Hypertension is the leading risk factor for heart disease. Improvements in both targeted and population-based strategies for blood pressure control can lead to better prevention and control of hypertension, according to a review paper published Sept. 3 in the Journal of the American College of Cardiology.

Hypertension is caused by a combination of genetic, environmental and social determinants. While genetic predisposition is nonmodifiable and conveys lifelong cardiovascular risk, the risk for hypertension is modifiable and largely preventable due to a strong influence by key environmental and lifestyle factors. Social determinants such as race and socioeconomic status are also risk factors for hypertension.

According to the authors, prevention and control of hypertension can be achieved through targeted and population-based strategies. The targeted approach is the traditional strategy used in health care practice and seeks to achieve a clinically important reduction in blood pressure for individual patients. The population-based strategy aims to achieve small reductions that are applied to the entire population, resulting in a small downward shift in the entire blood pressure distribution. Studies have shown that the population-based approach may be better at preventing cardiovascular disease compared with the targeted strategy. Factors preventing successful hypertension control include inaccurate blood pressure measurement and diagnosis of hypertension, lack of hypertension awareness and access to health care, and proper hypertension treatment and control. Low rates of medication adherence are also a common problem.

In the review, the authors discuss the Chronic Care Model, a framework for redesigning health care and addressing deficiencies in the care of chronic conditions such as hypertension, which may offer strategies for overcoming barriers at the health system, physician, patient and community levels. It is a collaborative partnership among the patient, provider and health system that incorporates a multilevel approach for control of hypertension. The model includes six domains – decision support, self-management support, delivery design, information systems, community resources and health care systems – which have been shown to lead to activated patients, responsive health care teams, improved health services and treatment outcomes, and cost-effectiveness. It also recognizes a collaborative partnership between the patient, provider and the care team. Community groups and organizations also play a significant role in providing health care information and support to various populations. Connected health, such as telemedicine and telephone and mobile health interventions, can also help deliver improved care to a greater number of patients with hypertension.

Lead author Robert M. Carey, MD, writes that while progress has been made in the understanding of blood pressure as a risk factor for heart disease and improving approaches to the prevention and treatment of hypertension, further research is still necessary to optimize care for these patients.

"Challenges to the prevention, detection, awareness and management of hypertension will require a multipronged approach directed not only to high-risk populations, but also to communities, schools, worksites and the food industry," he said.

This paper is the fourth in an eight-part cardiovascular health promotion JACC focus seminar, where each paper focuses on a different behavioral consideration that impacts cardiovascular health: nutrition and diet; healthy weight; exercise and physical activity; tobacco-free lifestyle; blood pressure; cholesterol; blood sugar; and psychological health.

Keywords: Risk Factors, Blood Pressure, Tobacco, Blood Glucose, Medication Adherence, Hypertension, Blood Pressure Determination, Health Promotion, Life Style, Treatment Outcome, Cholesterol, Diet, Health Services Accessibility, Patient Care Team

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