Nov 30, 2020, By: Lyne Cloutier, RN, PhD
- In the last decade, hypertension control in women 60 years of age or older has decreased, while hypertension control in men has remained high and stable.
- Older women are often at moderate to high risk from cardiovascular disease and should have blood pressure assessed at all routine clinical visits; those with hypertension should be treated and controlled.
- This article lists several simple diagnostic and treatment algorithms that can achieve hypertension control rates as high as 90%.
I wish to shed light on an important health issue, especially for older women.
It has been known for some time that increased blood pressure is a leading reversible risk factor for death and disability in older people in Canada and around the world. It can be treated effectively with antihypertensive therapy and lifestyle changes. Because older people have an added risk with age, greater care must be taken.
However, in the last decade, hypertension control in older women (60 years of age or older) has decreased, while hypertension control in men has remained high and stable (Leung, Williams, McAlister, Campbell, & Padwal, 2020). Several countries now have higher rates than Canada of hypertension control in older women.
This trend has continued despite the fact that between 2000 and 2010, Canada gained a reputation for having the highest national rate of controlling hypertension in older people, with reductions in cardiovascular death strongly associated with increased treatment of hypertension (Campbell et al., 2009). Nurses played a unique role in this achievement by engaging in education, using standardized protocols, measuring blood pressure regularly in a standardized way, and monitoring outcomes.
Unfortunately, rates of cardiovascular disease in Canada have also started to increase since 2010, after more than a half-century of consistent reductions. In fact, in 90% of women in Canada with uncontrolled blood pressure, the systolic blood pressure is high (greater than or equal to 140 mmHg) (Campbell et al., 2009). While some of the increases in cardiovascular deaths are related to the aging population, the rest of the increase in cardiovascular disease deaths is undoubtedly attributable to the well-established, mostly modifiable causes of cardiovascular disease not being effectively prevented in Canadians (hypertension, dyslipidemia, high glucose, poor diet, tobacco use, lack of physical activity, and obesity).
Nurses’ role in diagnosis and treatment
Unfortunately, rates of cardiovascular disease in Canada have also started to increase since 2010, after more than a half-century of consistent reductions.
Whenever nurses encounter older women, they should keep in mind some important issues. Older women are often at moderate to high risk from cardiovascular disease and should at a minimum have blood pressure assessed at all routine clinical visits. Those with hypertension (BP greater than 140/90 mmHg) should be treated and controlled as a core standard of care. A small proportion of women aged 60 and above will be at low cardiovascular risk (less than 10% risk of a cardiovascular event in 10 years) where lifestyle management would be a primary therapy.
Many if not most people with hypertension will require two or more drugs to control it. Critical steps to improve blood pressure control are summarized below. We should also keep in mind that persons with diabetes should have a blood pressure treatment threshold of 130/80 mmHg and a target of consistently less than 130/80 mmHg.
Nurses should also be aware of how a simple diagnostic and treatment algorithm, such as those listed in the resources below, can achieve hypertension control rates as high as 90%, when paired with a hypertension registry with performance reporting. This kind of registry/reporting should include the number of people diagnosed with hypertension as a percentage of the number estimated to have hypertension in the clinical practice, the percentage treated with antihypertensive therapy, and the percentage controlled.
Other important features of the algorithm and registry can include identification and recall for patients missing appointments and those without a recent blood pressure assessment. Samples of these simple algorithms and implementation resources can be found in the resources below, as well as a free, stand-alone, smartphone-based hypertension registry.
It is critical for the federal, provincial, and territorial governments to take a well-planned, strategic public health approach to the prevention and control of hypertension and to collaborate with the health and scientific sectors on monitoring, evaluation, and implementation. Many organizations have approved of this strategy, including the Canadian Nurses Association.
Hypertension management protocols:
HEARTS Technical Package for Cardiovascular Disease Management in Primary Health Care: Evidence-Based Treatment Protocols (PDF)
Links toolkit: Hypertension control
Implementation guide for a hypertension control program:
HEARTS Technical Package for Cardiovascular Disease Management in Primary Health Care: Tool for the Development of a Consensus Protocol for Treatment of Hypertension (PDF)
Links toolkit: Hypertension control
Developing a hypertension management algorithm:
HEARTS Technical Package for Cardiovascular Disease Management in Primary Health Care: Implementation Guide (PDF)
Hypertension management app by Simple
Critical steps to control hypertension
- Correctly measure blood pressure routinely, in all adults and especially older women.
- Treat people with hypertension with antihypertensive drugs to achieve control.
- If automated office blood pressure systolic (AOBP) value is greater than 130 mmHg, consider initiating treatment and lowering systolic blood pressure to less than 120 mmHg in those at high cardiovascular risk (e.g., Framingham risk score of less than 15% for men or women aged 75 years or higher), to optimize risk reduction. Persons with diabetes should have a blood pressure treatment threshold of 130/80 mmHg for office blood pressure measurement and a target of less than 130/80 mmHg.
- Use validated automated blood pressure devices, where feasible, for home blood pressure measurement and 24-hour ambulatory blood pressure measurement. For a systolic target of less than 120 mmHg, consider automated devices that operate without an observer present and that take and average multiple readings.
- Use standardized treatment protocols.
- Use registries with performance reporting to enhance hypertension control.
- Educate individuals and family members on self-management and lifestyle choices.
This call to action was initiated by the following leaders in hypertension:
Norm R. C. Campbell, MD
Donna McLean, RN, MN, NP, PhD CCN(C)
Patrice Lindsay, RN, PhD
Dorothy Morris, RN, BSN, MA, CCN(C)
Karey Shuhendler, RN, CCHN(C), MN
Alexander Leung, MD, FACP, FRCPC
Alan Bell, MD, FCFP
Mark Gelfer, MD, FCFP
Robert Petrella, MD, PhD, FCFP, FACSM
Ross Tsuyuki , BSc (Pharm), PharmD, MSc, FCSHP, FACC, FCAHS
Shelita Dattani, BSc (Pharm), PharmD
Leung, A. A, Williams, J. V. A., McAlister, F. A., Campbell, N. R. C., Padwal, R. S., & Hypertension Canada’s Research and Evaluation Committee. Worsening hypertension awareness, treatment, and control rates in Canadian women between 2007 and 2017. Canadian Journal of Cardiology. 36(5), 2020, 732-739. doi: 10.1016/j.cjca.2020.02.092
Campbell, N. R., Brant, R., Johansen, H., Walker, R. L., Wielgosz, A., Onysko, J., Gao, R. N., Sambell, C., Phillips, S., McAlister, F. A., & Canadian Hypertension Education Program Outcomes Research Task Force. Increases in antihypertensive prescriptions and reductions in cardiovascular events in Canada. Hypertension, 53(2), 2009, 128-134. doi: 10.1161/HYPERTENSIONAHA.108.119784
Lyne Cloutier, RN, PhD, is a full professor in the Department of Nursing Sciences at the Université du Québec at Trois-Rivières and is the co-chair of the Hypertension Canada guidelines for blood pressure measurement.