Overcoming health disparities, health care advocates and mindfulness can better manage BP and CVD
The Late-Breaking Science session “Mindful Disruption of Chronic HTN Management” on Sunday found that:
- Community health care worker interventions can reduce cardiovascular disease and overall mortality.
- Systemic and personalized changes can improve blood pressure control across socioeconomic disparities.
- Mindfulness training can better reduce blood pressure compared to usual care.
- A quadruple fixed-dose regimen lowers blood pressure more effectively than conventional treatment.
Nonphysician health care worker-led intervention reduces cardiovascular disease and mortality
A hypertension control program in rural China using nonphysician community health care workers, known as village doctors, reduced cardiovascular disease, cardiovascular-related mortality and all-cause mortality compared to usual care. The largest randomized trial comparing conventional hypertension care to community health care worker-led intensive intervention showed mean blood pressure 147.6/82.3 mmHg versus 126.1/73.1 mmHg after 36 months. Intensive intervention by village doctors resulted in significantly lower rates of cardiovascular disease, including myocardial infarction, stroke, heart failure or cardiovascular disease death, than usual care, 1.98% vs. 2.85% per year, HR=0.69 (p<0.0001) and significantly lower all-cause mortality, HR=0.85 (p=0.009).
“This study shows that nonphysician health care workers with appropriate training and supervision can treat patients with hypertension and very effectively reduce cardiovascular disease and mortality,” said Jiang He, MD, PhD, Joseph S. Copes chair and professor of epidemiology and director of the Tulane University Translational Science Institute. “This is the first major study to show that in a general population with hypertension, intensive blood pressure control reduces cardiovascular disease and overall mortality.”
The China Rural Hypertension Control Project selected 326 villages across three provinces in rural China. Half of the villages, 163, were randomly assigned to intervention led by nonphysician village doctors, the mainstay of health care in rural China, and 163 to usual care. The project enrolled 33,995 individuals 40 years and older, with uncontrolled hypertension defined as untreated BP≥140/90, treated BP≥130/80, or untreated BP≥130/80 among patients with a history of clinical cardiovascular disease.
Intervention village doctors were given additional training in hypertension management and delivered protocol-based hypertension treatment based on AHA guidelines. They also delivered free or discounted antihypertensive medications and conducted health coaching on lifestyle change and medication adherence. Village doctors were supervised by primary care physicians as needed and received performance-based financial incentives. The primary endpoint was reductions in a composite measure of myocardial infarction, stroke, heart failure or cardiovascular death. Overall mortality was a key secondary outcome.
At baseline, the mean age of participants was 63 years, 61% were female, mean BP was 156/88 mmHg, and the median duration of hypertension was seven years. Initial BP results at 18 months were reported at Scientific Sessions 2021, a 32.3% reduction in mean BP.
“This is the first study to show positive benefits of reducing blood pressure to 130/80 and lower in a general hypertensive population,” Dr. He said. “Globally, more than 75% of hypertension patients are living in low and middle income countries. If nonphysician community health care workers can treat hypertension to reduce cardiovascular disease and mortality in rural China, they can do it anywhere in the world.”
Health system and patient-level changes in hypertension care improve blood pressure control
Racial and ethnic disparities in hypertension care delivery and outcomes are well documented across the United States, even among patients who have regular contact with the health care system. One of the first trials to explicitly address disparities in hypertension care and control found that improving system-level support for hypertension care reduces blood pressure for about 60% of patients. Adding individualized patient support brought even greater improvement for Medicaid recipients and individuals with coronary heart disease.
“We have known for a very long time there are racial, ethnic and social class disparities in the control of hypertension and other cardiovascular risk factors,” said Lisa A. Cooper, MD, MPH, FACP, James F. Fries Professor of Medicine and Bloomberg Distinguished Professor at Johns Hopkins University School of Medicine, School of Nursing and Bloomberg School of Public Health. “We know what works to improve blood pressure control in these populations, but we also know there are real-world challenges to implementing practices that are consistent with treatment guidelines.”
The Reducing Inequities in Care of Hypertension: Lifestyle Improvement for Everyone (RICH-LIFE) Project addressed both system-level and patient-level barriers to appropriate blood pressure control. Systemic challenges include inconsistent and inappropriate blood pressure measurement, clinicians knowing patient blood pressure goal performance and disparities in care or outcomes across different racial and social groups in their practices, and lack of disparity awareness/training at the leadership level.
Patient-level challenges include medical issues such as understanding the causes of hypertension, medication instructions and timely medical visits. Nonmedical factors, such as access to medications or healthy food, unstable employment and housing and social support can also challenge hypertension management.
A total of 1,820 patients across 30 clinics in Maryland and Pennsylvania were randomized to either standard of care plus (SCP), with enhanced system support, or collaborative care/stepped care (CC/SC), enhanced system support plus nurse managers and community health workers to help address nonmedical barriers. The project population was 59.4% female, 57.4% Black, and 9.4% Hispanic with a mean age of 60.3 years. All participants had uncontrolled hypertension plus at least one additional cardiovascular risk factor at study enrollment.
Both groups showed similar blood pressure control at 12 months, 59% for CC/SC and 61% in SCP. Improvements for Black and white patients were similar within both groups. Among patients covered by Medicaid or who had diagnosed coronary heart disease, those in CC/SC had greater improvement in blood pressure control than SCP, 64% versus 58% (p=0.05) and 65% versus 60% (p=0.04), respectively. There were similar improvements in patient activation in both groups; however, CC/SC patients showed greater improvements in patient ratings of chronic illness care than SCP patients.
“We would like to see improvements in the measurement of blood pressure, feedback to clinicians on blood pressure control stratified by race and ethnicity, and leadership training on equity in blood pressure control,” Dr. Cooper said. “Also, individualized attention and assistance for disease management and health-related social needs for those on Medicaid or with heart disease could improve care and outcomes in those populations. We are still learning how to address hypertension disparities.”
Mindfulness training brings clinically relevant blood pressure reduction versus usual care
Just eight weeks of mindfulness training adapted to blood pressure management showed a 5.9 mmHg reduction in systolic blood pressure and outperformed enhanced usual care by 4.5 mmHg at six months (p=0.045). Plausible mechanisms for blood pressure reductions include changes in sedentary activity (p=0.02), adherence to the DASH diet (p=0.08), changes in perceived stress (p=0.05) and mindfulness (p<0.001).
“Part of mindfulness and meditation is to come to understand ourselves better and enhance our self-awareness, then to enhance our attention control so we can actually do the things we feel we want to do, like be more active or change our eating habits,” said Eric B. Loucks, PhD, associate professor of epidemiology and of behavioral and social sciences at Brown University. “We know that nearly everyone feels better after physical activity, yet adherence to activity guidelines is quite low. Mindfulness training focused on hypertension is a tool that helps people do more of the right things to improve their blood pressure and feel better about doing it.”
The Mindfulness-Based Blood Pressure Reduction (MB-BP) Trial randomized 201 participants with unattended office blood pressure ≥120/80 mmHg to usual care (100) or eight weeks of BP-adapted mindfulness training (101). Key adaptions included personalized feedback and education about personal hypertension risk factors, mindfulness and awareness training of individual’s relationships with hypertension risk factors, and support for behavior change.
Both groups received a home blood pressure monitoring device, training in home blood pressure monitoring and optional referral to a primary care physician. The control group also received an educational brochure on controlling hypertension.
The study group was 58.7% female, 81.1% non-Hispanic white, with a mean age of 59.5 years. The primary outcome was change in unattended office systolic blood pressure at 6 months.
Dr. Loucks noted that meta-analyses of pharmacologic trials have shown a 5-point reduction in systolic blood pressure is associated with a 10% reduction in heart attack, stroke and other cardiovascular events. The mean 5.9 mmHg reduction in the mindfulness arm represents a clinically meaningful change.
“MB-BP is grounded in mindfulness-based stress reduction, which has a 40-year history of success on several health outcomes,” he said. “There is already a functional pipeline of high-quality mindfulness instructors. With additional training in cardiovascular health and blood pressure reduction, mindfulness training may be a useful approach to improving blood pressure.”
Four-drug fixed-dose beats monotherapy for blood pressure control in QUARTET-USA
A daily fixed-dose combination of four ultra-low-dose medications reduced systolic and diastolic blood pressure (slide 9, 10) more effectively than conventional monotherapy in a small 12-week trial. The combination of candesartan (2 mg) + amlodipine (1.25 mg) + indapamide (0.625 mg) + bisoprolol (2.5 mg) lowered systolic blood pressure by 4.9 mmHg and diastolic blood pressure by 4.8 mmHg compared to standard dose monotherapy with candesartan (8 mg). In addition, only 19% of patients on combination therapy needed an add-on dose of daily amlodipine 5 mg to reach the AHA-recommended blood pressure target of ≤130/80 compared to 54% of those on conventional monotherapy.
“Most patients need multiple medications to get to target blood pressure,” said Mark Huffman, MD, MPH, on behalf of co-principal investigator Dr. Jody Ciolino and the QUARTET USA study team. Dr. Huffman is professor of medicine and co-director of the Global Health Center at Washington University in St. Louis and conjoint faculty at The George Institute for Global Health at the University of New South Wales, Sydney, Australia.
“Using these drugs at lower doses is key because most blood pressure lowering effect is observed at low doses. While blood pressure tapers off with higher doses, there is a logarithmic increase in side effects with higher doses. We’re looking for the sweet spot of blood pressure reduction and tolerability.”
The QUARTET-USA Trial extends an earlier trial in Australia conducted largely with Asian and Caucasian participants by the University of Sydney. This trial enrolled 62 Chicago-area residents in the Access Community Health Network who had a mean age of 53; 45% were female, 73% were Hispanic and 18% were Black. Most, 65%, had an annual household ≤$25,000. Mean baseline blood pressure was 138/84 mmHg. The trial was sponsored by the National Heart, Lung, and Blood Institute.
At 12 weeks, the unadjusted blood pressure was 121/73 mmHg in the intervention arm and 124/77 mmHg in the control arm. Fewer patients in the intervention arm discontinued, two patients versus eight, although there were more treatment-related adverse events in the intervention arm, eight versus three.
“We saw a similar direction and magnitude of effect using a similar four-drug combination as was seen in the Australian trial,” Dr. Huffman said. “There have been trials of combination therapy versus monotherapy before, but this is the first study of its kind in the U.S. A four-drug combination gets patients to goal faster than with the standard approach and with similar tolerability. I’d like to see quartet low-dose combination therapy widely available and affordable to patients.”