Achieving Blood Pressure Goals and Addressing Inequities in Blood Pressure Management After Stroke

Nonstandard Abbreviations and Acronyms

ALLHAT

Antihypertensive and Lipid‐Lowering Treatment to Prevent Heart Attack Trial

SDoH

social determinants of health

TASC

Telehealth After Stroke Care

TEAMS‐BP

Telehealth‐Enhanced Assessment and Management after Stroke‐Blood Pressure

VIRTUAL

Video‐Based Intervention to Reduce Treatment and Outcome Disparities in Adults Living With Stroke

Blood pressure (BP) control saves lives and reduces the burden of cardiovascular disease and stroke. Pooled results from randomized controlled trials demonstrate that if systolic BP is lowered by 5 mm Hg, the risk of stroke, major adverse cardiovascular events, and cardiovascular death can be lowered by 13%, 9%, and 5%, respectively. ¹ Compared with other risk factors, hypertension is associated with the highest risk for recurrent stroke. In a systematic review of randomized controlled trials for secondary prevention in stroke patients, lowering systolic blood pressure (SBP) reduces the risk of recurrent stroke by 27% (cumulative risk ratio, 0.73 [95% CI, 0.62–0.87]), myocardial infarction by 23% (risk ratio, 0.77 [95% CI, 0.57–1.03]), and cardiovascular death by 15% (risk ratio, 0.85 [95% CI, 0.75–0.96]). ² In meta‐regression analyses, the optimum SBP target for reducing occurrence of multiple adverse events was 130 mm Hg. Most importantly, the American Heart Association guideline for secondary prevention of stroke recommends lowering SBP to ≤130 mm Hg, ³ the same BP target for patients without stroke. ⁴

There are substantial health disparities related to hypertension, stroke risk, and BP management. Black individuals are at a significantly higher risk of stroke from elevated BP, especially in the Stroke Belt of the Southeastern United States. Epidemiological data showed that a 10‐mm Hg elevation in SBP was associated with a 24% increased risk of stroke in Black individuals, but only an 8% risk in White individuals. ⁵ In addition, the likelihood of BP control is 30% to 40% lower among Black than White people, despite a greater awareness and likelihood of treatment of hypertension. ⁶ , ⁷

BP Trends: The Role of Social Determinants of Health

The trends for hypertension control are worsening, as shown in the 2020 analysis from the National Health and Nutrition Examination Survey. BP control (defined as BP <140/90 mm Hg), improved to 53.8% from 1999 to 2000 to 2006 to 2007, remained stable until 2013 to 2014, and then declined to 43.7% in 2017 to 2018. ⁸ The trend was worst in the highest‐risk groups, which included young adults and Black and Hispanic individuals, compared with non‐Hispanic White individuals. ⁸ To address this problem, the National Heart, Lung, and Blood Institute/Centers for Disease Control and Prevention convened a workshop to determine the factors for this worsening BP control. ⁹ The workshop identified multiple factors that likely contributed to the decline in BP control, such as the obesity epidemic, hypertension guideline controversies, clinician burnout, and clinical and therapeutic inertia. ⁹

However, social determinants of health (SDoH) have the most significant impacts on BP control and medication nonadherence because of barriers to self‐management and self‐care, especially in non‐Hispanic Black individuals. ⁹ Analyses from the Multi‐Ethnic Study of Atherosclerosis reported that the likelihood of incident hypertension was higher in racially segregated neighborhoods than nonsegregated, with Black and Hispanic residents about 33% (HR, 1.33 [95% CI, 1.09–1.62]; and HR, 1.33 [95% CI, 1.04–1.70], respectively) more likely to develop hypertension, even after adjustment for relevant covariates. ¹⁰ An analysis of self‐reported SDoH factors and hypertension control from the National Health and Nutrition Examination Survey cohort reported that after adjusting for education, employment status, insurance status, and marital status (proxy for social support), Non‐Hispanic Black individuals had a higher prevalence of hypertension and uncontrolled BP. ¹¹ Although limited by data that were self‐reported and lacking some of the SDoH factors in the National Health and Nutrition Examination Survey cohort, there is a high likelihood that structural racism (eg, redlining and the limitations of moving to safer neighborhoods, access to care and transportation) is one of the major underlying causes of this disparity in hypertension prevalence. ¹¹

What Actions Can Address This Concerning Trend?

The National Heart, Lung, and Blood Institute /Centers for Disease Control and Prevention workshop generated several “Big Ideas”: actionable steps to improve BP control. These included an emphasis on patient‐centered care, simplified treatment (combination pills), self‐measured BP monitoring supported by clinicians, telehealth approaches to hypertension management, team‐based care, community engagement with clinicians, use of performance metrics to enhance accountability, development of novel health care delivery options, and tailored public health messages about the importance of hypertension. ⁹ To support some of these approaches the NIH and US Department of Health and Human Services have launched a program targeting young Black men to increase awareness of hypertension and BP.

BP self‐monitoring is an approach that is gaining acceptance because it increases awareness for the patient. If the clinician is able to review the data, home BPs can be used to manage BP remotely, increasing convenience for the patients. Self‐measured BP monitoring on its own, however, may not be effective to control BP. A meta‐analysis of patient‐level data from self‐monitoring reported that when combined with medication titration, education, or lifestyle counseling, SBP could be lowered by 6.1 mm Hg, depending on the intensity of the cointerventions. ¹² In addition, use of mobile applications along with automated feedback, personalized goal setting, reminders, educational materials, and data visualization features may be an effective tool for lowering BP. ¹³ Another meta‐analysis of randomized controlled trials of telemedicine and mobile health trials in patients with stroke showed a small but significant reduction in SBP (average 5.5 mm Hg with the interventions versus usual care). ¹⁴

Complex interventions based on the chronic care model for BP management have been tested in underrepresented communities. One example is a pragmatic randomized controlled 3‐arm trial of 495 patients with stroke or transient ischemic attack with uncontrolled SBP at enrollment and self‐identification as Hispanic or Black. ¹⁵ The interventions being compared were (1) usual home care (skilled nursing or rehabilitative care); (2) usual home care plus nurse practitioner transitional care program; and (3) usual home care, plus nurse practitioner, plus 60 days of coaching/self‐management from a health coach. All the participants had BPs measured at home. The primary outcome was change in SBP from baseline to 3 and 12 months. SBP decreased by 10 mm Hg from baseline to follow‐up, but there was no significant difference across the 3 arms. ¹⁵ The lack of benefit from the more intense interventions may be from suboptimal implementation of the interventions as designed (missed coaching and nurse practitioner calls) and the fact that participants in usual home care were receiving additional services including BP management. Another randomized trial of 487 participants (71% Hispanic and 18% Black) randomized to a complex, multilevel, multimodal intervention versus usual care showed no difference in SBP at 12 months (primary outcome) between the groups, although there was a significant decrease in self‐reported salt intake in the intervention. ¹⁶ Similarly, this trial was limited by only 15% of the participants receiving the full dose of the intervention. ¹⁶ Complex interventions delivered with maximum fidelity that target underrepresented, high‐risk populations are needed.

Addressing Inequities in BP Control in Patients With Stroke Through Research

Enrolling high‐risk patients in BP‐lowering trials, such as those from underrepresented minoritized populations, greatly improves generalizability of the trial results to these groups. However, in ALLHAT (Antihypertensive and Lipid‐Lowering Treatment to Prevent Heart Attack Trial), of the >26 000 participants analyzed, those living in the lowest‐income sites were less likely to achieve BP <140/90 mm Hg (odds ratio, 0.48 [95% CI, 0.37–0.63]), had greater all‐cause death (HR, 1.25 [95% CI, 1.10–1.41]), greater heart failure hospitalizations/death (HR, 1.26 [95% CI, 1.03–1.55]), and more end‐stage renal disease (HR, 1.86 [95% CI, 1.26–2.73]). Key factors in these poor outcomes included lower visit adherence (29.7% versus 40.8% in quintile 5) and lower medication adherence (36.3% versus 55.6%). ¹⁷ Data on both visit and medication adherence was missing substantially more often in the lowest quintile. ¹⁷ This suggests that more needs to be done to address SDoHs to improve trial participation and effectiveness of BP treatment to reap the full benefits of participating in clinical trials with a standardized treatment protocol. The consequences of poorly controlled BP (despite participation in the trial) and end‐organ disease are clearly illustrated in ALLHAT. ¹⁷

Under‐represented individuals with a history of stroke and hypertension are a group with the highest risk of stroke recurrence. Trials that include these patients must address the challenges in recruitment, adherence, and retention. Disabilities caused by stroke add further complexity to participation and successful completion of follow‐up in these trials. Stakeholders and communities engaged in the research process are essential to improving all aspects of clinical trial enrollment in trials in which health equity is a concern. ¹⁸ Therefore, the community most affected by the condition (eg, Black individuals at risk of stroke due to hypertension) need to be involved at all levels of research, with community as the foundation. The first step is often to engage in open honest discussion of the historical reasons for the community's distrust in medicine and the academic establishment. For example, the unethical mistreatment that occurred in the Tuskegee experiment of syphilis>50 years ago still influences many attitudes of Black individuals toward research. ¹⁹ The second step is community‐based interventions focused on reducing disparities in stroke, but only a few have been tested in patients with stroke. ¹⁸ Some successful strategies included collaboration with community partners (through a community advisory board) and use of culturally tailored materials. ¹⁸ More studies with this focus are clearly needed for hypertension management in stroke survivors from underrepresented communities.

Implementation strategies to improve BP control (as well as interventions for trials) should consider individual, organizational, community, and policy‐level factors, all of which are components of the socioecological model. ²⁰ At the individual level (both the patient and the clinician), beliefs about the importance of BP control can be a major factor in successfully reaching BP targets, but many other social determinants play a role, such as education, health literacy, and inadequate income. At the clinician level, understanding guideline targets and patients' risk as well as clinical inertia are potential factors, as well as recognizing and addressing conscious and unconscious bias. It is also important for clinicians and other health care personnel to understand the barriers to patients' understanding and to provide education to match individual health literacy. Organizational‐level barriers include the lack of support for self‐monitoring of BPs, for example, transfer of wearable BP data into the electronic health record for clinicians to review and make changes to medications. ²⁰ The community‐level barriers are generally encompassed into the SDoH: food insecurity, lack of access to health care, medications, healthy food, and safe places to exercise. Implementation of interventions most effective for BP among those from minoritized groups include dietary programs designed to help reduce salt intake, faith‐based interventions, and community‐based programs. ²¹ Policy‐level barriers relate to limited or insufficient health insurance coverage from state‐regulated programs such as Medicaid. ²⁰ Structural racism, which leads to “differential access to the goods, services, and opportunities of society by race” plays a major role in driving health disparities in BP management and poststroke care at all levels. ²²

Driven by the COVID‐19 pandemic, telehealth has been a mechanism to improve access to care and implementation of prevention strategies that could reduce health inequities. However, there are several barriers that can limit implementation of telehealth interventions in patients with stroke, such as level of disability, lack of caregiver support, Internet access necessary for visits and use of mobile devices, high cost of digital technology, and low literacy for using digital technology; many of these barriers contribute to the “digital divide” that can increase health disparities. ²³ Some pilot studies have shown promising results from complex interventions to lower BP in patients with stroke using telehealth and remote BP monitoring. One example is the TASC (Telehealth After Stroke Care) trial, which randomized 50 patients to a multidisciplinary team of primary care nurse practitioner, pharmacist, and stroke physician with home BP telemonitoring versus usual stroke discharge care with a tailored infographic for education about BP management. ²⁴ TASC showed a significant decrease in SBP of 16 mm Hg in the team‐based telemonitoring versus 3 mm Hg in usual care. In addition, the population was made up primarily of underrepresented groups (44% Hispanic and 32% Black) and more than half with less than a high school education. ²⁴ Two larger randomized controlled trials are currently ongoing: the VIRTUAL (Video‐Based Intervention to Reduce Treatment and Outcome Disparities in Adults Living With Stroke) study and TEAMS‐BP (Telehealth‐Enhanced Assessment and Management After Stroke‐Blood Pressure) trial. The VIRTUAL study is comparing interdisciplinary poststroke care delivered via telehealth plus remote BP monitoring to best evidence‐supported standard care for patients discharged after stroke or transient ischemic attack. The social determinants of health are comprehensively assessed, with the assumption that these factors are related to poor BP control and racial and ethnic disparities. ²³ TEAMS‐BP is a comparative effectiveness trial of 2 different BP management strategies in patients with stroke discharged home from the hospital or inpatient rehabilitation facility. Patients with SBP ≥130 mm Hg are randomized to intensive tailored telehealth management (cellular transmission of BPs and step counts from home, telehealth‐based medication titration, lifestyle coaching, BP‐focused care plan, and reports sent to the provider with data related to BPs that are in and outside of the goal range) versus intensive clinic management (regular in‐person clinic visits with a provider, medication titration as needed to meet the goal, and BP logs maintained by the participant). The primary end point of TEAMS‐BP is control of SBP at 6 months to <130 mm Hg. Of note, the trial is powered to determine effectiveness in Black individuals and those with physical or cognitive disabilities, and social determinants of health are systematically collected. Both the VIRTUAL and TEAMS‐BP trials should provide evidence for not only the effectiveness but also the stakeholder buy‐in for digital technologies that could provide a more rigorous assessment of BP management in these high‐risk patients after stroke.

In conclusion, health disparities are strongly linked to hypertension and secondary prevention of stroke. We have many barriers to overcome to reduce the current inequities from the health system, community, and individual levels, but several strategies could assist in moving the needle (Table). ²⁵ Current ongoing trials will potentially help shape the evidence for improving BP management equitably, by understanding participants' social needs to meet patients where they are and using technology to monitor and manage BP remotely to reduce recurrent stroke risk.

Table   .

Strategies and Suggested Resources to Address Health Inequities

Strategies to address health inequities	Suggested resources/collaborations
Involve relevant stakeholders at all levels of research studies	Patient Centered Outcomes Research Institute resources for training of all research personnel (https://www.pcori.org/engagement/value‐engagement)
Data collection to understand access to care and gaps for underrepresented groups	Population health resources, collection of social risks and social needs. 25 Examples: Accountable Health Communities Health‐Related Social Needs Screening Tool (CMS.gov); Health Leads (https://healthleadsusa.org/news‐resources/the‐health‐leads‐screening‐toolkit/)
Identify opportunities for education in research recruitment	Stroke support groups, community health fairs, faith‐based organizations
Real‐time data to determine effectiveness of interventions focused on disparities	Learning health system approaches/quality improvement initiatives, community metrics
Use of telehealth and mobile health to manage BP in stroke survivors	Centers for Medicare and Medicaid billing codes; health system investment in BP monitors; mobile applications for BP transmission and display of data
Increase diversity of clinical trial enrollment	Community advisory boards 18 ; Clinical and Translational Science Award resources focused on community engagement/researcher collaborations; focus on hiring investigators and research staff from underrepresented populations
Include use of allied professionals who can assist physicians with BP management in the community	Community health workers, pharmacists, and nurse practitioners have all been included in trials of complex interventions. 16 , 20 , 24
Systematic collection of validated social determinants of health in observational and randomized clinical studies	PhenX Toolkit for individual and structural SDoH (https://www.phenxtoolkit.org/index.php)

BP indicates blood presure; SDoH, social determinants of health.

Sources of Funding

None.

Disclosures

Dr Bushnell receives research salary support from the Patient Centered Outcomes Research Institute for PLACER‐2020C3‐21 070 as principal investigator for the TEAMS‐BP trial.