Managing hypertension with mHealth

The statistics for hypertension are stunning. 30% of US adults have hypertension (high blood pressure). Another 30% of Americans are pre-hypertensive.Less than half of those people with hypertension have their condition under control.  A fifth don't know they have it. The annual price tag for direct medical expenses related to high blood pressure is $131 billion. This is driven in part by the 55 million doctor visits that are prompted by high blood pressure. High blood pressure is present in most first heart attacks (69%), first strokes (77%), and in people with congestive heart failure (74%). High blood pressure was listed as a primary or contributing cause of death for about 348,000 Americans in 2008. High blood pressure rates increase with age:



What Causes Hypertension?

Hypertension is particularly dangerous because it so seldom produces symptoms. Many associate stress with high blood pressure. While stress can cause a temporary elevation in blood pressure through an increase in stress hormones, researchers haven't conclusively tied stress to long term hypertension. It may be that other behaviors linked to stress -- such as obesity, smoking, too much salt in the diet, drinking alcohol, and poor sleeping habits -- cause high blood pressure. Chronic kidney disease and adrenal disorders can contribute to high blood pressure. 

The reality is that hypertension results from a complex interaction of genes and environmental factors. Numerous genetic variants with small and large effects on blood pressure have been identified, but the genetic basis of hypertension is poorly understood. Lifestyle factors that lower blood pressure include reduced dietary salt intake, increased consumption of fruits and vegetables, exercise, weight loss, and reduced alcohol intake. Possible other factors include caffeine consumption and Vitamin D deficiency. 


How is Hypertension Diagnosed?

Hypertension is diagnosed on the basis of a persistently high blood pressure. This is typically measured with a blood pressure cuff (sphygmomanometer) at one month intervals over a period of three months. The systolic blood pressure is the maximum pressure during a heartbeat. The diastolic blood pressure is the lowest pressure between heartbeats. 


If you're diagnosed with high blood pressure, your doctor may recommend other tests, such as:

Electrocardiogram (EKG or ECG): A test that measures the electrical activity, rate, and rhythm of your heartbeat via electrodes attached to your arms, legs, and chest. 

Echocardiogram: A test that uses ultrasound waves to provide pictures of the heart's valves and chambers so the pumping action of the heart can be studied and measurement of the chambers and wall thickness of the heart can be made.

Other tests may be ordered to check for other damage related to high blood pressure: creatinine (kidneys), lipid profile (cardiovascular), and others.


How is Hypertension Treated?

Lifestyle changes are regularly suggested as part of a treatment plan. This includes regular physical activity, dietary changes, smoking cessation, a reduction of excessive alcohol consumption, and regular sleep. Here is how the Mayo Clinic (an Axial investor and partner) details these lifestyle changes:


Lifestyle Changes

Eat healthy foods. Try the Dietary Approaches to Stop Hypertension (DASH) diet, which emphasizes fruits, vegetables, whole grains and low-fat dairy foods. Get plenty of potassium, which can help prevent and control high blood pressure. Eat less saturated fat and total fat.

Decrease the salt in your diet. A lower sodium level — 1,500 milligrams (mg) a day — is appropriate for people 51 years of age or older, and individuals of any age who are African-American or who have hypertension, diabetes or chronic kidney disease. Otherwise healthy people can aim for 2,300 mg a day or less. While you can reduce the amount of salt you eat by putting down the saltshaker, you should also pay attention to the amount of salt that's in the processed foods you eat, such as canned soups or frozen dinners.

Maintain a healthy weight. If you're overweight, losing even 5 pounds (2.3 kilograms) can lower your blood pressure.

Increase physical activity. Regular physical activity can help lower your blood pressure and keep your weight under control. Strive for at least 30 minutes of physical activity a day.

Limit alcohol. Even if you're healthy, alcohol can raise your blood pressure. If you choose to drink alcohol, do so in moderation — up to one drink a day for women and everyone older than age 65, and two drinks a day for men.

Don't smoke. Tobacco injures blood vessel walls and speeds up the process of hardening of the arteries. If you smoke, ask your doctor to help you quit.

Manage stress. Reduce stress as much as possible. Practice healthy coping techniques, such as muscle relaxation and deep breathing. Getting plenty of sleep can help, too.

Monitor your blood pressure at home. Home blood pressure monitoring can help you keep closer tabs on your blood pressure, show if medication is working, and even alert you and your doctor to potential complications. If your blood pressure is under control, you may be able to make fewer visits to your doctor if you monitor your blood pressure at home.

Practice relaxation or slow, deep breathing. Practice taking deep, slow breaths to help relax. There are some devices available that can help guide your breathing for relaxation; however, it's questionable whether these devices have a significant effect on lowering your blood pressure.



Thiazide diuretics. Diuretics, sometimes called water pills, are medications that act on your kidneys to help your body eliminate sodium and water, reducing blood volume. Thiazide diuretics are often the first — but not the only — choice in high blood pressure medications. If you're not taking a diuretic and your blood pressure remains high, talk to your doctor about adding one or replacing a drug you currently take with a diuretic. 

Beta blockers. These medications reduce the workload on your heart and open your blood vessels, causing your heart to beat slower and with less force. When prescribed alone, beta blockers don't work as well in blacks or in older adults — but they're effective when combined with a thiazide diuretic.

Angiotensin-converting enzyme (ACE) inhibitors. These medications help relax blood vessels by blocking the formation of a natural chemical that narrows blood vessels.

Angiotensin II receptor blockers (ARBs). These medications help relax blood vessels by blocking the action — not the formation — of a natural chemical that narrows blood vessels.

Calcium channel blockers. These medications help relax the muscles of your blood vessels. Some slow your heart rate. Calcium channel blockers may work better for blacks and older adults than do ACE inhibitors or beta blockers alone. A word of caution for grapefruit lovers, though. Grapefruit juice interacts with some calcium channel blockers, increasing blood levels of the medication and putting you at higher risk of side effects. Talk to your doctor or pharmacist if you're concerned about interactions.

Renin inhibitors. Aliskiren (Tekturna) slows down the production of renin, an enzyme produced by your kidneys that starts a chain of chemical steps that increases blood pressure. Tekturna works by reducing the ability of renin to begin this process. Due to a risk of serious complications, including stroke, you shouldn't take aliskiren with ACE inhibitors or ARBs.

If you're having trouble reaching your blood pressure goal with combinations of the above medications, your doctor may prescribe: 

Alpha blockers. These medications reduce nerve impulses to blood vessels, reducing the effects of natural chemicals that narrow blood vessels.

Alpha-beta blockers. In addition to reducing nerve impulses to blood vessels, alpha-beta blockers slow the heartbeat to reduce the amount of blood that must be pumped through the vessels.

Central-acting agents. These medications prevent your brain from signaling your nervous system to increase your heart rate and narrow your blood vessels.

Vasodilators. These medications work directly on the muscles in the walls of your arteries, preventing the muscles from tightening and your arteries from narrowing.


How mHealth can Help with Health Literacy

The first step in patient engagement is patient education. With all of the medical misinformation available online, patients should have a trusted resource at their fingertips. Below is an sample of the Mayo Clinic's health library optimized for a smart phone:



How mHealth Can Help with Health Management

Patient engagement goes beyond education. Education should lead to active health management. Until the last few years, personal health management meant endless manual journaling -- a process that few maintained. The good news is that mHealth offers a solution that is at once less labor intensive and more effective than manual tracking.


Bottom Line

Hypertension is a wide spread problem that is getting worse. Projections show that by 2030, 27 million more people will have hypertension.  With patient engagement, health outcomes and the corresponding financial burden can improve. Health systems that provide patients with a platform for engagement will be positioned for success with pay-for-outcome arrangements with CMS and private insurers. 

Interested in mHealth for your health system? See:

mHealth and the Closing Window for Patient Engagement

mHealth ROI Part 1: Readmissions

mHealth ROI Part 2: HCAHPS / Value-Based Purchasing

mHealth ROI Part 3: Patient Loyalty