. Hypertension. 1983;5(6):828–36.

Ma C, Zhou Y, Zhou W, Huang C. Evaluation of the effect of motivational interviewing counselling on hypertension care. Patient Educ Couns. 2014;95(2):231–7.

Ma Y, Cheng HY, Sit JWH, Chien WT. The effects of a smartphone-enhanced nurse-facilitated self-care intervention for Chinese hypertensive patients: A randomised controlled trial. Int J Nurs Stud. 2022;134:104313.

Mattei da Silva ÂT, de Fátima Mantovani M, Castanho Moreira R, Perez Arthur J, Molina de Souza R. Nursing case management for people with hypertension in primary health care: A randomized controlled trial. Res Nurs Health. 2020;43(1):68-78.

Miao JH, Wang HS, Liu N. The evaluation of a nurse-led hypertension management model in an urban community healthcare: A randomized controlled trial. Medicine (Baltimore). 2020;99(27):e20967.

Okuda N, Murakami Y, Kadota A, Ueshima H. Development of health guidance techniques to improve hypertension in non-obese cardiovascular disease risk accumulators in the workers and the association with plasma BNP concentrations (in Japanese). Daiwa Securities Foundation Research Collection. 2010;33:114–9.

Persell SD, Karmali KN, Lazar D, Friesema EM, Lee JY, Rademaker A, et al. Effect of electronic health record-based medication support and nurse-led medication therapy management on hypertension and medication self-management: a randomized clinical trial. JAMA Intern Med. 2018;178(8):1069–77.

Rudd P, Miller NH, Kaufman J, Kraemer HC, Bandura A, Greenwald G, et al. Nurse management for hypertension. A systems approach. Am J Hypertens. 2004;17(10):921–7.

Ruppar TM. Randomized pilot study of a behavioral feedback intervention to improve medication adherence in older adults with hypertension. J Cardiovasc Nurs. 2010;25(6):470–9.

Schroeder K, Fahey T, Hollinghurst S, Peters TJ. Nurse-led adherence support in hypertension: a randomized controlled trial. Fam Pract. 2005;22(2):144–51.

Sen M, Rasjö Wrååk G, Rönmark P, et al. Lack of long-term effects from a pedagogical intervention upon blood pressure control–a randomized primary care study. Scand Cardiovasc J. 2013;47(5):289–96.

Swain MA, Steckel SB. Influencing adherence among hypertensives. Res Nurs Health. 1981;4(1):213–22.

Ulm K, Huntgeburth U, Gnahn H, Briesenick C, Pürner K, Middeke M. Effect of an intensive nurse-managed medical care programme on ambulatory blood pressure in hypertensive patients. Arch Cardiovasc Dis. 2010;103(3):142–9.

Wakefield BJ, Holman JE, Ray A, et al. Effectiveness of home telehealth in comorbid diabetes and hypertension: a randomized, controlled trial. Telemed J E Health. 2011;17(4):254–61.

Woollard J, Beilin L, Lord T, Puddey I, MacAdam D, Rouse I. A controlled trial of nurse counselling on lifestyle change for hypertensives treated in general practice: preliminary results. Clin Exp Pharmacol Physiol. 1995;22(6–7):466–8.

Zabler B, Tsai PY, Fendrich M, Cho Y, Taani MH, Schiffman R. Effect of a nurse case management intervention for hypertension self-management in low-income African Americans. Contemp Clin Trials. 2018;71:199–204.

Zang XY, Liu JF, Chai YF, Wong FK, Zhao Y. Effect on blood pressure of a continued nursing intervention using chronotherapeutics for adult Chinese hypertensive patients. J Clin Nurs. 2010;19(7–8):1149–56.

Zhu X, Wong FKY, Wu CLH. Development and evaluation of a nurse-led hypertension management model: A randomized controlled trial. Int J Nurs Stud. 2018;77:171–8.

Cochrane. org. ReviewManager (RevMan) is Cochrane's bespoke software for writing Cochrane Reviews. 2020. https://training.cochrane.org/online-learning/core-software/revman . Accessed.

Furukawa TA, Barbui C, Cipriani A, Brambilla P, Watanabe N. Imputing missing standard deviations in meta-analyses can provide accurate results. J Clin Epidemiol. 2006;59(1):7–10.

da Costa BR, Nüesch E, Rutjes AW, Johnston BC, Reichenbach S, Trelle S, et al. Combining follow-up and change data is valid in meta-analyses of continuous outcomes: a meta-epidemiological study. J Clin Epidemiol. 2013;66(8):847–55.

Turner RM, Davey J, Clarke MJ, Thompson SG, Higgins JP. Predicting the extent of heterogeneity in meta-analysis, using empirical data from the cochrane database of systematic reviews. Int J Epidemiol. 2012;41(3):818–27.

Rhodes KM, Turner RM, Higgins JP. Predictive distributions were developed for the extent of heterogeneity in meta-analyses of continuous outcome data. J Clin Epidemiol. 2015;68(1):52–60.

Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898.

The R Project for Statistical Computing. https://www.r-project.org . Accessed.

Lin L, Chu H, Murad MH, Hong C, Qu Z, Cole SR, et al. Empirical comparison of publication bias tests in meta-analysis. J Gen Intern Med. 2018;33(8):1260–7.

da Mattei Silva ÂT, de Fátima Mantovani M, Castanho Moreira R, Perez Arthur J, de Molina Souza R. Nursing case management for people with hypertension in primary health care: a randomized controlled trial. Res Nurs Health. 2020;43(1):68–78.

Sen M, Rasjö Wrååk G, Rönmark P, Carlsson AC, Törnkvist L, Wändell P, et al. Lack of long-term effects from a pedagogical intervention upon blood pressure control–a randomized primary care study. Scand Cardiovasc J. 2013;47(5):289–96.

Kes D, Polat U. The effect of nurse-led telephone support on adherence to blood pressure control and drug treatment in individuals with primary hypertension: a randomized controlled study. Int J Nurs Pract. 2022;28(3):e12995.

Prochaska J.O. RCA, Evers K.E. The transtheoretical model and stages of change: health behavior and health education : theory, research, and practice. 4th ed. 2008.

Takakusagi Y, Oike T, Shirai K, Sato H, Kano K, Shima S, et al. Validation of the reliability of machine translation for a medical article from japanese to english using deepl translator. Cureus. 2021;13(9):e17778.

PubMed Central   Google Scholar  

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Acknowledgements

We wish to thank the timely help given by Ms. Yuki Nakatsuka (Okayama University Hospital, Center for innovative Clinical Medicine) and Mr. Toshiki Iwasaki (Keio University Hospital, Clinical and Translational Research Center) in analysing Egger’s test. No additional compensation was provided.

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MI and AT had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Conception and design: MI, AT, HI, RT, MS, YH, SK, ES, and TAF. Acquisition of data: MI, AT, HI, RT, MS, YH, SK, and NH. Analysis and interpretation of data: MI, AT, ES, and TAF. Drafting the manuscript: MI. Revising it critically for important intellectual content: MI, AT, HI, RT, MS, YH, SK, MF, NH, ES, and TAF. Final approval of the version to be published: MI, AT, HI, RT, MS, YH, SK, MF, NH, ES, and TAF.

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Ito, M., Tajika, A., Toyomoto, R. et al. The short and long-term efficacy of nurse-led interventions for improving blood pressure control in people with hypertension in primary care settings: a systematic review and meta-analysis. BMC Prim. Care 25 , 143 (2024). https://doi.org/10.1186/s12875-024-02380-x

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

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• 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 .

• ↵ Ezzati M, Lopez AD, Rodgers A, Vander Hoom S, Murray CJL, and the Comparative Risk Assessment Collaborating Group. Selected major risk factors and global and regional burden of disease. Lancet 2002 ; 360 : 1347 -60. OpenUrl CrossRef PubMed Web of Science
• ↵ National Centre for Social Research. Health survey for England 2003. Department of Health, 2004.
• ↵ Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet 2005 ; 365 : 217 -23. OpenUrl CrossRef PubMed Web of Science
• ↵ Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003 ; 42 : 1206 -52. OpenUrl Abstract / FREE Full Text
• ↵ Inkster M, Montgomery A, Donnan P, MacDonald T, Sullivan F, Fahey T. Organisational factors in relation to control of blood pressure: an observational study. Br J Gen Pract 2005 ; 55 : 931 -7. OpenUrl Abstract / FREE Full Text
• ↵ Phillips LS, Branch WT, Cook CB, Doyle JP, El Kebbi IM, Gallina DL, et al. Clinical inertia. Ann Intern Med 2001 ; 135 : 825 -34. OpenUrl CrossRef PubMed Web of Science
• ↵ Mancia G, De Backer G, Dominiczak A, Cifkova R, Fagard R, Germano G, et al. 2007 guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J 2007 ; 28 : 1462 -536. OpenUrl FREE Full Text
• ↵ National Institute for Health and Clinical Excellence. Hypertension: management of hypertension in adults in primary care: partial update. Royal College of Physicians, 2006.
• ↵ Confederation NHS, British Medical Association. New GMS contract 2003: investing in general practice. British Medical Association/NHS Confederation, 2003.
• ↵ NHS Information Centre. Practice level QOF tables 2008/09—clinical domain—hypertension. 2009. www.ic.nhs.uk/statistics-and-data-collections/supporting-information/audits-and-performance/the-quality-and-outcomes-framework/qof-2008/09/data-tables/practice-level-data-tables .
• ↵ Heneghan C, Perera R, Mant D, Glasziou P. Hypertension guideline recommendations in general practice: awareness, agreement, adoption, and adherence. Br J Gen Pract 2007 ; 57 : 948 -52. OpenUrl Abstract / FREE Full Text
• ↵ Fahey T, Schroeder K, Ebrahim S, Glynn L. Interventions used to improve control of blood pressure in patients with hypertension. Cochrane Database Syst Rev 2005 ; 1 : CD005182 . OpenUrl PubMed
• ↵ Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care. Cochrane Database Syst Rev 2005 ; 2 : CD001271 . OpenUrl PubMed
• ↵ Oakeshott P, Kerry S, Austin A, Cappuccio F. Is there a role for nurse-led blood pressure management in primary care? Fam Pract 2003 ; 20 : 469 -73. OpenUrl Abstract / FREE Full Text
• ↵ Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions 5.0.2 [updated September 2009]. Cochrane Collaboration, 2009. www.cochrane-handbook.org .
• ↵ Review Manager (RevMan) [Computer program]. Version 5.0. Copenhagen: Nordic Cochrane Centre, Cochrane Collaboration, 2008.
• ↵ Adams G, Gulliford MC, Ukoumunne OC, Eldridge S, Chinn S, Campbell MJ. Patterns of intra-cluster correlation from primary care research to inform study design and analysis. J Clin Epidemiol 2004 ; 57 : 785 -94. OpenUrl CrossRef PubMed Web of Science
• ↵ Bebb C, Kendrick D, Coupland C, Madeley R, Stewart J, Brown K, et al. A cluster randomised controlled trial of the effect of a treatment algorithm for hypertension in patients with type 2 diabetes. Br J Gen Pract 2007 ; 57 : 136 -43. OpenUrl Abstract / FREE Full Text
• ↵ Bellary S, O’Hare JP, Raymond NT, Gumber A, Mughal S, Szczepura A, et al. Enhanced diabetes care to patients of south Asian ethnic origin (the United Kingdom Asian Diabetes Study): a cluster randomised controlled trial. Lancet 2008 ; 371 : 1769 -76. OpenUrl CrossRef PubMed Web of Science
• ↵ Jolly K, Bradley F, Sharp S, Smith H, Thompson S, Kinmonth AL, et al. Randomised controlled trial of follow up care in general practice of patients with myocardial infarction and angina: final results of the Southampton heart integrated care project (SHIP). The SHIP Collaborative Group. BMJ 1999 ; 318 : 706 -11. OpenUrl Abstract / FREE Full Text
• ↵ Moher M, Yudkin P, Wright L, Turner R, Fuller A, Schofield T, et al. Cluster randomised controlled trial to compare three methods of promoting secondary prevention of coronary heart disease in primary care. BMJ 2001 ; 322 : 1338 . OpenUrl Abstract / FREE Full Text
• ↵ New JP, Mason JM, Freemantle N, Teasdale S, Wong L, Bruce NJ, et al. Educational outreach in diabetes to encourage practice nurses to use primary care hypertension and hyperlipidaemia guidelines (EDEN): a randomized controlled trial. Diabet Med 2004 ; 21 : 599 -603. OpenUrl CrossRef PubMed Web of Science
• ↵ O’Hare JP, Raymond NT, Mughal S, Dodd L, Hanif W, Ahmad Y, et al. Evaluation of delivery of enhanced diabetes care to patients of South Asian ethnicity: the United Kingdom Asian Diabetes Study (UKADS). Diabet Med 2004 ; 21 : 1357 -65. OpenUrl CrossRef PubMed Web of Science
• ↵ Becker DM, Yanek LR, Johnson WR Jr, Garrett D, Moy TF, Reynolds SS, et al. Impact of a community-based multiple risk factor intervention on cardiovascular risk in black families with a history of premature coronary disease. Circulation 2005 ; 111 : 1298 -304. OpenUrl Abstract / FREE Full Text
• ↵ Bosworth HB, Olsen MK, Dudley T, Orr M, Goldstein MK, Datta SK, et al. Patient education and provider decision support to control blood pressure in primary care: a cluster randomized trial. Am Heart J 2009 ; 157 : 450 -6. OpenUrl CrossRef PubMed Web of Science
• ↵ Artinian NT, Washington OG, Templin TN. Effects of home telemonitoring and community-based monitoring on blood pressure control in urban African Americans: a pilot study. Heart Lung 2001 ; 30 : 191 -9. OpenUrl CrossRef PubMed Web of Science
• ↵ Woollard J, Burke V, Beilin LJ. Effects of general practice-based nurse-counselling on ambulatory blood pressure and antihypertensive drug prescription in patients at increased risk of cardiovascular disease. J Hum Hypertens 2003 ; 17 : 689 -95. OpenUrl CrossRef PubMed Web of Science
• ↵ Woollard J, Beilin L, Lord T, Puddey I, MacAdam D, Rouse I. A controlled trial of nurse counselling on lifestyle change for hypertensives treated in general practice: preliminary results. Clin Exp Pharmacol Physiol 1995 ; 22 : 466 -8. OpenUrl PubMed Web of Science
• ↵ Artinian NT, Flack JM, Nordstrom CK, Hockman EM, Washington OG, Jen KL, et al. Effects of nurse-managed telemonitoring on blood pressure at 12-month follow-up among urban African Americans. Nurs Res 2007 ; 56 : 312 -22. OpenUrl CrossRef PubMed Web of Science
• ↵ Rudd P, Miller NH, Kaufman J, Kraemer HC, Bandura A, Greenwald G, et al. Nurse management for hypertension. A systems approach. Am J Hypertens 2004 ; 17 : 921 -7. OpenUrl Abstract / FREE Full Text
• ↵ Taylor CB, Miller NH, Reilly KR, Greenwald G, Cunning D, Deeter A, et al. Evaluation of a nurse-care management system to improve outcomes in patients with complicated diabetes. Diabetes Care 2003 ; 26 : 1058 -63. OpenUrl Abstract / FREE Full Text
• ↵ Garcia-Pena C, Thorogood M, Armstrong B, Reyes-Frausto S, Munoz O. Pragmatic randomized trial of home visits by a nurse to elderly people with hypertension in Mexico. Int J Epidemiol 2001 ; 30 : 1485 -91. OpenUrl Abstract / FREE Full Text
• ↵ Jiang X, Sit JW, Wong TK. A nurse-led cardiac rehabilitation programme improves health behaviours and cardiac physiological risk parameters: evidence from Chengdu, China. J Clin Nurs 2007 ; 16 : 1886 -97. OpenUrl CrossRef PubMed Web of Science
• ↵ Lee LL, Arthur A, Avis M. Evaluating a community-based walking intervention for hypertensive older people in Taiwan: a randomized controlled trial. Prev Med 2007 ; 44 : 160 -6. OpenUrl CrossRef PubMed Web of Science
• ↵ Logan AG, Milne BJ, Achber C, Campbell WP, Haynes RB. Work-site treatment of hypertension by specially trained nurses. A controlled trial. Lancet 1979 ; 2 : 1175 -8. OpenUrl PubMed Web of Science
• ↵ McLean DL, McAlister FA, Johnson JA, King KM, Makowsky MJ, Jones CA, et al. A randomized trial of the effect of community pharmacist and nurse care on improving blood pressure management in patients with diabetes mellitus: study of cardiovascular risk intervention by pharmacists-hypertension (SCRIP-HTN). Arch Intern Med 2008 ; 168 : 2355 -61. OpenUrl CrossRef PubMed Web of Science
• ↵ Tobe SW, Pylypchuk G, Wentworth J, Kiss A, Szalai JP, Perkins N, et al. Effect of nurse-directed hypertension treatment among First Nations people with existing hypertension and diabetes mellitus: the Diabetes Risk Evaluation and Microalbuminuria (DREAM 3) randomized controlled trial. CMAJ 2006 ; 174 : 1267 -71. OpenUrl Abstract / FREE Full Text
• ↵ Jewell D, Hope J. Evaluation of a nurse-run hypertension clinic in general practice. Practitioner 1988 ; 232 : 484 -7. OpenUrl PubMed Web of Science
• ↵ Campbell NC, Ritchie LD, Thain J, Deans HG, Rawles JM, Squair JL. Secondary prevention in coronary heart disease: a randomised trial of nurse led clinics in primary care. Heart 1998 ; 80 : 447 -52. OpenUrl Abstract / FREE Full Text
• ↵ Hill MN, Han HR, Dennison CR, Kim MT, Roary MC, Blumenthal RS, et al. Hypertension care and control in underserved urban African American men: behavioral and physiologic outcomes at 36 months. Am J Hypertens 2003 ; 16 : 906 -13. OpenUrl CrossRef PubMed Web of Science
• ↵ Kastarinen MJ, Puska PM, Korhonen MH, Mustonen JN, Salomaa VV, Sundvall JE, et al. Non-pharmacological treatment of hypertension in primary health care: a 2-year open randomized controlled trial of lifestyle intervention against hypertension in eastern Finland. J Hypertens 2002 ; 20 : 2505 -12. OpenUrl CrossRef PubMed Web of Science
• ↵ Mundinger MO, Kane RL, Lenz ER, Totten AM, Tsai WY, Cleary PD, et al. Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial. JAMA 2000 ; 283 : 59 -68. OpenUrl CrossRef PubMed Web of Science
• ↵ Schroeder K, Fahey T, Hollinghurst S, Peters TJ. Nurse-led adherence support in hypertension: a randomized controlled trial. Fam Pract 2005 ; 22 : 144 -51. OpenUrl Abstract / FREE Full Text
• ↵ Denver EA, Barnard M, Woolfson RG, Earle KA. Management of uncontrolled hypertension in a nurse-led clinic compared with conventional care for patients with type 2 diabetes. Diabetes Care 2003 ; 26 : 2256 -60. OpenUrl Abstract / FREE Full Text
• ↵ Guerra-Riccio GM, Artigas Giorgi DM, Consolin-Colombo FM, Barreto-Filho JA, Lopes HF, Fleury Camargo AL, et al. Frequent nurse visits decrease white coat effect in stage III hypertension. Am J Hypertens 2004 ; 17 : 523 -8. OpenUrl Abstract / FREE Full Text
• ↵ Ko GT, Li JK, Kan EC, Lo MK. Effects of a structured health education programme by a diabetic education nurse on cardiovascular risk factors in Chinese type 2 diabetic patients: a 1-year prospective randomized study. Diabet Med 2004 ; 21 : 1274 -9. OpenUrl CrossRef PubMed Web of Science
• ↵ Litaker D, Mion L, Planavsky L, Kippes C, Mehta N, Frolkis J. Physician-nurse practitioner teams in chronic disease management: the impact on costs, clinical effectiveness, and patients’ perception of care. J Interprof Care 2003 ; 17 : 223 -7. OpenUrl CrossRef PubMed
• ↵ New JP, Mason JM, Freemantle N, Teasdale S, Wong LM, Bruce NJ, et al. Specialist nurse-led intervention to treat and control hypertension and hyperlipidemia in diabetes (SPLINT): a randomized controlled trial. Diabetes Care 2003 ; 26 : 2250 -5. OpenUrl Abstract / FREE Full Text
• ↵ Tonstad S, Alm CS, Sandvik E. Effect of nurse counselling on metabolic risk factors in patients with mild hypertension: a randomised controlled trial. Eur J Cardiovasc Nurs 2007 ; 6 : 160 -4. OpenUrl Abstract / FREE Full Text
• ↵ McHugh F, Lindsay GM, Hanlon P, Hutton I, Brown MR, Morrison C, et al. Nurse led shared care for patients on the waiting list for coronary artery bypass surgery: a randomised controlled trial. Heart 2001 ; 86 : 317 -23. OpenUrl Abstract / FREE Full Text
• ↵ Bengtson A, Drevenhorn E. The nurse’s role and skills in hypertension care: a review. Clin Nurse Spec 2003 ; 17 : 260 -8. OpenUrl CrossRef PubMed
• ↵ Roland M, Torgerson DJ. Understanding controlled trials: what are pragmatic trials? BMJ 1998 ; 316 : 285 . OpenUrl FREE Full Text
• ↵ Sol BG, van der Bijl JJ, Banga JD, Visseren FL. Vascular risk management through nurse-led self-management programs. J Vasc Nurs 2005 ; 23 : 20 -4. OpenUrl CrossRef PubMed
• ↵ Page T, Lockwood C, Conroy-Hiller T. Effectiveness of nurse-led cardiac clinics in adult patients with a diagnosis of coronary heart disease. International Journal of Evidence-Based Healthcare 2005 ; 3 : 2 -26. OpenUrl CrossRef
• ↵ Kinnersley P, Anderson E, Parry K, Clement J, Archard L, Turton P, et al. Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting “same day” consultations in primary care. BMJ 2000 ; 320 : 1043 -8. OpenUrl Abstract / FREE Full Text
• ↵ Dierick-van Daele AT, Steuten LM, Metsemakers JF, Derckx EW, Spreeuwenberg C, Vrijhoef HJ. Economic evaluation of nurse practitioners versus GPs in treating common conditions. Br J Gen Pract 2010 ; 60 : e28 -e35. OpenUrl Abstract / FREE Full Text
• ↵ Houston MC. Handbook of hypertension. Wiley-Blackwell, 2009.
• ↵ Cook NR, Cohen J, Hebert PR, Taylor JO, Hennekens CH. Implications of small reductions in diastolic blood pressure for primary prevention. Arch Intern Med 1995 ; 155 : 701 -9. OpenUrl CrossRef PubMed Web of Science
• ↵ Neal B, MacMahon S, Chapman N. Effects of ACE inhibitors, calcium antagonists, and other blood-pressure-lowering drugs: results of prospectively designed overviews of randomised trials. Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet 2000 ; 356 : 1955 -64. OpenUrl CrossRef PubMed Web of Science

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Guideline-Driven Management of Hypertension: An Evidence-Based Update

Affiliations.

• 1 Department of Medicine, University of Virginia Health System, Charlottesville (R.M.C).
• 2 Department of Medicine, Case-Western Reserve University School of Medicine, Cleveland, OH (J.T.W.).
• 3 Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN (S.J.T.).
• 4 Departments of Epidemiology and Medicine, Tulane University, New Orleans, LA (P.K.W.).
• PMID: 33793326
• PMCID: PMC8034801
• DOI: 10.1161/CIRCRESAHA.121.318083

Several important findings bearing on the prevention, detection, and management of hypertension have been reported since publication of the 2017 American College of Cardiology/American Heart Association Blood Pressure Guideline. This review summarizes and places in context the results of relevant observational studies, randomized clinical trials, and meta-analyses published between January 2018 and March 2021. Topics covered include blood pressure measurement, patient evaluation for secondary hypertension, cardiovascular disease risk assessment and blood pressure threshold for drug therapy, lifestyle and pharmacological management, treatment target blood pressure goal, management of hypertension in older adults, diabetes, chronic kidney disease, resistant hypertension, and optimization of care using patient, provider, and health system approaches. Presenting new information in each of these areas has the potential to increase hypertension awareness, treatment, and control which remain essential for the prevention of cardiovascular disease and mortality in the future.

Keywords: American Heart Association; antihypertensive agents; blood pressure; cardiovascular disease; hypertension; mortality.

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• Predictive characteristics and model development for acute heart failure preceding hip fracture surgery in elderly hypertensive patients: a retrospective machine learning approach. Yu Q, Fu M, Wang Z, Hou Z. Yu Q, et al. BMC Geriatr. 2024 Mar 28;24(1):296. doi: 10.1186/s12877-024-04892-8. BMC Geriatr. 2024. PMID: 38549043 Free PMC article.
• Functional Roles of Furin in Cardio-Cerebrovascular Diseases. Wichaiyo S, Koonyosying P, Morales NP. Wichaiyo S, et al. ACS Pharmacol Transl Sci. 2024 Feb 7;7(3):570-585. doi: 10.1021/acsptsci.3c00325. eCollection 2024 Mar 8. ACS Pharmacol Transl Sci. 2024. PMID: 38481703 Review.
• Roth GA, Mensah GA, Johnson CO, et al. Global burden of cardiovascular disease and risk factors; 1990-2019: Update from the GBD 2019 Study. J Am Coll Cardiol. 2020;76:2982–3021. - PMC - PubMed
• Pencina MJ, Navar AM, Wojdyla D, Sanchez RJ, Khan I, Elassal J, D’Agostino RB Sr, Peterson ED, Sniderman AD. Quantifying importance of major risk factors for coronary heart disease. Circulation. 2019;139:1603–1611. - PMC - PubMed
• Ettehad D, Emdin CA, Kiran A, Anderson SG, Callender T, Emberson J, Chalmers J, Rodgers A, Rahimi K. Blood pressure lowering for the prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet. 2016;387:957–967. - PubMed
• Bundy JD, Li C, Stuchlik P, Bu X, Kelly TN, Mills KT, He H, Chen J, Whelton PK, He J. Systolic blood pressure reduction and risk of cardiovascular disease and mortality: a systematic review and network meta-analysis. JAMA Cardiol. 2017;2:775–781. - PMC - PubMed
• Carey RM, Muntner P, Bosworth HB, Whelton PK. Prevention and control of hypertension. JACC Health Promotion Series. J Am Coll Cardiol. 2018;72:1278–1293. - PMC - PubMed

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Hypertension across the lifespan

Older adults.

Hilliard, Tara C. PhD, APRN, ACNP-BC; Bruce, Kellie PhD, APRN, FNP-BC; Esquibel, Karen A. PhD, APRN, CPNP-PC; Mello, Inola DNP, APRN, FNP-C; Moore, Amy DNP, APRN, FNP-C

At Texas Tech University Health Sciences Center School of Nursing in Lubbock, Tex., Tara C. Hilliard is an Associate Professor and Director of Adult Gerontology Acute Care NP Studies, Kellie Bruce is an Associate Professor and Director of Family NP Studies, Karen A. Esquibel is an Associate Professor and Director of Pediatric NP Studies, Inola Mello is an Associate Professor of Nursing, and Amy Moore is an Associate Professor of Nursing.

The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

For 77 additional nursing continuing professional development articles related to cardiovascular topics, go to NursingCenter.com/CE .

Effective diagnosis and management in the older adult population can increase functional capacity and decrease morbidity and mortality.

Editor's Note: In previous issues, we've looked at pediatric and adult hypertension. Join us this issue for the last of our three-part series as we explore hypertension in older adult patients .

The older adult population has expanded exponentially over the past quarter century in the US. The number of individuals older than age 80 has more than doubled in the past decade. The lifetime risk of being diagnosed with hypertension (HTN) is greater than 90% in those older than age 55. This lifetime risk, combined with the rising number of older adults, has led to an increased prevalence of HTN within this population. Comorbidities can make treating HTN more complex in older adults, with the need to consider treatment in coordination with other disease processes. Untreated HTN in the older adult patient can lead to cognitive decline and increased morbidity and mortality from cardiovascular and renal events.

Case studies

A 73-year-old female patient with a body mass index (BMI) of 19 has been treated for stage 1 HTN with chlorthalidone 25 mg once daily for the last 10 years. Her atherosclerotic cardiovascular disease (ACVD) risk is less than 10% and her complete blood cell (CBC) count, electrolytes, thyroid-stimulating hormone (TSH), urinalysis, and ECG have been within normal limits since her diagnosis.

She occasionally drinks one glass of red wine, has never smoked, and has done routine strength training for 30 minutes a day, three times a week, for the past 5 years. She lives alone in a split-level home and uses the stairs multiple times each day. Even before her diagnosis, she was dedicated to eating healthy. Her diet consists of fruits, vegetables, regular protein in the form of baked chicken and fish, dairy products, and whole grains; she rarely eats out. She takes supplemental calcium, vitamin D, and magnesium.

The patient's BP remains at the goal of less than 130/80 mm Hg. She monitors her BP at home periodically, and those readings indicate that there's no masked uncontrolled HTN. She's scheduled for her annual follow-up appointment and advised to continue home BP monitoring.

A 58-year-old Black male patient was diagnosed with stage 2 HTN after having four separate BP readings greater than 140/90 mm Hg during the past year. The BP readings were obtained accurately using a calibrated automatic monitor with an appropriate size cuff. The patient sat upright in the chair with both feet flat on the floor and his arm supported. The nurse verified that he hadn't smoked, consumed caffeine, or exercised at least 30 minutes before checking his BP. The patient refused to start antihypertensive medication but did agree to ambulatory monitoring and a follow-up appointment in 1 month.

The patient has a previous history of smoking and a BMI of 32. His lab results, including fasting blood glucose, CBC count, lipid panel, serum creatine with estimated glomerular filtration rate, basic metabolic panel, TSH, urinalysis, uric acid, ECG, and an echocardiogram, are all within normal limits except for elevated total cholesterol and low-density lipoprotein cholesterol. His ACVD risk is calculated at 10.4%. As a Black male, the patient's goal BP is less than 130/80 mm Hg regardless of a diagnosis of diabetes, heart failure, or chronic kidney disease (CKD).

Environmental factors are evaluated, including access to DASH diet food sources, routine activity, and alcohol limitations. The DASH diet includes foods low in sodium and high in fiber, potassium-rich fruits and vegetables, lean proteins, fish, and dairy. Calcium supplements are recommended and weight loss with the addition of regular exercise is also encouraged.

At his follow-up appointment, the patient's ambulatory and office BP readings average 156/100 mm Hg. The concern for cardiovascular events and CKD due to the risk of more severe HTN in Black adults is stressed with the patient and he agrees to start medication. Hydrochlorothiazide 25 mg and amlodipine 5 mg daily is initiated. A low-sodium diet is stressed based on genetic salt sensitivity. The patient is scheduled to return for follow-up in 1 month to reassess his BP after initiation of antihypertensive therapy.

Significant epidemiology

Individuals with CVD are living longer today than in previous eras. Due to multiple comorbidities, the needs of older patients with CVD are more complex. Age itself is a risk factor that predisposes older adults to CVD. In 1900, the number of people age 65 and older in the US was approximately 3 million. With successful advances in medical care, the numbers now exceed 46 million, with a substantial increase in those who are age 85 and older.

Older adults are likely to develop some type of CVD due to physiologic and pathologic changes as they age, even with no previous history of CVD, and these changes can also lead to HTN (see The aging heart ). The heart becomes thicker and stiffer with age, including an increase in myocardial thickness with left ventricular hypertrophy and enlargement of the left atrium. As the intimal-medial thickness of the vascular wall increases, elastic fibers fray and the ability for the arterial wall to expand and contract is reduced. Stiffening of the arteries results in a rise in systolic pressure. The diastolic pressure rises until approximately age 60 and then begins to drop due to a lack of recoil from the larger arteries.

HTN occurs in more than 70% of adults age 65 and older. Research has substantiated that treatment for HTN in people age 60 and older prevents myocardial infarctions and decreases the risk of death due to cardiovascular events. The 2008 Hypertension in the Very Elderly Trial proposed that a BP of 150/80 mm Hg or lower was beneficial for those older than age 75. Conversely, the 2015 SPRINT Trial (updated in 2018) found that a lower systolic BP with a target of 120 mm Hg in older adults is more effective in preventing cardiovascular events. In addition, the SPRINT Trial found a decrease in the incidence of dementia and fewer complications in those with CKD. Guidelines published in 2017 by the American College of Physicians and the American Academy of Family Physicians recommend pharmacologic treatment for patients age 60 and older who have a systolic BP of 150 mm Hg or greater. They further stratified older patients as “elderly” and “very old,” with less stringent targets as the patient ages.

How aggressively a patient with elevated BP is treated must be individualized. Close BP monitoring in older patients must be thorough due to fall risk and the potential for deterioration in renal function. Masked diastolic hypotension can be a problematic and not uncommon occurrence in older patients who are being treated for HTN. When deciding about BP targets, the benefits must outweigh the risks. Target pressures may change as the patient ages, with consideration for quality of life.

Guidelines for diagnosis

The American College of Cardiology (ACC) and the American Heart Association (AHA) continue to sponsor the development of guidelines for the prevention, detection, evaluation, and management of high BP in older adults, defined as those age 65 and older. The ACC/AHA guidelines are intended to support patients at risk for developing CVD. It's important to identify common CVD risk factors in patients with HTN. Adults age 65 and older have the highest prevalence of HTN and the greatest risk of morbidity and mortality due to CVD. They also tend to be underdiagnosed and undertreated for HTN.

The guidelines indicate a target BP of less than 130/80 mm Hg. The designated BP threshold for the initiation of pharmacotherapy is greater than or equal to 130/80 mm Hg as a more aggressive limit to prevent CVD. Once diagnosed with HTN, BP readings are categorized as stage 1 or stage 2. Systolic and diastolic BP are based on the average of two or more readings obtained on two or more separate occasions.

The BP categories for older adults are:

• normal BP: systolic <120/80 mm Hg
• elevated BP: systolic 120 to 129/80 mm Hg
• stage 1 HTN: systolic 130 to 139 mm Hg or diastolic 80 to 89 mm Hg
• stage 2 HTN: systolic ≥140 mm Hg or diastolic ≥90 mm Hg.

It's critical that accurate measurement and recording of BP take place to minimize errors in diagnosis and treatment. The patient should sit quietly for 5 minutes before taking the BP reading. Support the limb used to measure BP, ensure the cuff is at the level of the heart, select the correct cuff size, and deflate it slowly while auscultating. The ACC/AHA guidelines also advise the use of clinical judgment to determine BP targets in older patients with limited life expectancy and multiple comorbidities.

Guidelines for treatment

Treatment of HTN in older adults is multifaceted. There are several distinctive elements that must be considered when creating a treatment plan for an older patient with HTN. Polypharmacy presents a significant treatment dilemma in many older patients. Drug-drug interactions may result in negative adverse reactions, such as hypotension and bradycardia. Also compounding the treatment dilemma is the fact that many randomized controlled clinical trials include few older subjects; less outcome data may be available for the older adult population.

Once a diagnosis of HTN is established, the treatment plan should be individualized based on patient comorbidities, functional ability, cognitive state, and family/caregiver support. The BP goals for older adults are well established. Treatment guidelines are specifically designed to correlate with each category. Prevailing thought indicates that a lower systolic BP in older patients is associated with improved long-term outcomes.

Before initiating pharmacotherapy for an older patient, lifestyle modifications should be attempted, including the adoption of a low-sodium (1,000 mg/day or less), low-carbohydrate, balanced diet; weight loss when appropriate; and routine aerobic exercise (90 to 150 minutes/week). Patients should also be educated about tobacco cessation, when appropriate, and limited alcohol intake. Medication reconciliation should be completed at each visit with an eye toward detecting drugs that may increase BP, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and over-the-counter (OTC) cold medications (see A closer look at OTC medications ). Stress reduction techniques, such as meditation and biofeedback, should be addressed with each patient. When appropriate, patients should be screened for secondary causes of HTN, which include excessive use of alcohol, NSAID use, illicit drug use, obstructive sleep apnea, and CKD.

If nonpharmacologic interventions are unsuccessful, pharmacotherapy should be initiated. Before initiation of any antihypertensive medication, the patient's baseline renal function and electrolyte values should be evaluated. If there are abnormalities, the condition should be further evaluated. Patients should also be evaluated for their ability to participate in the treatment plan, including understanding medication instructions, home management techniques such as BP and pulse recordings, and medication adverse reactions. The patient's family and/or caregiver should always be actively involved in drafting the treatment plan. After pharmacotherapy is initiated, the patient should be seen back in the office within a few weeks for follow-up.

Angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers, thiazide diuretics, and calcium channel blockers are considered acceptable as first-line medications for older patients. Due to the risk of bradycardia, beta-blockers aren't recommended as initial single medication therapy. The risk of hypotension eliminates alpha-blockers as first-line treatment in older patients.

Because BP control in older adults is more complex, a multidrug approach is often required. Initial treatment should include one of the four drug classes mentioned above. A single medication should be trialed first. If the first drug, at its maximal dosage, is unsuccessful at bringing the BP into target range, a second drug from the preferred first-line options should be started. If necessary, a third medication can be used.

Dual medication therapy may be taken in a single pill; for example, lisinopril/hydrochlorothiazide (HCTZ). However, the dual medication pills should only be used once the patient has established tolerance for both the drugs contained in the pill. Beginning HTN therapy with a dual medication pill can make it difficult to determine the source of adverse drug reactions. For example, a patient is initially started on lisinopril/HCTZ for HTN. They experience a significant skin rash 3 days after starting the combination medication. Is it the lisinopril or the HCTZ causing the rash?

All patients should be taught how to properly check BP at home. They should check their BP routinely and keep a log of the readings. The log should be brought to each office visit. If patients are physically or cognitively unable to check their own BP at home, the caregiver should be taught proper techniques for BP measurement. Home health nurses can also play a vital role in the care of the older patient with HTN by providing teaching on proper medication administration and supervising patient BP measuring techniques.

Older adults capable of using current healthcare technology apps may benefit in several ways. There are apps that provide reminders for the patient to check their BP, as well as tracking/logging their BP. Other apps provide medication reminders.

Nursing implications

Nurses play a key role in improving BP monitoring and patient outcomes, providing holistic care as a member of the interdisciplinary team. Key points for nurses include the following:

• select the appropriate size BP cuff to ensure accurate BP measurement; the cuff bladder should cover 80% of the length of the upper arm
• apply appropriate technique: have the patient sit comfortably with both feet on the floor, their legs uncrossed, their back supported, and their arms at heart level; deflate the cuff slowly
• ensure vigilant follow-up at regularly scheduled intervals with the healthcare provider and referral for emergent situations; follow-up care must continue to ensure that BP readings are within range, especially if patients experience changes in diet and weight
• educate patients about medication administration, including the best time to take the medication; the appropriate route; the correct dosage; and potential adverse reactions, such as hypotension, dizziness, and cough
• teach patients how to take BP at home and record the readings; patients should compare their BP cuffs with those used in the clinic regularly to ensure accuracy
• provide nutritional, exercise, and relaxation techniques to help lower BP.

Individualized care

The identification, diagnosis, and management of HTN in older adults must occur with recognition that older patients may have multiple comorbidities that make treatment more complex. We must be cognizant that elevated BP in older patients should be monitored for progression toward a diagnosis of HTN. As the older adult ages, diagnostic and treatment guidelines for HTN allow for a higher systolic BP to reduce fall risk from possible hypotension if BP is treated too aggressively. It's important to consider the risk versus benefit when setting individualized BP goals within the context of the older patient's concurrent diagnoses and mental and functional capacity. Optimal treatment of HTN will result in decreased morbidity and mortality and promote a higher quality of life for older adults.

cheat sheet

Older adult bp categories.

• Normal BP: systolic <120/80 mm Hg
• Elevated BP: systolic 120 to 129/80 mm Hg
• Stage 1 HTN: systolic 130 to 139 mm Hg or diastolic 80 to 89 mm Hg
• Stage 2 HTN: systolic ≥140 mm Hg or diastolic ≥90 mm Hg

A closer look at OTC medications

OTC drugs and herbal supplements often affect BP but because patients often don't consider them to be medications, they may not self-report use. OTC oral, nasal, and ophthalmic decongestants, as well as NSAIDs, are well-known for increasing BP. There's conflicting online information on supplements available to patients. For example, ginger can be found listed as an herb that will both lower and raise BP. Potassium is listed as a nutritional supplement that will regulate BP; however, potassium supplementation can be dangerous for patients taking certain BP medications such as ACE inhibitors. Caffeine, bitter orange, licorice, St. John's wort, ginseng, arnica, guarana, blue cohosh, yohimbe, and chaste berry are known to raise BP. Ephedra and ma huang raise BP and are now illegal in the US; however, some supplements may contain ephedra-like compounds that aren't indicated on the packaging. Questions regarding OTC medications and herbal and other supplements must always be a component of nursing assessment for patients with HTN.

INSTRUCTIONS Hypertension across the lifespan: Older adults

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Late-Breaking Hypertension Studies Address Medication Timing, Benefits of Combination Pills, More

Aug 31, 2024

ACC News Story

New late-breaking science presented at ESC Congress 2024 in London adds to the growing body of evidence looking at the potential benefits of single combination pills in managing hypertension, as well as whether evening vs. morning administration of blood pressure (BP)-lowering medications affects cardiovascular outcomes.

On the medication-timing front, two separate trials – the BedMed and BedMed-Frail trials – found no major differences in major cardiovascular events or safety among both primary care and nursing home patients taking blood pressure medications in the morning vs. the evening.

"We found bedtime vs. morning administration [provided] no difference in MACE, nor in potential hypotensive, visual, cognitive or other safety events in a general population and importantly, in frail older patients, a subgroup who are generally excluded from clinical trials," said Principal Investigator Scott Garrison, MD . "We can now dismiss the treatment timing as being important and advise patients to take their BP medication when they are least likely to forget."

In the first of three trials looking at combination pills, a single-pill combination (GMRx2) containing low doses of telmisartan, amlodipine, and indapamide "showed good tolerability and clinically relevant BP reductions" in early treatment of patients with mild to moderate hypertension compared with placebo. The trial, which was simultaneously published in JACC , randomized participants in a 2:2:1 ratio to GMRx2 1/4 dose (telmisartan 10 mg/amlodipine 1.25 mg/indapamide 0.625 mg), GMRx2 1/2 dose (telmisartan 20 mg/amlodipine 2.5 mg/indapamide 1.25 mg), or placebo.

"GMRx2 reduced BP quickly in mild-to-moderate hypertension and more effectively than dual therapy in a broad, large hypertensive population, without safety concerns," said Principal Investigator Anthony Rodgers, MBCHB, MPH, PhD . "The availability of a single-pill combination could help to reduce current therapeutic inertia, helping patients achieve BP control quickly in a small number of steps, with potential benefits for improved adherence."

In a related editorial comment , Oyere K. Onuma, MD, MSc, FACC , noted that the results from the trial are the first in a series of studies aimed at obtaining regulatory approval for the combination pill and highlighted the "need for additional further research to assess its efficacy against usual care strategies in higher risk populations and to define the best strategies to support widespread implementation in target populations." Onuma writes: "In the face of tremendous innovations and progress in many facets of cardiovascular care, time is overdue for a major paradigm shift in BP control. Low-dose single pill combinations can and should be a key component of that change."

A second study out of Nigeria and simultaneously published in JAMA compared the efficacy and safety of GMRx2 in triple one-quarter, one-half, and standard doses (10/1.25/0.625 mg; 20/2.5/1.25 mg; and 40/5/2.5 mg) with standard care among Black African adults with uncontrolled hypertension.

"We found that the effects of GMRx2 in Nigerian patients appeared consistent with those seen in broader populations, demonstrating excellent effectiveness, even when compared against a standard-care protocol that achieved much better results than usually seen in routine practice," said main investigator Dike Ojji, MD .

In a related editorial comment also published in JAMA , George A. Mensah, MD, FACC , said the greatest value from the Nigerian study and others like it "will come when the low-dose, triple-drug combination pill protocols become widely available and used sustainably in the long term by all who need it." He writes: "As the old African proverb teaches, a sick man who eats many herbs may not know what made him well – but if the concoction is available, accessible, affordable, acceptable, safe and effective, and if it brings him good health, he will gladly take it every time. So it will be for the low-dose combination pills for hypertension."

In a third trial – QUADRO – researchers found that adding isoprolol to a combination of three other BP-lowering drugs in a quadruple single-pill combination was more effective at reducing BP than taking the same three drugs in separate pills in patients with resistant hypertension.

According to the trial investigators, individuals with resistant hypertension typically need to take multiple medications to control their hypertension, which often contributes to greater non-adherence. "The availability of a quadruple single-pill combination could help with non-adherence and provide much-needed effective BP control in resistant or difficult-to-treat hypertension," they said.

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: ESC Congress, ESC24, Antihypertensive Agents, Myocardial Infarction, Heart Failure, African Americans

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Article Contents

Data availability, zilebesiran, a ribonucleic acid interference agent targeting angiotensinogen, proves a promising approach in hypertension.

Conflict of interest: Professor Webb’s employer, the University of Edinburgh, has been paid by Alnylam for his contributions to the zilebesiran programme in hypertension. He has undertaken recent consultancy roles with Idorsia, Janssen, and Silence pharmaceuticals in the field of cardiovascular research.

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David J Webb, Zilebesiran, a ribonucleic acid interference agent targeting angiotensinogen, proves a promising approach in hypertension, Cardiovascular Research , Volume 120, Issue 10, July 2024, Pages e41–e43, https://doi.org/10.1093/cvr/cvae140

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Hypertension (HTN) is estimated to affect one in three adults worldwide, a prevalence that has doubled in the past 20 years and is expected to rise further. 1 As the leading global risk factor for cardiovascular disease, HTN causes over 10 million deaths every year. 2 Despite its consequences, HTN remains undertreated, with less than half of those treated exhibiting controlled blood pressure (BP). 1 Existing treatments have limitations of efficacy, tolerability, and adherence. 3 Indeed, only a worrying 50% of patients are still fully adherent to treatment after 12 months of treatment. One promising new approach is the use of ribonucleic acid (RNA) interference agents that target and knock down hepatic synthesis of angiotensinogen (AGT), the sole precursor of angiotensin peptides ( Figure 1 ). The use of rapidly advancing technology has generated small interfering RNA (siRNA) with low immunogenicity linked to N-galactosidase (Gal-NAc). 4 Gal-NAc siRNAs bind to a receptor (ASGPR) which is exclusively expressed in the liver and present at high abundance, which rapidly transports the siRNAs to endosomes. These serve as a depot for messenger RNA (mRNA) knockdown, to which siRNAs can recycle ( Figure 1 ). Knockdown leads to reduced AGT generation 4 and, as a consequence, renin-mediated angiotensin synthesis. This technique has already been successful therapeutically in rare diseases, 4 as well as in hypercholesterolaemia (by targeting the liver protein PCSK-9). 5

This figure shows the arrival of zilebesiran, a first-in-class AGT siRNA conjugated to triantennary Gal-NAc within the liver circulation followed by (1) high-level binding to the ASGPR; (2) clathrin-mediated endocytosis into endosomes; (3) recycling of ASGPR to the cell membrane and (4) release of AGT siRNA into the cytosol; (5) binding of AGT siRNA to RISC; (6) siRNA unwinding and strand separation; (7) discarding of the passenger strand and (8) binding of the guide strand to AGT mRNA; (9) cleavage of AGT mRNA into fragments; and (10) recycling of the AGT siRNA guide strand for further AGT mRNA cleavage. The endosomal reservoir of siRNA, together with siRNA recycling, likely accounts for the long duration of action in reducing AGT protein and hence reduction of angiotensin II levels and consequently blood pressure. AGT, angiotensinogen; ASGPR, asialoglycoprotein receptor; Gal-NAc, N-galactosidase; RISC, RNA-induced silencing complex. AGT siRNA is shown in green. AGT mRNA and fragments are shown in purple.

The AGT siRNA, zilebesiran, is administered subcutaneously (sc) as a single dose and largely taken up by the liver, where it causes AGT knockdown ( Figure 1 ). The main part (Part A) of Phase I studies 6 used seven single ascending doses of zilebesiran (10, 25, 50, 100, 200, 400, and 800 mg), each with 12 untreated HTN subjects randomly assigned 2:1 to active or placebo treatment. Part B explored the effect of 800 mg zilebesiran sc under high- and low-salt dietary conditions, and Part E explored the effect of 800 mg zilebesiran sc when administered with irbesartan. The primary outcome was safety and tolerability, the secondary outcome was reduction in serum AGT, and the key exploratory outcome was change in BP measured by 24-h ambulatory BP monitoring (ABPM). Of the 107 patients enrolled, 5 had mild, transient injection site reactions, but there were no reports of hypotension, hyperkalaemia, or worsening of renal function resulting in medical intervention. Patients receiving zilebesiran had substantial dose-related decreases in serum AGT levels (≥90% by week 8 for doses ≥ 100 mg) that correlated with the administered dose. Single doses of zilebesiran (≥200 mg) were associated with decreases in systolic BP (SBP; >10 mm Hg) and diastolic BP (DBP; >5 mm Hg) by Week 8. These changes were consistent throughout the diurnal cycle and, at doses of ≥200 mg, sustained at 24 weeks. Results from Part B were consistent with a high-salt diet attenuating the effect on BP and Part E with an augmented effect on BP by co-administration with irbesartan. 6

In summary, zilebesiran was not only well tolerated but also clearly produced substantial dose-dependent reductions in AGT. Additionally, using the gold standard of ABPM, zilebesiran reduced BP to a substantial and clinically relevant degree (∼8 and 12 mmHg at 8 and 24 weeks with the 800 mg dose vs. placebo, respectively). Interestingly, as shown in supplementary figure 5 the original phase I paper, substantial AGT knockdown seemed to be important for efficacy in BP reduction, consistent with the 50,000-fold higher levels of AGT in blood than those of renin. 7 The KARDIA programme built on these exciting data. KARDIA-1 8 examined different dosing regimens of zilebesiran in untreated HTN patients, confirming the impressive reduction in SBP seen in Phase I, at ≥15 mmHg vs. placebo, with duration consistent with use of a 600 mg dose at 6-monthly intervals. There were no new safety signals that might hinder the development of the programme. KARDIA-2 examined the effect of combining 600 mg zilebesiran given with an angiotensin 1 receptor blocker (ARB; olmesartan), calcium antagonist (amlodipine), or diuretic (indapamide) in HTN. The top-line results of KARDIA-2 have recently been reported 9 by the manufacturer, Alnylam, as showing clinically significant BP reductions when added to standard of care, and safety and tolerability data were reported as encouraging. The study was presented in April 2024 at the ACC meeting, and, compared with matched blinded placebo, zilebesiran reduced SBP by 14 mmHg in combination with indapamide, 10 mmHg in combination with amlodipine, and 4 mmHg in combination with olmesartan. 10 The next step is initiation of KARDIA-3 (NCT06272487), which addresses the efficacy and safety of zilebesiran used as add-on therapy in a placebo-controlled trial in patients with HTN at high cardiovascular risk who are not controlled by standard of care medicines (on at least two but not more than four medicines). The primary outcome is change from baseline to 3 months in mean seated office SBP, with secondary measures which include ABPM at 3 and 6 months. Again, change in serum AGT will be explored. This programme, therefore, includes treatment-resistant HTN, but not restricted to this group.

Based on what we currently know from KARDIA-1 and -2, the large and durable BP-lowering seen with zilebesiran in HTN in Phase 1 seems to be confirmed, at least out to 6 months. In addition, the studies with a Gal-NAc siRNA for hypercholesterolaemia, inclisiran, suggest that the general safety of the approach will be acceptable. 5 However, there are still hurdles. In particular, the renal risk of combining two inhibitors of the renin–angiotensin system is well described. 11 In contrast, the KARDIA programme explores the safety and additional efficacy of this combination, the results of which will be very interesting. In addition, there remains the issue of reversing the effects of zilebesiran during an episode of hypovolaemia (such as through dehydration, sepsis, or haemorrhage) to avoid acute kidney injury (AKI). This problem has not yet emerged but has been considered. Part B of the Phase 1 study 5 showed that a high-salt diet could reverse BP-lowering, and intravenous (iv) saline might do this faster. In spontaneously hypertensive rats, 12 BP could be rapidly reversed by iv administration of angiotensin II or noradrenaline and partially restored by fludrocortisone. If sustained reversal might be required, a specific REVERSIR™ 13 has been designed as a short, synthetic, high-affinity oligonucleotide that can reverse the siRNA’s effect substantially over a few days. Whether this approach will be needed is currently unclear, but AKI likely remains the major risk of using an AGT siRNA in HTN. Of course, studies of safety and clinical effectiveness in broader populations, including patients with co-morbidities, are still awaited, as are cardiovascular outcome studies. The cost-effectiveness of this approach will depend on pricing (as existing treatments are all relatively cheap).

Finally, if shown to be safe and acceptable to patients, the AGT siRNA zilebesiran stands out as a promising approach to the combined problems of treatment-to-target and of non-adherence in HTN treatment (a long-standing and substantial problem in routine care), because of the large size and durability of its BP-lowering effect.

No funding was used in completing this work.

No new data were generated or analysed in support of this research.

NCD Risk Factor Collaboration (NCD-RisC) . Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants . Lancet 2021 ; 398 : 957 – 980 .

WHO . Hypertension Fact Sheet, March 2023. https://www.who.int/news-room/fact-sheets/detail/hypertension (14 April 2024, date last accessed).

Burnier M , Egan BM . Adherence in hypertension . Circ Res 2019 ; 124 : 1124 – 1140 .

Google Scholar

Ranasinghe P , Addison ML , Dear JW , Webb DJ . Small interfering RNA: discovery, pharmacology and clinical development—an introductory review . Brit J Pharmacol 2023 ; 180 : 2697 – 2720 .

Ray KK , Wright RS , Kallend D , Koenig W , Leiter LA , Raal FJ , Bisch JA , Richardson T , Jaros M , Wijngaard PLJ , Katelein JP ; for the ORION-10 and ORION-11 Investigators . Two phase 3 trials of inclisiran in patients with elevated LDL cholesterol . N Engl J Med 2020 ; 382 : 1507 – 1519 .

Desai AS , Webb DJ , Taubel J , Casey S , Cheng Y , Robbie GJ , Foster D , Huang SA , Rhyee S , Sweetser MT , Bakris GL . Zilebesiran, an RNA interference therapeutic agent for hypertension . New Engl J Med 2023 ; 389 : 228 – 238 .

Addison ML , Ranasinghe P , Webb DJ . Emerging insights and future prospects for therapeutic application of siRNA targeting angiotensinogen in hypertension . Expert Rev Clin Pharmacol 2023 ; 16 : 1025 – 1033 .

Bakris GL , Saxena M , Gupta A , Chalhoub F , Lee J , Stiglitz D , Makarova N , Goyal N , Guo W , Zappe D , Desai AS ; for the KARDIA-1 Study Group . RNA interference with zilebesiran for mild to moderate hypertension: the KARDIA-1 randomized clinical trial . JAMA 2024 ; 331 : 740 – 749 .

Alnylam Pharmaceuticals Inc . Alnylam Reports Positive KARDIA-2 Topline Study Results Demonstrating Clinically Significant Blood Pressure Reductions When Zilebesiran is Added to Standard of Care Antihypertensives. https://investors.alnylam.com/press-release? id=28036# (9 April 2024, date last accessed).

KARDIA-2: Novel BP-Lowering Drug Reduces SBP With Just One Injection. 7 April 2024. https://www.acc.org/Latest-in-Cardiology/Articles/2024/04/02/17/02/sun-8am-phase2-kardia2-acc-2024 (14 April 2024, date last accessed).

Fried LF , Emanuele N , Zhang JH , Brophy M , Conner TA , Duckworth W , Leehey DJ , McCullough PA , O’Connor T , Palevsky PM , Reilly RF , Seliger SL , Warren SR , Watnick S , Peduzzi P , Guarino P ; for the VA NEPHRON-D Investigators . Combined angiotensin inhibition for the treatment of diabetic nephropathy . New Engl J Med 2013 ; 369 : 1892 – 1903 .

Uijl E , Ye D , Ren L . Conventional vasopressor and vasopressor-sparing strategies to counteract the blood pressure-lowering effect of small interfering RNA targeting angiotensinogen . J Am Heart Assoc 2022 ; 11 : e026426 .

Zlatev I , Castoreno A , Brown CR , Qin J , Waldron S , Schlegel MK , Degaonkar R , Shulga-Morskaya S , Xu H , Gupta S , Matsuda S , Akinc A , Rajeev KG , Manoharan M , Maier MA , Jadhav V . Reversal of siRNA-mediated gene silencing in vivo . Nat Biotechnol 2018 ; 36 : 509 – 511 .

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• Int J Community Based Nurs Midwifery
• v.5(3); 2017 Jul

Living with Hypertension: A Qualitative Research

Afzal shamsi, phd.

1 Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran

Nahid Dehghan Nayeri, PhD

2 Nursing and Midwifery Care Research Center, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran

Maryam Esmaeili, PhD

Background:.

Hypertension affects many aspects of the patients’ life. Factors such as attitudes, beliefs and experiences, and social and cultural conditions of patients have effective roles in hypertension treatment process. The aim of this research was to explore perspectives and experiences of patients with hypertension while living with this disease.

This is a qualitative research using content analysis approach. 27 hypertensive patients who referred to hospitals affiliated to Tehran University of Medical Sciences were selected based on purposive sampling, and semi-structured interviews were carried out. Graneheim and Lundman’s approach was used for analysis of data and Lincoln and Guba’s criteria were used to confirm the trustworthiness of the study’s findings

Experiences of the participants were divided into three main categories as follows: (1) disease shadow; (2) dual understanding of the effect of drug therapy consisting of two sub-categories known as ‘‘perceived benefits,’’ ‘‘negative consequences’’; and (3) facing the disease that includes the two subcategories of ‘‘Compatibility’’ and ‘‘Negligence and denial’’.

Conclusion:

Based on the findings, patients with hypertension had experienced many physical, psychological, social, familial and spiritual problems due to the disease and their cultural context. These patients obtained positive experiences following the compatibility with hypertension. Comprehensive planning tailored to the cultural, social context and their beliefs is necessary to solve problems in these patients.

I NTRODUCTION

Hypertension is a silent disease and is almost without obvious symptoms in its early stages. 1 Patients are healthy at this stage and have good performance. 2 Clinical symptoms and subsequent problems arise after vascular changes 1 which affect many aspects of the lives of the patients. 3 This disease significantly damages many organs of the body as an independent risk factor 4 and causes problems such as cerebrovascular disease, coronary disease, heart failure, chronic renal failure, vascular disease, 5 , 6 and eye problems. 7 The negative effects of hypertension on psychological aspects of these patients in addition to shortcomings in the abilities of the person 8 and its chronic and progressive course lead to reactions such as anxiety and depression in them. 9

Studies have shown that identifying and controlling blood pressure causes can help to prevent development of this disease and its complications. 10 , 11 The World Health Organization reported that prevention, care and treatment of hypertension are among the key points in promoting public health. 12 Since hypertension is usually a lifelong illness, it requires continued treatment. 13 Multiple medications are often prescribed to control hypertension which increase the risk of drug interactions and side effects. 14 However, multifaceted compliance is required in addition to medication to control hypertension and achieve appropriate therapeutic purposes. 15 These patients usually do not comply with treatment approaches and their blood pressure is not well controlled, 16 so a medical institution in the United States has named hypertension as neglected disease due to patients’ failure to comply with treatment guidelines and lack of proper control. 17

The results of a systematic review on the qualitative research revealed that in different ethnicities, causes of high blood pressure or aggravation factors are different. Therefore, the perspectives and experiences of patients should be profoundly examined. In this systematic review, it was concluded that in the patients’ views, the lack of attention of the health team toward the high blood pressure is one of the key obstacles to the success of health programs in these patients. 18 Studies that have examined the perspectives and experiences of patients with hypertension obtained different conclusions as to its causes including the factors such as genetics, race, generation status, 19 nationality, attitudes, beliefs, 18 cultural, social, environmental, and economic subjects. 20 These factors have a significant role in the process of hypertension treatment and patient adherence to treatment regimens. 21 Therefore, recognition of these factors from the perspective of patients and based on their experiences will lead to more precise understanding of the disease which can lead to production of knowledge in this field 22 and help healthcare professionals in effective interventions in the control and treatment of hypertension. 23 Accordingly, qualitative studies can be conducted for a true understanding of the behaviors, lifestyles, knowledge, attitudes, feelings, beliefs, values and experiences of these patients. 24

Results of the evaluations of researchers of the present research showed that there was no research in this area in Iran and limited researches of other countries cannot be generalized due to cultural, social and economic differences. Thus, the present qualitative research aimed at exploring the perspectives and experiences of living with the disease in hypertensive patients.

M ATERIALS AND M ETHODS

This is a qualitative research using the conventional content analysis approach.

Settings and Participants

This study was conducted from August 2015 to April 2016. Participants in this study included 27 patients with hypertension who referred to medical centers affiliated to Tehran University of Medical Sciences. Purposive sampling was used with maximum diversity (depending on the age, gender, education, marital status and duration).

Inclusion criteria were willingness to participate in the study, ability to share experiences, fluency in Persian language, alertness and orientation, diagnosed with hypertension for at least two years and age older than 18 years. The exclusion criteria of the study were having cognitive impairment, mental illness confirmed by a physician or the individual patient. Sampling continued until data saturation.

Data Collection

The main method of data collection in this research was deep semi-structured interviews. The researcher explained the objective of the study and research questions for each participant. Interview was conducted at the due time and place based on the participant’s comfort. The participants agreed to participate in the study and signed informed consent. Interviews were conducted in a private room. Each interview started with general questions such as “What experiences have you had after hypertension?” and “What types of effects has hypertension had on your life?”

Participants were asked to express their understanding after being hypertensive. The interview continued to obtain a deep understanding of the studied subject. Interviews were recorded using a digital voice recorder. At the end of each interview, they were written word by word and analyzed. Duration of the interview sessions was between 45 and 90 minutes based on tolerance and interest of the participants to describe their experiences. In the second session, the interview was carried out in the case of necessity.

Data Analysis

A content analysis method was used to analyze the data, in accordance with Granehim and Lundman; 25 the interviews were reviewed several times to obtain a sense of the whole. Then, the first author extracted units of analysis. The text was divided into condensed meaning units that were abstracted and labeled with a code. Various codes were then compared based on the differences and similarities and sorted into three categories and four subcategories, which made up the manifest content. The tentative categories were discussed by three researchers and revised. Finally, the underlying meaning, or the latent content of the categories, was formulated into themes. We tried to have the maximum homogeneity in the categories and maximum heterogeneity between categories.

Data Trustworthiness

Measures proposed by Guba and Lincoln 25 were used to ensure the validity and accuracy of the data. Data credibility was done using continuous data comparison. Prolonged engagements with participants and devoting sufficient time to collect the data helped us to have better understanding of their experiences.

Dependability of data was done using member check method. Weekly meetings of the research team were held and discussions were carried out about the collected information for dependability of data. Also, three of the experts had very close cooperation with the research team during the analysis and interpretation of the data in qualitative research (peer review). Confirmability of data was obtained using systematic collection of data and maintaining documentations related to the research. Sampling with maximum diversity was carried out for data transferability; in this way that samples of both gender were selected with different ages, education level and jobs and from multiple clinical centers affiliated to Tehran University of Medical Sciences.

Ethical Considerations

The present research is the result of a nursing doctoral thesis of Tehran University of Medical Sciences which was approved in Research Ethics Committee of Tehran University of Medical Sciences with the code of IR.TUMS.REC.1394.1497. Objectives and methods used in the study were fully explained to the participants. All participants signed informed consent before entering the study. They were also informed about the confidentiality of the contexts and were ensured about anonymity in the study. They were told that this study was voluntary and there is the possibility to withdraw at any stage of the study without any consequences for them. Time and place of interviews were determined with the agreement of the participants and based on their preferences.

The participants’ age range was 28-74 (with an average of 52.6±1.1). A total of 27 individuals were interviewed, among whom 15 were women and 26 were married. Other specifications of the participants are shown in the Table 1 .

The participants’ characteristics

Three main categories of “disease shadow”, “dual understanding of the effect of drug therapy”, and “facing the disease” were extracted from data analysis which were the result of experiences of patients living with this disease ( Table 2 ). The meanings of each of these categories have been provided using direct quotes of the participants below.

The main categories and primary categories extracted from the participants’ experience

Disease Shadow

According to the participants, hypertension had affected all aspects of their health (physical, mental, social, family and spiritual). Understanding hypertension was dependent on clinical symptoms and their severity. All participants had experienced one or more symptoms of hypertension during the course of the disease. This symptom was temporarily perceived in many participants; they believed that hypertension was a common disease, and even some individuals who were recently diagnosed with hypertension did not believe that hypertension was a disease. However, all patients were concerned about possibility of recurrence of the symptoms of hypertension. Hypertension has caused many complications such as myocardial infarction, stroke and kidney failure in a number of participants. Experiences of one of the participants were as follows:

“… I had headaches and dizziness and my face would turn red; I referred to a doctor and he said my blood pressure is too high. I had a very high blood pressure a few years ago. It caused stroke and kidney failure …” (64 year old woman, married).

Some participants had experienced problems such as reduced physical activity and nutritional constraints after being hypertensive and its symptoms. Most of the participants who had experienced such problems were women. Hypertension caused sleep problems such as nightmares, waking and sleep deprivation in a number of participants. One of the patients expressed about experiencing sleep disturbances:

“… I experienced sleep disturbances when I had high blood pressure. I could not sleep well and had nightmares; … my high blood pressure has been controlled since I was administered drugs and I can sleep better now…” (74 year old woman, married).

Understanding the psychological experience of the disease was among the points mentioned by participants; they referred to problems such as sexual dysfunction, anxiety and spiritual.

Many participants had seen devastating effects of diseases related to blood pressure in their family and first degree relatives. These participants believed that their high blood pressure was hereditary and were afraid and concerned about the future of their own health and their children. On the other hand, this concern has caused these participants to follow up their disease and complete their treatment. Respondents who had suffered from hypertension complications had experienced this fear and concern more. Some of the patients who had suffered hypertension at an early age had a sense of shock, depression and fear.

Some of the male participants had experienced decreased libido and sexual function due to hypertension which had led to disturbance in interpersonal relations with their wives. None of the participants had shared their sexual problem with their doctor while this problem was causing concern for them. Experiences of one of the participants were as follows:

“…ever since I have high blood pressure, I have become more impatient towards sexual relations; I do not like it anymore, especially when my blood pressure is high …” (45 year old man, married).

Some of the participants also stated that hypertension has had negative effect on their spiritual experiences. They believed hypertension was preventing them from doing some of the religious practices.

“… Ever since I have high blood pressure, … I cannot even take fast, or go to mosque like before, or worship …” (45 year old man, married).

Another experience of the participants after being hypertensive was social and family problems such as financial difficulties, feelings of inadequacy, defective interpersonal relationships and disruption of family relationships.

Participants had experienced different financial problems after hypertension. Financial problems were not related to the cost of the disease in the majority of participants because they were under insurance and did not pay for the treatment. Most of these problems were related to feelings of inadequacy in income which had emerged after s hypertension and development of its symptoms in participants. The experience of one of the participants was:

“…Hypertension makes people sluggard; you do not want to wok … it makes people economically weak but again I am thankful for having Insurance; otherwise, I should have paid a lot of money for my disease …” (53 year old man, married).

Defective interpersonal relationships and impaired family relationships were among the experiences of participants after the onset of hypertension. Participants had experienced these problems especially after occurrence and exacerbation of the symptoms. Among them, mostly older men were aggressive towards their families and others. However, some participants felt remorse after reduction of hypertension symptoms and tried to improve their personal relationships, especially with their families. Experiences of one of the participants were as follows:

“…hypertension has gone on my nerves; I have become aggressive toward my family. I immediately feel sorry when I snap and then I try to settle the problem …” (55 years old man, married).

Dual Understanding of the Effect of Drug Therapy

Patients reported two types of experience of living with hypertension at this level; some referred to positive effects of medication and some believed in negative effects of medication.

Perceived Benefits

Experiences of positive effects of medication were expressed by participants in the form of the sense of being able to control the disease, satisfaction and being healthy. They were all trying to regularly use the prescribed medicines. These positive effects were felt more after taking blood pressure medications in the participants suffering from complications of hypertension or severe signs and symptoms of hypertension. They had accepted medicines as the most important part of hypertension’s treatment. Experiences of one of the participants were as follows:

“…My doctor prescribed medicine for high blood pressure; I feel a lot better since using them; my blood pressure is being controlled better… I regularly use my medicines…” (41 year old woman, married).

Negative Consequences

Some of the participants had experienced negative consequences such as drug side effects and a sense of drug dependence after using prescribed antihypertensive drugs. These consequences occurred mostly in those who had become hypertensive recently or those who did not have severe symptoms of hypertension. Some of these participants completely gave up blood pressure medication due to side effects such as nausea, weakness and pain in their stomach. Not using medication or discontinuing it due to the feeling of dependence on drugs were more prevalent in younger people. Experiences of one of the participants were as follows:

“… Hypertension pills had disturbed my sleeping … I visited a doctor and he said it was because of my hypertension pills… I started using medicines a little less on my own; I am afraid of being addicted to medicines…” (49 year old woman, married).

Facing the Disease

Participants reported two types of experience of living with hypertension in facing their disease. Some expressed the experience of compatibility and others expressed the experience of indifference and neglect. Some of the participants believed that they should use proper strategies to control and cope with their disease to have a quality life, but some others tried to reject their disease.

Compatibility

Participants used the help of their family, modifications of lifestyle behaviors (such as diet, exercise, cessation of smoking) and spiritualties after becoming hypertensive and becoming aware of it in order to manage their blood pressure, all showing compatibility with the disease and its control.

All participants expressed the experience of being supported by their families. These supports were in the form of relaxing, financial aid, proper cooking, providing information about the disease, and reminding the medications. Among these, most of the supports were psychological. These supports were more for older people and from their wife and children. Experiences of one of the participants were as follows:

“…my daughter checks my blood pressure regularly and gives me my medicines …” (64 year old woman, married).

The highest modifications of lifestyle behaviors and adherence to them were mentioned by the participants who had suffered from big events such as heart attack, stroke and kidney failure following being hypertensive or patients who had experienced the need to have a medical emergency following extremely high blood pressure. These patients believed that they can control not only their blood pressure but also other diseases with it by modification of health-related behaviors. Female participants more adhered to healthy diet and not smoking; in contrast, men had experienced more regular sport activities. One of the participants stated:

“…Ever since I realized how dangerous high blood pressure is, I tried to comply with … I can exercise whenever I can …” (57 year old man, married).

Some participants relied on God to protect their health. Even if they had extremely high blood pressure, they felt they did not have a serious problem because they are protected by God. Some others believe that God supports them in blood pressure control and provides them with peace. All the subjects believed in the positive role of spirituality in blood pressure control. However, female patients, especially the elderly women used their spiritual experiences more in controlling their blood pressure. Experiences of one of the participants were as follows:

“… I always rely on Imams and God when I have high blood pressure, … I feel calm when I am praying; it reduces my blood pressure …” (39 year old woman, married).

Negligence and Denial

A small number of participants were oblivious in the fight against their blood pressure disease and this disease had a low value in their perspective. This negligence was more in patients who afflicted with hypertension in recent years or participants who had not experienced persistent symptoms due to hypertension. These patients were mostly male. They did not believe in high blood pressure as a serious and dangerous illness. Experiences of one of the participants were as follows:

“…I think I haven’t worked hard enough for myself; when I found out I have high blood pressure, I did not follow my diet; … I did not think that blood pressure is important …” (47 year old woman, married).

Some of the participants used herbs such as lemon juice, vinegar, and sour tea to lower their blood pressure instead of taking prescribed medicines. This experience was more common in older patients. The important point was that most of these people used non-pharmacological methods to control their high blood pressure as opposed to the advice of their physicians. These patients stated that this treatment method with herbs had been in their culture from the past. They believed more in advice of their friends and family elders more than medical advice. One of the participants said:

“… I use lemon juice and green tea when I have high blood pressure; … I consulted with a cardiologist who said pill was much better, but I think herbal medicines are much better than medical drugs …” (39 year old woman, married).

D ISCUSSION

The findings of this study showed that experience of these patients was in three areas of disease control, dual understanding of the impact of drugs, and dealing with the disease. High blood pressure affects all aspects of daily life. All participants in this study had experienced one or more than one chronic symptoms of blood pressure. They believed that blood pressure and these symptoms had had negative effect on their daily life activities, such as reduced physical activity and dietary restriction. Patients with hypertension have no symptoms in the early stages and can normally do their activities of daily living and their daily lives are affected and disturbed after chronic experiencing symptoms of hypertension. 3 Most of the participants in qualitative studies about evaluation of experiences of hypertensive patients have complained about signs and symptoms of hypertension and problems with daily life activities. Some of these patients have experienced a good impression despite high blood pressure and its symptoms. 26 - 28 Unlike the results of these studies where patients were feeling good despite having high blood pressure symptoms, all patients in our study were concerned about the possibility of recurrence of the symptoms of high blood pressure. Factors such as patients’ attitudes and their social and cultural conditions have a role in the process of acceptance and treatment of hypertension by patients. 21

In this study, based on psychological experiences, the participants had experienced problems such as fear and anxiety, decreased libido and sexual function disorder and spirituality. The participants’ fear and concern were more related to blood pressure complications which had made them follow up their patients and complete their treatment.

The results of a qualitative study on hypertension patients showed that fear and concern were experienced as a common sentiment among the participants. Patients who had directly or indirectly experienced complications of high blood pressure mostly experienced fear and anxiety and were concerned about high blood pressure. 28 Other similar non-Iranian studies also showed that patients had experienced a kind of fear and concern of complications of high blood pressure; this is in line with the results of our study. 28 - 30 Fear and concern do not always have negative effects and can force the patients to do positive health behaviors. 31

Feelings and emotions have different values and interpretation in different cultures. 28 The major difference between our study and these qualitative studies 28 - 30 was the fact that one of the concerns experienced by participants in our study was hereditary behavior of disease and the risk of hypertension for their children which has not been referred to in these studies. The results of our study also referred to the experience of patients with hypertension in the field of spiritual and sexual dysfunction which may be due to more in-depth interviews in the present study and cultural and religious differences of these patients.

One of the main concepts of this study was the patients’ social experiences. Participants had experienced the financial burden of the disease, impaired interpersonal relationships, and family relationships disruption following hypertension. The results of a qualitative study showed that all participants had experienced different financial difficulties associated with hypertension which had forced them to rely on helps from the government, family and friends. 28 Economic problems are a major hurdle for patients to access appropriate health services and adherence to drug therapy. 32 Results of foreign qualitative studies showed that hypertensive patients experienced some degrees of financial problems following treatment of hypertension and its complications; they often do not follow up the treatment due to financial problems. 30 , 32 Unlike the results of these foreign studies, financial difficulties were not related to the cost of disease in most participants in the present study and most of these problems were related to feelings of inadequacy in income which had emerged in participants after developing symptoms of hypertension. People are covered by medical insurance in Iran’s health system and primary health care services are available at a low cost and the patient can receive medication and health services at low costs. Patients with high blood pressure usually experience poor interpersonal relationships and no sense of purpose about the future. 31 The results of a qualitative study showed that the participants had also experienced impairment of relationships with the family (parents and children), friends and relatives. 30 In Iran, families have a close relationship with each other due to the cultural context of the region and family members help the relatives with disease. 33 The important point is that the participants in our study experienced regret after having problems with family and tried to remedy and improve this relationship. These patients had experienced a better relationship with their family when they had lower blood pressure which has not been referred to in foreign studies. 28 , 30 Some of the participants had experienced the positive effects of drug therapy in this study and some others referred to negative consequences of using blood pressure drugs. The results of a qualitative study showed that some of the patients had ignored the doctor’s orders and used drugs only at the time of the occurrence of the symptoms of blood pressure due to fear of dependence and its complications; this led to emergence of complications such as cardiovascular or cerebrovascular diseases. 26 In another qualitative study, it was shown that hypertension patients felt they were healed with taking medication and reducing the symptoms of high blood pressure. In addition, most of these patients had stopped taking medication without consulting their doctor due to reduction of the symptoms of high blood pressure. 18 The experience of drug therapy for hypertension is varied and depends on such factors as previous experience of drug treatment of the patient and his/her family members, the general attitude to drug treatment, and the level of medical knowledge and confidence in the health care system. 29 In our study, most patients experienced a regular intake of prescribed medications and following their doctor’s orders while most patients in the above studies 26 , 18 did not take drugs or took drugs irregularly and arbitrarily. These findings could reflect the positive attitude of the participants in our study towards blood pressure drugs. The findings of the this study showed that many patients relied on their families’ help, modification of lifestyle behaviors (diet, exercise, cessation of smoking), spirituality, and raising awareness to manage their blood pressure. This finding showed the importance of blood pressure control and prevention of its complications among participants in our study. The results of a study on hypertension patients showed that most patients with hypertension were able to reduce their blood pressure by changing their lifestyle and this was a cost-effective and safe way. 34 It was shown in qualitative studies conducted on patients with high blood pressure that participants actively followed up, controlled and treated their high blood pressure. 35 , 36 These results are in line with those of our study except that the participants in our study used spirituality and family assistance as original and effective strategies to manage high blood pressure while these cases had not been referred to the above studies. 35 , 36 This finding can be due to the differences in cultural, theological and social context of Iran with other countries. In this regard, results have shown that lifestyle of hypertension patients and management of this disease are different on the basis of ethnic groups and cultural context of each region and these differences sometimes create barriers to manage hypertension. 26 , 37

In this study, few participants were oblivious to their blood pressure so that they did not try to modify their lifestyle. Researches have shown that patients with hypertension are asymptomatic in the early stages or have temporary symptoms. Many patients do not consider high blood pressure as a disease and do not pay much attention to it. 16 , 26 Traditional beliefs and assumptions (based on personal experiences) of patients sometimes makes them not accept medical treatment or stop it and do not change their improper behaviors until severe complications caused by high blood pressure. 26 Findings showed most patients with hypertension did not change their lifestyle correctly not only when they were free of symptoms, but also after disease complications. 28 Similar results were reported in in other qualitative studies 26 , 18 which are in line with our study.

In our study, lack of using hypertension drugs was more seen in patients who were recently diagnosed with high blood pressure. One of the reasons for it can be the fact that high blood pressure is a silent disease and has almost no obvious symptoms and serious complications in its early stages. These patients do not believe in using drugs to control blood pressure at the beginning of the disease. The results of a qualitative study showed that the attitude of patients with hypertension toward medication will change with time. They show resistance to drugs at first and then look at drugs as a savior and after it as a natural thing to use drug. 29

This study explored how a sample of Iranian patients with hypertension realized their condition and the strategies they employed in managing it. The qualitative exploration allows an understanding of the patients’ perspectives and contributes to an understanding of why treatment and control may fail in this group.

One limitation of this study was that the participants with many years of hypertension had problems in remembering and sharing their experiences and their relatives were used to overcome this limitation. Lack of similar studies in Iran was among other limitations of this study to compare with data of this study.

C ONCLUSION

Based on the findings, patients with hypertension suffered many problems in different aspects of health such as physical, psychological, social, familial and spiritual due to their disease and cultural context. Also, the use of blood pressure medications led to both positive and negative experiences in these patients. These patients cope with their disease based on their cultural context and beliefs and were able to gain positive experiences in the control and treatment of hypertension following it. Comprehensive planning appropriate with these patients’ cultural and social context and their beliefs are required to solve these problems. It is recommended that further researches should be done on hypertensive patients in other cultures in order to determine more dimensions of these patients with regard to cultural differences.

A CKNOWLEDGEMENT

The present study is a part of Mr. Afzal Shamsi PhD thesis, which was approved by Tehran University of Medical Sciences (Decree Number: IR.TUMS.REC.1394.1497). The researchers would like to thank the support of Tehran University of Medical Sciences and cooperation of all participants in this study.

Conflict of Interest: None declared.